Which to follow: MD or Policy?

[Angeljho]

I work part time at an LTC facility. We have a clear policy that states when a patient is transferred to the hospital and stays out of our facility for more than 24 hours, the orders at our facility must be discontinued and new orders written. A returning patient happened to come back on the 25^th hour. The charge nurse told me that the MD didn't want to be bothered with discontinuing and writing new orders since the patient returned just an hour outside of the 24 hour window. She then said she's just going to follow the MDs old/current orders because that's what the MD instructed, and she didn't want to bother herself with transcribing the same exact orders.

Would you follow the policy (which could use some revising IMO) or just follow the MDs current orders?

[Angeljho, MSN, NP]

From what I understand of OP's post there's a policy in place that states that the physician first has to discontinue the old order and then write a new one and this apparently hadn't been done. Seems like a cumbersome policy to me and amending it seems like a good idea. It does seem to give both the nurses and the providers headaches

Yes, the policy definitely needs revising. MD orders to "continue previous meds" or "resume all meds" cannot be written at this facility. The pharmacy would call in a heartbeat. Even for internal transfers between units, the orders must be discontinued completely and then re-written even if no changes were made.

[BostonFNP, APRN]

It's a pretty common policy that all orders must be reviewed by the MD before being continued whenever a change in the level of care occurs. Just writing "continue previous orders" doesn't do anything to confirm that the MD has reviewed the orders. The reason for this is that it's not hard to find examples of a patient continuing on a med that they shouldn't continue on, for instance if they're sent out from the nursing home to the hospital, where it's found they have a subdural hematoma, then they go back to the nursing home and MD writes "continue previous orders" which included coumadin. The best way to ensure the MD is aware of the coumadin and making a conscious decision about continuing or D/C'ing it is to review and reorder all the meds individually.

Do your hospitals not require the discharging provider to reconcile all medications?

If the provider then calls with a verbal order to continue those medications and the RN chooses to not follow those orders due to policy doesn't that:

1. Put patient at risk for the sake of policy.

2. Put the RN at risk rather than the provider.

Something similar, yet opposite to the scenario you described, happened recently with a patient I was involved in care of recently. The nursing home did not restart a patient on a BB and VKA after an aborted procedure for which they were held, in spite of orders for the attending provider, and the patient had a CVA.

Bad things can happen on both sides.

Sent from my iPhone.

[dudette10, MSN, RN]

Do your hospitals not require the discharging provider to reconcile all medications?

If the provider then calls with a verbal order to continue those medications and the RN chooses to not follow those orders due to policy doesn't that:

1. Put patient at risk for the sake of policy.

2. Put the RN at risk rather than the provider.

Something similar, yet opposite to the scenario you described, happened recently with a patient I was involved in care of recently. The nursing home did not restart a patient on a BB and VKA after an aborted procedure for which they were held, in spite of orders for the attending provider, and the patient had a CVA.

Bad things can happen on both sides.

Sent from my iPhone.

Yes, that's the part that was missed from this scenario. After discharge, I wouldn't just take a "resume previous meds" order because that would put the pre-hospitalization meds back on the MAR. You want to put the discharge med rec on the MAR, not the PTA ones.

Which brings me to a different, but related, question. When I discharge anyone, I always put the last dose in hospital date/time, then write when the next dose should be taken for every med on the med rec. I also do that when I discharge a patient back to a nursing home, I include the discharge papers with the big packet of info that the secretary prints out, and I inform the receiving NH RN during report to look for it. I've been told at work by other nurses that they never do that. Isn't that what everyone SHOULD do?

[MPKH, BSN, RN]

Does your patient not return with transfer orders from the hospital? I work acute care and whenever we send a patient back to LTC, the doctor will write a set of transfer orders for the patient. We then fax a copy of the orders to the facility as well as give a copy of the orders to take with the patient back to the facility.

That way, all the physician back at the facility has to do is either agree or disagree with the orders, and amend them as he sees fit.

[imintrouble, BSN, RN]

After many years of worrying about whether I would be fired for making a wrong choice, I decided to err on the side least likely to cost me my job.

The MD might be livid that I bother him, but the facility can and will fire me for not following policy.

My method usually saves me a lot of "stew" time.

The MD can demand I be fired, but that outcome is less sure than a LTC and its policies.

[~PedsRN~, BSN, RN]

We have some physicians that don't like to initiate new order sets when patients are transferred, etc - and just like to assume that we will use the order sets from the floor from which they came. Well, I will not be doing vent care or lubing up eyeballs on my floor, so doc - your ICU orders don't count. If they are well enough to be out of ICU, they are well enough to NOT need those q2 neuro checks you had going when they were sedated, doc.

I will D/C inappropriate order sets in a hot second and then call the docs and be like.... Whooops! I D/Cd your ICU orders as per our policy, and just realized we don't have any general admission orders. Cna you put those in? Thanks.

[danielle2000, MSN, RN]

Policy trumps what he/she wants. It is good practice to cover thyself and follow policy considering nurses are bunt of legalities and blamed for mishaps. If something were to go wrong you best believe the chances of this doctor backing you up in a court room is nil. He/she will be saving their own ass and will proceed to throw you under the bus.

[Angeljho, MSN, NP]

Does your patient not return with transfer orders from the hospital? I work acute care and whenever we send a patient back to LTC, the doctor will write a set of transfer orders for the patient. We then fax a copy of the orders to the facility as well as give a copy of the orders to take with the patient back to the facility.

That way, all the physician back at the facility has to do is either agree or disagree with the orders, and amend them as he sees fit.

Yes, we do medication reconciliation. Usually our pharmacy is on top of things when it comes to this; but there are loopholes. When a patient is transferred to the hospital, the nurse has to fax that transfer order to the pharmacy. Once 24 hours occur, the pharmacy usually contacts us anyway and tells us that we need a D/C all meds order so they're not dispensing medication for a patient who's not present on the unit. They're usually on top of things.

The problem occurs when the transfer orders are not faxed to the pharmacy and the pharmacy doesn't know a patient is out. The orders are never D/C'd and the medication continues to get dispensed so sometimes the nurse and MD don't bother themselves when the patient returns. It was the 25th hour and patients usually return before 24 hours or way after 24 hours.

[browneyes3000]

I would follow the hospital policy.

[Angeljho, MSN, NP]

I will D/C inappropriate order sets in a hot second and then call the docs and be like.... Whooops! I D/Cd your ICU orders as per our policy, and just realized we don't have any general admission orders. Cna you put those in? Thanks.

This may be the route to take at the moment. Sadly, we have lazy MDs (what facility doesn't); so the way I see it, if a nurse D/C's everything, they'll be backed by the policy and the MD HAS to write new orders. Usually when the patient returns and we realize the orders were never D/C'd, we try to get the MD to D/C all orders right away, review the hospital info, reconcile the meds, and order new meds (whether there are changes or not). However, the ones who complain "unnecessary work" gives us a hard time.

[bell1962]

He really doesn't need to rewrite the orders. He could just give an order to resume all previous meds.

Exactly what I was going to say..

[Mr. Murse]

To me, it would depend on the doctor and your workplace in general. On the floors I've worked, we've had certain doctors that I knew liked things done a certain way and barring any contraindications, I knew I could take certain liberties with their orders because I had worked with them long enough to know the way they liked things.

In the OP's case, if the doctor seeing the patient had actually told me verbally in advance just to continue the old orders when the patient arrived, then I would have had no problems entering the orders under their name.

On the other hand, if the charge nurse had just told me "don't bother the doctor, just put in the old orders" and I had personally not known whether or not that's what the doctor wanted (especially considering the patient had been to the hospital and their condition may have changed), then I would have called to verify with the doctor. For time's sake, I probably would have even suggested we just continue the old orders, but to cover my butt I would have verified with them first.