Scary ER RNs

[applesxoranges, BSN, RN]

So this hospital is a bit different. It's not bad. It's just different. They are moving towards becoming inline with the main company's policies since they were bought out a few years ago. They do things different but they also don't have a pharmacist on after 6 pm so I can understand why they do things differently sometimes. Such as the one time I asked what do they do when they have to give more than one gram of vanco. Apparently in the ER, everyone gets 1 gram of vanco and no more. Ok... No pharmacist or pharmacist tech to mix the vanco.

Next thing I noticed is that K+ is always cosigned with another nurse. No idea. Stubborn RN said that other company's metro facilities require a cosign but I don't think they do considering I worked at the company's smaller hospital and they didn't require a cosign for potassium. No nurse in the city that I have talked to has had to cosign potassium.

They mix a lot of their drugs but the way they mix it is kind of weird. It's not wrong, it's just more old fashion compared to the way the metro mixes their antibiotics. We have bags that have adapters built in or ones that hook onto the bags and then the vials. Some medications are screw in type to the bags too. Their way is to draw it up with needle/syringe and mix it that way. Not wrong, but kinda weird and kinda risky. I've done that before where I mix my own drips (in a back of a rig) but whatever.

I've asked about things like "aren't we supposed to be using safety devices to transfer blood" which lead to nurses giving me weird looks. Last competency day, they introduced the safety devices I asked about. (One was nice because it screwed onto the end of the IV so I could draw blood that way instead of utilizing the syringe).

Anyway... today was sort of scary. Basically they moved an antibiotic policy to be inline with metro's policy. Two nurses were questioning it and I said 30 minutes whereas they were thinking 3-4 hours (which is the floor length usually). I told them I am pretty sure it is 30 minutes. They are fussing around with books and I said look online for the policy since I know the rural hospital posts their policies online because I've seen them when searching for a metro policy the other day regarding some med.

I find the policy. It is word from word from metro policy except metro was dated over a year ago (shortly after the shortage ended) and the rural was a few weeks ago.

Sure enough it was 30 minutes with a slightly different loading dose. I print it off and tell the RN that I found the policy online and it's 30 minutes. Her response, "No."

How scary is that?

[Lev, MSN, RN, NP]

I think practices vary from hospital to hospital. I can speak for my ER.

I think a gram of vanc is a pretty typical dose. Sometimes I see 1.2 g but usually the patients just get a gram.

I have never cosigned potassium...but I can understand why they cosign it.

We also mix our drips (that we don't stock premixed in the pyxis and when pharmacy is slow) with a needle and syringe. The antibiotics are either premixed by pharmacy or for common ones like rocephin or zosyn (stocked in the pyxis) we use the 50 or 100ml saline bags with adapters to spike the vial of powdered antibiotic.

I have seen the use of both the safety transfer device and the blunt filter needle to transfer blood from a syringe into a specimen tube.

Ok that last bit is just scary.

[akulahawkRN, ADN, RN, EMT-P]

In my ED, we don't normally co-sign potassium. In our ED, when we mix antibiotics, we use vial adapters that attach to IV bags. There are medications that we pull fluids from an IV bag and mix in a syringe and replace it into an IV bag. We have transfer devices that allow us to pull blood directly off an IV catheter directly to a blood tube, or we use a syringe with a transfer device to pull directly from an IV catheter and then put it into a blood tube. Vanco? Normally our ED gives 1 gm when we do give it. We also have other antibiotics available but when we do use Vanco, most patients get 1 gm.

That last bit isn't so much scary (they're used to doing several hours vs 30 min) than it is an entrenched mindset of "that's not the way we've always done it." It's not necessarily dangerous or scary... but it can lead to scary moments where you know the way the hospital approves things to be done and everyone else isn't aware or recognizes it.

I have had similar things happen to me, and it was only after I ended up giving a presentation about certain subjects that people have suddenly seen the light that the way things have always been done isn't always the right way or the best way to care for a patient, given the latest EBP. Now these same nurses that directed me to do things because they thought they were right are now coming to me for advice for how to care for certain kinds of patients and our patients seem to be getting better care for it!

Hang in there, you're at the bleeding edge of changing local practice and they're just resistant to change.

[applesxoranges, BSN, RN]

One hospital recently realized that the ER providers were not calculating an adequate dosage of vanco so it is a pharmacy calculated dose now. We frequently see 1.5, 2, 1.75, etc. i think the pump has ten different doses we can select. It's just weird that they do 1 g fits all when clearly that guy that weighs 350 pounds will not get the same dosage as the guy that weigh 150. So I understand for a facility lacking a pharmacist 24 hours a day why they do it that way.

The scary part is saying no when I found the policy and printed it for her because they were freaking out about it. Saying no doesn't negate policy...

Oh and another one was sepsis protocol. We had the protocol and education 1 year ago. I mentioned that there should be a protocol a dozen times. They acted like I was crazy. Protocol just rolled out for them (hence the headache of which doI hang first).

If she said ok or anything else, I wouldn't have questioned her as a nurse. The "no" scares me. I told my significant other that he shouldn't go there unless he was dying because if he was dying they would ship him

[Emergent, RN]

I gather from your post that you are working in a small hospital that got bought into a bigger hospital chain. There are 2 ER nurses that are used to doing things the way they always were done. You are the newcomer and are used to the hospital chain's policies, so you're trying to educate these old dinosaurs by looking up policies and handing them to the nurses, pointing out how wrong they are?

Good luck with that. I predict you won't get voted most liked nurse.

You keep saying you are scared, that this is so scary! I say, be brave, you can do it, there's no monster behind the door!

[applesxoranges, BSN, RN]

Eh, I don't really care if I get voted most liked nurse or not. It's a job as far as I am concerned. I wouldn't call them old since one is in their high 30s to low 40s and the other one I would put at around 25.

They brought up the policy and were freaking out about it. I happened to know what is standard for the metro and apparently now standard for the rural division. The level of anxiety about it was kind of ridiculous since I would have probably gone off of what pharmacy programs into the pumps since each facility can change the pumps.