are you required to call DON first before calling MD?

jjjoy, LPN · Sep 17, 2008

As others have noted, if it's an emergent crisis, do what you need to do to keep the patient safe and alive! Time is of the essence!

But there are also cases, where, as other noted, it wouldn't hurt to call the DON before calling the MD or paramedics. It could just take a few minutes and you could consider a consultation as opposed to an approval. That is, it's a little extra input for you to make your decision with, but if you disagree with the DON about what to do, you do what you need to do to keep the patient safe. And if you can't get hold of the DON, well, you need to move forward as patient need dictates and not just wait around several hours for a call back.

For some nurses, it would be a blessing to have a DON who was willing to help out with these decisions because they might not have enough experience with making the call about sending a patient out or not and having the DON willing and available to check in with before making a decision would be a good thing. For you, it might be less useful, but if there's time, why not just give her a heads up and get her input before making the call?

If after talking with the DON about the situation and the available options, you still want to send the patient out, do you think the DON would seriously override your decision? If she would, you might not want to continue to work under that person. Otherwise, the DON should thank you for checking in with her and let you continue with your own decision making about the patient's care.

pielęgniarka, RN · Sep 17, 2008

For a while at my facility, we were going by this pretty religiously: If resident is a DNR, we're supposed call the family or POA to see if they would like the resident sent out or if they would like us to call the MD for orders and keep the resident in house to treat. If family cannot be notified call the MD directly. Anyone else do it this way?

Often they [MD] will state to not send the res in, othertimes they will give the ok. One night shift I had a DNR with large, I mean multiple LARGE coffee ground emesis. Stunk terrible like those GI Bleeds. Called res. son as res was post stroke and unable to speak, residents son stated the res. would not like to go back to the hospital, so I called the MD to cover my butt and he gave orders to just monitor per son's wishes and contact primary MD in the AM. Primary MD in the morning set up hospice.

Most of the time the floor nurses or charge nurse calls the MD themselves for order to send to ER and the DON can get the information when she gets back in-- Unless it was something really dramatic she'd be contacted quickly. The nurse should really do a good assessment before calling the doctor, it's just lazy to not do so.

Like another post mentioned, it could be the docs are complaining about too many calls, but -- They are getting paid to be on call and assist us with our fragile geriatric populations!! On the other hand, it could be the family that is complaining about 2000 dollar ambulance rides and then hospital bills when sometimes it can be handled in house using E-kit meds.

Sara

CoffeeRTC, BSN, RN · Sep 17, 2008

This comes up every so often at my facility. The problem is lack of critical thinking. SRSLY, for the most part alot of what is sent out to the ER could be taken care of at the LTC. Labs? xray? EKG? Dopplers? IVs? Yeah...we can do that inhouse BUT....if it needs to be done today or right now, maybe not. See that is the critical thinking that is lacking. Most of our docs realize this, but it is the on calls that we don't. yeah...I resent the fact that some DONs will insist upon the call first, but I do see where they are coming from. I think it is an excellent resourse to have (bounce an idea off of another nurse) but to be honest, if it is something that I feel (and the doc and family or resident) needs to be checked out at the hospital....I'm gonna send first and then call.

noc4senuf · Sep 18, 2008

I am a DON and am on-call each night through the work week and rotate call on the weekends. I receive a call from one of my nurses maybe once a month and it is usually something about other staff and not the residents. My nurse handle things very well on when to call doctors and I do not profess to know more than a doctor. IF a nurse questions whetherto take action, then they talk to the in-house charge and a decision is made amongst themselves.

CapeCodMermaid, RN · Sep 20, 2008

This post brings up several issues.

You are responsible for your actions. If it were my patient I wouldn't leave it to a supervisor to decide whether or not the patient needed to be sent out. Certainly nothing wrong with getting a second opinion but it's still your responsibility.

I don't expect the nurses to call me before sending a patient out to the hospital. If I am in the building most of the time they call me to let me know what's going on. And, yes, I have over ridden doctors when they say don't send the person. If I think the patient needs to go, they go. The regulation is clear that in an emergency, a person with sufficient skills and knowledge does not have to wait for an MD order to send in an emergency. The staff nurses most likely wouldn't do that, but the docs know me and trust my judgment because I am there.

On the flip side, there are many times that the patient is better served by being treated at the SNF. It has nothing to do with census. If you read the latest studies on elderly nursing home patients being sent to the hospital, you will learn that sometimes it is more detrimental overall for the patient. Most of the time they are seen by ER docs first who have not as much knowledge and experience dealing with old people. Many times they come back worse than when they went.

This is the reason why assessment skills are critical in long term care. We have to rely on ourselves and our co-workers...not the docs. Assessing your patient and being able to communicate the issues to any doc whether it's the PCP or some covering doc who has never laid eyes on the resident is crucial.

LesMonsterRN, ADN, RN · Sep 23, 2008

As others have noted, if it's an emergent crisis, do what you need to do to keep the patient safe and alive! Time is of the essence!
But there are also cases, where, as other noted, it wouldn't hurt to call the DON before calling the MD or paramedics. It could just take a few minutes and you could consider a consultation as opposed to an approval. That is, it's a little extra input for you to make your decision with, but if you disagree with the DON about what to do, you do what you need to do to keep the patient safe. And if you can't get hold of the DON, well, you need to move forward as patient need dictates and not just wait around several hours for a call back.
For some nurses, it would be a blessing to have a DON who was willing to help out with these decisions because they might not have enough experience with making the call about sending a patient out or not and having the DON willing and available to check in with before making a decision would be a good thing. For you, it might be less useful, but if there's time, why not just give her a heads up and get her input before making the call?

I agree with all of this. :nurse: In my facility we are asked to call the DON if we're unsure about a decision or need additional guidance but we're not taken to task if we're sure of what we're doing and call the doc before we call the DON.

fallinnstyle · Nov 23, 2009

Am reviving this thread because this issue is stressing the heck out of me.

A new policy at work is that we have to call the unit manager before calling the MD to notify of change in condition. I mean I work nocs and we have a house supervisor (whose job I thought was to be the go-to person for extra assessment opinion). But,,,,even if the patient is O2 sating @65% on O2, or bleeding out, we still have call the unit manager BEFORE notifying the MD,,,coz they may say send them out to the hospital .......and we all know that would not be financially appropriate......

I mean,,,,how would I go about explaining to the BON that @ 0140, I noted the pt laying on a large amount of blood and actively bleeding, called unit manager @0142 no answer but left msg call me back STAT, notified my supervisor @0143 who was there by 0145 and agreed with my assessment that the pt needed to get to the hospital and that the MD should be notified.....But wait! the unit manager hasn't called me back and the supervisor is already in trouble for allowing another nurse to call the MD the other night coz her nursing assessment indicated that action. @0200 with the unit manager still not calling back, I say screw it and call the MD on call who ofcourse says send the pt out to the ER.

I mean,,,,who am I trying to take care of?? the patient or the management????? Will the BON look at my license and say, oh but you were just doing what the facility asked you to do......even though it meant disregarding all my experience and assessment skills, and those of the supervisor and,,,,my patient advocate duty to the patient.

I understand the facility not wanting to get billed for stuff like labs that really could have been drawn inhouse, but for goodness sake......why would you hire me and a supervisor to be responsible for these patients? If you want this to be the policy, then there should be a person in house (meaning they can do an actual physical assessment) at all times capable of making the call the MD or Not decision and be willing to take credit for that decision in writing in the patient's chart......

Isn't this the reason we have an MD or FNP on call at all times?? they decide the medical direction of their patients,,,right?

I think my time in patient care is fast coming to an end....When I start having to justify why the full code patient that is a pretty blue color and the only thing in the crash cart is a suction machine without the required attachement and empty O2 canisters which we have requested to be filled for the last 2 months needs an ambulance ride to the ER,,,,,then I know for sure it's time to look elsewhere.

Sorry......kinda long winded. Thanks for letting me vent...

noc4senuf · Nov 23, 2009

If the person you were speaking about was a FULL CODE, then i would expect as a licensed nurse that you call the MD or NP and report your findings. There is plenty of time to notify other staff after you have got the ball rolling.

Plagueis · Nov 24, 2009

My facility doesn't have this kind of policy, thank goodness. Of course, we don't have a charge nurse, manager, or supervisor on the 3 to 11 and 11 to 7 shifts, so it's really up to us LPNs to decide whether or not to send someone out. If a facility requires notification or approval before sending someone out, then that person should be available at the facility, such as a supervisor. Why have a supervisor if the DON is the one to be making the final call on whether to send a resident out, or for other matters requiring MD notification?

indigonurse · Nov 25, 2009

To best answer this post

1)Review your nurse practice act

2) Review the state and federal regulations for the setting you are working in.

3) Review the facilities policy in regards to residents exhibiting change of condition, requiring hospitalization, etc

4) Know if your residents have advanced directives, are a full code, no code, no hospitalization, etc. before you make a decision to start CPR or send them to a hospital. That is the person who is assigned to the residents responsiblity not the DON's.

If a person who is a full Code has respiratory distress or cardiac distress, start CPR, then have someone call 911 the way you were trained to do.

There are some things that can be treated in house by calling an MD and getting an order and there are some things that are considered a life threatening emergency and 911 must be called. It sounds like the DON does not trust the judgement of their staff. If this is the case then the DON should make sure that all new hires and current employees are inserviced on this matter.

According to the federal regulations an MD must be called for any change in a residents condition. This can be done after 911 has been called, and the resident has been stabilized or sent out. You are obligated to follow the MD's orders. If the DON wants to be called first and wants to make a decision this can be intrepreted as practicing medicine without a licens on her part and gross negligence on a licensed nurses part.

I personally know of a situation where a DON had a policy to call her first before sending a resident out. An LVN noticed a resident had a low blood sugar and called 911. An RN supervisor on duty read this policy and told the LVN to cancel the 911 call and the LVN did. The resident died. Then got sent out. The department of health reviewed the death months later on a routine visit and turned the DON, RN supervisor and LVN into the board of nursing. It took about a year but the licensing board determined that the LVN who was assigned to the resident who noticed the low blood sugar, was responsiblbe for the residents death and lost her license. Why? Because the board said that the LVN was the first one to notice that there was a change in the residents condition and was responsible for doing the correct thing which was to call 911. The board further concluded that the LVN admitted in her notes that she knew about the change in the residents condition and had no proof that the RN told her to cancel the 911 call which the RN denied doing or that there was a policy to call the DON first because they had nothing written like that in the policy book. The licensing board stated that the LVN did the right thing by calling 911 first and when was allegedly told to cancel the call by the RN should have refused and should have told the RN to call and cancel the 911 call first.

It is always best to do what is right for a resident and risk loosing your job then going along with an illegal request and loosing your license.

TrickieTam · Nov 26, 2009

My last facility went to this rule after we went under new ownership and they hired a new DON. I would always call the doctor first then her, it would make her so mad. I feel like in an emergency situation I should work as quickly as possible for the safety of my resident. Forget the middle man and get me the order to ship this person out for better care. She would be the last I notified in those situations.

litbitblack, ASN, RN · Dec 4, 2009

Well are these DONS trying to micromanage. I work in a cert alz long term care and we always call the family first as we have to get thier permision to do anything. for any reason. and, isnt the pt and family charged for labs and xrays that are done even if its at the facility. So as i would be protecting my license when i am making my decision about taking care of my resident. I will page the doc first then notify DON if need be. It would be mine that got taken away not hers. I can find another job.