So I'm orienting in an MICU. Having a nice conversation with a nurse, well regarded on the unit (just won an award), had worked there for decades, and is not my preceptor. She mentions that one of the problems I'm going to have coming to the unit, that many PCU nurses have, is I'm not used to the level of critical thinking doctors expect from me.
"For example," she says, "if I'm worried about my patient, I'll just go ahead an order a gas! If I think there's something up with his abdomen, I'll have a KUB done. This way I'm prepared when I call the doctor!"
I was horrified. For years I had been told the story of an ER nurse in my hospital who wrote a phantom order just once (not for a med, for a blood test I believe) and was fired on the spot. I can't even get skin care creams without an order. She said "Oh, we take verbals all the time."
To me, that's different. If a doctor rounds, and says, "OK, we'll recheck BMP and mag in 4 hours," I smile sweetly and say, "Will you be putting those orders in yourself, sir, or do you need me to write them for you?" We are 100% computerized order entry, and written orders are frowned upon unless they truly are from the telephone, but I don't mind if they won't be near a computer and it gets things done faster.
But I'd never dream of ordering a test without speaking to a doctor first! Luckily this will never be a problem for me; we have remote-monitored eICU at night, when I will be working, and there is always an intensivist available at the push of a button. And it's usually not a problem for her, as the usual daytime intensivist writes his own orders on the BMW in the middle of interdisciplinary rounds. But some weeks an off site intensivist is in charge.
I know I'm not crazy when I say it's wrong. But this is a judgement free zone: are there places where this is considered OK?
I think you should get familiar with your employer's P&P so you'll know what you can & cannot do. We are talking about 4 different actions here:
1) verbal/telephone order - doc verbally gives an order & co-signs or authenticates within a specified time frame - ACCEPTABLE
2) standing order - Written documentation by docs/hospital for a general order for all patients who meet specified criteria - ACCEPTABLE (e.g., All pregnant women receive a Tdap)
3) Written order - doc electronically enters an order for a service in real time ACCEPTABLE & PREFERRED
3) no order order - Nurses order services that require an MD order without an MD order - NOT ACCEPTABLE
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
3) no order order - Nurses order services that require an MD order without an MD order - NOT ACCEPTABLE
But VERY common, almost unnoticed daily occurrence is most places I have worked. Usually encouraged by the physicians with comments like "thanks for taking care of that and not waking me with it last night".
The other that you didn't mention, and that has happened to me a number of times. Order given over the phone by resident, then denied by said resident in the morning when his attending is annoyed at the resident's orders.
Right? For the most part, when I call the docs "sir/ma'am" or "Dr. ___," they respond, "Uh oh.... what'd I do?" Kinda like when your mom used your middle name when addressing you...
In most ICUs RN can put in orders for things like labs and xrays. Where I work an RN can pretty much order anything if there is an indication for it. These things should be covered in unit standing orders and policies.
If I call one of our ICU docs about (lets say) respiratory issues he is going to want to know what the ABG said, and to either have a chest xray to look at or expect that we would have already ordered it and it's on it's way.
Before I call a doc about a patient's chest pain I will of course obtain and 12 lead EKG and probably ordered, drawn and sent a troponin, depending on the circumstances.
This is very normal and perfectly legal. I wouldn't work in hospital where RNs did have that abiliety.
I'm in the ED so we've always got a doc close at hand and therefore never head down this path... but I will pull a med on override, or draw tubes, or shoot a quick EKG, or call x-ray to head our way with a portable, while waiting for the chance to get the verbal from the doc.
We'll often give nebs before we get the order, often start a bolus, or infrequently push some Zofran... kind of a gray area and very dependent on the doc and the circumstances... I've never done anything for which a doc has not immediately followed with COE orders or signed off on the hand written verbal orders.
It is actually different in critical care, and no, it's not illegal.
Like many here, I was skeptical that it was really legally acceptable to act first when necessary, and discuss with the MD later, but at least according to by state's BON surveyors, that's not only acceptable but it's their expectation of a competent critical care nurse.
All orders must be discussed and confirmed with the MD/LIP as soon as is reasonable, but are not required in some settings prior to assessments or interventions being performed. The expectation is that these are based on a thorough understanding of what the MD wants, so technically you are initiating actions in collaboration with the MD, not in the absence of the MD, which is the key difference.
There are tons of protocols in critical care but they aren't intended to cover everything, there are too many situations where protocols can't accurately take into account all the variable that a nurse's brain can. As one surveyor explained it to me; part of an ICU's protocols are in a binder, the rest are in the nurses' heads, and that's not only OK but expected.
In my experience this is different in teaching hospitals where critical care nurses don't always practice the same level of autonomy due to the prevalence of residents, but the surveyor I spoke to said the same expectations apply in either environment even if they aren't typically utilized in teaching hospitals.
I've been a nurse in the Critical Care Unit for many years and I've never put in an order without a phone call to the Intensivist to say (for example) "Your patient in room 32, Mr. Wheezy, doesn't have orders for a CXR and is vented. Do you want to put in the order, or shall I"? Quite often, I know exactly what order I will receive, so I'll save them time by asking if they want "XYZ" done or not because of "ABC". My facility is really big on Evidence Based Practice, so we have Care Bundles that we go by. (for example, Sepsis Bundle)
I realize that the onus of the patient's medical plan of care is on the Intensivists, and they realize it too. My facility is very good at having the nurses back if a physician does complain about a nurse not doing something that is not within their scope of practice to do. I've actually seen 'those' kinds of physicians quietly slip away and not come back. We are VERY lucky in the CCU where I work in that we have pro-nurse Intensivists who are respectful of the nursing staff. After having worked in this particular CCU for over five years, I can definitely say that if I was really sick, I would not want to go anywhere else.
When you call the doctor for orders, you are also notifying him of his patients change in status. You play a very dangerous game of Russian Roulette with your license if you start putting in orders on your own without the scope of practice to back those orders up. It is not what a prudent nurse does. Complacency is not your friend.
If you need any further encouragement to call for orders, I invite you to read the following article:
Mercer, S., & Tino, A. (2011). Falsifying Medical Records: A Systems Approach Investigation. Journal Of Nursing Regulation, 2(3), 41-43.
"A charge nurse in Kentucky falsified medical records by writing that she received a verbal order from a physician to administer an anxiolytic to a patient. An investigation by the board of nursing (BON) revealed that the nurse was guilty. However, the investigation also revealed that the work environment created by physicians, nurse managers, and facility managers forced nurses to falsify medical records. Because of this case, when the Kentucky BON investigates a complaint against a nurse today, it also investigates the culture in which the alleged violation took place"
"Nurses and physicians working in specialty areas can develop a high comfort level with each other's approach to care. Nurses may come to believe they know physicians' prescribing habits so well that they can write an order without talking with the physicians. Physicians can become comfortable with this practice and encourage it for convenience' sake, especially if this practice minimizes middle-of-the-night phone calls for what the physicians consider simple orders".
"A Case of Falsification
Mary Smith, BSN, RN, was working as a full-time, night-shift charge
nurse in a cardiac unit in a Kentucky hospital. One night in June of 2004, Seth Leggat, who was recovering from cardiac surgery, was becoming increasingly agitated. According to Ms. Smith, the shift was hectic, and she made many calls to Dr Jones regarding Mr Leggat and other patients. During one call about pain medicine for another patient, Dr, Jones told her to do whatever she wanted to do. During a later call, he called her "stupid and incompetent, "
She had worked with Dr. Jones for several years and knew he ordered lorazepam (Ativan) for agitated patients. Rather than make another call, she wrote a physician's order in Mr Leggat's chart for "Ativan 1 mg IV push now per verbal order from Dr Jones. " After she administered the drug, the patient's condition deteriorated, and he was transferred back to the intensive care unit.
The next morning, when Dr. Jones reviewed Mr. Leggat's chart, he emphatically stated that he had not been called for the Ativan order and he had not given the verbal order. A complaint was sent to the nurse manager, and an internal investigation began.
When questioned by hospital managers, Ms, Smith admitted that she wrote the order. However, she explained that this was common practice in the unit. According to her, everyone knew that charge nurses wrote orders for physicians and that physicians signed the orders the next morning. She said physicians often told charge nurses to make smart decisions, and the physicians would sign the orders later. She also said that nurse managers made clear that if a nurse did not do as a physician wanted--that is, avoid calls in the middle of the night--the nurse would "end up in the office. " Once, when Ms, Smith could not reach a physician for orders, she called the medical director. The next day, her nurse manager told her never to do that again,
Ms, Smith was fired, and at the hospital's direction, she reported the episode to the board of nursing (BON), The hospital filed a formal complaint with the BON, indicating that Ms. Smith was terminated for falsifying medical records and administering medication without a physician's order."
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
All orders must be discussed and confirmed with the MD/LIP as soon as is reasonable, but are not required in some settings prior to assessments or interventions being performed.
Exactly. We rapid response nurses have a policy that allows us to place any patient in restraints if they are indicated. We don't need orders to do it, but to have to notify the responsible physician and get an order from them. We just don't need to get the order prior to intervening.
As said here; there are standing protocols for ordering common needed things such as the ABG. Often standing order sets exist which make this practice ok under hospital policies. The well- seasoned and respected RN ordering in this fashion with or without standing orders probably has long-standing relationships with the physicians such that she knows what to order, why, when.
But you are new to the ICU; and usually there is a physician quite handy for whatever happens. Why not just run it by the physician first? As already said; you are notifying the physician of change as well as allowing the physician to call the shots. It is the physician who is practicing medicine. In the end, it is not the RN who ought to be practicing medicine. That is really out of her scope.
I would, as said, familiarize self completely with the order sets, hospital policies and protocols; and go from there. Sometimes it is just better to follow the rules no matter how irritating it may be to a physician or an RN. Of course in an emergent situation, an RN must do what is needed for the safety of the patient. But in reality, how necessary is it to order a KUB if there is no standing order without the physician knowing that a change is happening?
Protect your patient, protect your license. Let the physician practice medicine and let the RN practice nursing. In the ICU it is necessary to be able to think like a physician, but we still need to act like an RN; within our scope. And being new, I think it best to develop your own practice within scope and with caution.
The RNs who are always talking about how stupid, slow, inane some physicians are; and how they would make different medical decisions really bug me. What is wrong with being a nurse? If a nurse doesn't like being a nurse, then go become a physician. Oops maybe that sounded harsh.
What is wrong with, "Dr So and So, I have a feeling something is going south with Pt. So and So because of this and that, (or just because I have a gut feeling).Do you think we ought to get a KUB, blood gas, (whatever it is you think should be next)..." that shows you are thinking critically without taking the physician's job as your own.
Maybe I'm wrong. But of course in reality, if a patient is swinging, spitting, and endangering self and staff I would have no problem using soft restraints before I called the physician for an order. So there you go....grey areas. In the end...ask yourself....what would the BON do?
In the ED we enter orders all the time, based on a patient's clinical presentation, without actually talking to an MD. For example, a patient with chest pain will have labs (CBC, BMP, trop, coags), EKG, chest X-ray ordered by the RN without talking to the MD. RNs are never going to order any meds without talking to a doc, nor would the nurse order a more elaborate rad test (CT, MRI, etc.) other than an X-ray on his/her own. Another example, a woman in her 20s comes in with lower abd/pelvic pain. The RN will order a UA and a urine HCG. These orders are not entered/carried out by RNs who just want to feel special by ordering tests…they are an expectation of being a RN in our ED.
We have standing orders pre approved and signed by the doctor for each patient. We can order any lab work and any xray we think is necessary as well as giving things like Tylenol and robitussin. We write it up as a standing order, implement it, and then the doctor comes and signs it with rounds. Its just the procedure here.
mariebailey, MSN, RN
948 Posts
I think you should get familiar with your employer's P&P so you'll know what you can & cannot do. We are talking about 4 different actions here:
1) verbal/telephone order - doc verbally gives an order & co-signs or authenticates within a specified time frame - ACCEPTABLE
2) standing order - Written documentation by docs/hospital for a general order for all patients who meet specified criteria - ACCEPTABLE (e.g., All pregnant women receive a Tdap)
3) Written order - doc electronically enters an order for a service in real time ACCEPTABLE & PREFERRED
3) no order order - Nurses order services that require an MD order without an MD order - NOT ACCEPTABLE