"resuming previous orders" written by surgeons

[ChrissyS.]

Most of my life I've been a circulator, and now I am currently the Unit Coordinator in a small hospital that is rapidly expanding beyond it's capabilities. As we update policies and procedures, "resume previous orders" is a glaring no-no, and we're trying to change the way of thinking around here. Here's the problem(s). The floor nurse is wanting the perioperative nurse to paw through the chart and find the previous orders, rewrite them and present it in a format for the surgeon to sign-while doing their other million-and-a half periop duties.Big No. Who does it? The floor? The surgeon?

The next problem is in the instance of a surgical consult. Let's say that Ms. Smith has been in the hospital for 4 days under the care of an internal doc, that patient gets referred to my surgeon for a procedure like an EGD/COLON, and then sent back to the floor. My surgeon has no intention of changing the internal doc's plan of care, he was just consulted for a procedure. How does the surgeon communicate to the nursing staff that the internist's orders are to be continued? Do these have to be rewritten as well? Who does it?

I appreciate any input any of you may have... Thanks! ChrissyS.

[suzanne4, RN]

No one should be writing out the orders for the physician to sign. Some of the orders are always going to be changed. It is not the responsibility of the nurse on the floor, nor the nurse in the OR to do this.

The surgeon can write the orders that pertain to the surgery that he or she did, and then write an order to contact the other physician for further orders. He should not be re-writing orders for drugs that he doesn't use or is not familiar with.

As for the colonoscopy/EGD: The physician can write the IV order for now, NPO status that he wants followed, pain med if deemed necessary, and medications that are needed to go along with what they did, then again:

contact Dr.--------, or his associate for further orders. Since it was a procedure, the orders will need to be obtained from the internist or whoever wrote them.

[caroladybelle, BSN, RN]

It is the MDs responsibility to write new orders for the patient.

The reason is that the patient's circumstances have presumably changed. And it "requires" an MDs expertise to reassess, reevaluate and alter the plan of care.

Now, getting the MDs to actually do their job is the hard part. For as much as they gripe and moan about the increasing power of NPs and scope of practice, when it comes to actually doing their jobs in this regard, they are rather slack.

"Resume preop orders", along with, "Continue home meds", are two orders that should never be considered acceptable for patient safety. Yet, they are consistantly overused. It is the MDs job to write all old and new orders.

(I will still lay odds that they will still find a way to not do so, and that management will find a way to dump it on a group of nurses..just to make the MDs happy, and despite the fact that it endangers the nurses' licenses and patient health).

[mcmike55]

I feel for ya.....you've got a tough job ahead of you.

I agree, the periop nurse (pacu,or) should not have to wade through orders for the doc to sign. And as you said, "resume preop orders" does not fly these days.

A couple things we do at my hospital.

We use pathways for many things. We have pathway order sheets for fem-pop bypasses, various ortho procedures, etc.

These are checkmark, fill in the blank or cross off type pre printed forms, put on the chart prior to surgery. They include, pre op and post op orders.

That way, routine orders are quickly taken care of, then there are blanks to add pt specific orders.

I have seen the surgeon still order "further orders per Dr......", that type of thing.

Most of our docs work together pretty well, probably the worst is ortho. They would preferr the medical guy carry the majority of the care, H&P, meds, etc.

A recent addition is a home medication list. The admitting nurse logs all meds the pt takes at home, dose and frequency. The doc will counter sign the list, marking the ones that he wants to continue, and notes changes, such as dosage. This becomes a med order sheet, then becomes the pt's home going medication list.

The trick, I guess, is finding a system that nurses, pharmacy and docs can all live with. Making EVERYONE happy is not an option...one or two...maybe!

Mike

[MissJoRN, RN]

Like Mike, my suggestion would be a pre printed for with options for the surgeon to select ot to cue him to wite in an additional option. Just make sure that policy is that they cross out orders they don't want as well as checking the ones they do...no room to check off an order later that might be missed accidentaly or, worse, to cover an error.

[RN34TX]

I work PACU and we have check off sheets for some specific cases like open hearts or crani's but otherwise they are hand written.

We too often have to call the doc back and remind them that "continue previous orders" and they need to come back and re-write them, which they do, most of the time without complaining.

My jaw dropped to the floor when I read the comment about the floor nurses and/or docs wanting the peri-op staff to thumb through and re-write orders so that the doc only has to sign them to save time and trouble on their part.

First of all, I don't know any floor nurses that would be willing to do such a time consuming task so why they'd expect us to do it is beyond me, and if there are any nurses who would be willing, then they need to get a backbone because that kind of coddling on the nurse's part is where spoiled rotton prima donna surgeons are born.

If a doc ever expected me to do something like that I'd be saying:

"If you think we sit on PACU patients too long now and never have enough open slots, wait until we have to start thumbing through old orders to put new ones together for you, that could take a long long time."

[amnesia]

Definately not your job. This is the MD's responsibility alone.

[mattsmom81]

Like Carolina said...ss long as hospitals continue coddle their physicians, nurses will be pressured to 'resume home meds' and 'continue preop orders'. Those facilities I've worked at, the docs do both religiously...and the nurses are coerced into accepting it. In an employee at will state...well, you know the rest.