SwiftieRN

Seeking advice. To provide some background information, I work on a cardiovascular procedural unit. We see same day cardiac procedures (pacemaker/ICD implants, cardioversions, ablations and cardiac caths to name a few). On our unit some doctors put in their own post orders, and then the majority do not so the cardiology mid levels do it. We work mostly with the midlevels and it's always been that way since I came to the unit 5 years ago. You have someone that bleeds you call them first; you need post orders- you call them first; you have labs to report- you call them first. They are also usually the ones who write the discharge orders. I feel like there has been increasing frustration among the midlevels and nurses on our unit. They have even made comments that we call them over "stupid stuff.” It has come to the point that they don't like speaking to us, and our nurses don't like having to call them. For example, I have discussed with my unit director that if providers want a baby aspirin administered prior to their cardiac caths then there should be standing orders so we don't have to call the midlevels all the time. He said he is working on communicating this and trying to change order sets in the computer. It still hasn't happened so we still have to call and get an order, causing the midlevels to become frustrated. Getting to the specific frustration I am seeking advice on- the providers have been putting some order sets in post cath that appear as a nursing misc order code that state "have cardiology NP/PA to discharge home post PCI checklist: in 6 hours" some will say "in 4 hours.” We have asked them if we are supposed to follow this and we have been told from different midlevels all patients who receive stents stay 6 hours, or some will say it depends where the stent is- if it's left they stay 6 hours and if right it's 4. Then the midlevel will write the actual discharge order as "discharge to home after nursing parameters are met.” A nurse had a patient with this very same order set and discharge order and the patient said that she was told she didn't have to stay that long. The nurse called the midlevel to clarify (as patient was not happy) and he then told her that those are just order sets the doctor clicks and doesn't pay attention to and the midlevel then became agitated and went on to say that he has told all of us there this several times and we just need to follow the discharge order he wrote. It is really frustrating being told one thing and then something different. Is it that hard to have clear and concise orders?? If a doctor doesn't want something in their orders then don't do it?! I also do not feel like "discharge to home after nursing parameters are met" is clear and concise enough. I appreciate when doctors write "discharge after 6pm if site free of bleeding/hematoma and ambulating without difficulty.” That is clear and concise. Who is to say what our nursing parameters actually are? I've always been told post procedure make sure they can eat/drink, pee, free of pain/nausea, says >92% on room air (or at baseline), and BP changes <20% baseline. Again, that is what I've always been taught working on this unit, but there is no place in our order sets that clearly define our nursing parameters. How would that hold up in a court of law if something were to happen? what are your thoughts? Do you feel the nursing parameters discharge order is safe? If you work in a similar area what are your processes? Any thoughts on how to resolve this issue and repair the relationship with the midlevels and nurses? Thank you for any advice.