Problems with obtaining needed orders- advice appreciated.

[perfectbluebuildings, BSN, RN]

What do you do when you have a seriously decompensating patient and their physician will not provide appropriate orders? I can't be too specific but we dealt with this situation recently. The physician did come and assess the patient but was pretty irritated that they had to do so, and even after assessing the patient they thought they were not decompensating but that certain symptoms were a normal variation. The patient ended up requiring rapid response intervention soon after this and transferring to ICU, so it was not just that the nurses were coming up with nitpicky problems about the patient out of thin air.

I know this is very very vague, but i don't want to put too many details. How do you provide care for a patient when they need interventions that absolutely require a physician order, I mean something that is extremely obvious and not all that difficult to initiate treatment for, but the physician is simply unwilling to order it. It was quite frustrating. I have dealt with somewhat similar situations in the past, but never one where the patient so blatantly needed intervention and the physician was so stubbornly unwilling to provide it.

I am also worried about what if the patient had had a less experienced nurse caring for them- what the outcome might have been. And thinking I should have done more to help convince the physician that intervention was needed.

Please help :)

[Esme12, ASN, BSN, RN]

What do you do when you have a seriously decompensating patient and their physician will not provide appropriate orders? I can't be too specific but we dealt with this situation recently. The physician did come and assess the patient but was pretty irritated that they had to do so, and even after assessing the patient they thought they were not decompensating but that certain symptoms were a normal variation. The patient ended up requiring rapid response intervention soon after this and transferring to ICU, so it was not just that the nurses were coming up with nitpicky problems about the patient out of thin air.

I know this is very very vague, but i don't want to put too many details. How do you provide care for a patient when they need interventions that absolutely require a physician order, I mean something that is extremely obvious and not all that difficult to initiate treatment for, but the physician is simply unwilling to order it. It was quite frustrating. I have dealt with somewhat similar situations in the past, but never one where the patient so blatantly needed intervention and the physician was so stubbornly unwilling to provide it.

I am also worried about what if the patient had had a less experienced nurse caring for them- what the outcome might have been. And thinking I should have done more to help convince the physician that intervention was needed.

Please help :)

I would go to the charge nurse and sup on duty and tell them of the situation. I would attempt the MD once more and if he called back and still refused I would inform him that I was calling the department head to acquire intervention for the patient. Or simply call a rapid response (or code if need be) ......that will get you a response. There is always more than one way to skin a cat!

[Up2nogood RN, RN]

I've been through this before. It's frustrating to know something is going down and the doc ignores your judgement. I paged the *green* residents numerous times one night for a pt with prolonged tachypnea/altered mental status and suggested an ABG order early on in the night. They pulled up the chest xray and looked at me and said well his lungs look fine and went on their merry way. I pestered them all night long, stopping short of suggesting a transfer. I took it upon myself to draw am labs early and the WBC was over 50. Not a good ending to that one, he was a 1:1 the whole night, probably would still be with us if they would have consulted a more senior resident and transferred the pt to the unit. Still haunts me to this day but what a lesson learned.

After the code ended and we were debriefing they could not look me in the eye. I hope they take that memory with them in their career and remember to listen to their nurses.

[Debra ACRN]

I think this is where our advocacy skills must be brought to full fruition. Drs are influenced by facts so have it all written down. I would have stood in his face and asked him since when is a pulse ox of 80, crackles throughout, VS of blah blah blah etc.. just a normal variation. Get in her face and say that you think this patient is in terrible shape and needs immidiate intervention. Make her explain to you why it isn't any thing to worry about.

I never take it personally, I would have seen them as blowing off the patient, not me. Never forget, you are the one with the most hands on experience in day to day care, you know what you are doing, and are a VALUABLE member of the health care team. If one of the team drops the ball you must pick it up and shove it where ever you need to in order to get some action.

It helps that I am 6 foot tall and I can often use it to be a little intimidating but for sure use direct eye contact and carry yourself in such a way as to signal the fact that you are not done with this conversation until a mutually acceptable agreement has been reached.

We have way more power then most of us actually use. I run a nurse run clinic and we use docs as consultants, you better believe they listen to us but we also listen to them. If you are wrong and it is a normal variation then have them teach you about it. Let them learn from you too. Just remember we are all there to get the patient well. Don't let anyone shirk their duties.

[Flying ICU RN]

At the end of the day what truly counts is that the interventions on your part are, appropriate, timely, and to the maximum limits of you clinical privileges. When the latter becomes the issue, the documentation needs to reflect your diligent and again approriate efforts in circumventing your clinical limitations, (IE involvment of superiors).

Given all of the above T's crossed and I's dotted, it is out of your hands (and responsibility) at that point.

Bad outcomes happen, despite your best efforts. Sometimes you simply need to dig a foxhole and hunker down.

[perfectbluebuildings, BSN, RN]

Thanks for all of your advice. I actually was the charge nurse in this situation, probably should have made that clear. As far as what we did, the patient had at least one nurse in his room pretty much the entire time until transfer, and the nursing supervisor was fully aware of the situation, in frequently as well, and we were providing all the interventions that we could on our own and frequent specific assessments of the patient.

I have in the past been able to say to physicians "but what about this, and don't you want this," etc., and wheedle out some interventions that are necessary. (I'm a shy person in my personal life, but when it comes to advocating for my patients, that goes out the window!) That just was not happening this time and I am really not sure why. It could have been something I did or didn't do, and of course I thought of other things I could have said to him, later on that night after I went home.

But at the same time, I was not the only nurse trying to convince him intervention was necessary. I am just so angry as I am sure you can understand, because it WAS the patient suffering in this scenario, and it seemed to turn into just stubbornness that the physician did not want to admit he was wrong about the patient, despite mounting evidence to the contrary.

I don't know. I need to stop venting and making this all about me. I so appreciate all your advice.

[classicdame, MSN, EdD]

don't forget about chain of command. Check your facility policy.

[wooh, BSN, RN]

Your facility should have a policy for escalation. Generally it's something like staff nurse calls doc, doc refuses to come, staff nurse tells charge, charge calls doc, doc refuses to come, maybe a rapid response if your hospital has a team for it, nursing supervisor gets notified, if hasn't gotten any action yet, then it goes to some upper level doc.

Make sure you follow your hospital's policy.

I'm very lucky, generally I think the docs are overdoing it rather than underdoing it at my facility. I'm usually the one saying, "They met discharge criteria yesterday! Send them home before they catch something worse here!"

[grandmawrinkle]

The only thing that I can offer is that perhaps the rapid response team should have been called sooner. Where I work, there are specific parameters (we call them "triggers") for when the RRT should be called. Floor nurses shouldn't be trying to handle near emergencies by themselves; RRTs have been shown to improve patient outcomes -- so use them!

Presumably your patient met the criteria to call RRT before they crashed. The RRT RNs in my institution have specific protocols they follow for most common clinical emergencies/near emergencies so they can do a lot of stuff without a doctor present. They also handle calling the physician with their assessment and recommendations, including ICU transfer if that is appropriate. Our doctors are REQUIRED to listen to the RRT assessment per policy; if they disagree and RRT documents in the chart that they were called and MD did not listen to their recommendations or implement them, it's on them if something bad happens to the patient. This usually doesn't happen though; our doctors know that the RRT RNs are ICU skilled and would not be bothering them if there wasn't a serious issue.

Unfortunately, sometimes it is all a matter of reputation or clout when it comes to getting a doctor to listen to you. The rapid response team in my institution has it. It doesn't sound like your floor does.

If patient had a bad outcome that you genuinely feel could have been prevented with an earlier intervention and your doc didn't do it, that is malpractice. I would go to your manager with it and write it up. I had to do this one time (CRNA let a patient get profoundly hypoxic during an intubation attempt and arrested) and it was taken very seriously; it went to the hospital peer review board.

[RNTwin]

go up the chain of command....charge nurse>manage>director>physician>attending>medical director>etc...

and document that you went up chain of command, the BON is very gray in alot of issues and they can interpret the rules as they please...

[nurse2033, MSN, RN]

Document every call you make and the outcome. If you call and they ignore your concerns you have at least covered yourself from liability. That said, you still haven't done much for your poor patient. How you frame your requests can make a big difference. We use an SBAR format for calls that I think is really helpful.

S=situation

B=background

A=assessment

R=request

If you get this info all arranged before you call you can give a consise report/ request that will let the doctor know what they need to know, and hopefully come to the same conclusion you are seeking. Here's an example- I'm calling you because Mr. S. is having increased trouble breathing, he's an 82 yo COPD pt admitted yesterday for pnuemonia, currently his RR is 36, he has wheezes in all fields and one word dyspnea, he's on max O2 and SaO2 falling through 90%, temp is 101.2, HR is 132 and BP 86/42, I've paged respiratory, do you think an ABG and blood cultures would be appropriate?

When you get the the request part it all depends on your confidence. You might have a long list of things you think the patient needs, or just state you are concerned and you think they should come see the patient. If you show the doctor from the start that you know what you are doing, you are much more likely to have their confidence and get the orders your patient needs.

[perfectbluebuildings, BSN, RN]

Most of these are things that were done. We did have the physician come see the patient. And the rapid response team was called fairly soon into the situation and called the physican also, but they were also unable to convince him of what needed to be done. Another physician did end up being called. It seems that we were doing most things right, I just wanted to get some feedback on if there was anything else we should have been doing. Thanks!!!