Pressors in Surgery Center?!

[Jen04 nurse]

I just wanted to get a consensus that I'm not going crazy or if you've ever heard of this before.

So I have had over 14 yrs of nursing experience in ICU, PACU, agency etc.

This new place I'm working basically is an ambulatory surgical center only considered a hospital because there is a one room ER- no ICU etc. Most of the nurses here have not done ICU, ER, or any critical care esp no training in hemodynamics etc.

The nurse mgrs have req training on using a smart pump for adm of vasopressors in the event of an emergency.

I feel this is more dangerous and a high liability to put vasoative drugs in the hands of nurses who have never been educated and expect it to be safe. The nurses would be mixing these as well. Not to mention it would be through PIVs since there are not docs that could start a central line here.

I'd love to hear what other nurses with experiemce in various settings think about this.

[blondy2061h, MSN, RN]

I think you should have the training to start pressors, obviously with the providers in close proximity. It's scarier not to be able to start them when you need to than to start them. Since you don't have an ICU, clearly plans should be made quickly to transfer anyone requiring them for more than a brief anesthesia related period to a higher level of care. I would also want to be careful you're not missing sepsis by using them, by correlating clinical condition. Obviously, all this is contingent on proper education.

[Wuzzie]

What is the plan for after you've started the pressors?

[AnnieOaklyRN, BSN, RN, EMT-P]

I am guessing you are required to have them. Also you forget you have anesthesiologists who are well versed in the use of Pressors. It is up to the nurses to make sure they are familiar with emergency medications, and this would include taking ACLS, especially in a place where there isn't a lot of help by the sounds of it.

You would need to transfer this person via ambulance and a majority of ALS ambulances are equipped with pressers (we carry Dopamine, epi, and Levophed on mine), so the medic(s) could also help with this situation.

Annie

[AnnieOaklyRN, BSN, RN, EMT-P]

What is the plan for after you've started the pressors?

Transfer to a hospital one would assume!

[MunoRN, RN]

It sort depends on what you mean by "pressors". Phenylephrine is a pretty standard PACU drug, even in ambulatory outpatient surgery centers, although when needed it may be more commonly administered by the anesthesiologist even though the patient is in the recovery phase where nurses are not comfortable with it. Phenylephrine typically isn't administered as a drip in the recovery setting however, if the patient appears to be in need of ongoing pressors for the foreseeable future, the facility should be calling 911.

[Wuzzie]

Transfer to a hospital one would assume!

Well yes but I was either hoping more details would be forthcoming.

[blondy2061h, MSN, RN]

It sort depends on what you mean by "pressors". Phenylephrine is a pretty standard PACU drug, even in ambulatory outpatient surgery centers, although when needed it may be more commonly administered by the anesthesiologist even though the patient is in the recovery phase where nurses are not comfortable with it. Phenylephrine typically isn't administered as a drip in the recovery setting however, if the patient appears to be in need of ongoing pressors for the foreseeable future, the facility should be calling 911.

A place that is technically a hospital can't just call 911. They need a more formal arrangement in place. I'm not sure if you're part of a bigger system and your providers can admit at more equipped facilities?

[Wuzzie]

A place that is technically a hospital can't just call 911. They need a more formal arrangement in place. I'm not sure if you're part of a bigger system and your providers can admit at more equipped facilities?

This^ What's more by the time the patient is requiring pressors you've kind of crossed over from a 911 scenario to a CCT one.

[applewhitern, BSN, RN]

Is there a reason why the nurses can't educate themselves? There should be a policy set in place as to how to mix the different drugs. You can give most of the drugs thru a peripheral IV. If you have a concentration that requires a central line, you are probably going to transfer the patient to a different facility, anyway. I have worked ICU for 30 years. Not all patients needing critical drips will have a central line; we give them thru peripheral IV's all the time. Maybe an experienced nurse can write up the policy for the use of these drugs and let the facility's medical staff approve it. There is no reason why the nurses who work there cannot educate themselves on proper administration and monitoring of any meds they might potentially use.

[AnnieOaklyRN, BSN, RN, EMT-P]

This^ What's more by the time the patient is requiring pressors you've kind of crossed over from a 911 scenario to a CCT one.

Actually in most jurisdictions even a hospital can call 911 in the event they have an emergent transfer and are unable to use any other means to get the person to a hospital that can handle their care.

We have quite a few stand alone day surgery centers in my area and they call 911 if they have an emergent transfer. If its non urgent for a patient that just needs a bit of monitoring over night then they call a contracted ambulance service to transfer the patient ALS to BLS depending on the needs.

Annie

[AnnieOaklyRN, BSN, RN, EMT-P]

This^ What's more by the time the patient is requiring pressors you've kind of crossed over from a 911 scenario to a CCT one.

Actually a 911 ALS ambulance, and even a transfer ALS truck could take a patent with pressers! We hang the on patients who dial 911 who are hypotensive and transport them (obviously we assess them and try fluids first, but you get the idea), so there isn't that much of a difference (obviously the cause might be related to anesthesia which we would not normally see in the field), other than they will be hung prior to our arrival instead of us doing it. In my state we can even take blood products if they are already hung. You are not going to wait 45 plus minutes for a CCT to transfer a patient down the street to a hospital, that would be crazy, especially if the patient becomes normotensive with the pressers on board.

In this case I am assuming they have a contract with an ALS provider for situations that require the patient to be transferred to a hospital, but also as stated in another post hospitals and medical facilities can call 911 if they have a patient that is not within their capabilities to handle, and that patient required emergent transfer, and they are unable to get a contracted ambulance at the appropriate level within a reasonable time frame.

In the end if you staff or physician is uncomfortable sending the patient with a particular crew an alternative would be to send a physician or nurse, but in my experiences a majority of nurses are uncomfortable on ambulances because it is a totally different environment. I have given many of them vomit bags because they don't like riding backwards!

Annie