Over order or minimalist?

[chrisktrauma]

I remember when I first started ER nursing, I used to get so frustrated at doctors when they would over order on every patient that walked through the door. Example: 17yr old male no medical hx, healthy in appearance with c/o cough, 99.0 temp and "chest pain". Doc ordered ekg, cbc, cmp, lactic acid, amylase, lipase, mg, phos, BC x2, cxr, d-dimer and cardiac enzymes and some meds. On the other end of the spectrum I had a 56 yr old patient who was an employee of the hospital who had a c/o nausea and dizziness. In appearance she was dusky and diaphoretic. They ordered zofran, antivert, po challange and discharge all in initial orders. This is where patient advocacy and critical thinking plays a huge role in er nursing. Everything came back negative on 17 yr old, he was dced with dx of bronchitis. The 56 yr old passed away the next day of unknown etiology. Not always will you be able to override or convince doctors of your thoughts, but in the case of the 17 yr old you can ask for rationale for all the orders provided patient presentation. on the 56 yr old, patient appearance was the key. I was not the assigned nurse but had I'd been the patient wouldve been worked up to assess dizziness and cardiac standpoint. At very lead she was middle aged female with nausea and diaphoresis. should be automatic EKG a least.

There is a fine line between minimalist and neglecting certain aspects or missing clues. ER nurses and all nurses are the eyes and ears of our patient experience and greatly control their outcomes. Never be afraid to be vocal and to push for what you believe in. If patient is to be discharged and you believe they should be admitted with good reason- ask the doc.

thoughts? I'm sure many rn's have similiar experiences.

[Sassy5d]

I totally agree.

I completely understand, in this sue happy society, to over work up patients.

Where I work, any time you mention dizziness, nurses automatically do the EKG. We don't need to wait for the doc.

I kept bugging a doc 1 time, for orders for a ct. This guy was beyond dizzy.. He looked like a newborn with the startle reflex. The doc was unimpressed. Was planning on dc him. Puked all over me.

I finally got the order for the ct and he had had a stroke. Cerebellum.

[iluvivt, BSN, RN]

I vote for overwork but I'm a little shocked that the 56 year old female with those complaints was not given a cardiac workup. There is tons of information out there now on how women present differently than men for an AMI. How can you write the discharge order without identifying the cause of the symptoms or even knowing the response to the treatment that was ordered? Studies prove it...mortality is lower with better RN staffing an good nursing care.Do you think some of it can be the mentality in some EDs and by some clinicians to move the patient along and get them admitted or send them on their way? In are overcrowded, often understaffed EDs is seems almost conducive to medical error. Our ED is so overcrowded patients are placed in the hallways,in chairs, have long waits and no privacy..it's pretty horrid and it always messy and loud and seems so chaotic. I found myself in need of urgent medical care 2 weeks ago and I could not bring myself to go the ED . Instead I chose an urgent care center and ended up really good care.

[psu_213, BSN, RN]

Most of the time, in my opinion, our docs overwork stuff rather than underwork it. I don't really have a problem with it-- at the very least, their (the doc's) reputation is on the line if their is a poor outcome.

Every once in a while I have issues with overworking a pt though. I was taking care of an 18 yr old female with no PMH. She described to me reproducible "severe" right upper abd pain. No SOB, no increase in pain with breathing. Line/lab (more than some docs would have done, but I no problem with this), UA/hCG (no problem with this either, hCG negative). Now the issues. The doc says the pt described flank pain (she didn't tell me about this, but we all know pts. change their stories). He does a CT to r/o kidney stone. This test wasn't really the end of the world, but it only gets better from there.... No stone, but the doc ordered a d-dimer with the labs and, of course, it came back mildly positive. Now he is obligated to do a chest CTA, which of course was negative. So we have exposed her to 2 doses of CT radiation plus a nice helping of IV contrast. All to get a discharge diagnosis of "muscle strain." Again, the doc was more on the line than me for a "missed" problem, but it just seemed like a heck of a w/u for not very much wrong.

[CodeteamB]

This is one reason I love nurse initiated protocols. At my hospital the 56 yo female would have had an ECG, basic bloodwork, and depending on the RN a troponin all before she even saw a doctor.

We have some doctors that really do over order but generally in a reasonable "cover my butt" kind of way. There is one in particular who likes to hunt zebras and we get some wild orders from him but as far as work-ups go I rarely see anything I would go so far as to disagree with.

I would personally (like all of us probably) rather the doc go a little overboard on their BS cases than summarily discharge a truly ill patient. It's the nature of the beast in Emergency medicine.

[Anna Flaxis, BSN, RN]

In my experience it seems like the gray hairs tend to rely more upon their physical exam and the patient's story to help guide their diagnostic decision making than the newer, younger docs do. It seems like the less experienced docs are more likely to order a full body scan for everyone, no matter the complaint, while the experienced docs do a more thorough exam and history taking, then zero in on their differential diagnosis in a more targeted fashion.

[emtb2rn, BSN, RN, EMT-B]

This is one reason I love nurse initiated protocols. At my hospital the 56 yo female would have had an ECG, basic bloodwork, and depending on the RN a troponin all before she even saw a doctor.

Same in my ER and those initial labs would've included cardiac enzymes. EKG would most likely have been done in triage.

I find the newer PAs tend to do the million dollar workup quite often. Although we have one very experienced PA who still orders pretty much everything on everybody.