Multiple Critical Patients During Single Coverage

[engineeredout]

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And it's pretty crazy how an ICU can be run by just a PA at night who can't even do central line.

'Merica

 

[Janders]

I mean it really depends on what you consider a full sterile line. Technically you only did part of the process.
All these people saying they did it in <2 min sterile is either skipping parts or not doing it correctly. How long did you wash your hands for? Hand washing alone is supposed to take ~30-40 seconds. You also have to wait for prep to dry. And this doesn't apply for emergencies obviously, but if just for difficult IV access, aren't you supposed to get consent/explain the procedure , risk, benefit, etc for central lines?? Not sure how it works in the ED.
Also if you are using 3ml Chlorapreps to prep, you are supposed to wait 30+ seconds before draping! If you use larger chloraprep, you have to wait longer.

And it's pretty crazy how an ICU can be run by just a PA at night who can't even do central line.

Well, to clarify the specific circumstances, the PA wasn't running the ICU. He/she was the first call person for Gen Surg. Technically a hospitalist (who cannot place a CVL) was "running the unit" overnight. Said hospitalist HAD gotten consent from family for said CVL. And said PA had truly prepped the patient and let everything dry for a couple minutes while I walked upstairs. Now you are correct, i don't recall scrubbing in x 1 minute at the sink. I do recall using the hand sanitizer x 30s applied as I left the ED and again another hand sanitizer bolus as I walked into the ICU room which is down a couple halls and up a flight of stairs. So pretty damned close to a true, full sterile properly consented line!

Anyway the point of my story, which I think you are completely agreeing with, it is is very rare to put in a true sterile, consented CVL with real-time U/S in <5 minutes unless the stars and moon align and your sign is in the house of the rising sun. For me it took a PA 10 minutes of excellent prep time, probably another 5 minutes of "close" time, and another doc to get on the phone and consent the patient. And at least one RN to grab all the supplies and have the patient set up nicely. A rarity in the ED! The time from needle-to-skin to dressing-applied is the MINORITY of the time you invest in the line, unless you have excellent help.

This is opposed to a crash IO or a crash "dirty" fem line which I promise you I can get in in <1min and <2min respectively, but are plainly suboptimal for many usages.

 

[Janders]

For me The challenge is finding the sterile probe cover. It is never in the same spot and 50% of the time I end up using a sterile glove with non-sterile US gel stretched over the probe and hope it is sterile enough that the patient doesn't get an infection.

If I worked in a place where everything was set up and draped so I could stealth in and place a line in 5 min I would do a lot more of them. Sadly I never have worked at a place with that experience so I avoid lines like the plague

So we largely fixed the sterile probe cover issue by having a bucket on the back of our U/S machine which holds a couple spare U/S gel bottles and a dozen or so sterile probe covers. Granted it runes out eventually, but there is a box of sterile probe covers above the fridge in the PIXIS room so its easy to refill 😉

My issue is the current CVL comes with its own package.
Plus 3 separate IV luer lock ports in 3 separate packages (the ones in the kit aren't acceptable to the hospital, so these are added in).
Plus 3 separate sterile IV NS flush syringes, since this cannot be included in the kit.
and heaven forbid you want more than the 1mL of lidocaine they give you in the kit-- in the damned lil glass ampule made to cut your thumb!
and of course you need to get the size of gloves you want
and if you want more chlorhexidine to properly drench the skin-folds you are playing in...

Anyway I usually feel like I honestly spend more time opening packages that placing the silly line!

 

[southerndoc]

You know you guys can customize your kits, right?

We have a 3 mL vial of lidocaine, biopatch, suture materials/stat lock, and 3 10 mL sterile flushes (attached in a separate container that is attached to the tray). Like someone else mentioned, our ultrasounds have a wire basket on the back that contains sterile probe covers and gel. Literally, all that the nurse needs to grab is the ultrasound machine and a central line kit. Both are kept in the same place so they're easy to grab. We mapped out a lean process to lessen the number of steps needed for everything.

 

[Hercules]

You know you guys can customize your kits, right?

We have a 3 mL vial of lidocaine, biopatch, suture materials/stat lock, and 3 10 mL sterile flushes (attached in a separate container that is attached to the tray). Like someone else mentioned, our ultrasounds have a wire basket on the back that contains sterile probe covers and gel. Literally, all that the nurse needs to grab is the ultrasound machine and a central line kit. Both are kept in the same place so they're easy to grab. We mapped out a lean process to lessen the number of steps needed for everything.

Same here. I don’t quote some of the times others have here, but I definitely don’t spend my time chasing down supplies (I’ve got multiple other things I should be doing instead). That would be a very poor use of the most expensive and often rate limiting person in the ED team. You wouldn’t hire a mid level and use them as a scribe so don’t use yourself to perform nursing functions when it can in any way be avoided. If your nurses and techs don’t see it that way, then you have an ED cultural problem you need to fix.


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[Janders]

Yeah, we made our own custom kits.

But then they went on backorder (who knows why, probably that scarce saline?).

So now we have to use a different, cobbled together kit.
We do store all the requisit stuff in once big tupperware-- but I still have to open each stupid wrapper 🙂

 

[OnlyOneZlatan]

This turned into a dick comparing contest really fast

 

[deleted547339]

This turned into a dick comparing contest really fast

You must be new here.

 

[Arch Guillotti]

What is wrong with all of you ED guys?

Every single anesthesiologist on SDN can place a central line in 1 minute!

😉

 

[Janders]

Blame Anesthesia.

 

[Angry Birds]

What is wrong with all of you ED guys?

Every single anesthesiologist on SDN can place a central line in 1 minute!

😉

Can we consult you for central lines then? You can bill us for the entire minute.

On a serious note, I am remembering one of my first days of intern year (Transitional Year). I was on covering the medical floor along with the world's worst family medicine senior resident. It was in the middle of the night and she (the FM resident) needed to intubate a patient. After missing three times, she asked me to try. I, the inept intern with zero experience, was no better. I was convinced that this must be the most difficult patient to intubate in the world... We paged anesthesia, and the anesthesiologist came in his pajamas, didn't say a word to us, and tubed the patient with his eyes closed in less than a minute. Then, he walked away without confirming placement. Reminds me of a UFC fighter who was known for knocking out his opponents with a punch and then just walking away...

This same senior resident would, on another day, ask me to come down to read her patient's chest x-ray because she didn't know how to.

She was literally the worst. She is probably off somewhere killing people right now as we speak.

Speaking of... I remember when rapid responses and codes were called in rooms on the floor... Holy smoke it was quite a s*** show. I would have no idea what to do, and I was so grateful when it was one of the first things I learned as an EM intern the next year... I would then be amazed at how amazing our lack of care had been the year prior during my Transitional Year. I suspect it may have been a program-specific thing though, as it was a very, very cush TY--combined with some FM folks who had to do floor months as resident hospitalists even though all they wanted to do was outpatient clinic...

 

[slurpy15]

If you're putting in a CVL just because of difficult vascular access and not because they need it for some other reason, you should be putting in an US guided peripheral line. If you don't know how to do one/aren't good at them, start practicing them on your shifts when you're not as busy.
If that fails/blows repeatedly/whatever: put a long 18g into their IJ. Or drill an IO. Either way, I can think of very few cases where one or all of these alternatives wouldn't work at least until things calmed down.

Also, just because the patient is on pressors doesn't mean that they immediately need a CVL. If you've got a working PIV and you're running levo, that's fine. Put the CVL in later, or if you're absolutely getting murdered, explain it to the hospitalist and have them get the PICC team to come in and do it in the ED or upstairs.

YES. Your techs should be putting in US guided peripherals. Ours are FANTASTIC at it and LOVE the US. Talk to the nursing director. IMHO, most community shops don't require enough CVCs to maintain skills, and it's also time-consuming. I am so out of practice now that our techs are great at US IVs and IOs that it would take me...awhile. There is excellent evidence that running pressors through a PIV for several hours (or longer) is quite safe. CVCs are kind of a residency/academic thing. Not enough time in the community.

 

[GeneralVeers]

YES. Your techs should be putting in US guided peripherals. Ours are FANTASTIC at it and LOVE the US. Talk to the nursing director. IMHO, most community shops don't require enough CVCs to maintain skills, and it's also time-consuming. I am so out of practice now that our techs are great at US IVs and IOs that it would take me...awhile. There is excellent evidence that running pressors through a PIV for several hours (or longer) is quite safe. CVCs are kind of a residency/academic thing. Not enough time in the community.

I agree. I always inwardly roll my eyes when a colleague I'm working with announces they are going to be "busy doing a central line". That just means I have to pick up the slack and see all of the patients for the next 30 minutes to an hour. Often when I look at the chart, I am not even sure why they are putting one in as there is no hard indication like refractory hypotension. I will also have ICU "request" that I place on on some patients being admitted to the ICU even if they aren't on pressors. I politely decline, as it's non-emergent and could easily be done in the morning.

 

[gamerEMdoc]

I agree. I always inwardly roll my eyes when a colleague I'm working with announces they are going to be "busy doing a central line". That just means I have to pick up the slack and see all of the patients for the next 30 minutes to an hour. Often when I look at the chart, I am not even sure why they are putting one in as there is no hard indication like refractory hypotension. I will also have ICU "request" that I place on on some patients being admitted to the ICU even if they aren't on pressors. I politely decline, as it's non-emergent and could easily be done in the morning.

Love it when the ICU requests the ED to place a line on a patient that doesn't at all need one who isn't on pressors. Generally, you are supposed to have an indication for the procedure before you do it.

 

[Hamhock]

There is excellent evidence that running pressors through a PIV for several hours (or longer) is quite safe.

Really? Have you reviewed this evidence by reading the papers?
Or are you simply repeating what someone else told you?

That said, I frequently run vasopressors through peripherals. However, I'm not believing that I'm acting on any good evidence. I'm fully aware that I am RARELY meeting the inclusion criteria for the studies you are likely referring to...and I know my nurses aren't assessing the sites as well or as frequently as proposed.

HH

 

[slurpy15]

Really? Have you reviewed this evidence by reading the papers?
Or are you simply repeating what someone else told you?

That said, I frequently run vasopressors through peripherals. However, I'm not believing that I'm acting on any good evidence. I'm fully aware that I am RARELY meeting the inclusion criteria for the studies you are likely referring to...and I know my nurses aren't assessing the sites as well or as frequently as proposed.

HH

Of course it's not completely definitive or risk free. I get that. But neither are central lines with their infections, dropped lungs, and lost wires. I have great nurses and techs who are skilled with US. I can transfer folks to an ICU within an hour or two of starting pressors and then they can go crazy with lines. Not nearly all adverse events were after 4 hours. I feel comfortable. YMMV.

Best article/study: Safety of peripheral intravenous administration of vasoactive medication. - PubMed - NCBI
Blog meta-analysis: Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access - R.E.B.E.L. EM - Emergency Medicine Blog
What Scott Weingart says: Peripheral Vasopressor Infusions and Vasopressor Extravasation

 

[slurpy15]

Of course it's not completely definitive or risk free. I get that. But neither are central lines with their infections, dropped lungs, and lost wires. I have great nurses and techs who are skilled with US. I can transfer folks to an ICU within an hour or two of starting pressors and then they can go crazy with lines. Not nearly all adverse events were after 4 hours. I feel comfortable. YMMV.

Best article/study: Safety of peripheral intravenous administration of vasoactive medication. - PubMed - NCBI
Blog meta-analysis: Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access - R.E.B.E.L. EM - Emergency Medicine Blog
What Scott Weingart says: Peripheral Vasopressor Infusions and Vasopressor Extravasation

I should add that I would be less comfortable if I had to keep folks in my ER for more than four hours on pressors or if I had bad nursing. But...not an issue where I currently work.

 

[GeneralVeers]

I should add that I would be less comfortable if I had to keep folks in my ER for more than four hours on pressors or if I had bad nursing. But...not an issue where I currently work.

My philosophy on this is that I don't manage the patient through their entire ED stay. Once I hit the admit button, I will deal with any new or acute issue that arises, but managing drips, fluids, sedation, and vents needs to be done by the ICU attending. When the nurse asks me about these issues I tell them to call and wake up the ICU attending. Patients admitted by another doctor, but still in the ED are not my responsibility at all. I direct the nurse to call the ICU attending for any and all issues.

 

[dchristismi]

... in the damned lil glass ampule made to cut your thumb!

BTDT. I hate those.

 

[shoal007]

My philosophy on this is that I don't manage the patient through their entire ED stay. Once I hit the admit button, I will deal with any new or acute issue that arises, but managing drips, fluids, sedation, and vents needs to be done by the ICU attending. When the nurse asks me about these issues I tell them to call and wake up the ICU attending. Patients admitted by another doctor, but still in the ED are not my responsibility at all. I direct the nurse to call the ICU attending for any and all issues.

Be sure to tell the lawyers that too. As you can tell, I am opposed to this style of EM. If the patient is still in the ED, it's still my patient.

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[GeneralVeers]

Be sure to tell the lawyers that too. As you can tell, I am opposed to this style of EM. If the patient is still in the ED, it's still my patient.

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Not true at all. Just because a patient is physically in the ED doesn't put them under my care. That's why I never put orders or intervene on admitted patients I haven't seen, as it will keep my name off the chart completely. They are treated like any other admitted patient, and I only intervene in case of intubation/code.

Once admitted I have transferred care, and the admitting physician is now responsible. I may do them a favor and continue to manage for a period of time if I'm not busy.

 

[Groove]

Once the pt is admitted to the ICU, I clearly document a transition of care to the accepting intensivist. There is nothing more annoying than multiple ICU holds with several pt's on vents, all with sedation and drips and requiring active management, all of which have been admitted over an hour ago, yet the nurses are coming to me for admission orders and the intensivist is pretending they don't exist until they arrive in his/her unit. Once I have admitted the pt to the ICU, it is the intensivists job to come down and manage them. Obviously, I'm the closest physician to the pt and the most equipped to handle a sudden decompensation and/or change in status but those are common sense situations. Even when they happen, I inform the ICU and expect them to come down and take over if at all possible. If you're managing their pt for 3 hours and having your nurses (who are already overstretched) doing the work of an ED and ICU nurse at the same time, you are providing absolutely zero incentives for them to move their own pt's out and make room for the admitted ones in the ED.

 

[GeneralVeers]

I inform the ICU and expect them to come down and take over if at all possible. If you're managing their pt for 3 hours and having your nurses (who are already overstretched) doing the work of an ED and ICU nurse at the same time, you are providing absolutely zero incentives for them to move their own pt's out and make room for the admitted ones in the ED.

Exactly. I don't want to encourage bad behavior, and I make other doctors do their job. They are on-call after all. When the nurses come to me, I politely say: "That patient is under the care of Dr. XXX now. Please call him/her for additional orders.".

 

[Siggy]

I think the only major catch is that the ED nurses actually have to... you know... call the inpatient team and actually follow the orders. When the ED nurses decide that they don't need to follow the inpatient team's orders on patients boarding in the ED because, "There's a doc right there" (while pointing at the ED doc), then don't blame us for not managing the patients. We can't babysit the nurses in the ED.

 

[southerndoc]

I think the only major catch is that the ED nurses actually have to... you know... call the inpatient team and actually follow the orders. When the ED nurses decide that they don't need to follow the inpatient team's orders on patients boarding in the ED because, "There's a doc right there" (while pointing at the ED doc), then don't blame us for not managing the patients. We can't babysit the nurses in the ED.

Just keep in mind that this has not been the view of juries. Patients in the ED - regardless of whether being admitted or not - have traditionally been thought of as the ED's responsibility. Numerous cases of successful litigations have occurred for ED physicians failing to treat boarded patients (including repleting electrolytes in DKA patients on insulin infusions). One recent case involved a patient boarding for 18 hours and successful suits against both the original ED doc and another ED doc (who did not even know the patient was in the department because the patient was admitted and the ED was large).

 

[GeneralVeers]

Just keep in mind that this has not been the view of juries. Patients in the ED - regardless of whether being admitted or not - have traditionally been thought of as the ED's responsibility. Numerous cases of successful litigations have occurred for ED physicians failing to treat boarded patients (including repleting electrolytes in DKA patients on insulin infusions). One recent case involved a patient boarding for 18 hours and successful suits against both the original ED doc and another ED doc (who did not even know the patient was in the department because the patient was admitted and the ED was large).

Still rare enough to not be something I am worried about. Why would I provide un-reimbursed care for a patient who is already admitted? Extending your "juror logic" we should be liable for ALL patients in the hospital, as we are often the only physicians there at night.

 

[Siggy]

Just keep in mind that this has not been the view of juries. Patients in the ED - regardless of whether being admitted or not - have traditionally been thought of as the ED's responsibility. Numerous cases of successful litigations have occurred for ED physicians failing to treat boarded patients (including repleting electrolytes in DKA patients on insulin infusions). One recent case involved a patient boarding for 18 hours and successful suits against both the original ED doc and another ED doc (who did not even know the patient was in the department because the patient was admitted and the ED was large).

And that's... unfortunate. EM docs aren't hospitalists, hospitalists aren't EM docs. If there's a significant difference in treatment plans between the ED doc and the inpatient doc, shouldn't the inpatient doc's plan take priority for the patient that has already been admitted to their service?

Of course the question also should be why didn't the inpatient doc check the labs that they ordered?

 

[southerndoc]

Still rare enough to not be something I am worried about. Why would I provide un-reimbursed care for a patient who is already admitted? Extending your "juror logic" we should be liable for ALL patients in the hospital, as we are often the only physicians there at night.

Not much successful litigation for patients not in the ED except when emergencies occur, the ED physician is notified, and doesn't respond (or in one case, caused a pneumothorax with a subclavian line, and although recognized and treated promptly with a chest tube, still resulted in a judgement against the ER doc).

 

[TooMuchResearch]

Not much successful litigation for patients not in the ED except when emergencies occur, the ED physician is notified, and doesn't respond (or in one case, caused a pneumothorax with a subclavian line, and although recognized and treated promptly with a chest tube, still resulted in a judgement against the ER doc).

A pneumothorax is a known complication of central line placement. Maybe it's just where I live, but that seems ridiculous.

 

[GeneralVeers]

Not much successful litigation for patients not in the ED except when emergencies occur, the ED physician is notified, and doesn't respond (or in one case, caused a pneumothorax with a subclavian line, and although recognized and treated promptly with a chest tube, still resulted in a judgement against the ER doc).

Which is why we shouldn't be doing non-emergent procedures on admitted patients. That line could easily have been done by radiology the next day. I do know some gung-ho ED docs who will go up and place a line at the request of the ICU, or place one on an intubated patient after a code. I usually just shake my head and try not to comment.

 

[TooMuchResearch]

Which is why we shouldn't be doing non-emergent procedures on admitted patients. That line could easily have been done by radiology the next day. I do know some gung-ho ED docs who will go up and place a line at the request of the ICU, or place one on an intubated patient after a code. I usually just shake my head and try not to comment.

Why does an intubated patient necessarily need a line? We don't place lines that aren't immediately needed in our departments. I rotated at a place in residency that put them in pretty much every sick patient before they went upstairs. Fun for training. Wouldn't want to work there. And they're busy too... think they wonder why the LWBS rate is so high?

 

[GeneralVeers]

Why does an intubated patient necessarily need a line? We don't place lines that aren't immediately needed in our departments. I rotated at a place in residency that put them in pretty much every sick patient before they went upstairs. Fun for training. Wouldn't want to work there. And they're busy too... think they wonder why the LWBS rate is so high?

Right. A central line is not an emergency (generally) and on all of these admitted ICU patients, it can certainly be done in the morning. I would never work in place where I was expected to be on-call for any lines in the hospital.

 

[Technorino]

As an incoming intern, this thread intimidates me. Good day to you, sirs.