order needed for EFM?

[canoehead, BSN, RN]

At the last OB committee meeting the head of the department proposed revising policy so nursing required a physician order to start continuous fetal monitering. This would require night calls to docs, but worse, no way for nurses keep track of FHR when they feel the doc is not responding to their concerns. (That has been a big issue that keeps coming up) The argument is that nurses are overusing the moniter, impeding labor progress, and that if a moniter strip does not exist the lawyers can't overanalyze them during a suit.

We currnetly use intermittent auscultation for normal moms and babies, and use EFM for high risk labor patients, or at nursing discretion. Needless to say nursing staff is not pleased at physicians wanting to take away their autonomy, or their means of keeping track of patients that are a going concern.

Can anyone offer an opinion, or resources, to bring up at the next OB Committee meeting on this issue.

[HazeK]

where are you working?

what state?

In Nevada, Standard of Care is EFM...w/

"aulscultation" being only by special Rx.

(we have a high number of lawyers per capita...

therefore, everyone likes having "hard copy" to cover their butts, so to speak!)

We practice very autonomously....

IF your med staff passes this....

suggest you call them EVERY time you feel EFM appropriate.... being sure to chart that you have called, requested it, and if they order it or decline it.....

Bet you $$$$ they give nursing more autonmy rather than continuing all those late night calls!!! :-)

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[jamistlc]

Greetings,

Personally I think that EFM is not classified as invasive and should not require a Physician order, but it may not be reimburssed by the insurance carrier and the Hospital Adm. maybe trying to cut costs or insure they get paid for the use of the equipment.

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[Nay]

According to AWHONN auscultation:does not detect LTV or STV;is not continuous and may ,therefore,miss or delay detection of decreases and increases of the FHR;does not generate a graphic record for assistance in decision-making or future review;requires education,practice,skill,and a 1:1 nurse:fetus ratio;may be disrupted by uterine contractions;and may be limited by position and movement of the mother or fetus,as well as maternal size.

Hope this helps. Nay

[Q.]

I have my own thoughts on this.

At my facility, we don't need an order for EFM. That is part of the nursing assessment and is used at discretion. We do require an order for intermittent monitoring. We only use the doppler for 28 weeks and lower.

However, I do think we use EFM too much - it inhibits labor progess (at times) and promotes interventions. Under certain circumstances, obviously, it is necessary: epidural, pitocin, MgSO4, etc.

The only order r/t EFM that we need at my facility is to intermittent monitor - otherwise continuous is the standard of care.

[fiestynurse]

Here in Southern California the standard of care is continous EFM, unless the patient requests otherwise or the doctor orders intermittent monitoring. In my opinion, the lack of fetal monitoring can get you into more legal hot water, then too much fetal monitoring. EFM is part of the nursing assessment!! I invision delays in putting on the monitor, while you wait for a doctors order. Boy!! Huge risk there!!! Your doctors really need to think about this further and consult with the hospital's lawyers.