I work nights on a cardiac floor that of course includes lots of admits for chest pain. I often get this scenario:
Patient admitted at 1am from ED, chest pain was 10/10 on admit to ED, recieved MONA, etc, pain relieved by the time patient is admitted. So, around 3am patient experiences chest pain and what orders do we have? Tylenol. Xanax. wow. really? No nitro, no morphine, nothing?? Then I have to call the doc and get one of two scenarios:
1. Call Doc, Doc doesnt call back unless we page 3 times because they are asleep. I would be too if i were them. They proceed to order the morpine/nitro/whatever we need or ask for, no problem.
2. Call doc, doc proceeds to yell about the fact that of course he knew the patient is having chest pain, he/she admitted them and sent them up with Tylenol because it isnt cardiac pain and/or they are drug seeking.
Ugh. so here is my wish list to docs:
1. If a patient is admitted for chest pain; address it. Send a note or a message if you are unwilling to give anything for pain.
2. If you are willing to give pain meds and you have a patient admitted with pain, ORDER PAIN MEDS!!! You took the effort to order basic PRN's like tylenol, just add one more on. You know people dont come to the ER for "pain" if tylenol is going to do the trick.
3. I realize that the patient is most likely not experiencing true "chest pain" after enzymes are negative and they have a clear cath. This does not mean the patient does not have pain that needs to be addressed. No, this pain wont kill them, but you dont have to ignore it, either.
4. I can spot a drug seeking patient also. I see them all the time, and the generally arent shy about what they want. ("Give me Phenergan at the same time, and fast!!")
Haha...I try to do that all the time and they never know. Our floor orders come from telephone calls (to/from the "admitting" MD) instead of the ED doctor, and if there are any orders crazy/unclear/missing/inappropriate, they're handed off for the floor nurse to take care of.
Are you saying that you don't have any orders when the patient comes to the floor, and you have to then call the admitting doc for orders? I'm not clear on what you mean here.
I realize that the process varies somewhat by institution, but this is what happens in my ED. The ED doc consults with admitting doc and cardiologist. The ED doc does the physical writing of the floor orders based on the consultation with the other docs. If anything needs to be clarified before the patient goes to the floor, it is done with the ED doc. The only time that the nurses in the ED ever contact an admitting or consulting physician is if a patient is being held in the ED after they are admitted due to lack of beds on the floor. Even then it's very rare, since our ED docs are willing to address most things that the patient might need.
As for the ED nurse, he/she should either know why orders are what they are when calling report, or be willing to find out why if there is a reasonable question by the floor nurse (I only mention "reasonable" because some floor nurses will nit-pick and question EVERYTHING until it's ridiculous...but that's another thread!). There will still be times when the pt won't have the orders that the floor nurse would prefer, but this should be the exception rather than the rule, and he/she should at least know why.
GM2RN - some hospitals, ER doesn't have to give verbal report. That's where I ran into it. ER would fax report, the ER US would call to see if we got the fax (time allowing) - and medics would just bring the patient up. No chance to even speak to the ER nurse.
Otherwise, yes just easier to get it in report before the pt gets to the floor.
Ahhhh yes...now that you mention it, I do remember this being an issue in another thread.
All I can say is that I don't think it should happen this way. We are allowed to fax report on our non-tele med/surg patients if we want to, but we are required to give verbal report on all others. Personally, I almost never fax my report unless I'm having trouble getting the receiving nurse on the phone and my patient is not complex. Honestly, I just can't conceive of doing it properly any other way.
In all 3 ERs in which I have worked, the ER MD had nothing to do with writing admission orders -- that is the responsibility of the admitting MD team.
OP, I'm kinda siding with the doc on this one. If initial workup points to a non-cardiac etiology of a patient's chest pain, I'm not sure I would want to keep medicating them with morphine. Maybe trying Tylenol first is not a bad idea.
The tendency of ERs to freely dispense IV narcotics has conditioned large segments of the population to what it feels like to have *all* pain taken away immediately (often with an accompanying buzz) and that is now their expectation of pain relief.
Why are you not addressing this when you get report from the ED?
Where I work, nurses taking report will often ask what the patient has ordered for pain. I try to remember to look at my orders before giving report and address this with the ED docs ahead of time, but sometimes I'm busy and forget, so this gives me an opportunity to get it taken care of before the pt leaves the ED.
Sometimes the reason no pain meds are ordered is because it was just overlooked by the ED doc. He is busy too, so all I need to do is ask and it's done. Or, if there is a reason that the doc doesn't want to order anything stronger than tylenol that I don't already know about, this is an opportunity to find out before the pt goes to the floor.
There might be a number of reasons why you don't have orders for pain meds, but the answer to your problem could be as simple as finding out in report.
Assuming that I am the nurse actually admitting the patient, our ED nurses dont handle admitting orders. Their job is to stabilize then ship them up or out. Our ED docs don't write orders for admitted patients. All ED orders are null and void once the patient is admitted. (God, I would LOVE to keep the ED orders...they understand the proper dose of Haldol and pain meds when needed...) The admitting docs often write orders from all over the hospital or even at home. The ED nurse often doesnt know if a patient is capable of walking or not- it isnt a priority. Our ED reports often go something like this- Did you read the ED report? Ok. we will send them up.
Altra- That is a very good point you make. The push for 100% patient satisfaction has turned patients in to monsters sometimes. I think a ginger ale should do the trick once in a while instead of pushing zofran.
Once a patient has had a clear cath, clear enzymes, normal EKG, Im ok backing off of morphine. Until then, it is my butt if I don't follow chest pain protocol or at least address it with a doc (and document!!) If I have prior notice that the doc is aware and doesn't want them to have meds, no problem- and i can push check that magical "doc aware" button in my pain charting.
Our CP admits never have orders written specifically for NTG, morphine, ASA, they are automatic per ACLS protocol which is defined as a standing protocol including metoprolol. Docs can amend the protocol by writing "Morphine only for EKG changes", "Morphine only for unrelieved CP after NTGx3", "Give GI cocktail first" etc. It's pretty rare to see morphine withheld per orders unless a patient has already been ruled out with trops or myoview/angiogram.
When I worked tele, at night at least the majority of our admitting orders are written by the ED doc. Usually when I call the admitting Doc at night they have minimal knowledge of the specific admitting orders, when I float to the ED I've overheard the calls from the ED doc to the admitting Doc and they usually are along the lines of "I want to admit so-and-so for CP rule out, EKG normal, baseline trop negative, I'm thinking a myoview in the AM", then the ED doc writes the admitting orderset. The cardiologists are more likely to see the patient in the ED and write admitting orders, although it's not all the time and when they do see the patient in the middle of the night to admit them it's usually after the patient has already arrived on the floor with orders written by the ED doc.
I've heard about faxed reports before with no phone call and it always surprises me since that is considered straightforward patient abandonment in my state, which is defined by withdrawing care for a patient who requires continuing care without confirming that the person receiving the patient has both received and understood the report.
Ask the Drs to do what our Drs do - get them to write up GTN whatever, and add something like: ONLY after patient is assessed and nurse thinks they need it. Then you can cover yourself and tell this to the patient as well. It seems to work, I actually show the patient what the Dr has written on their med chart, then if they have a problem, they can take it up with the Dr - I love saying those last few words!
Our CP admits never have orders written specifically for NTG, morphine, ASA, they are automatic per ACLS protocol which is defined as a standing protocol including metoprolol. Docs can amend the protocol by writing "Morphine only for EKG changes", "Morphine only for unrelieved CP after NTGx3", "Give GI cocktail first" etc. It's pretty rare to see morphine withheld per orders unless a patient has already been ruled out with trops or myoview/angiogram.
When I worked tele, at night at least the majority of our admitting orders are written by the ED doc. Usually when I call the admitting Doc at night they have minimal knowledge of the specific admitting orders, when I float to the ED I've overheard the calls from the ED doc to the admitting Doc and they usually are along the lines of "I want to admit so-and-so for CP rule out, EKG normal, baseline trop negative, I'm thinking a myoview in the AM", then the ED doc writes the admitting orderset. The cardiologists are more likely to see the patient in the ED and write admitting orders, although it's not all the time and when they do see the patient in the middle of the night to admit them it's usually after the patient has already arrived on the floor with orders written by the ED doc.
I've heard about faxed reports before with no phone call and it always surprises me since that is considered straightforward patient abandonment in my state, which is defined by withdrawing care for a patient who requires continuing care without confirming that the person receiving the patient has both received and understood the report.
That's basically the way it works in my ED too, although it's actually pretty rare for the cardiologist to see our patients in the ED, especially on nights. I've only seen it happe twice in the two years I've been with that hospital. Both were very unstable patients and both happened to be within the past three weeks or so.
In all 3 ERs in which I have worked, the ER MD had nothing to do with writing admission orders -- that is the responsibility of the admitting MD team.
OP, I'm kinda siding with the doc on this one. If initial workup points to a non-cardiac etiology of a patient's chest pain, I'm not sure I would want to keep medicating them with morphine. Maybe trying Tylenol first is not a bad idea.
The tendency of ERs to freely dispense IV narcotics has conditioned large segments of the population to what it feels like to have *all* pain taken away immediately (often with an accompanying buzz) and that is now their expectation of pain relief.
Yeah, I have to kind of agree with that last part. I've taken to discussing this with patients very early on in their treatment so they know not to expect that they will be 100% pain free 100% of the time, but instead have realistic expectations of their pain being at a "manageable" level. Not that we don't hope for them to be totally pain free while giving safe doses of meds, but just so they know that it may not be possible since some people don't respond as well as others to medication.
GM2RN
1,850 Posts
Are you saying that you don't have any orders when the patient comes to the floor, and you have to then call the admitting doc for orders? I'm not clear on what you mean here.
I realize that the process varies somewhat by institution, but this is what happens in my ED. The ED doc consults with admitting doc and cardiologist. The ED doc does the physical writing of the floor orders based on the consultation with the other docs. If anything needs to be clarified before the patient goes to the floor, it is done with the ED doc. The only time that the nurses in the ED ever contact an admitting or consulting physician is if a patient is being held in the ED after they are admitted due to lack of beds on the floor. Even then it's very rare, since our ED docs are willing to address most things that the patient might need.
As for the ED nurse, he/she should either know why orders are what they are when calling report, or be willing to find out why if there is a reasonable question by the floor nurse (I only mention "reasonable" because some floor nurses will nit-pick and question EVERYTHING until it's ridiculous...but that's another thread!). There will still be times when the pt won't have the orders that the floor nurse would prefer, but this should be the exception rather than the rule, and he/she should at least know why.