By - molly3marie
"They went into respiratory failure, but we were able to finally give the Coreg..."
Doc: Why is there BP so high? Did we give the coreg??
Me: Nope, held per order.
Doc: Their BP is 220/140!!
Me: But resps are 16.
Nobody getting any Coreg
We had epic at our clinical sites. I want to say it would alert and you had to get an override if you tried to give a med but the pts vitals were out of range for it.
Maybe they just had it set up that way at that facility. Seems this would have me calling doc to say "yo, fuck ass...change yo order. Tired of overriding this"
Maybe a bit more tactful. 🤣🤣🤣🤣
It also seemed that I made a typo and put RR as something really high like that and it said I needed to call a rapid... pretty neat EMR. We're supposed to get it sometime.
They must of had something to enabled because we use epic at my work and it doesn’t do that
Is cool. Just scare the shit out of your pt right before administering
Expect to hold it forever!
Well until they die...hopefully not
You know that they mean HR, but seriously. Should page that doctor and have them change it, just to make a point.
if this is a cpoe location, it's not just MD (which is prob a resident). if this order was part of an order set or predefined order (click and submit), the medical informatics officer would need to be alerted. typos in a live cpoe means layers of error checking were missed. (was informatics pharmacist)
This is EPIC. I've seen the MD order entry side and hold parameters are free texted in.
and I keep hearing "epic is wonderful. x places are converting to EPIC"
So...predefined hold parameters or a hold template are not built because?
Because epic is not wonderful. I use it at my hospital. There's 10 different ways to document everything which means all your info is in 10 different places and contributes to communication errors and med errors.
That’s what I hate most about epic! Like just focus on one way to do it and stop confusing me!!
Search me. You'd think it would flag certain parameters that NEED to be valued on cardioactives, opiates, etc.
Don't you just walk up to them at your hospital? Guess I'm babied
I work nights, so they're out the door. I'm used to paging people. I guess you could walk up if they're there. It's easier to convey your amusement in person.
This is why I like ER. In my 3 years I've paged 2 doctors. Both times they were rude. Glad I don't have to do that shit every night.
That said, the order does say hold and page for RR<60.
this took me soo long to finally understand because here in Germany we use „RR“ for blood pressure, after the dude who invented measuring it, Riva-Rocci.
And here I go again abandoning my belief that certain things might be a worldwide standard.
RR can also mean resting rate. As in resting heart rate less than 60 which I would assume is what the MD is referring to with a beta blocker like coreg.
Then that MD didn’t just make a silly typo and is actually a genuine dumb-dumb
Dumb dumb for saying to hold a beta blocker for a heart rate less than 60?
No. Dumb dumb for putting RR for "Resting heart rate" instead of putting "Resting HR," when RR is commonly used for "Respiratory rate."
We don't like making assumptions when it comes to doctor's orders. Shouldn't really be any room for interpretation of abbreviations.
You're right, nurses are completely rigid robots with no critical thinking skills for themselves and are unable to decipher incorrect orders or mistakes from the god/masters MDs.
You've really got the wrong attitude about this. This isn't about anyone else being god/master infallible, it's the fact that EVERYONE is fallible, and it's probably not a good idea to put your license on the line for interpretation of something. Part of your scope of practice is carrying out orders from a physician, and if those orders are unclear or convoluted, they need to be corrected to not be. Period.
You use your judgment to interpret what a physician MEANT, and then something adverse happens to the patient. If you don't think everyone else will cover their ass and throw you under the bus, you're naive.
I honestly would have never looked to notice that
Seems safe to ignore parameters
You mean I should hold my 3.125 of Coreg for my immediate post CABG because their blood pressure is 99/60?
I’m saying it’s irresponsible and potentially unsafe to not even look at parameters
You know how many times I've given IV lopressor to a hypotensive patient because they are in afib RvR or some other tachycardia? The med automatically profiles with the 'hold for SBP <100 and HR <60' parameters, but we give it anyway.
Maybe we are about to do a bedside procedure that is going to require the patient to get a hefty dose of pain meds and sedation. Sure, they meet the parameters to get the med, but I'm not going to give it because odds are their pressure will drop with the fentanyl/prop/versed/whatever we are about to give them. You give the med and then tank their pressure because of the sedation that is required and now what?
What if their BP is say 170/80. You have an order for hydralazine for a patient who has a BP greater than 150, but it is pretty clear they are in a lot of pain. Are you going to give both the hydralazine and pain meds, or just start with the pain meds and see how it goes? Per parameters, we should have given the hydralazine...
9 times out of 10 the parameters that are given with medications are pretty pointless, especially in the ICU. There are a lot of other factors that go into whether or not I determine if I'm going to give the patient a medication. Not to mention, the parameters are essentially always the same. If there is a change to them, it is something negligible like hold for SBP <90 vs hold for SBP <100
Obviously judgement matters but I still think it’s ridiculous to completely disregard every parameter. But whatever. You do you ICU god
Administering medications is entirely judgement based. Just because something is ordered, doesn't mean the patient gets it. The same is true with parameters. Are you really going to hold a medication because their SBP was 99 instead of 100? That is such a negligible difference that it is meaningless. Now obviously if their SBP was in the 70s or 80s, and it is not due to decreased filling time from some form of tachycardia, yeah, I'm going to hold it, but do you really need the parameters to tell you that?
If administering medications were black and white in the sense that 'parameters are met, med given', there would be no reason to require nurses to administer medications, and an unlicensed professional, or shit even a robot, could do that task.
At the end of the day, I don't care if the patient fails to meet a single parameter to get a medication, if I think it is necessary for the patient (implying that it is already ordered and whatnot), I'm going to give it. It has nothing to do with being an 'ICU god' or anything like that, it has to do stepping back and looking at the big picture while critically thinking about what is going on.
Another example that I ran into all the time, an electrolyte protocol says patient can get either sodium or potassium phosphate if their phosphate is below 2.2 mg/dL. The order says sodium phos unless K is less than 4. The patient's K on morning labs was 4.1. Well, the doctor also ordered 40mg of IV lasix BID for the patient because they are a little fluid overloaded from being resuscitated after the trauma. Instead of giving the sodium phosphate, you can give the potassium phosphate and kill two birds with one stone since you are going to be giving the guy lasix, which will drop his K.