Nurse refuses order....

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ranmyaku

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While on night float, I had a nurse refuse to do something that I ordered over the phone.

Basically, nurse called me, I wasn't exactly sure what to do. So I called my upper level with my plans... upper level agreed with my plan and added on an additional order... I call nurse back and she says she doesn't think thats a good idea and refused to do it.

How do you handle this?
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This is a little vague but a reasonable course of action in this situation is to verify the order with your senior. If they verify it (ie. you'd better be right) then go to the floor and write the order in the chart with instructions that if there are any questions they should call the senior or the attending. Write very legibly and include the names and numbers for the senior and attending.

If it's something that might be critically important the senior needs to get on the case immediately.
 
ranmyaku said:
While on night float, I had a nurse refuse to do something that I ordered over the phone.

Basically, nurse called me, I wasn't exactly sure what to do. So I called my upper level with my plans... upper level agreed with my plan and added on an additional order... I call nurse back and she says she doesn't think thats a good idea and refused to do it.

How do you handle this?
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Go see the patient!!!! In fact, if you aren't sure what to do with a question, before you call your upper level, GO SEE THE PATIENT.

Then, if the nurse refuses the order, pass the issue to your upper level. If the nurse won't do it for him/her, its attending time and I get the pleasure of writing up a nurse and having them all pissed at me for a while. You don't need that if you are trying to survive as an intern.

Did I mention that you need to go see the patient? Maybe, just maybe, the nurse is trying to save you from yourself and maybe she's right.
 
Saw an example of this as a med student. Pt was developing septic shock. Blood pressures were dropping and tachy. Senior wanted to run fluids as fast as possible into pt. I think 1 L/hr. Nurse said she could only do 250 cc/hr, which my senior knew was a lie. Senior goes over nurse to nursing manager to explain reasons and nurse manager agreed. Pt subsequently got the fluids. Of course, pt next day feeling better had enough energy to give us an entitlement attitude. :rolleyes:
 
ranmyaku said:
While on night float, I had a nurse refuse to do something that I ordered over the phone.

Basically, nurse called me, I wasn't exactly sure what to do. So I called my upper level with my plans... upper level agreed with my plan and added on an additional order... I call nurse back and she says she doesn't think thats a good idea and refused to do it.

How do you handle this?
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Definitely go see the patient--the nurse may change her mind if you see the patient first. Next, call your senior back and tell him/her what the nurse said, if she doesn't budge. Don't try to get involved in trying to get a nurse to do something, try to get someone else to do it and they may be able to coax her to do it. Sometimes its jsut a personality conflict where they just plain don't like you and won't do what you say. Document everything that happened in the chart. That way you're covered and you can't get in trouble. This has happened to me before. The nurse refused to give a patient morphine and this patient was fresh out of surgery. I had to document it or else I'd get in big trouble as if it were me that didn't give the morphine. It was one of those on-call in the ICU in the middle of the night scenerios.
 
call the vp of nursing at home to discuss the situation with her/him
 
ranmyaku said:
While on night float, I had a nurse refuse to do something that I ordered over the phone.

Basically, nurse called me, I wasn't exactly sure what to do. So I called my upper level with my plans... upper level agreed with my plan and added on an additional order... I call nurse back and she says she doesn't think thats a good idea and refused to do it.

How do you handle this?
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I agree. Go see the patient first, and make sure that you still want to carry out your original plan. Double-check with your senior if needed. If the nurse still refuses to carry out the order, go to the nursing supervisor and explain what you want done, and why you want it done.
 
I imagine that the nurse doesn't just choose random orders to ignore, so maybe this is an opportunity for better communication. Maybe the nurse just didn't understand the REASON for the order, and once it was explained would do it. Seems like an easier solution to talk to the nurse yourself before climbing the chain of command and involving others. (I had this happen as a medical student a few times after developing a plan with the team and then explaining it to the nurse after s/he balked at the orders.)
 
Second the suggestion above.

1. See the patient
2. See the nurse

By "See" I mean "in person", not over the phone.

See the patient first, make sure you know what is really going on. BTW, you should do this BEFORE you call your senior.

If the nurse has a problem, chances are there is something lost in the communication. See the nurse, ask review your findings and what you want to do, and ask why they disagree. Sometimes they will now agree with you (simply not having the whole story), or they will have some valid concern ("The patient has a severe allergy to PCN. Would giving them ampicillin be OK"), or they will have a completely invalid concern ("The last time I gave a patient that much fluid, they died, so it must be bad"). Regardless, it is well worth the 5 minutes of your time it takes to figure out which of these is the issue and fix it. If you don't and just try and jam it down their throat, even if you're right, you will generate the aura of a troublemaker and you will be miserable.
 
You should thank the nurse for possibly preventing you from doing something dumb. Always see the patient on night float unless it is for something trivial like ambien for sleep, or a post operative day one fever without any other symptoms. I have never had a nurse flat out refuse to do something after I've examined the patient and discussed my concerns to the nurse personally. Believe it or not, nurses are there to help patients, not just annoy doctors in the middle of the night. I'd bet that after seeing the patient and discussing the patient's care with the nurse, the conflict will be resolved. I have met some very strong willed nurses but they have all stood firm for what they believed was the right thing for the patient. Most of the time they are right, sometimes they are wrong, and that's where communication comes in. They have never just refused to do something because they didn't like me or the patient.
 
Gastrapathy said:
Go see the patient!!!! In fact, if you aren't sure what to do with a question, before you call your upper level, GO SEE THE PATIENT.

Then, if the nurse refuses the order, pass the issue to your upper level. If the nurse won't do it for him/her, its attending time and I get the pleasure of writing up a nurse and having them all pissed at me for a while. You don't need that if you are trying to survive as an intern.

Did I mention that you need to go see the patient? Maybe, just maybe, the nurse is trying to save you from yourself and maybe she's right.
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Sorry I was a little vague with the whole scenario. I did go see the patient, 2 times actually. I had the issue with the nurse after I had seen the patient... so it went like this... call from nursing -> I see patient -> give order -> tell her to call me if anything comes up again --> get another call 1 hour later -> go see patient again --> then I don't know exactly what to do --> I walk to call room where senior is sleeping and get advice (b/c senior did not answer 2 pages) --> then I call nurse with new order --> she refuses.

I was intending my question to be geared toward what to do after you have seen the patient and discussed with upper level and then the nurse still refuses the order. Though now that I read my OP I see that it sounds like I never saw the patient; however, I did see the patient personally, assess the situation, then called the upper with my ideas.
 
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ranmyaku said:
Sorry I was a little vague with the whole scenario. I did go see the patient, 2 times actually. I had the issue with the nurse after I had seen the patient... so it went like this... call from nursing -> I see patient -> give order -> tell her to call me if anything comes up again --> get another call 1 hour later -> go see patient again --> then I don't know exactly what to do --> I walk to call room where senior is sleeping and get advice (b/c senior did not answer 2 pages) --> then I call nurse with new order --> she refuses.

I was intending my question to be geared toward what to do after you have seen the patient and discussed with upper level and then the nurse still refuses the order. Though now that I read my OP I see that it sounds like I never saw the patient; however, I did see the patient personally, assess the situation, then called the upper with my ideas.
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OK, so you did assess the patient and formulate a plan, with guidance from your senior. What I would have done was to figure out the issue the nurse had with the order. If the nurse was correct, I would try to come up with a different plan. If not, then I would go to her supervisor.
 
If you had a reasonable order, verified with your senior, and discussed the plan with the nurse and the nurse still refuses, then write up a formal complaint or talk with the charge nurse.
 
Any details? Did the nurse say why he/she was refusing? We do not typically go around looking to refuse all orders. I can only think of one situation in my entire career where I refused. Did the nurse have valid concerns? I typically try to look out for my doc and have questioned simple oversites such as allergies; however, to out right refuse is rather unique?

If the nurse was being an ass to be an ass, write it up.
 
May I ask, what was the order? If a nurse refused an order, then my logical response would be to ask why. So, did the nurse tell you why?

Curious why this scenario is so vague and lacking in details.
 
ranmyaku said:
While on night float, I had a nurse refuse to do something that I ordered over the phone.

Basically, nurse called me, I wasn't exactly sure what to do. So I called my upper level with my plans... upper level agreed with my plan and added on an additional order... I call nurse back and she says she doesn't think thats a good idea and refused to do it.

How do you handle this?
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You should always see the patient if a nurse is questioning the safety of your phone orders.

I know there are interns out there who order Ativan to sedate agitated patients and then find the patients dead the following morning from respiratory failure or maybe prescribe Haldol to agitated patients with a prolonged QT interval.
 
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I think the big thing here was to find out the nurse's concerns, then explain why you feel that despite her concerns, the orders for the patient are safe and in their best interest. In the example above of a nurse refusing to run fluids at a rate of 1L/hr, it's most likely because that is well above the norm for the nurse, and she was probably concerned about fluid overloading. Educating her on the fact that 1L/hr is a correct protocol, letting her know that you realize that 1L/hr is out of the norm for her, and letting her know that this is regularly done in this particular clinical scenario and is actually shown to be the most important factor in patient outcome (well that and antibx), would probably save some time than getting into a pissing match or forcing her hand.

That said, I'm not criticizing what hte above person did in their story. You can also just talk with the nursing supervisor and explain your clinical reasoning in an expedient, polite manner as they did. But again, the big thing there isn't that they gave orders to the higher up, it's that they explained clinical reasoning to someone who was balking over a patient care issue isntead of getting into a pissing hierarchy match.
 
So, as you describe the situation, I'm not sure what I would do. It would depend on the details (and its up to you whether you wish to divulge them).

I would probably start by explaining why the patient needs the planned intervention. If that didn't work, I'd talk to the charge nurse on the floor. From there, if it isn't trivial, this kind of a situation is probably beyond what an intern should handle. Not because you aren't capable, but because the resident (and really the staff physician) are better equipped to handle the blowback.

Most of the time, when a nurse objects to an order its for a good reason.
 
Wow, I am surprised you are all talking about getting the attending involved. Where I did residency, we seldom, if ever, called an attending at home about something like this. Attendings just were not part of the decision making loop at all after hours, unless the patient was about to die, we were about to withdraw care, or a major turn for the worse such as having to send the patient to the ICU or OR in the middle of the night. So suggesting getting the attending involved might not be appropriate at his/her particular residency. It just may not be something that is done.

I'm surprised you are all saying that nurses seldom if ever refuse orders without a good reason. Actually, sometimes they do. I agree that often nurses have valid reasons for concern and can stop interns from screwing up. However, sometimes a nurse just wants to show power over the intern or just disagrees with the plan in a situation where the intern might be more right, or there might be two or more equally valid options for a treatment plan for the patient (but the one chosen is not to the nurse's liking). Some nurses also just don't like interns and feel that they don't have anything to offer to the patient care team, either because they've had bad experiences with interns in the past or because they don't really understand the medical training system and expect a month 1-3 intern to be able to function like an upper level resident or attending. I too would like to know more about the clinical situation. If you are trying to order IV fluids on a patient who looks already to be volume overloaded, then I would agree with the nurse's decision to refuse the order. However, if you just chose a different pain medication or to order a different imaging study than she/he wanted, I would probably not agree.

p.s. Your senior resident sucks. He/she should be getting out of bed to go and discuss stuff with the nurse at this point, and if you were not sure what to do, he/she should probably be going to examine the patient as well (or at least considering it). At this point in the year you are really not that experienced yet clinically...in my case I didn't feel that great being left alone on the wards until November/Decemberish of my intern year.
 
maceo said:
call the vp of nursing at home to discuss the situation with her/him
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uhhhh, okay...

hell, why not the CNO??????

next...

that's like calling the chief of police at home over a disputed traffic stop...

or like calling the medical director to help with a frequent flyer in the ED...

or like calling the president with...nevermind

Oh, and not actually speaking to the person whom you perceive to be the problem, is a typical nursing move...
 
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dragonfly99 said:
Wow, I am surprised you are all talking about getting the attending involved. Where I did residency, we seldom, if ever, called an attending at home about something like this. Attendings just were not part of the decision making loop at all after hours, unless the patient was about to die, we were about to withdraw care, or a major turn for the worse such as having to send the patient to the ICU or OR in the middle of the night. So suggesting getting the attending involved might not be appropriate at his/her particular residency. It just may not be something that is done.

I'm surprised you are all saying that nurses seldom if ever refuse orders without a good reason. Actually, sometimes they do. I agree that often nurses have valid reasons for concern and can stop interns from screwing up. However, sometimes a nurse just wants to show power over the intern or just disagrees with the plan in a situation where the intern might be more right, or there might be two or more equally valid options for a treatment plan for the patient (but the one chosen is not to the nurse's liking). Some nurses also just don't like interns and feel that they don't have anything to offer to the patient care team, either because they've had bad experiences with interns in the past or because they don't really understand the medical training system and expect a month 1-3 intern to be able to function like an upper level resident or attending. I too would like to know more about the clinical situation. If you are trying to order IV fluids on a patient who looks already to be volume overloaded, then I would agree with the nurse's decision to refuse the order. However, if you just chose a different pain medication or to order a different imaging study than she/he wanted, I would probably not agree.

p.s. Your senior resident sucks. He/she should be getting out of bed to go and discuss stuff with the nurse at this point, and if you were not sure what to do, he/she should probably be going to examine the patient as well (or at least considering it). At this point in the year you are really not that experienced yet clinically...in my case I didn't feel that great being left alone on the wards until November/Decemberish of my intern year.
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I agree with all of this. Certainly before I get the late night phone call, I would expect that the senior resident tried to fix it. And this is where some judgement is in order. If this is a serious clinical issue, I want the call. If not, we can hash it out in the am.
 
chimichanga said:
uhhhh, okay...

hell, why not the CNO??????

next...

that's like calling the chief of police at home over a disputed traffic stop...

or like calling the medical director to help with a frequent flyer in the ED...

or like calling the president with...nevermind

Oh, and not actually speaking to the person whom you perceive to be the problem, is a typical nursing move...
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you are either a master of sarcasm or don't understand sarcasm whatsoever.
 
Taurus said:
Pt was developing septic shock. Blood pressures were dropping and tachy. Senior wanted to run fluids as fast as possible into pt. I think 1 L/hr.
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For the record, programming a pump to infuse at 999 mL/hr is not "as fast as possible" or the way to get volume into a patient with septic shock. Unless there's a compelling reason not to slam the fluids in, give a bolus like you mean it. :)

Floor nurses are pansies when it comes to giving fluids and especially blood.
 
pgg said:
For the record, programming a pump to infuse at 999 mL/hr is not "as fast as possible" or the way to get volume into a patient with septic shock. Unless there's a compelling reason not to slam the fluids in, give a bolus like you mean it. :)

Floor nurses are pansies when it comes to giving fluids and especially blood.
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This is so painful. I cringe and then try not to scream when I get the page asking "Dr. Gutonc, I got an order for a bolus of 1L NS but you didn't say what rate you wanted that to go at." After 2am I've taken to answering, "if it's not at least half in by the time I hang up and walk to the patient's room I'm going to write you up for endangering patient safety."
 
gutonc said:
This is so painful. I cringe and then try not to scream when I get the page asking "Dr. Gutonc, I got an order for a bolus of 1L NS but you didn't say what rate you wanted that to go at." After 2am I've taken to answering, "if it's not at least half in by the time I hang up and walk to the patient's room I'm going to write you up for endangering patient safety."
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Universal frustration I guess. I was actually shown a floor "policy" that no bolus could be given by a nurse at a faster rate than the famous 999 when I was an intern. So I stood at the bedside, squeezed in 2 L with my Mark 1 pressure bag (hands) and left.
 
Ah, the sound of the IV pump cycling like a pissed off sewing machine - usually around 3AM. Floor call sucks.
 
Gastrapathy said:
Universal frustration I guess. I was actually shown a floor "policy" that no bolus could be given by a nurse at a faster rate than the famous 999 when I was an intern. So I stood at the bedside, squeezed in 2 L with my Mark 1 pressure bag (hands) and left.
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Guess they've never tossed back a pitcher of beer :D
 
Gastrapathy said:
Universal frustration I guess. I was actually shown a floor "policy" that no bolus could be given by a nurse at a faster rate than the famous 999 when I was an intern. So I stood at the bedside, squeezed in 2 L with my Mark 1 pressure bag (hands) and left.
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I'd kill for a default to 999ml/h when I ordered a bolus.

True story. I come on cross-cover @ 7p. Signout includes that "Mr. Jones is looking kind of crumpy but responded to a 1L bolus earlier. He got a 2nd L 2 hours ago." At about 8, I call the RN to find out how Mr. Jones is doing. "Well, his systolic is 75 but he's almost done with his bolus so I expect it will be better soon." I then ask what rate his "bolus" has been going at. "150ml/h" is the reply. I then noted that his maintenance fluid was running at 150 an hour. "Oh, I know, we stopped that to give him the bolus."

A little bedside visit and a demonstration of what bolus means (Mark 1 pressure bag as above) with Y-tubing going into his 20g PIV and 1 of the 3 ports of his port-a-cath. Took longer to get the tubing and plug it all in than it did (10 minutes) to push the fluid. The RN just stood there dumbfounded.
 
pgg said:
For the record, programming a pump to infuse at 999 mL/hr is not "as fast as possible" or the way to get volume into a patient with septic shock. Unless there's a compelling reason not to slam the fluids in, give a bolus like you mean it. :)

Floor nurses are pansies when it comes to giving fluids and especially blood.
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I had a nurse refuse to give a fluid bolus to a patient with SBP who was becoming septic and hypotensive, and had no urine output for the last 6 hours (had a foley in). This was at 6 am. After explaining to her why i wanted it, I then had to get my senior, and she finally agreed. An hour later still no fluid and told the nurse again. Then we were rounded with the attending, who again said to give the fluid and asked why she didnt, to which the nurse explained she thought it would all "go into his bell". Later we went back to see it "bolusing in" at a whopping rate of 150 cc hr.
 
docdaname said:
I had a nurse refuse to give a fluid bolus to a patient with SBP who was becoming septic and hypotensive, and had no urine output for the last 6 hours (had a foley in). This was at 6 am. After explaining to her why i wanted it, I then had to get my senior, and she finally agreed. An hour later still no fluid and told the nurse again. Then we were rounded with the attending, who again said to give the fluid and asked why she didnt, to which the nurse explained she thought it would all "go into his bell". Later we went back to see it "bolusing in" at a whopping rate of 150 cc hr.
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unbelievable....i'm glad i work in the ER where there's no confusion about how to give a bolus
 
I had a nurse once refuse to give a beta blocker that I ordered for a patient in afib, because she thought it would drop his bp too much. She said that I could give it if I wanted to, but she would not because she felt it was unsafe. So she handed me the crushed up pill and a cup of applesauce and I spooned it into the patient. Seemed pretty silly to me that she felt so strongly about it she would not give it to him, but had no problem crushing up the pill, getting me the applesauce and handing it all to me so I could give it all to him.
 
bjolly said:
I had a nurse once refuse to give a beta blocker that I ordered for a patient in afib, because she thought it would drop his bp too much. She said that I could give it if I wanted to, but she would not because she felt it was unsafe. So she handed me the crushed up pill and a cup of applesauce and I spooned it into the patient. Seemed pretty silly to me that she felt so strongly about it she would not give it to him, but had no problem crushing up the pill, getting me the applesauce and handing it all to me so I could give it all to him.
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I don't understand why nurses tend to be so afraid of losing their jobs for following doctors orders. They must have countless lectures about this in nursing school. I'm amazed at their constant fear... they are always charting this or that, typing nursing notes about the most trivial things, and saying things are either "uncomfortable" or "against policy" (which is usually just made up).

On the other hand, interns are sometimes a bit too bold...
 
Gastrapathy said:
Universal frustration I guess. I was actually shown a floor "policy" that no bolus could be given by a nurse at a faster rate than the famous 999 when I was an intern. So I stood at the bedside, squeezed in 2 L with my Mark 1 pressure bag (hands) and left.
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Can I get an amen. 999 is only 16cc/minute, I've taken to figuring out where the pressure bags are on each floor myself and doing this myself since non-ICU nurses are incapable of not using the pump.

I don't know about other hospitals, but mine has gotten the annoying habit of hiring fresh nursing grads for the ICU. Not long ago I had a pt in septic shock and after my 4th liter, I ordered another and she about **** her pants and said something about trying to drown my pt and refused and I had to hook it up myself in the unit. Granted, this was also the same new grad that gleefly proclaimed that she "had never had a vented pt" the night I tubed her pt and it took her 10 minutes to find the sux and etomidate and get it drawn up. I was thanking god for the old-timer RT who was on that night.

to the OP. If you've seen the pt and you've seen the nurse, nicely ask what her concern is, there have been times I've learned things from nurses, but if and when the nurses concerns are unfounded, take a moment to educate and ask them to carry it out again. If that doesn't work, the next step (if you're the sr) is to call the charge nurse for the floor and if that doesn't work, call the nursing supervisor. one of my classmates had a nurse refuse to give glucagon to a pt with a beta-blocker overdose before, the fallout on that one wasn't pretty the next day.
 
Interesting how concepts vary from hospital to hospital. I remember working an ER where the nurses thought bolus was analogous to pump at 999/hr. I had more than a few horrified looks when I pulled out the pressure bag. Then again, all of my patients with orders for discharge following their bolus were headed out the door well before any of my co-workers' patients.

Regarding the new grad comments; unfortunately, new nurses should not be working by themselves without proper precepting and orientation. There exists a significant delta between what is taught in nursing school and the reality of practice. Perhaps, if we focused on teaching students about cAMP, we would know that giving glucagon for a beta blocker overdose is life saving. I remember having to take over the care of a renal failure patient when one of my fellow nurses refused to give calcium chloride for his profound hyperkalemia and sine wave.

Unfortunately, it seems newly minted nurses spend less and less time learning about the pathophysiology of disease in the class room. Then again, the clinical experience for newly minted nurses appears to be lacking significantly. Perhaps this is simply specific to some areas.

Tired: The whole narcotic restriction is rather interesting to say the least. I have had more adverse reactions with morphine boluses than fentanyl boluses. You may be right, a guideline designed to keep interns up all night.
 
I had a nurse refuse to put an IV back into a 43 day old baby that was getting IV antibiotics during a 48h r/o sepsis protocol. I explained the baby needs IV antibiotics and needed to have the IV in, she just kept asking if there were PO antibiotics we could use because the baby was a hard stick. She refused to place the IV until I got the fellow involved. Then the nurse started swearing telling me again how hard a stick the baby was when I said, "I confirmed with the fellow, and we need the IV."
 
Ashers said:
I had a nurse refuse to put an IV back into a 43 day old baby that was getting IV antibiotics during a 48h r/o sepsis protocol. I explained the baby needs IV antibiotics and needed to have the IV in, she just kept asking if there were PO antibiotics we could use because the baby was a hard stick. She refused to place the IV until I got the fellow involved. Then the nurse started swearing telling me again how hard a stick the baby was when I said, "I confirmed with the fellow, and we need the IV."
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It is good to be reminded that our orders means someone else's work. In the this situations, I understand the nurse's unwillingness to put back in the IV, but most nurses will understand that the priority is the patient.

Along the same lines, I try to minimize unnecessary lab draws because sometimes it means multiple sticks for the patient. Ouch... can't imagine being a patient and getting labs drawn everyone morning at 5am.
 
Tired said:
What exactly do you "understand" about the nurse's unwillingness to replace the IV? Because from where I sit, this looks like an RN who knows she's not very good at placing IVs, and rather than ask for help from more experienced colleagues, would rather place the infant's health at risk in order to avoid embarassment.
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depends. Would you have been able to get the line with 2-3 sticks? If so, then yeah I agree with you.
 
Tired said:
An infant on a r/o sepsis protocol getting IV antibiotics . . . and you're going to judge whether or not to replace the IV by how many times you have to stick them? Scary.

You try once or twice. If you can't get it, ask someone better. If they still can't get it, call Peds Surg to do a cutdown. When they need the line, they need the line, that's all there is to it.
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not arguing whether or not IV antibx is needed as that is obvious. commenting on whether the RN is "understandable", i.e. being lazy or being practical and needing more info regarding her hesitancy to stick the kid.
 
Rendar5 said:
not arguing whether or not IV antibx is needed as that is obvious. commenting on whether the RN is "understandable", i.e. being lazy or being practical and needing more info regarding her hesitancy to stick the kid.
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When the first IV was placed, I was told it took 7 sticks and a few people tried. I know they got the IV in that night (not sure how many sticks -- wasn't told); I went off service the next day, but I do know the team added a 2nd antibiotic for further coverage.
 
Tired said:
What exactly do you "understand" about the nurse's unwillingness to replace the IV? Because from where I sit, this looks like an RN who knows she's not very good at placing IVs, and rather than ask for help from more experienced colleagues, would rather place the infant's health at risk in order to avoid embarassment.

Yes, our orders make work for ancillary staff. On the other hand, that is what they're being paid for, isn't it?
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When I say I understand, I mean I see where the nurse is coming from in terms of her unwillingness. If a nurse refuses or hesitates, then it tells me to pause a bit to try to understand the other side. I make my case to that nurse. If she refuses a second time, then on to the charge nurse. If that's a no go, then on higher up. If you have the whole nursing staff against you, something is definitely wrong with the communication or the order.

No need to act all righteous. I'm just saying that there's a lot of things we doctors order that are not always necessary as well. So, just have a little understanding. Sheesh.

BTW, I'm still curious what the original order the OP is referring to. I'm starting to think this whole scenario was made up.
 
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Tired said:
What exactly do you "understand" about the nurse's unwillingness to replace the IV? Because from where I sit, this looks like an RN who knows she's not very good at placing IVs, and rather than ask for help from more experienced colleagues, would rather place the infant's health at risk in order to avoid embarassment.

Yes, our orders make work for ancillary staff. On the other hand, that is what they're being paid for, isn't it?
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Rendar5 said:
depends. Would you have been able to get the line with 2-3 sticks? If so, then yeah I agree with you.
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Tired said:
An infant on a r/o sepsis protocol getting IV antibiotics . . . and you're going to judge whether or not to replace the IV by how many times you have to stick them? Scary.

You try once or twice. If you can't get it, ask someone better. If they still can't get it, call Peds Surg to do a cutdown. When they need the line, they need the line, that's all there is to it.
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Maybe one lesson would be for both members of this team (doc and nurse) to think a little creatively and with an eye to the specifics of a patient's clinical situation. A stable baby on a 48hr r/o sepsis admission does not need an IV. It just happens to be more convenient. Amp, Gent, and Cefotax (A&G or A&C are a typical R/OS cocktail) can all be given IM and the shortest interval they are dose is q12 for Amp and Cefotax (q24 for Gent). So if the kid is stable, q12 IM is only going to happen four times with 6 shots (can't do this with Acyclovir, unfortunately; but Acyclo isn't a standard part of a R/OS admission [yet?]). Throw in a little LMX or EMLA before the sticks and it's probably a more palatable option than a cutdown. This would require talking to the nurse (who may balk at the shots to the point where the IV becomes more reasonable sounding) and the parents. And yes, I've done stuff like this before. Got a kid (with a pissed off family) home without a PICC because they were willing to do IM CTX qDay at there primary's office (the family was a whole lot less pissed when they could finally go).
I'm not presenting this response to this scenario being Pollyanna. I know some nurses will just be a pill no matter what. But sometimes it really isn't that much effort to find a reasonable workaround in non-emergency situations if people are willing to talk it out and think a little outside of the "norm".
 
Tired said:
Hospitalized patients need an IV, period.
I respectfully disagree. If you said "most to nearly all hospitalized patients would likely benefit from having an IV in place" I'd be more inclined to go with you on that. However, there are few "always" (implied in your statement) or "no[ne]" in medicine. When "rules of thumb" and "guidelines" become dogma it is generally not a good thing. Evidence and individual clinical scenarios quite frequently do not bear dogma out. Medicine, fortunately, though frustratingly, is a moving target. Becoming entrenched in one way of thought is the enemy of individual growth and can, on occasion, unnecessarily complicate or compromise a patient's care.[/COLOR]

If you are finding ways to "work around" not having one, due either to parental reticence or nursing refusal to do their jobs, you are placing your patient at risk and you know it.
I know no such thing. How am I placing patients at risk? In this scenario given: the baby is in the hospital for clinical observation and parenteral antibiotics. The baby is still in the hospital receiving parenteral antibiotics being clinically monitored. You infer that I have a low index of suspicion for the potentiality of clinical deterioration in the setting. In fact, quite the opposite. I am well aware, having seen it, that even a routine rule out sepsis baby can precipitously tank. Do you think an IV will magically prevent this? The cases in which I have seen this all had IVs in place. You're hoping that an IV will allow you more rapid access for resuscitation? Okay, I buy that. But, these kids, who hopefully are caught quickly (even the routine ones need to be watched like hawks), get transferred to the PICU it even if they have an IV, they get arterial monitoring lines and usually a CVL (99% of the time placed by the pediatric intensivist/pediatrician). Acute fluid resuscitation would be the priority and if a PIV or CVL can be placed rapidly enough an IO can. The previous placement of an IV, isn't likely to have played a large role one way or the other. Going back earlier to the point where I would have been discussing the options of replacing an IV or going down the IM route with the nurse and parents (it wouldn't do IM only for the nurse's wishes; the parents would have to be requesting it as well) I would treat it like any other situation in which to obtain "informed consent". Indications (continued antibiotic administration), anticipated benefits (possibly less painful), anticipated risks (possibly more painful, risk of clinical deterioration and need for rapid infusion fluids which might require an IO in an emergency), alternatives (place an IV). etc. Just the discussion may bring the parents/nurse around to wanting an IV. But what if they don't? Are you going to call CPS, FAP, the parent's command (for the military folk) just to get the IV when there is a reasonable alternative (based on the dogma that "all patients in the hospital need an IV, period")? As your career progresses you are going to be faced with patients and families who are going to question what you want to do and why you want to do it. It is physician arrogance to think that they will never be right and the physician's judgment will never be wrong. Sometimes a suspicious family member has saved a patient's life in the face of an incorrect doctor. Sometimes it has just spared a patient pain by forcing consideration of alternatives.
And for the occasional clinically stable (i.e. expected to go home in 48 hours) baby who noone, not even the NICU nurses, can get a peripheral IV, are you going to call the surgeon for a cutdown? My guess would be that the surgeon would be reticent. [/COLOR]

Suppose the patient actually *is* septic (an uncommon scenario in "rule out sepsis", I know), do you really want to be trying to get that line as the infant clinically decompensates? I spend enough time with the Pediatric Surgeons to know how well that works out.
I addressed this above.[/COLOR]

Basically, you are treating a routine admission like a routine admission, which I know is common. But these kids are admitted precisely because there is a small but real risk that they can go bad any second. Not keeping a line placed is grossly irresponsible, and something that isn't tolerated in the surgical fields where I have been.
I will reiterate that regardless of whether the child has an IV for antibiotics or is getting them IM, they need to be monitored very closely. It should never be taken for granted that they are just a "routine" rule out sepsis case. I think we both agree that to be cavalier in the situation is folly. But by finding a different way to do the right thing is not being cavalier. Not keeping the line in is not "grossly irresponsible" in the right clinical circumstance. There might be a slight (at most [again, in the right clinical circumstance]) increase in risk, but one that is well within the range of acceptable limits if the parents are informed and agree. I'm not a surgeon, so I don't know what is "not tolerated" in the surgical realm. But surgeons are often best at managing surgical and mixed surgical/medical problems (in peds, ex. NEC, HPS), not routine medical problems that rarely directly interface with their area of expertise. This may affect your frame of reference, though I'm always appreciative of the frame of reference their surgical colleagues bring to the table.[/COLOR]

Also, for the life of me, I cannot understand why anyone would order something they consider unnecessary.
I'm not quite sure what you meant by this, but I'll address it in the way that I think it was meant. People order procedures, tests, interventions, monitors, IVs quite frequently that they consider beneficial but aren't quite sure if they are "necessary". I'm sure you're quite acquainted with surgeons being asked to do a test/procedure at the behest of an internist or pediatrician who thought it was the right thing to do, but the surgeon did not. Sometimes we do things just to "ward off evil spirits" knowing that there's no science or evidence behind it. I agree, that few people truly order something they consider unnecessary, but we order things all time that may not be truly needed.[/COLOR]
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Just an FYI, nurses are required to have an order specifying the rate of any IV administration before giving it. It's a JCAHO requirement and yes, it can affect our jobs. Also, at least in the hospital where I work, floor nurses are truly not allowed to administer IV fluids off pump.

It doesn't always make sense, but it is what it is. When you write or verbalize an order for a bolus, specify the rate as you would for any other IV fluid administration. If a patient on the floor is critical enough that a bolus must be giving faster than 999/hr, consider a transfer to ICU. Floor nurses often have a large patient load and lack the knowledge/experience/time to handle a patient who is hemodynamically unstable.

Finally, yes, we're pretty much told in school that it's our job to keep the doctors from killing the patients. Not nearly enough time is spent on pathophysiology, and often the instructors haven't been at the bedside for more than a decade. I have lots of frustrations with nursing eduction--we'll see how successful I am in changing things. ;)
 
Tired said:
Yellow font is hard to read.
Sorry, it was dark orange and showed up on my computer fairly well. I've adjusted to a more legible color.

I have to admit, I've always appreciated your clinical input on SDN, generally find myself agreeing with you. But in this case, I just don't.
Read further, and I think you'll find that we probably agree ~95% or more. But I appreciate the sentiment and welcome back. Glad for safe returns.

I mean, really, your backup plan is to place an IO? Perhaps your hospital is different, but everywhere I have worked, IOs are rare, and so the kits to place them are hard to find. You could rely on a spinal needle I suppose, if you can find one. But all that, just because the nurse balked at putting an IV back in? Trying to get access on a hard stick is the *absolute worst* thing that you can start off a code with, and so heading it off in advance is the right thing to do.
They'll have an IO in the PICU and the ED. Now if you're in a smaller hospital with your patient on the ward and no PICU and an ED that may be poorly supplied-that's going to have to go into your risk benefit analysis for the parents. More about them later... But, the potential need for fluids without an IV in place would have to be part of that discussion.

(Order edited for flow)
n this case, we weren't talking about a family refusing, we were talking about a trained professional refusing to do his/her job. I would *never* alter the care plan because a nurse didn't want to do something. Not only does that risk your patient's welfare, but it sets a terrible precedent whereby nursing can veto physician orders. Not a good idea.
I wouldn't do it for the nurse's sake either (I think I mentioned that above). In fact quite the opposite. I too believe that it would be preferable to have the IV. 9 times out of 10, you'll be able to enlist the help of the parents in getting this done with a little time explaining your rationale. It may be made harder by the annoying nurse that has already tried to form some kind of us-against-them alliance with the parents and has set out a care plan that he or she thinks is best, but this is often overcome as well. I have fought hard for IVs and for sticks for lab tests that I thought were prudent even though I knew it caused pain. And I've done it by getting the parents on board.

I get that parents get finky about this stuff sometimes, and that there will be a small subset who are bitter that their kid is in the hospital, and view our life-saving interventions as being cruel to their precious angels.
In those cases, the best you can do is counsel them ("If you refuse the IV, that is your right, however, you should be aware that if your child's condition acutely worsens, your refusal may put their life at risk.") and try to work around it. We all deal with that. I get it.
Just remember, IVs fall out. Just because it was placed once, doesn't mean it will be there later-and you may not know it. Some piece of metal or some monitor is not a replacement for clinical accumen. So don't overemphasize their value. They are but one back up tool for your brain and your hands and nothing more.
Now as to why I went down the parents-being-involved-route: was just a reasonable intellectual avenue to explore. The nurse refusing on their own is probably fairly easily death with within the RN "chain of command" and with collaboration from the parents. Things get more challenging when the family is the one pushing the avenue of treatment/intervention that you don't want. And it their right. Have I had to threaten to call CPS to keep a rule out sepsis bay in the hospital?-yeah. But like I asked before: am I going to call CPS/FAP for an IV when there is reasonable (though maybe not my ideal) alternative-you can try, but you may not finding yourself getting far. In your career, even as a surgeon, you're going to come into situations when someone with decision-making power for the patient (or the patient themselves) is not going to agree with what you want to do even though you may passionately believe that you're right. We all need to know what the "alternatives" entail in the "informed consent" paradigm. I gave a clinical scenario. The point was to show that rigidly holding to dogma belongs in religion, not in medicine. You can hold to your beliefs to a reasonable limit, but life and circumstance may force you to become more flexible and think creatively while still being in the bounds of what is right for the patient.

I guess we're going to have to agree to disagree on this one. I have never let a patient go without IV access, and I never will.
Most likely, you will never have to. But never say never. There may be someone out there someday who has more authority than you who says otherwise. You need to be prepared for this. A "reverse-corollary" (for lack of a better phrase) will be that someday you'll have consultants recommend a treatment plan that you don't agree with even though they are the experts who know what is right. That presents an equally challenging scenario.


And BTW - I wasn't clear in the "unnecessary orders" part of my last post. I was referring to the above poster (not you) who said something to the effect that "lots of our orders aren't really that necessary." I don't write unnecessary orders. If I write for a diabetic diet, a regular diet is not an acceptable substitute. When I write for "OOB and walk in hallways tid", that's not a suggestion or request, that's part of an aggressive rehab regimen that I expect to be done. I don't write for "unnecessary orders" and anyone who does either (a) doesn't understand why they are writing for what they're writing, or (b) should seriously reconsider how they are praciticing medicine on the wards.
I don't think I disagree with that sentiment-and have found myself frustrated when my orders have been treated as suggestions as well. But I do think that we all need to be reflective of the beliefs (that often exist without evidence) that underlie some of our orders-as I outlined above
Click to expand...

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Tired said:
I mean, really, your backup plan is to place an IO? Perhaps your hospital is different, but everywhere I have worked, IOs are rare, and so the kits to place them are hard to find.
Click to expand...

IO's are the backup plan for unsuccessful IV placement x2 in PALS. Doesn't necessarily include this kid, but not as rare as you think. I've done a few in the ED and PICU, and they are easier to place than a central line.
 
Farmer Jane said:
Well, sure, when you take it out of the paragraph.
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Farmer Jane said:
It doesn't always make sense, but it is what it is. When you write or verbalize an order for a bolus, specify the rate as you would for any other IV fluid administration. If a patient on the floor is critical enough that a bolus must be giving faster than 999/hr, consider a transfer to ICU. Floor nurses often have a large patient load and lack the knowledge/experience/time to handle a patient who is hemodynamically unstable.
Click to expand...

Okay, so I put the whole paragraph back in, and it still sounds ridiculous. A patient requiring a wide open bolus of fluid does not equal a hemodynamically unstable patient.

Perhaps you meant to say a patient who does not stabilize after multiple boluses of fluid and requires pressors should be transfered to the unit?
 
tkim said:
Okay, so I put the whole paragraph back in, and it still sounds ridiculous. A patient requiring a wide open bolus of fluid does not equal a hemodynamically unstable patient.

Perhaps you meant to say a patient who does not stabilize after multiple boluses of fluid and requires pressors should be transfered to the unit?[/QUOTE]

Totally agree. If I received a call from the floor for a transfer to the unit, I would not accept the patient unless multiple boluses have been tried and failed.
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Like I said, where I work floor nurses are not allowed to give IV fluids off pump. They can give a bolus at 999, no problem. Ultimately yes, if a patient is crumping so that a bolus at 999 is truly not enough, that patient requires far more monitoring than a floor nurse can give. They may have nine other patients (I once had twelve). They may not be certified in ACLS or experienced in telemetry. That patient requires monitoring and possibly intervention not only during that time period but also afterwards, and floor nurses do not always have the ability to do that. That's why you couldn't pay me enough to go back to the floor. My patients are trainwrecks, but I only ever have one or two. :laugh:

ETA: My hospital system is implementing sepsis criteria that requires admission to ICU if a patient was hypotensive at any time. They found that when patients were hypotensive but stabilized with IV fluids, often later they crumped, triggered a Rapid Response event, and were transported to ICU in crisis.
 
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