As I mentioned in a recent post, during my residency, we took call from home. That meant that nurses could call us with issues about cross cover patients all night long, and we still had to work all day the next day.
Early in the year, several of us residents noticed that practically every night around 11 or 12, we were getting called about several of an attending named Dr. Brown's patients. It was always the same thing: "Can we give Mrs. Smith something for sleep?" And we'd give a verbal order for Ambien then go back to sleep ourselves.
(The ultimate insult is getting woken up from sleep to be told that a patient can't sleep. And then you can't get back to sleep. And you can't take anything because you're on freaking call.)
Since all the admission orders had a check-box to give Ambien for sleep, we finally cornered Dr. Brown's resident and asked him why he wasn't checking off that box. He said that Dr. Brown wouldn't let him, because she wanted to know if the patient had trouble sleeping and asked for a sleep medication.
Because there's absolutely no way to tell if a patient got a PRN order overnight unless you make the person on call give a verbal order for it.
Eventually, we bullied the resident into telling Dr. Brown that he was going to be checking off that box from now on.
Man, as a nurse I'd just as soon not have a PRN order for Ambien. I've seen a few too many patients get a dose and then spend the night confused, agitated, and trying to pull out their lines.ReplyDelete
What's really creepy is that in the morning when they calm down, they don't remember any of it, and they think they slept really well.
Yes, but what if a patient can't sleep? The nurse will call cross cover, who knows nothing about the patient and will give Ambien. So why create the extra step?Delete
If a patient can't sleep, then he watches a lot of bad TV until he gets tired at 2 AM, and the possible consequence is that he will be tired the next day.Delete
If he gets Ambien and gets agitated and confused and spends the night arm-wrestling nurses, then the possible consequences are that he falls out of bed, or forcefully decatheterizes himself, or otherwise manages to cause himself injury. And is still tired the next day.
So I would almost never wake up a doc just to get an Ambien order. I'm not creating an extra step. I'm removing all the steps.
Right, but what is the downside of having the PRN order? If it's PRN, it's still optional whether the patient gets the medication. And if there's no PRN, it's optional whether the nurse calls the doctor. All I'm saying is that if the reaction of the doctor on call is always going to be "give Ambien" then there's no point in not having that PRN order.Delete
The downside depends on what the physician intends by the PRN order.Delete
When I worked ICU, the one doc who always wrote for PRN Ambien intended that it be given whenever the patient complained of not sleeping. That doesn't leave much room for nursing judgement. In that situation, if I omitted the Ambien without some documented contraindication, I might be construed as going outside my scope of practice.
So basically, what you are saying is that you don't like Ambien and no patient should get it ever. Fair enough. But that doesn't mean there shouldn't be *something* on the books for insomnia, because if the patient complains he can't sleep, the nurse WILL call the on call doc, who doesn't know the patient from Adam and will just give the first thing that pops into their head (likely Ambien). Not having the PRN order doesn't save the patient from getting Ambien. It just results in the resident being woken up before it's given.Delete
We may be talking past each other. From my point of view, as the nurse, when I'm in that situation then the on-call physician doesn't get woken up either way. I am the one who would be waking the physician, if I made the phone call, which I won't.Delete
One night without sleep is not really an urgent patient care need. That's something we can mention to the doc during rounds the next day. So I suppose I was assuming the midnight phone call for Ambien was a rare, exceptional situation.
If that's not the case at your hospital, your nurses must have had very different training than I had.
No, it wasn't rare. It happened every single night, often multiple times. To the point where it almost seemed like they'd omitted the PRN order for the sake of torturing us.Delete
If nurses didn't believe in sleep meds and would not call us for such a thing, it would have been fine to leave out the PRN. But you would have been the rare exception in that hospital.
Egad. Please accept my apology on behalf of my people.Delete
At what point, are the nurses not allowed to call you? Right after 12am?
I was really excited about the possibility of taking home call. But now it just sounds awful. Especially since I've always had issues with sleeping.
Huh? They are allowed to call at ANY time from 5PM to the next day at 7AM.Delete
"At what point, are the nurses not allowed to call you? Right after 12am?"Delete
Ha ha ha! I seriously laughed for like 10 minutes!!
Anon 1 - I looked forward to home call too & HOME CALL SUCKS. It was better before the days of "duty hours." I know, I started training pre- and finished post-duty hour implementation. As a fellow, I quickly realized that all night I got called for stupid things, even though there was an in-house intern & resident. Often the intern didn't try to think or ask their resident, and/or the nurse who didn't trust the intern. I was fatigued from poor quality, intermittent sleep (just couldn't get my REM on) and had to work 12-14 hrs the next since I wasn't "post-call." I would have much rathered staying inhouse overnight to field these issues and at least gotten a post-call day.Delete
I too missed the post-call half-day. And night float made me want to hurt somebody (like, because I was constantly angry with my circadian rhythm being completely off.... not because I wanted to make med errors or something... just to clarify!).Delete
I'm confused. Why is there no way to tell if a patient got a PRN med overnight (or otherwise)? Can't you just look at the MAR?ReplyDelete
Possibly she was thinking the sleepy on call resident would put more thought into why the patient wasn't sleeping rather than just giving Ambien.
I believe Fizzy was being sarcasticDelete
Of course, Dr. Brown wanted to know if his patients had trouble sleeping because it might be indicative of something ... most likely, a noisy hospital room, with a sun-downing roommate, a hard bed, and scratchy sheets. Of course they will have trouble sleeping!ReplyDelete
Brian: If the patient has that reaction to Ambien, I would assume that the information would be passed on and the prn order would be d/c'd. It would happen only once, right? (of course, if you are the night nurse, once is enough!)
It would only happen once per patient.Delete
After the second or third patient it happens to, it gets kind of old.
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