annoying little thing some of our docs are doing

Specialties Emergency

Published

That thing would be writing orders without seeing the patient. The doc looks at the CC and perhaps the triage note (although based on some orders, the latter does not seem like it always happens) and then write orders for it before they assess the pt. One case was a 30 something year old male with a CC of upper abd pain. Doctor orders: IV, abdominal labs, urine, cardiac monitor, chest Xray, and troponin. I go in to do my assessment (still before the doc is in there) and it turns out the guy has a hx of GERD and ran out of his PPI.

It has happened in other circumstances too. One time I thought the doc had already been in the room so I carried out the orders including starting an IV (which meant I had to explain why the doc thinks the pt needs an IV even if he hasn't evaluated the pt). While I'm in the middle of lining him, the doc comes in to the room for the first time. I finish up. As I'm leaving, the doc tells him there is nothing we can do for him since he has been seen at our ER multiple times for the same CC (another abd thing). Patient gets upset since he has been stuck for no reason for an IV that was in 5 minutes.

Docs who do this are trying to save time. Since docs are judged on their times (i.e. time it takes them to make a disposition) it makes sense. However, someone has decided to judge nurses based on customer service scores, and putting in IVs for no reason is decidedly bad for PG scores.

Anyone else deal with this?

OK, rant over...for now.

Specializes in ER.
In our ER we have chief complaint driven protocols in which we can order stuff based on the CC on behalf of the doc based on pt presentation. So often things (lab work, line, X-ray, EKG) are done before the doc sees the pt. we can also give certain Meds (ie nitro and Asa to a chest painer or nebs to a sob). If a pt is on the fence (not sure if doc is going to want full work up) we let doc see pt before we do anything. Sometimes the doc beats us to the pt but other times its a huge time saver. I don't really have a problem doing these things because honestly the lab work and X-rays and EKG are data collection that gives the doc a better idea of what's going on.

I've worked in a hospital that used those protocols, and they seemed inappropriate, perhaps it was the way my hospital used them. If we got someone co chest pain we went through the thousand dollar workup, took up a monitered bed, when in actual fact we knew theis person had severe GERD, a negative stress test within the last 6 months, and hadn't filled their PPI prescription. It was a lot more work for us, but a lot more money the hospital could justify charging insurance. Worse, the patient was scared, getting a lot of tests weekly, and all the fuss made sure they would keep coming back, just to "get checked." AND the real chest pains waited longer, we generally had 2-3 monitered beds filled with people that would be considered less acute in the other hospitals I worked in.

It was premeditated insurance fraud, but so long as everyone stuck to the party line there wasn't a way they could be prosecuted. The real loser was the patient who got stuck in the system with follow up appts and fear.

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No this isn't good practice for doctors but in the case of 'unnecessary IV placement ' tell me this ;

Scenario: 25yo male walk in to triage CC is headache with no hx of CHI and it was sudden onset...all normal diagnostics are run all are negative, after an hour pt codes....he has no IV so someone is wasting valuable time trying to place a line when he could have had one placed when he first arrived.

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Specializes in Emergency, Telemetry, Transplant.
Fine. Let them cancel them. It's still worth it for the more than 9 out of 10 orders that aren't canceled. Seriously, every who doesn't have chf or renal failure and has a blood sugar of 500 or more in triage per glucometer is getting at least a liter fluid bolus.

In the case of a critical CBG, yeah, it is a bit of a no brainer that will need line and lab. Another example would be crushing chest pain in a 60 year old. Even with a normal EKG, they will almost certainly need labs and be admitted for a stress.

But on the other hand, just this past week, pt checked in with abd pain. Triage note read "burning abd pain x2 days." Well, it turns out this person has a history of GERD, an Rx for a PPI that she, for whatever reason, does not take. She only got a GI cocktail and another Rx for Prilosec. If the doc had ordered line/lab just based on their CC, it would have lead to a waste of time and resources.

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Specializes in Emergency, Telemetry, Transplant.
Scenario: 25yo male walk in to triage CC is headache with no hx of CHI and it was sudden onset...all normal diagnostics are run all are negative, after an hour pt codes....he has no IV so someone is wasting valuable time trying to place a line when he could have had one placed when he first arrived.

This becomes a bit of a slippery slope. A 52 pt slipped while walking down stairs at home. Pt twisted his ankle. Probably just a sprain. While the the pt waits for his X-ray, should we start an IV since he has a family hx of cardiac issues? If we get into a policy of starting and IV "just in case" something happens then we might as well just have an IV nurse in triage.

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Specializes in ER.

I don't have a problem with this practice when it is utilized appropriately. If I feel it is not appropriate and the doc hasn't evaluated pt yet I will bring it to their attention. It is rarely a problem.

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Specializes in Emergency & Trauma/Adult ICU.
Are you kidding me? I hate when doctors insist on seeing patients before writing orders. All belly pains are getting protocols. Why bother waiting til they tell you about it in person? They already told the paramedic, the triage nurse, the primary nurse...it just slows everything down.

Completely disagree. SEE THE PATIENT and then use that provider status to decide what's appropriate. The belly pain that hasn't had a BM in 4 days is different than the lower abd pain/vag discharge and is different than the diverticulitis flare up ... etc.

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Specializes in Emergency.

Completely disagree. SEE THE PATIENT and then use that provider status to decide what's appropriate. The belly pain that hasn't had a BM in 4 days is different than the lower abd pain/vag discharge and is different than the diverticulitis flare up ... etc.

Altra, I'm totally with you on this one! Maybe 2 months into my orientation my preceptor left me on my own to make a coffee run. This particular morning the entire ED was swamped and we all were pretty much in the weeds. Before my preceptor left she peeked her head in a pt's room while I was starting a line to let me know that I had a new abd pain, but there was no rush. Just start acute abd protocol when I was finished what I was doing. What she failed to mention was that the pt with abd pain x3 days got dumped into the room by the triage nurse with nothing more than basic vitals because the pt had a Hx of Hep C, and she assumed that was the source of abd pain. Fast forward 15 minutes later when I first lay eyes on my new abd pain with chart in hand and happen to notice that in addition to the pt's Hx of HCV, pt was also dx'd with DM, high cholesterol, was probably a good 100 lbs overweight, not to mention schizophrenic. Despite the cc of "abd pain x3 days", that little voice in my head smelled a rat. Not only did this guy have at least 3 solid risk factors for heart disease, but his psychiatric Hx gave me great pause. So despite the fact that I had a full pt load and not a single tech or nurse was available to help, I bypassed the line and labs and did an EKG. Imagine my surprise when my newbie eyes spotted a big 'ol STEMI. I don't remember in which leads I saw it, but I just remember mumbling something like "uh oh." Worst of all, as I was getting another set of vitals and calling for the attending, his BP had gone from normotensive in triage to 70/40 and was now extremely diaphoretic. The dude was decompensating in front of me, but had arrived almost 30 minutes before!

Less than 15 minutes later I was accompanying my pt down to the cath lab. His left circumflex artery was about 75% occluded, but worst of all, his RCA was nearly 100% occluded! The interventional cardiologist actually pulled me aside after the catherization and stent placement to tell me that this man wouldn't have survived the day had his STEMI been missed! I got to talk to him as he was being wheeled into recovery. The man I first met who hadn't been making much sense which the triage nurse, my preceptor, and even his caretaker who accompanied him all chalked up to his schizophrenia, was now having a lucid conversation with me! He thanked me for believing him and not blowing him off like a lot of people had. I'll never forget that conversation!

That experience taught me the importance of assessing the patient, not the chief complaint or immediately utilizing protocols. Protocols are really important and help with flow in busy, short-staffed EDs, but they really shouldn't precede a nurses's visual assessment and clinical judgement!

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Specializes in Emergency, Telemetry, Transplant.
Maybe 2 months into my orientation my preceptor left me on my own to make a coffee run. This particular morning the entire ED was swamped and we all were pretty much in the weeds. Before my preceptor left she peeked her head in a pt's room while I was starting a line to let me know that I had a new abd pain, but there was no rush.

Good job in the situation...I think the one who really should be thanking you is your preceptor. If it had been in our ER and she had gone for a coffee run and abandoned her trainee, especially with a STEMI in progress (whether she realized that or not when she left), she would be looking for a new job.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
In our ER we have chief complaint driven protocols in which we can order stuff based on the CC on behalf of the doc based on pt presentation. So often things (lab work, line, X-ray, EKG) are done before the doc sees the pt. we can also give certain Meds (ie nitro and Asa to a chest painer or nebs to a sob). If a pt is on the fence (not sure if doc is going to want full work up) we let doc see pt before we do anything. Sometimes the doc beats us to the pt but other times its a huge time saver. I don't really have a problem doing these things because honestly the lab work and X-rays and EKG are data collection that gives the doc a better idea of what's going on.

Also it's a time saver because while you're getting the pt settled in and doing their vitals you are also doing things that you know are going to be ordered anyway thus saving you a second round with the pt.

J

I agree....I have only worked in departments that allowed nurses to, at least, partially use their brains. Based on chief complaint.......These department "protocols" only initiated by the nurse who first encounters the patient....AFTER the patient is assessed by the nurse. These protocols were disease specific and assessment specific with parameters if the "patient" looks sick with a blanket ryder at the "charge nurse/triage nurses discretion". Only experienced, trained triage nurses occupied triage. We also had protocols that empowered the nurses to set off other protocols that would include "basic" meds like ASA, ibuprofen, tylenol, nebs ets......and orders for IVF if needed (no narcs).

The triage nurse orders x-rays etc for sprains and fractures and decided whether patients were going to the main Ed or urgent care....also protocol based and if "obvious deformity" set another group of orders with IV orders and some pain control. This was in a LARGE community department that had only 16 main rooms and 12 urgent care and served over 50,000 a year or >220 in 24 hours. This was a huge time saver for the patients, it shortened ED wait times which in turn increased satisfaction. It really streamlined the process and actually dropped our overall w/u costs/expenditures.

I would go crazy in a ED that I had to mother may I for every thing I would need to do......The docs I worked with had confidence in the nurses and they were completely on board.

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No that would be unacceptable. We treat the patient based on current symptoms, not past medical history when situations like this present.

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What's the big deal? If the orders are way off base, let the doc know and verify if he/she still wants the same orders.

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Specializes in ER, progressive care.

We have care sets, where we can order labs, saline lock insertion, EKG, urine, etc based on the patient's CC, but AFTER the nurse has seen them. If a patient presents with what sounds to be a UTI, the triage nurse (or us) will go ahead and order a urine and urine HCG...if a patient presents with chest pain, I will go ahead and order a continuous cardiac monitor, saline lock insertion and routine labs. The docs are totally okay with it and most of them would rather have us order too much than order nothing at all. A lot of times if a doc orders a CBC and BMP or CMP I will go ahead and draw a rainbow, that way the doc can order additional labs if necessary and they will already be done. I love this autonomy that we have in the ER, you don't really get that on the floor.

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