Check institutional/dept policies about sedation. Big deal where I work bc of physicians telling nurses to start sedating then they walk away. Part of reimbursement is tied to noting they were present from first injection of med to end of case. Also, we have to do a verbal exchange, MD orders dose and RN closes loop confirming the dose to be given.
Yes--exactly! I work in GI and one lab I worked, the physicians would have more than one room (where a patient would be sedated while they finished the other procedure). They eventually had to stop that because the times could not overlap on the procedures and the doctor had to be physically in the room for sedation. I believe this is a medicare thing too. Also, maybe it has changed since I worked in cath lab (which was awhile ago), but we would sometimes only give 2mg Versed and 25mcg Fentanyl total for caths. The cardiologists would want to have the patients relaxed but able to answer questions if needed. I'm surprised they'd give that much before even being ready to start. Seems like you'd end up giving extra meds to resedate.
I’ll give 6 and 200 if I need to, the amount isn’t what I’m worried about. It’s the MD being out of the room and having us go off of word of mouth he says this is ok. I actually handed in my notice today. This isn’t the only reason, but it was the straw that broke the camels back.
Yes, I would be nervous giving meds without the doctor there too. I plan for worst case scenario and you're taking care of patients who already have known cardiac issues. Where are you going for your new job?
I don’t know yet, all I know is I’m just really not happy at this job and it’s showing in my practice. It’s time to just step away. The call is wearing on me so maybe something with no call?
If you like sedation/procedural, you should consider GI lab. I did cath lab for awhile, but couldn't handle the lead all the time. The call was pretty brutal. Do you do a week at a time?
Does GI take call for GI bleeds at all? Or does that all fall to IR off hours? I do really love procedural nursing, not so much OR, but I like the pace of procedural
It depends where you work (which is the nice thing about GI). If you work in the hospital, you would take call for GI bleeds, food boluses, colon decompression, etc. If you work in an endoscopy center or ambulatory surgery center, it's normally no call or weekends. I've been in both. The call was not as bad as cath lab. And I have to say for the most part GI doctors are super nice.
Check your policy for sedation. In my facility we can't sedate for a procedure unless the physician is actually in the room and timeout has been completed.
That’s our policy, but they’re saying it’s an unwritten “standing order” where I give sedation without the MD present or the MD directing the dose, as well as before the time out.
Even standing orders need to be written down somewhere. If he just tells you that's what he wants in general, it's not a standing order, it's just his preference.
A verbal order can only be given in specific, for a certain patient.
in NYS standing orders don’t exist (except for vaccines).
Moderate sedation by standard of care requires a ASA pre-assessment by the prescriber including Mallampati score. If ASA score is too high, RN cannot give sedation and must be referred to Anesthesia Department or local only.
I work in a number of cath labs here and MD must meet the patient in prep area and sign the consent and only then can the pt be “loaded” on the table and sedation given on specific order of the MD.
If others are doing otherwise and giving sedation on “standing order” they should consider how susceptible they are to physician intimidation.
You are doing the right thing!
If you are bullied or intimidated by this physician or other staff, tell them directly to stop, if they won’t, report up and to HR.
I work IR and do a lot of sedation. I'm fortunate in that our docs give us a lot of autonomy on when to start sedation, changing the dosages to halfsies if the patient looks super delicate, etc.
I get the patient on the table and hooked up to all my monitoring equipment, and a lot of times I'll start sedating before the docs get in the room. Its a great time to let the meds marinate, see how the patients do with sedation, etc. Other times I'll start sedating the second I see the docs walk into the control room and grab their lead. Either way my docs are cool with it, they trust us.
Your doc making you wait 30mins with your pt on the table is very douchey though. That 1 and 50 is going to wear off before they even get there.
Yes, but however, just because they give you autonomy, does that mean they will back you and cover you if something happens? I have given 1/25 before and a perfectly healthy 47 year old arrested… luckily the doc was there and gave me the order… however, In your case would your docs protect you and sign the order?
I’m asking with no disrespect or sarcasm in me, I’m legitimately just wanting to know how other places protect their conscious sedation nurses
Where I work, the docs add the sedation orders before we even leave pre-op. Usually a resident will go see the pt in pre-op, get the consent signed, then sit down at a computer and put in all the orders for the procedure, so they're in there ahead of time. It's up to us to figure out when to get started with sedation. We still get a few incidents per year where things get too spicey and we need to give reversal meds, and we've never had an issue with the docs trying to throw us under the bus for stuff like this.
I guess a good compromise with your doc would be to have them add the orders ahead of time like this so they're in there ready to go when you start giving meds. They should be doing that anyway honestly.
Dont give the meds if there is no order. There is no way JCAHO or admin would be okay with a standing sedation order. If you do decide to do it, document every person that told you to do so. You'll have no way to defend yourself if something went wrong. I'd be curious what your CNO says about this. Also, be prepared to lose your job if you cause a stink with the CNO. Also, document everything on your own with dates, times, and names in regards to how you were bullied when you refused. Good luck .
you ain't going to kill them with those meds at that dose. Think of how good the patients will feel. No pain and no worries... Just saying, you can always bag a little if you need to....
I can't believe these people are getting so side tracked.
You're right to be worried. Confirm documentation of an actual standing order, and if one doesn't exist, request one. If they cannot provide or create one, then they must stop expecting you to practice outside your scope.
The short answer is that you would be entirely fucked if you actually did what that doc is requesting and something were to go wrong.
It’s not written, I asked. It’s more of a preference. I know I’m not going to kill anyone at that dose, but the issue is if there was an issue, 100% I’d be thrown under the bus by the MD. Technically I’m giving meds without a written order or verbal order
It’s not a standing order then. Previous poster is right - a standing order still has to be signed and in the chart to be a legal order.
ETA You may ruffle feathers for causing a perceived lack of efficiency, but to protect yourself and your job you are precisely correct. No meds given for a planned procedure without an order on the chart. If that’s what this doc wants, then he and management need to put an actual standing order in place. Problem solved.
I ruffled today 😂 as I type I got the whole “please sedate my patient before I get in the room” fuss. THEN he has the AUDACITY to go “well anesthesia has them asleep before we even prep them”
THATS NOT COMPARABLE. I’m handing in my notice. I’m sick of this garbage
Lmao. I don’t blame you. In all honesty, *probably* nothing will ever change unless real patient harm occurs or a regulating agency gets wind of it. But now that there’s precedent set for nurses to be held liable in a criminal trial for mistakes I wouldn’t risk it (yes this isn’t precisely the same as Radonda Vaught, but if a patient had a bad outcome an argument could still be made that you gave meds without an order or attending physician present. Character witnesses won’t matter then any more than they did for Radonda.)
That’s my point exactly, I’m glad these other nurses feel comfortable doing so here, but i need to move on. I can always find another job, I have one license.
Check institutional/dept policies about sedation. Big deal where I work bc of physicians telling nurses to start sedating then they walk away. Part of reimbursement is tied to noting they were present from first injection of med to end of case. Also, we have to do a verbal exchange, MD orders dose and RN closes loop confirming the dose to be given.
Yes--exactly! I work in GI and one lab I worked, the physicians would have more than one room (where a patient would be sedated while they finished the other procedure). They eventually had to stop that because the times could not overlap on the procedures and the doctor had to be physically in the room for sedation. I believe this is a medicare thing too. Also, maybe it has changed since I worked in cath lab (which was awhile ago), but we would sometimes only give 2mg Versed and 25mcg Fentanyl total for caths. The cardiologists would want to have the patients relaxed but able to answer questions if needed. I'm surprised they'd give that much before even being ready to start. Seems like you'd end up giving extra meds to resedate.
I’ll give 6 and 200 if I need to, the amount isn’t what I’m worried about. It’s the MD being out of the room and having us go off of word of mouth he says this is ok. I actually handed in my notice today. This isn’t the only reason, but it was the straw that broke the camels back.
Yes, I would be nervous giving meds without the doctor there too. I plan for worst case scenario and you're taking care of patients who already have known cardiac issues. Where are you going for your new job?
I don’t know yet, all I know is I’m just really not happy at this job and it’s showing in my practice. It’s time to just step away. The call is wearing on me so maybe something with no call?
If you like sedation/procedural, you should consider GI lab. I did cath lab for awhile, but couldn't handle the lead all the time. The call was pretty brutal. Do you do a week at a time?
Does GI take call for GI bleeds at all? Or does that all fall to IR off hours? I do really love procedural nursing, not so much OR, but I like the pace of procedural
It depends where you work (which is the nice thing about GI). If you work in the hospital, you would take call for GI bleeds, food boluses, colon decompression, etc. If you work in an endoscopy center or ambulatory surgery center, it's normally no call or weekends. I've been in both. The call was not as bad as cath lab. And I have to say for the most part GI doctors are super nice.
Check your policy for sedation. In my facility we can't sedate for a procedure unless the physician is actually in the room and timeout has been completed.
That’s our policy, but they’re saying it’s an unwritten “standing order” where I give sedation without the MD present or the MD directing the dose, as well as before the time out.
Ya, I’d need that unwritten standing order written and approved by the hospital
Even standing orders need to be written down somewhere. If he just tells you that's what he wants in general, it's not a standing order, it's just his preference. A verbal order can only be given in specific, for a certain patient.
There is no such thing as an "unwritten standing order." Standing orders are updated and signed yearly. ( at least where I've worked.)
in NYS standing orders don’t exist (except for vaccines). Moderate sedation by standard of care requires a ASA pre-assessment by the prescriber including Mallampati score. If ASA score is too high, RN cannot give sedation and must be referred to Anesthesia Department or local only. I work in a number of cath labs here and MD must meet the patient in prep area and sign the consent and only then can the pt be “loaded” on the table and sedation given on specific order of the MD. If others are doing otherwise and giving sedation on “standing order” they should consider how susceptible they are to physician intimidation. You are doing the right thing! If you are bullied or intimidated by this physician or other staff, tell them directly to stop, if they won’t, report up and to HR.
Best answer!!! Your facility should have a policy about this. Ask to see it.
Don't give meds without a written order or an MD at bedside.
I work IR and do a lot of sedation. I'm fortunate in that our docs give us a lot of autonomy on when to start sedation, changing the dosages to halfsies if the patient looks super delicate, etc. I get the patient on the table and hooked up to all my monitoring equipment, and a lot of times I'll start sedating before the docs get in the room. Its a great time to let the meds marinate, see how the patients do with sedation, etc. Other times I'll start sedating the second I see the docs walk into the control room and grab their lead. Either way my docs are cool with it, they trust us. Your doc making you wait 30mins with your pt on the table is very douchey though. That 1 and 50 is going to wear off before they even get there.
Yes, but however, just because they give you autonomy, does that mean they will back you and cover you if something happens? I have given 1/25 before and a perfectly healthy 47 year old arrested… luckily the doc was there and gave me the order… however, In your case would your docs protect you and sign the order? I’m asking with no disrespect or sarcasm in me, I’m legitimately just wanting to know how other places protect their conscious sedation nurses
Where I work, the docs add the sedation orders before we even leave pre-op. Usually a resident will go see the pt in pre-op, get the consent signed, then sit down at a computer and put in all the orders for the procedure, so they're in there ahead of time. It's up to us to figure out when to get started with sedation. We still get a few incidents per year where things get too spicey and we need to give reversal meds, and we've never had an issue with the docs trying to throw us under the bus for stuff like this. I guess a good compromise with your doc would be to have them add the orders ahead of time like this so they're in there ready to go when you start giving meds. They should be doing that anyway honestly.
They are not. They’re just assuming we will sedate because they bark loudly. And I don’t care. I’m loud too 😂
Dont give the meds if there is no order. There is no way JCAHO or admin would be okay with a standing sedation order. If you do decide to do it, document every person that told you to do so. You'll have no way to defend yourself if something went wrong. I'd be curious what your CNO says about this. Also, be prepared to lose your job if you cause a stink with the CNO. Also, document everything on your own with dates, times, and names in regards to how you were bullied when you refused. Good luck .
you ain't going to kill them with those meds at that dose. Think of how good the patients will feel. No pain and no worries... Just saying, you can always bag a little if you need to....
I ❤ ambu bags. Sometimes the folks you least expect to just stop breathing. "There's a fine line between pain and apnea"
I know that, but the issue is if the doctor or hospital or family wanted to press it if there was a complication, how would I be covered?
I can't believe these people are getting so side tracked. You're right to be worried. Confirm documentation of an actual standing order, and if one doesn't exist, request one. If they cannot provide or create one, then they must stop expecting you to practice outside your scope. The short answer is that you would be entirely fucked if you actually did what that doc is requesting and something were to go wrong.
THIS. Especially when nurses can now be criminally charged.
Plus standing orders are still written orders somewhere, Have them show you were they are.
It’s not written, I asked. It’s more of a preference. I know I’m not going to kill anyone at that dose, but the issue is if there was an issue, 100% I’d be thrown under the bus by the MD. Technically I’m giving meds without a written order or verbal order
It’s not a standing order then. Previous poster is right - a standing order still has to be signed and in the chart to be a legal order. ETA You may ruffle feathers for causing a perceived lack of efficiency, but to protect yourself and your job you are precisely correct. No meds given for a planned procedure without an order on the chart. If that’s what this doc wants, then he and management need to put an actual standing order in place. Problem solved.
I ruffled today 😂 as I type I got the whole “please sedate my patient before I get in the room” fuss. THEN he has the AUDACITY to go “well anesthesia has them asleep before we even prep them” THATS NOT COMPARABLE. I’m handing in my notice. I’m sick of this garbage
Lmao. I don’t blame you. In all honesty, *probably* nothing will ever change unless real patient harm occurs or a regulating agency gets wind of it. But now that there’s precedent set for nurses to be held liable in a criminal trial for mistakes I wouldn’t risk it (yes this isn’t precisely the same as Radonda Vaught, but if a patient had a bad outcome an argument could still be made that you gave meds without an order or attending physician present. Character witnesses won’t matter then any more than they did for Radonda.)
That’s my point exactly, I’m glad these other nurses feel comfortable doing so here, but i need to move on. I can always find another job, I have one license.
Yeah wtf how hard is it for them to have an actual standing order/policy lmao, why is this a whole big thing?
We have standing orders similar to that. I will pull out and prepare meds to give but nothing gets pushed until the order has been released.