Pushing Dilaudid?

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Hello everyone,

I've worked at two hospitals in my career. The first one where I was precepted I was taught to hang dilaudid in a 50cc bag over 15 minutes to avoid giving the pt a high and perhaps snowing them. At this new place I work they all push it. We have a lot of drug seekers that come in, the nurses push (often high doses) of dilaudid, then I'm their nurse and they complain because I hang it. My take is that they are mad because they aren't getting a rush. I am not comfortable pushing, for example 4mg of dilaudid. In my previous experience when hanging it people got effective more long term relief when I hung it. Now I'm questioning it as I want to give the drug appropriately. It says in the drug book that it can be pushed over 2-5 minutes but it says nothing about hanging it. Just out of curiosity, how do you all give IV narcotics?

Doc,

I'd just add to the mix, the elephant in the room. Press Ganey.

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Thanks for all the input-

A few replies:

Press Ganey-- we can mark patients to not get a survey. And do you think that person is going to fill out the survey, much less have a valid adadress to get it? They are too busy selling their Vicoden. Fear of a bad review does not justify giving drugs to a seeker.

"Can't afford to go the doctor"-- Which is more- $100 doctor bill or a $5,000 hospital bill??? As a doctor I am glad they feel bad about not paying the doctor but the hospital needs to pay its bills too. IS it more ethical to stiff a hospital? Any of you want to volunteer to work for free to cover the 4 day stay for that seeker?

Dilaudid oral-- the conversion is 1 mg IV to 5 mg oral. So we overuse IV Dilaudid and underdose oral Dilaudid.

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Doc,

Good that you can hold surveys... but my comment was not pointing to nursing staff. We don't write the orders.

Many MANY seekers are not the type you speak of, they are your run-of-the-mill suburbia, and the well-to-do. They DO fill out those forms... which should point you to corporate image/marketing (It is the money honey, and we want to look good. We cannot have people say we leave them in pain). Your justification rules don't apply to corporate marketing.

Nursing is my second career and I bet you can guess what my first was.

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Thanks for all the input-

A few replies:

(1)...Any of you want to volunteer to work for free to cover the 4 day stay for that seeker?

(2)...we overuse IV Dilaudid and underdose oral Dilaudid.

1. I would wager a majority of allied health workers would already think they are 'working for free' on many of these cases when they are faced with unreasonable patient ratios, flat wages that aren't exactly reflective of the load they carry, the care they provide or the risks they face in the process, not to mention the declining opportunities to get away from poor work situations.

Especially when they work for organizations reporting hundreds of millions in losses, but still paying billions in bonuses at the top of the chain, while the worker's won't even see a pittance of a clothing allowance in the trenches, and 'should feel privileged' just to be working there when they don't get a holiday bonus, or if they do it wouldn't replace one of the three pairs of shoes they lost to the blood/vomitus/feces of their patients.

Solution? Take a little risk yourself and don't admit the one's you think are 'seekers', don't dump them on the floor with dubious diagnosis to 'loose money on them' (while trying to 'milk the system' in ways that pay), while making someone else deal with them at the risk of their license while you don't wish to be bothered 'after hours.'

2. Then you should take it upon yourself to prescribe correctly to the best of your ability. (Which probably means being something more than a "Signature" and a hard to reach grumpy voice on the other end of the phone.)

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Specializes in Health Information Management.
Thanks for all the input-

A few replies:

Press Ganey-- we can mark patients to not get a survey. And do you think that person is going to fill out the survey, much less have a valid adadress to get it? They are too busy selling their Vicoden. Fear of a bad review does not justify giving drugs to a seeker.

"Can't afford to go the doctor"-- Which is more- $100 doctor bill or a $5,000 hospital bill??? As a doctor I am glad they feel bad about not paying the doctor but the hospital needs to pay its bills too. IS it more ethical to stiff a hospital? Any of you want to volunteer to work for free to cover the 4 day stay for that seeker?

Dilaudid oral-- the conversion is 1 mg IV to 5 mg oral. So we overuse IV Dilaudid and underdose oral Dilaudid.

Whether you like it or not, people with low incomes are permitted to seek medical attention at a hospital and have the bill partially or fully dismissed, based on their income level. It is a woefully ineffective and costly system, I agree. But at the moment, many people are hurting for money. If it comes to paying $100 for a doctor's appointment or nothing at the local hospital, what do you think the person without access to insurance who has a relatively low income (but isn't eligible for Medicaid) is going to do? How is that choice unreasonable for that individual? It's unnecessary in terms of actual expense and level of intervention, but for the patient involved, it's a way to get care and still be able to pay the rent. I devoutly hope we can all find a better system soon.

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Specializes in Peds, PACU, ICU, ER, OB, MED-Surg,.

Signature Doc,

You cannot merely go by the online database. Many people truly do have severe chronic pain and could possibly have filled that many prescriptions. You have to remember about the people that you label seekers, they can and do get sick and have "real" pain.

I personally think doctors spend very little time with these patients. It is the nursing staff that is constantly belittled, cussed, nagged, threatened and made to fear for their jobs by these patients. Not to mention, when we do call the doctor then we are belittled, cussed, nagged and threatened, and made to fear for our jobs by the physicans. We are in a no win situation.

I suggest if you do write a protocal, program, policy etc. you have a pain specialist contribute. Also think about having a nurse help as we can tell you whether it's practical or not.

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And just because no one else mentioned it...

Thanks for all the input-

...

Press Ganey-- we can mark patients to not get a survey.

...

I suppose that provides for really relevant studies... oh, wait. No it doesn't.

That one statement makes Press Ganey (and similar surveys) irrelevant to anyone who is intellectually honest, except where it is used against them in their profession by those who are not honest. I hope you don't treat other area's of research in the same manner.

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That one statement makes Press Ganey (and similar surveys) irrelevant to anyone who is intellectually honest, except where it is used against them in their profession by those who are not honest. I hope you don't treat other area's of research in the same manner.

Are you implying that Press Ganey is "research"? Not even close to research- It is a marketing tool, that's all.

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Specializes in Medsurg/ICU, Mental Health, Home Health.
Are you implying that Press Ganey is "research"? Not even close to research- It is a marketing tool, that's all.

I don't think anyone's implying that it's a scientific study. I'm not a fan of Press Ganey, either, but I do admit that it is market research. There is such a thing.

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... and marketing research in corporate healthcare decides more P&P than I think you are aware of Doc. Far from ethical but it's time to begin to understand what makes those that rule your world tick. You get to carry the ethical weight on your shoulders as in the end it'll always be YOUR rear-end (psst, corporate knows it :rolleyes: - hey, it works for them). You keep shooting arrows at the wrong target.

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Are you implying that Press Ganey is "research"? Not even close to research- It is a marketing tool, that's all.

Are you saying that you are fine implementing standards of care and protocols based on something other than research?

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IV dilaudid is de5signed to be pushed over 2 to 5 minutes. The medication is designed to be used for immediate relief of severe pain so running it over 30 minutes (though it can be done that wat safely) is discouraged for 3 main reason

1. it is longer the patient has to suffer in agony before gwtting relief

2. the patient may not get the entire dose as there is always some left in the tube

3. and most importantly this is a short acting drug usually last 2 to 3 hours so if it you are not giving the whole dose at one time they are not only not getting the total benefit but the med tens to wear off quicker

So infusing for acute pain is not really a widely accepted practice and this holds true with most pain meds

The other issue is howthe order read because if the order is not written to infuse with saline over an amount of time this could also be an issue it is a fine line on of those gray areas

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