Ordering antibiotics!?!

[Bec7074]

So today I cared for a gentleman who became febrile at 38.7. I called the doc and pan cultured him as ordered, including a UA. The patient was not on antibiotics and was admitted for a lung AVM. The UA came back positive for Many bacteria, WBC, nitrates, etc. Since I work nights, I knew the doc wouldn't be looking for it. I called him (he's awake and in house) to let him know it was positive. However he never started the patient on antibiotics and acted like he didn't know why I was calling. I don't understand why the patient doesn't receive broad spectrum antibiotics. Any thoughts? I was just wanting to do what's best for the patient and get this UTI under control and reduce his length of stay. The only thing I can think of was it was a busy night on our ICU and they were admitting a gunshot wound down the hall. Any insight?!

[BrandonLPN, LPN]

Could he have been waiting for the culture?

[RNperdiem, RN]

My random thought...

Was this doctor a cross-covering doctor?

I find cross covering docs tend to "band-aid" patients until the morning when the regular doctors go on rounds and discuss the patients and problems in depth and formulate a plan.

That is one more reason to like working days.

[iluvivt, BSN, RN]

The patient needs to be on antibiotics so the infection does not advance into urosepsis if he is not at that point already. The only thing I can think f is that maybe he wanted to wait until he saw the patient on rounds so he could assess the patient and also check on sensitivities if they were done..but in the meantime I agree he needed some antibiotics! Did you have a WBC ct and di you tell him about the pt's symptoms?

[classicdame, MSN, EdD]

This is the reason people are in the hospital - to get 24 hour care. I believe the doc dropped the ball and should have ordered meds. How hard is that? The final report on the culture could be 3 days away. Could always change meds if another is deemed more appropriate later.

[psu_213, BSN, RN]

Yes, I would agree that ABX are appropriate given the positive UA; however, there are may reasons why the doctor may not have ordered them right then over the phone--which others here have already mentioned. Were ABX started in morning?

[Bec7074]

Just an update. Went back to work tonight and the patient is on vanc and meropenem. And still febrile with nasty urine....but it made me feel better.

Working nights can be frustrating. I often feel the "keep Em alive till 7:05" which is unfair to patients.

[Anna Flaxis, BSN, RN]

Ugh, how frustrating.

Have you heard of the SBAR format for communicating with others about the condition of the patient?

S=Situation

B=Background

A=Assessment

R=Recommendation

Following this format, you would have told the doctor something like "Mr. Smith is a ____yo admitted for lung AVM. He developed a temperature of 38.7 and cultures were sent. The UA is positive for many bacteria, WBCs, nitrates, etc. My assessment is that Mr. Smith has a UTI, and I'd recommend starting him on antibiotics. Would you like to order antibiotics?"

Then the doctor can say yes or no, and hopefully if he/she says no, they'll include a rationale.

[BrandonLPN, LPN]

I was told by the nurse who precepted me that it's overstepping our bounds to "recommend" anything to a doctor. (she meant both LPNs and RNs)

[Anna Flaxis, BSN, RN]

It's not overstepping our bounds at all. We ask doctors for orders that we think are appropriate all the time. If you had a patient with a fever who had no Tylenol ordered, would you feel it's overstepping your bounds to call the doctor for an order for Tylenol?

[BrandonLPN, LPN]

I think she meant you would call the doctor, tell him about the fever, but suggesting a medication or diagnostic test ot treatment or whatever was being presumptuous.

[Anna Flaxis, BSN, RN]

Really? Wow. Why is it being presumptuous to know that a patient with a UTI needs antibiotics?

Suggesting a specific antibiotic might be sort of presumptuous, but....