So many chiefs....

[AngelfireRN, MSN, RN, APRN]

I just wonder...

All of us mid-levels at the walk-in clinic system I work in came in the other day to a nice memo..."The on-call physician MUST be called before sending a patient to the ER, due to an increase in inappropriate transfers."

Thus far, what we've been able to gather... a patient was sent to the ER for a terrible lac to her leg. She was quite elderly, and it was questionable whether or not the wound would require a dual-layered closure. Neither myself nor the other provider had ever done one, nor were we comfortable attempting to close this wound, due to circumstances. This was explained to the patient, and we did prescribe her abx for prophylaxis and call report to the ER. The ER would up doing a singl-layer closure, and we all got to hear about it.

A pregnant client presented, requesting IV fluids. She was pretty advanced in her gestation, and we have no means to monitor a fetus in clinic. She was directed to ER or to her PMD or OB, where she and the fetus could be monitored. She never signed in to be seen, one of the triage girls came back and inquired of myself and the other provider if this was a case we were comfortable with. We both agreed it was not. Somehow, my name was attached to the file, even though I never laid eyes on the patient, nor did the other provider. We were never even certain that there was an actual patient, or if it was a phone inquiry. We both assumed it was hypothetical( I know, stupid us).

A pediatric head wound presented, with a lac to the bone, right between the eyes. Out the door, due to the proximity to the eyes. This is what I was taught in school, that close to an eye, refer, do not touch. Apparently, this is not the norm, or so I have been informed. They "do them all the time". That was my call, to refer. I had no idea that the other provider/owner was versed in sewing that type wound, and he was unavailable for consult at the time.

The clinic system is owned by both NPs and MDs. The two NP owners actually work in the clinics, seeing patients with the rest of the mid-levels. They (at least one of them) are the impetus behind this new decree. We have been informed that, if there's a question, to come to one of them, and they'll show us how to do whatever it is that we're not comfortable with. The issue of what to do if they're NOT here hasn't been addressed.

So, basically, it's become a no-no to make a judgement call, based on training and experience. We're required to get permission to punt, as it were. I love this place. I LOVE this job. I also love my license.

So, my question is, when it's decided between two providers (as was every case (save one) sent out) that the best course of action is the ER, what can be done if the on-call or the owner NP insist that the patient be treated? Sure, if they're here, they can see them, but if not? I'm really afraid that one of these that "we do all the time" is going to blow up in our face, and we're going to be left holding the bag. I also fear that, after a certain number of calls to get permission, it'll escalate to "Just see whatever walks in".

I know we're in it to make money, but at 100+ patients a day, I feel that one or two sent out in the name of prudence will not make a noticeable difference.

Any advice would be appreciated. Thanks!

[traumaRUs, MSN, APRN]

Definitely a fine line. With the info you've provided, I would have done the same thing in the setting you are in - free-standing clinic.

[AngelfireRN, MSN, RN, APRN]

Thank you, trauma. With unequivocal agreement between 2 providers, I though that would be enough to justify a judgement call. Apparently we were wrong. That's why I'm so glad there are 2 of us on at all times, somebody to bounce stuff off of.

Nice to know someone else agrees. Thanks again.

[sirI, MSN, APRN, NP]

Agree, I probably would have sent to ED as well.

Do ya'll have any input on these "policies"?

[AngelfireRN, MSN, RN, APRN]

Not that I'm aware of or have been informed of. They make them, we follow them. I ran into the same problem my first week with our weight loss program. A patient did not meet the criteria to be treated, according to the printed policies given to me on my hire. I refused to dispense the medication (a controlled substance). I was read the riot act and told I should have treated her.

When I showed them the writing (set up by THEM) that backed up my decision, I was told , "Well, we always go ahead and treat." To which I very politely said that I would, as soon as the policy was changed to reflect the new dosing guidelines. Thus far, it hasn't changed, and she hasn't been treated.

[mammac5]

I agree with these decisions to send folks to the ER, given the information presented.

Kid with a head lac - goes to the ER. There's going to be one child somewhere with what appears to be a straightforward head lac that ends up having a fracture and you're going down for that one.

Pregnant lady - if you're not the OB or PCP for her, I would not touch her. Period. You're just asking for a law suit if you treat a pregnant woman that is not your patient and there is some bad outcome.

Elderly patient with leg laceration - maybe you could've handled that, but if you looked at it and made the judgement call that's it was beyond your current knowledge, skill, and experience then you did the right thing.

That deal with the weight loss medication - I personally wouldn't Rx a weight loss drug for any patient with whom I didn't have some sort of on-going relationship. If you're new to me and you want a new script for weight loss med, that is obviously not an urgent need and I want to see what else you've been doing (and are willing to do) to lose weight first. I can see Rx-ing narcs for someone who is in obvious pain with an injury, even if I don't know that patient prior to this visit. I can see Rx-ing benzos for someone who has been on them, at least to see them through temporarily so they don't go into withdrawal. Diet pills? No.

It would be great if your new employers were willing to get to know your judgement process and listen to your explanations of why you make the decisions you make, learn to trust your judgement, and allow you the freedom to practice autonomously. But reality is this may take lots of time to build that type of relationship. Try to be patient.

[AngelfireRN, MSN, RN, APRN]

I did explain my rationale, for each case. The owner/NP that is here today was just insistent that I saw the pregnant patient and refused to treat her. I maintained that it was not me, nor was it the other provider, NO ONE saw her. She was NOT triaged, was NOT seen. We never even knew that she was actually in the building.

Her response was "I'll have the OM pull that chart so you can see who it was." Fine and dandy, because I did not sign it. I texted the other provider that was with me that day, she backed me 100%, my recollection of the event was correct.

As to the others, my rationale was not enough. I should have come to one of them for direction. Except I could not. They were neither one here during the time in question.

I think the better part of this will be to just call for whatever, since there really have not been that many cases, it should not be a big bother to run it by.

Just irks me that someone with my training, to say nothing of a second provider with similar credentials, needs a permission slip to turf to the ER.

[BCgradnurse, MSN, RN, NP]

Angel,

I would have sent these patients out, too. The patients' welfare is the number one priority, and you made decisions that reflected that. It's too bad the "chiefs" don't see that.

[globalRN]

I think u were quite right to do what u did.

The office management sounds scary...like a lawsuit waiting to happen.

Time to look for another job is what I think!

I just wonder...

All of us mid-levels at the walk-in clinic system I work in came in the other day to a nice memo..."The on-call physician MUST be called before sending a patient to the ER, due to an increase in inappropriate transfers."

Thus far, what we've been able to gather... a patient was sent to the ER for a terrible lac to her leg. She was quite elderly, and it was questionable whether or not the wound would require a dual-layered closure. Neither myself nor the other provider had ever done one, nor were we comfortable attempting to close this wound, due to circumstances. This was explained to the patient, and we did prescribe her abx for prophylaxis and call report to the ER. The ER would up doing a singl-layer closure, and we all got to hear about it.

A pregnant client presented, requesting IV fluids. She was pretty advanced in her gestation, and we have no means to monitor a fetus in clinic. She was directed to ER or to her PMD or OB, where she and the fetus could be monitored. She never signed in to be seen, one of the triage girls came back and inquired of myself and the other provider if this was a case we were comfortable with. We both agreed it was not. Somehow, my name was attached to the file, even though I never laid eyes on the patient, nor did the other provider. We were never even certain that there was an actual patient, or if it was a phone inquiry. We both assumed it was hypothetical( I know, stupid us).

A pediatric head wound presented, with a lac to the bone, right between the eyes. Out the door, due to the proximity to the eyes. This is what I was taught in school, that close to an eye, refer, do not touch. Apparently, this is not the norm, or so I have been informed. They "do them all the time". That was my call, to refer. I had no idea that the other provider/owner was versed in sewing that type wound, and he was unavailable for consult at the time.

The clinic system is owned by both NPs and MDs. The two NP owners actually work in the clinics, seeing patients with the rest of the mid-levels. They (at least one of them) are the impetus behind this new decree. We have been informed that, if there's a question, to come to one of them, and they'll show us how to do whatever it is that we're not comfortable with. The issue of what to do if they're NOT here hasn't been addressed.

So, basically, it's become a no-no to make a judgement call, based on training and experience. We're required to get permission to punt, as it were. I love this place. I LOVE this job. I also love my license.

So, my question is, when it's decided between two providers (as was every case (save one) sent out) that the best course of action is the ER, what can be done if the on-call or the owner NP insist that the patient be treated? Sure, if they're here, they can see them, but if not? I'm really afraid that one of these that "we do all the time" is going to blow up in our face, and we're going to be left holding the bag. I also fear that, after a certain number of calls to get permission, it'll escalate to "Just see whatever walks in".

I know we're in it to make money, but at 100+ patients a day, I feel that one or two sent out in the name of prudence will not make a noticeable difference.

Any advice would be appreciated. Thanks!

[AngelfireRN, MSN, RN, APRN]

Well, got to test theory the other day...

Complaint of severe, sudden onset abd pain, light palpation to a certain area caused the patient to almost come off the exam table. No injury reported, nada. I ordered a KUB, but thought the patient needed a US or CT. We had no capability to do those, it was evening on a weekend, so nothing is open.

Called the on-call, who agreed wholeheartedly, and gave his consent. Moot point, because the patient refused to go. He was on our 'no control' list, meaning there's a history of something to prompt us to no longer dispense controls to him.

I'm assuming he thought the complaint would be enough to just gain a script, and he didn't count on getting a provider who was truly concerned, especially based on his reluctance to be tested (called his wife to ask if SHE thought he needed a CT! No, she wasn't medical, lol). But we all know about assumptions.

[CrunchRN, ADN, RN]

Hydrate a very pregnant lady without fetal monitoring? That is madness!

[AngelfireRN, MSN, RN, APRN]

Thank you, Crunch. We both thought so as well.