Writing doctors orders without an actual doctors order

[Toadroad]

Hi all. So I recently started a new job in a CVICU and am wondering if it is common practice at other places to put in orders without actually getting it from the doctor? I'm new to the ICU and nurses in the unit im on write orders for the doctor all the time without actually getting them. It's one specific Ct surgeon that they do it for bc he doesn't want to be bothered. Nurses order things like abgs, bicarbonate, amiodarone, calcium, bipap, chest x-rays, haldol, and other things without calling the doctor. The doctor doesn't want to be bothered especially at night so nurses are expected to order drugs and such that we think the patient needs. I don't totally feel comfortable doing this and am wondering if this is generally what is expected of me if I work in an ICU? I had a situation last night where I called the doctor on some abnormal abg results and patient was having some respiratory distress and he got real annoyed at me and said "I can't see the patient you make the decision on whether he needs to be intubated or not". Btw im still in orientation and just wanted to get some feedback

[Medic/Nurse, BSN, RN]

This is kinda off topic - but early in my career, I was in field as a medic and I had a very severe diabetic that was obtunded with a glucose that was too low to read, 40 miles from the ED, and no way in hell to get access on her. I tried EVERYTHING. And if I can't get access, you have none. She did have a port. I had only seen done several times and had one unsuccessful attempt - did not have Huber needle and no protocol for doing it. Actually it was FORBIDDEN.

I called our hospital medical control and the doc advised to give the patient "multiple subQ injections of D50".

I was sure I had a bad connection. I told him I was going to call him right back. I called state police post and asked for a recorded monitored line patched access to the physicians line at the hospital medical control - they complied (they were our dispatch agency) - I had him repeat "give the patient multiple subQ injections of D50" and "do not access the port". I replied that the patient had no subQ tissue weight under 90 pounds at 5'6" and I was unable to comply. Thank you medcontrol. We will be enroute will contact you with ETA. Have a good day.

I had given IM Glucagon earlier. It was going to be useless as she had no reserves.

Now I really owned this. We are loading & going enroute. I was going to cut O2 supply tubing and do a DL assisted confirmed NG tube and dump D50 in the gut while transporting. Her nurse sister met us 10 miles in and had equipment & the ability to access port and supplemented some D25. She was awake and intact on ED arrival. "Pulled my NG", the port access stayed. Observed for a few hours and had a meal.

I wrote up up a variance for my medical director. No big deal. NG tubes were in our protocol, though drug delivery via NG tubes was not. I ultimately had no issues. He remarked my innovative thinking may have saved the patient and was solid clinically. Sure. I was freaking desperate. Desperate does that. Death is scary.

Can anyone imagine the hell and wrath I would have likely endured if I HAD injected that girl subQ with D50? I just cannot.

The lesson.

I like RECORDED LINES. A LOT.

Recorded lines can be your friend.

Should hospitals used RECORDED LINES for ORDERS? I think it would stop a lot of NONSENSE.

When you call a doc for orders you call on the "doc order line" - easy peasy?

:angel:

[jennycRN]

I have worked night shift most of my career and do not "just have an understanding" with any provider. Who will have your back if you take an action outside your scope of practice and there is an adverse outcome?

[mmutk, BSN, RN, EMT-I]

This is common practice for the ICUs. When I was an ER nurse this was less common but still came up on occasion. It absolutely can bite you in the a$$ if you do something wrong. However, it is going to continue because the MD isn't there all the time. Certainly protocols would be better in these situations, but

I have never worked in an ICU that did that.

You will have to ask the more experienced nurses for help until you figure out what the MDs expect. Once you get more comfortable you will feel better being the Doctor for the patient. I'm not saying it's right, all I'm saying is it's going to happen anyways.

[CCU BSN RN]

Ask your charge nurse or a more experienced nurse to put in the orders for you or call the doc yourself until/unless you feel comfortable.

We always have a provider in house, on the floor for our CVICU patients, but I've worked jobs with understandings like this.

It's very difficult as a new-grad or new to ICU nurse to know when this is appropriate vs. inappropriate and when it will get you in serious trouble. Hence, use someone else as a resource or call the MD directly. I know it's tough with short staffing, etc. and you don't want to rock the boat or get your colleagues in trouble by reporting that they're 'practicing medicine without a license' and I'm not necessarily suggesting that you do that. Just tread VERY carefully here, please.

[cindyz01, ADN, RN]

In every hospital there's an administrative entity to which every doctor has to report to. Learn your chain of command. BUT! Do your homework before escalating the situation. Everything you learned in nursing school applies respectively as needed. You are no longer a student, you are now a nurse, and you know the boundaries that come with that. No matter what, remember your best friend and the right answer always involves PATIENT's SAFETY. Even if another nurse offers to enter the orders for you. I would definitely recommend that you protect your parents and opt for the "right thing to do"

I'm an ICU nurse too, and In my hospital we do have an option called "Z" order which is same as "in patient plan of care" That's used to order little things like if the MD ordered tube feeds, then I use the "Z" option to order a feeding pump. If I get an order to insert an NG tube, I order an x-ray under "Z" option to verify placement. I'm sure the provider wants placement to be verified prior to it being used.

Read your policies, and ask questions while you're still "new".

[RNHeartNurse]

I work in a CVICU. We have a lot of standing orders. They include drawing labs, ABGs, ordering chest x-rays, initiating temporary pacemakers, placing orders for certain meds (insulin drips, amino drips etc) and more. However, it is still expected that results and changes in condition be reported to providers. Some of these standing orders include notifying the physician after 7am if they are initiated. This way nurses are covered, and physicians are generally happy.

[RN-SKR]

Unless you have specific protocols for those medications that you can start within your practice, I wouldn't do it and would be calling the MD too!

I think that is very unprofessional of that MD!

Just always remember document what you did, like calling the MD to update about the situation, and their response to the situation. They will not protect you if something were to happen, so ALWAYS document!

[elkpark]

As already noted, it is entirely possible and common to have written, approved (by the medical staff) protocols and standing orders and legitimately work from those, but I would never be willing to make any decisions, place any orders, or administer any medications outside the scope of my practice on the basis of an "understanding" with one or more physicians, no matter how well the physicians and I know each other. Without some formal protocol or standing order set, you are simply practicing outside your scope, practicing medicine without a license, end of story. If something goes wrong, I am not willing to depend on a physician to take a fall to protect me.

Getting called at all hours and getting "bothered" by the nurses is what the ICU physicians signed up for when they chose to specialize in critical care. If they find it unacceptable, maybe they should change specialties. I hear dermatologists rarely have off hours problems to deal with.

[Amplifyd]

Certain groups at our hospital have ICU protocols for things like replacing electrolytes In a patient with good renal function. However I never place any order outside of a protocol without directly talking to a provider even when I worked night shift. The provider will get over waking up, but I'm not losing my license over someone else's sleep or even worse cause patient harm by prescribing a medication I have no right to order. I know it is difficult not to rock the boat, but you have to be safe with your patients

[delphine22]

Getting called at all hours and getting "bothered" by the nurses is what the ICU physicians signed up for when they chose to specialize in critical care. If they find it unacceptable, maybe they should change specialties. I hear dermatologists rarely have off hours problems to deal with.

I say this all the time. If they don't like it, don't go to medical school and don't be on call. I'm not the doctor. I worked in an ICU at night where if the pt came up vented from the ED we'd write our own sedation orders before the pulmonologist saw them in the AM. I wasn't comfortable writing for propofol or fentanyl on my own BECAUSE I'M NOT A DOCTOR. I always called, or my charge would call for me and write the order under his name. One time a nurse did it and the doc came in the morning and said "I didn't want fentanyl." He didn't push the issue -- but what if he had?

[JellyDonut]

Way back in the olden days when i was an ICU nurse we commonly wrote orders for certain providers daily. This was back when paper charting was all the rage (LOL). it was how I learned the ropes in the ICU and I worked with very experienced nurses. Often the surgeons would leave and yell out verbal orders along with, "and whatever else you think they need". Our open heart standing orders had at the end, "or whatever else the RN deems necessary". Those were different times back then.

Years later I move and work for a teaching facility where you did nothing without a physician order. I found it frustrating and honestly felt it sometimes got in the way of caring for the patient. I remember a patient desaturating and I started bagging the patient and performing some deep suctioning. I was later reprimanded for not calling a rapid response as nurses cannot determine the proper treatment for saturations under 90%. In reality they wanted the residents to handle these type of situations.

in the end I think it was my frustration with the restrictions that pushed me to get out of nursing and reach for new goals.