They want us to give drip meds on med/surg

[bindikwan]

Hello fellow nurses,

I need your input! I work for a large hospital system in Texas. Recently management rolled out a class that is mandatory for all nurses. It's called "Advancing Acute Care Nursing" and this class entails is teaching how to titrate drip medications that are typically reserved for IMU/ICU. Some of the medications include Diltiazem, Epinephrine, Lidocaine , Vasopressin etc.

Here is the issue, after this class we will be expected to start these medications on med/surg floors. Management is pushing for this because "we cannot delay patient care". Of course this comes with huge issues, which we have brought up to management. Is our patient to nurse ratio going to change if we are expected to do this? These drugs require much closer monitoring so are we expected to do this with 5-6 patients as it is currently? Management has given us no clear answer about this and has made statements such as, "well you're nurses, you can't hang a medication when it's ordered?" And specifically regarding the concern with the amount of patients we take now and how are we supposed to do this with patient's who need much closer monitoring while on these drips, management has told us that, "Other hospitals are also doing this". This doesn't make me feel any better but I want to know if this is indeed true. Is this a new thing at your hospital on the med/surg floors? I would love to hear back specifically from med/surg nurses in Texas.

In talking to my nurse friends from other states they have all said no, it's not a thing. Thanks in advance guys! Appreciate you!

[JKL33]

Can't comment much on the issue at hand except to say that there is nothing you can say that is going to change their minds about this.

Classic:

- Pretend it's about safety ("care delay")

- But don't actually plan to staff for safety

When opposition voiced:

- Insult everyone, then

- "Everyone else is doing it"

??‍♀️

I mean, this is written down in a book somewhere that lots of people seem to have read.

You'll have to make a choice, accept it or don't. They don't care which you choose.

[Kallie3006, ADN]

I have worked where we could start Cardizem gtt on the unit but could not go over 10mg/hr, we also did heparin and argatroban gtt with titrations. I have not ever worked where we could initiate epi, pressors, insulin, etc on the floor. That was one hospital in Texas.

Another we could not even do a Cardizem push on the floor those patients needed to be on PCU, HVU or ICU no exception.

I understand the need to keep from delaying the patient's care however I have also noticed that there are no qualms on transferring the patient when they need a medication that by policy you cannot give on that floor. I have not witnessed delaying their care just because the need to transfer is there. I have witnessed a delay in transfer because there is not as much rush for higher level when the medication is being given on the floor thus leaving the floor nurse with 4 or 5-floor status patients and an ICU status until the transfer in fact occurs.

I do not believe that you will be able to change their minds regardless of what experiences you will find on here though, unfortunately. In theory, it sounds wonderful, the patients are being taken care of, the nurses are being trained yada yada, but who knows when the last time someone that aided with these new policies of yours, has worked the floor.

[marienm, RN, CCRN]

I work in ICU, but in my hospital a rapid-response nurse would stay with a patient when starting many of those gtts. (These are also our code-team nurses.)

I'm not trying to nitpick, because I think your concerns about monitoring/titratimg are very valid, but the gtts you list are very different. At my hospital, we don't titrate vasopressin at all. We do check vitals frequently (and maybe stop the gtt if VS are improving) , but otherwise we just change the bag when it's empty. Diltiazem is sometimes titrated by providers outside of the ICU (but definitely needs frequent vital signs while actively titrating). Epi is a third-line pressor in many cases, so unless it was started during a code I would never expect it to be started in med-surg. See what I mean? It sounds like the gtts they're proposing don't even make sense.

On the other hand, if a pt needs an epi gtt, you'd better not wait to start it! But I say that with the luxury of knowing that the RR nurse would be with the pt until the pt was transferred.

[Nurse SMS, MSN, RN]

I worked a stepdown unit with med-surg overflow and we had all those drips, as well as insulin, heparin and others. Standard patient assignment was 5. It sounds like they are transitioning you into a stepdown unit.

[NurseKatie08, MSN]

I'm on a med/surg transplant floor & there are multiple drips that we initiate or titrate. We do insulin, heparin, argatroban, bivilarudin, diltiazem, amiodarone, lasix, bumex, lidocaine for pain mgmt, epidurals for pain mgmt, morphine & dilaudid (primarily for comfort measures patients). Also one of two med/surg floors in the hospital which can take Remodulin & Flolan for pulmonary hypertension. Insulin can require q1h titration at times, and yes that's with 3-4 other patients & most of the insulin gtts are fresh liver or kidney transplant patients who are otherwise very sick/technically complex patients. Our heparin is usually q6 titration which isn't bad, argatroban & bivilarudin a little more frequent. When we get the Remodulin/Flolan patients they are usually on their chronic home dose, but transferring from their home pump to the hospital pump is scary. Yes, this is a med/surg floor, not step down!

[JKL33]

I wonder why in situations like this, admin doesn't seem to have a single forethought of making their case. You know, come with a little evidence....discuss (without insult, mockery, and derision) why the sky isn't falling. Show that there is a well-researched plan...

I don't understand why they pretend like they want educated people at the bedside (who are capable of processing some of these details). It all just seems such an utterly foolish way to approach change.

I can't believe "all my friends are doing it" is the best they can come up with - - but its usually the gist of what they end up offering in the way of evidence.

[rockchickrn, ADN]

I’m glad I’m not in med-surg anymore!

[Forest2]

On 4/18/2019 at 9:42 PM, JKL33 said:

Can't comment much on the issue at hand except to say that there is nothing you can say that is going to change their minds about this.

Classic:

- Pretend it's about safety ("care delay")

- But don't actually plan to staff for safety

When opposition voiced:

- Insult everyone, then

- "Everyone else is doing it"

??‍♀️

I mean, this is written down in a book somewhere that lots of people seem to have read.

You'll have to make a choice, accept it or don't. They don't care which you choose.

The only thing that is the same everywhere is what you have mentioned here.

[Sunshine229, ADN]

Follow up with JACHO. They don't care about your license. I worked in the ER, 4-1. Ratio. When they'd get over packed they would try and make us take a 5th pt and we would refuse. Pt safety first. No your rights and scope of practice, cause in the end they won't have your back. Been there, done that.

[OncologyCat, BSN, RN]

My employer recently allows pt on Ketamine drips to be on med-surg (they used to be transferred to step down for such a drip). Scares me a little bit but so far I think our unit doesn’t have anyone on ketamine drip yet.

We’ve been doing insulin drip and heparin drip, and morphine drip for CMOs, but any other kinds of drips pt needs to go to a higher level of care. We don’t do any cardiac drips.

[canoehead, BSN, RN]

If the drips involve titrating (and they will) the patient requires 1-1 care. It would be safer for the ICU or RR nurse to be called to the floor to start the drip while the floor nurse facilitates transfer. ICU nurses start those drips like they breathe, but a floor nurse who does it once a year might take 15-20 minutes to get it made up and do it safely.

Once they get you starting those drips, don't be the slightest bit surprised to find they want you to keep the patients.