TPA and bad outcomes

[pb57]

After giving TPA and having a bad outcome nurses often feel responsible for the outcome. Do any EDs have debriefings after these situations. Are nurses allowed to voice there concerns if they don't feel comfortable giving the med in a specific situation....are nurses allowed to share their experiences with the drug with families. As a pt advocate I want the family and pt to realize the dangers are so real, there is so little info on the dangers of TPA out their for the public to be as educated as they should.

[Altra, BSN, RN]

I have observed a bad outcome related to TPA administration. However, I have never been in a situation where I felt it was given inappropriately. Nothing in life is guaranteed.

The physicians with whom I have worked have, IMO, adequately explained the risks vs. benefits of TPA and other interventions which carry significant risk.

I personally feel it would be inappropriate to "share" another patient's outcome with a patient or family who are currently deciding on intervention options. They are better served by listening to the big picture, and the relative risks, than they are by hearing one patient's story, whether the outcome was good or bad.

[xx--RN--xx]

There are specific guidelines for TPA administration. IMO, as a patient advocate you have a responsibility to speak for the pt if someone is pushing to administer TPA outside of the recommended guidelines. Beyond that, if the pt is a candidate for TPA administration...and they understand the risks...why, as a nurse, would anyone not want give them a chance to regain some of their neurological functioning despite the risk of something like ICH?

If it were me in the bed, I'd rather risk everything taking a chance at even some recovery than live the rest of my life with something like global aphasia, loss of swallow ability, loss of function of left/right side of my body etc.

JMO

Edit to add: I don't look at it as potential harm to the pt as much as a better chance for the pt to be at a higher level of neurological functioning with the TPA as compared to not getting the TPA. Maybe I'm naive.

[pb57]

thank you all for replies, it all helps process more clearly. I have never seen it given inappropriately and I think the Drs do a great job explaining the risks/benefits, but it is difficult to not think and rethink about. Would a debriefing be beneficial?

[ann4997]

Some facilities have policies on debriefings for different kinds of "critical incidences." There is a lot of research that suggests how beneficial they can be for helping people realize their role and how to get past the distress without feelings of guilt or "if I only...Maybe if I...". Debriefings, as such, usually contain a counselor or a professional peer who can help guide the session as well as assess the need for individuals who might benefit from further counseling. If your facility doesn't offer debriefings, maybe you could look into an EAP; it sounds like you have some thoughts/feelling that you are working through and might benefit from speaking with someone. Good luck to you.

[Esme12, ASN, BSN, RN]

I think that it is the MD's responsibility to explain all aspects of an informed consent. I don't think it is the nurses responsibility to tell every "worse case senario" to every patient. I think that is a confidentiality breech besides just TMI for a patient to understand. If you have been nurse long enough you have seen plenty "worse case senario's" and we all know that we can't predict outcomes.

If I think it is inappropriately being given......I won't give the drug. I will try to have a conversation with the MD.....but if I think it is wrong.....I won't give it. They can give it themselves or find someone else. But, I have never had to refuse.

I had to have a conversation once as to why I was alarmed an cautious. I just had a really bad feeling......the MD decided to wait......If we had given th TPA for the patients heart attack they would have died from the leaking/sealed aneurysm. Sometimes it pays to listen to that little voice........

[Esme12, ASN, BSN, RN]

I think if the staff seems especially upset or disturbed or they keep taking about an incident......I will have a debriefing. Sometimes formal with gief counslers and trauma experts. Sometmes just a small group cookout and lunch. I always made sure that the staff knew I had an open door at ALL times for ANY reason.......even just if they needed a hug......:)

[SilentfadesRPA]

you wrote "After giving TPA and having a bad outcome nurses often feel responsible for the outcome."

my question is why would anyone feel responsible for the outcome ? I have had terrible traumas and horrific situations from patients who were infants on up - I have felt sad / cried / wished things had been different and been very empathic with friends and family.

But in all honesty, I have never felt responsible at all for any of the outcomes that have happened nor felt coworkers were responsible.

Perhaps I am not understanding the word "responsible" or it is just a syntax thing ? I take the word as though I had personally something to do with the result ie it would be my doing or fault or my failure in doing - is that what you mean as in you or the nurses feel guilty?

I think debriefings are a great tool in ERs or ICUs where providers are exposed to horrific situations and able to express their feelings.

There is a difference in places I have worked that had debriefings them compared to those who do not use them - less turn over and more team cohesiveness .

Marc

[SilentfadesRPA]

"I think if the staff seems especially upset or disturbed or they keep taking about an incident......I will have a debriefing. Sometimes formal with grief counselors and trauma experts. Sometimes just a small group cookout and lunch. I always made sure that the staff knew I had an open door at ALL times for ANY reason.......even just if they needed a hug......:)"

You sound like your a great person to work with and for.

Marc