Expect little and you get little in return. I got this comment from, I can only assume, a burned out nurse. It was in regards to a post some time back about nurses calling non critical critical lab values.
I had to laugh when I read about your night shift nurses calling you at odd times......... Welcome to the world of MD. I wish I had a dollar for every time I had to save a doctors butt for things they didn't order or do. You as a MD agree to be on call at night we don't make them. There are hospital policies that we have to abide by, but obviously you did not look these up before you wrote this article. Hmmmmm.......If I don't call "your" Critical, "non critical lab, and your patients dies from it, will you go to court for me and cover me? Think not! Like I said, maybe you should check your hospital policies so you can at least "sound" educated. Or not. I bet your one of the md's that go assess their patients without washing their hands first, with no stethoscope in hand,think you know exactly everything after being in the room 2 mins. Don't dare grab my stethoscope with your dirty ear wax on them that you don't even bother cleaning.
In answer to your questions. I would go to court for and testify in your defense if you used your critical thinking skills to make educated decisions based on sound scientific principles. If a patient dies with their noncritical critical platelet count of 30K I would defend your decision not to call me. If a patient dies with their non critical critical Hgb I would defend your decision not to call me. If a patient dies with their non critical critical HCO3 I would defend your decision not to call me. I say this because I know that the cause of death would not be a non critical critical lab value.
When you are allowed to use your thinking cap to make educated decisions on what is critical and what is not, you have proven yourself to be worthy of your training. Patients do not die from noncritical critical lab values. By definition, they are not critical. How's that for defending your ability to be a nurse.
As for hospital policy, I have already made an inquiry into the standards at Happy's Hospital with the hopes of changing the policy on calling noncritical critical lab values to allow nurses to be nurses and not just robots.
Now, hospital policy also works in the other direction, protecting the hospital from uneducated robot nurses who can't tell me what the "bicarb" level is when they are looking at a BMP. Who can't tell me the difference between Lovenox and Coumadin dosing or how both are used in the prevention of VTE on an ortho floor.
Hospital policy should not be set on the lowest common denominator. If you expect little, you get little in return. Making hospital policy based on the least capable nurses is like organizing medical school around the capabilities of its most educationally challenged students.
I presume, based on my experience, that there are a lot of nurses who have no business being nurses. They have some how forgotten how to think and have become nothing more than documenteurs of facts for legal based chart medicine, hiding behind the hospital policies that protect them from their own horrid lack of skills. These are the nurses who scare me to death. Not because I think they are bad people, but because they are incapable of understanding basic science principles necessary to recognize healthy from sick. These are nurses who should not be nursing, no matter how big the nursing shortage.
Training nurses to just be a body to collect facts will make for worthless nurses. If that's all you do, you could be a nurse's aid in four weeks at the community college. Allowing incompetent nurses to take care of patients is an embarrassment for the nursing profession. And something you,as a nurse, should be ashamed of. If you are going to be a nurse, know what you are doing and do your job well, don't just do it.
And shame on hospitals for establishing their protocols for the lowest common denominator. By doing so, you are just begging for the lowest denominator of care as well. Expect little and you get little in return.
I don't call all my critical labs. i.e. critical wbc that is dropping from previous day (it's usually c-diff as the culprit)and treatment has been initiated or low sodium that is critical but improving from previous labs...hyponatremia takes a little time to correct..don't want to do it fast. But all this is based on reading progress notes and rounding with the docs.But if I'm out of my comfort zone, I'll call. Also different docs get excited about different things so sometimes you're betweeen a rock and a hard spot. Hospital policy is always about reducing to the lowest common denominator..why else would our wound care instructions always start with turn and reposition patient...duh.
ReplyDeletehappy do you really think that layers care about sound scientific principles?.
ReplyDeletedo you think they would really believe in critical thinking skills to make educated decisions ?
The answer is simple of course they wont, they will come with poor asociations, looking a reason for blaming someone. come on even doctors sometimes make poor asociations. medical boards sometimes are overflown of stupid ideas, what would you expect from layers from a jury.
Information sometimes, might be controversial, but it isnt, there are few things on meds that are controversial, what is different is the quality and quantity of information and magnanement of each health provider, medical criteria is just an excuse that oftens support lack of knowledge.
In front of a jury, the info could be controversial, and only those with a extensive clinical and theorycal background, on basic health siences, could understand this, nor the jury, nor the layers. so you are most likely to be sued.
is this already so hard for nurses to undertand that the value is non critical, what would you expect from non health provider a judgment scenario.
if you arent able to understand the basics of physiology this is a dark territory.
Normal values 0,5 - 1,5
1 day creatinine 0,5
2 day creatinine 0,75
decreasing urine output
is that normal?, most of people dont understand that. most of them will say is normal.
I'm afraid it's only going to get worse, Happy. I'm not sure policy is the answer, either, and I'll get to this in a minute. Healthcare is marketed as this recession-proof industry, and its going to draw people who recently lost their jobs who are desperate for employment. Fortunately, most nursing schools are getting more competitive because of this, and hopefully it'll weed some of the lemons out. Nursing isn't for everyone, after all.
ReplyDeleteHowever, the concern is that some of these tech/trade-school type of nursing schools are putting people out into the field that have no business in healthcare. I'm sure there are some that graduate from there and turn out to be great nurses. However, I don't think this happens the majority of the time.
My suggestion is not to alienate what are going to be some of your few allies in the coming reform. Rather than going to the hospital policy makers, go to Human Resources. Get involved in the hiring and vetting of nurses. I know it probably amounts to tedium, and, lest we forget, there is a nursing shortage; but I would argue that sometimes, beggars can be choosers.
My reasoning is as follows:
1. It could get much, much worse. Rather than notifying you of critical lab values, these people could be causing the critical values. Or worse, they just decide to not do their job forgo notifying you altogether. What happens when your patient's K is 7.1 and you never get wind of it?
2. Its much easier to exercise the foresight, look at the school they graduated from, ask them a few questions to gauge critical thinking and knowledge, and see if they can get the job done. That's the beauty of a recession: The hospitals aren't the ones begging anymore.
3. I've talked to physicians who have funded extensive education for their "team" of nurses. They took responsibility and really invested in the nurses they felt were worthwhile. This is, in my opinion, a much more productive route to take.
I realize that by taking these steps you may expose yourself to more liability for the mistakes from your nursing staff, but it seems to me that you'd be OK with the tradeoff, yes?
You presume, based on your experience, that there are alot of nurses who have no business being nurses. Just curious, where would you put that, percentage wise at your hospital? Is "alot" over 50%? 20%? Seriously, you'd have a hard time quantifying a generalization like "has no business being a nurse".
ReplyDeleteYou like to talk about the awesomeness of your doctorly powers that nurses just don't GET Is perhaps possible that you don't understand what being a nurse is really all about?
I hate to pin everything on the evils of CMS and joint commission, but I'm afraid they might be your culprit here.
ReplyDeleteThis falls under joint commission's "improve communication" initiative. I work for a hospital system that used to let us use our judgment as to when to call the physician for alert labs. Now, if the lab calls it to us, we are REQUIRED to notify the physician (and chart it on a special form, of course). Drug screen positive for marijuana? Have to notify. Dialysis patient's creat is 10.6? Have to notify. Drunk dude's etoh is 325? Have to notify. Four hours later, it's down to 287? Have to notify AGAIN. This applies even to those of us who work in the ER, where the physicians are present and look at their own labs in a timely manner. Asinine. (All of the above examples, plus a few others, happened one recent weekend).
I know some hospitals are still letting their nurses use their critical thinking skills, but I fear that it will soon be a thing of the past.
However, I disagree that it is due to "hospitals establishing their protocols for the lowest common [nursing] denominator." Though I agree there are certainly nurses that I've worked with who have no business being nurses, I can say the same for several physicians I've worked with.
Instead, hospitals are rewriting policies to match the joint commission's initiatives/CMS's "never events."
Kimberly, RN
Don't want to be called in the middle of the night with a non-critical "critical" result?
ReplyDeleteDon't order the test in the middle of the night!
Want it drawn in the middle of the night and expect it to be "critical"?
Leave orders for the expected result in the chart and cover the nurses ass.
Don't like the values considered "critical"?
Sit on the committee and change them.
Don't blame the folks who are DOING THEIR JOB by following the policies set by their respective organizations.
Well, to be fair, docs have very little control over what time morning labs are drawn. At the hospitals where I've worked, they can be done anywhere from about 2am to 6am. Many docs DO try to get them run at about 5am, but everyone's labs can't be drawn at the same time. Unless there is a reason why the lab needs to be drawn at a certain time, the lab pretty much decides what time those morning labs get done.
ReplyDeleteDocs also can't write an order bypassing hospital policy, unless the policy is worded to allow it. Many docs (and nurses) don't understand this. Hospital policy is the final word. For example, policies on routine IV rotation often say something like "IV sites are to be changed every 3 days and prn, unless a physician's order is obtained to leave the IV in longer." In this case, the hospital policy is to rotate IV sites every three days, but this policy can be bypassed with a physician's order.
If hospital policy is that the patient can't go out and smoke, then the doc can't write an order to allow the patient to smoke (well, he/she can write the order, but it shouldn't be followed). If hospital policy is that a vas cath can't be used for routine IV med administration, then an order from a doc to use the vas cath to infuse ... whatever ... isn't any good. (This is often an order that has the "unless ordered by a physician" provision, but I have worked in facilities where it is completely forbidden).
Likewise, an order from a doc to NOT call a non-critical "critical" lab isn't going to do much, unless hospital policy has a provision that allows the policy to be ignored on physician order.
-- Kimberly, RN
So let me get this straight you say nurses and RN don't have any where the training you do and can't do your job so shouldn't think they can, yet you get mad when they call you to do your job and you ask that they determine what is normal and abnormal? Isn't that your job?
ReplyDeleteIt's not that they aren't smart people. It's that the message they get sent from administration ("clipboard nurses") is that acting like a real nurse is a bad idea and increases risk.
ReplyDeleteHospitals that let nurses actually be nurses do exist, and they are wonderful places for us docs to work in. They also tend to have great nurses since only nurses who actually want to practice nursing work there.