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.
In your situation I would document what was going on in there. I would also ask them like yesterday what would the protocol be if/when one of the other practitioners who can suture or assess more sick patients are not present?? You have to get an answer for this right away.....if they fail to reply I would have to agree with the other respondent and look for another position elsewhere. They are a law suit ready to happen. Another option is to get them to train you in the areas you lack so that you can be one of those practitioners who are more adequately trained.......I look forward to knowing how to do all of that medical stuff that is sooo my style and I have wanted to do so for many years.....
nursegirl2001
101 Posts
In your situation I would document what was going on in there. I would also ask them like yesterday what would the protocol be if/when one of the other practitioners who can suture or assess more sick patients are not present?? You have to get an answer for this right away.....if they fail to reply I would have to agree with the other respondent and look for another position elsewhere. They are a law suit ready to happen. Another option is to get them to train you in the areas you lack so that you can be one of those practitioners who are more adequately trained.......I look forward to knowing how to do all of that medical stuff that is sooo my style and I have wanted to do so for many years.....