What Protocol?

5am. My patient on a Lasix drip has a potassium of 3.0 from the labs I drew an hour before. Shit, what to do?

Wake the doc up and get my ass chewed?

Or…

Consult the protocol and start giving potassium replacement per protocol?

For the sake of my bony ass, the second option really seems the best, but, alas there is no protocol ordered, nothing in the regs saying I can implement it on my own, I am stuck calling the doc to get an order for potassium replacement. It went better than expected thankfully.

But I never should have been in the position if the docs had been anticipating that this might be an issue and planned accordingly. I mean, let’s thing this through…CHF patient, being aggressively diuresed with a Lasix drip running at 20mg/hour with a pretty awesome urine output, odds are pretty good that all of that peeing is going to impact the level of potassium… So to stave off the inevitable call, when there is a protocol on the books, wouldn’t it be a smart idea to write, “Potassium replacement per protocol.”. Unfortunately though, it appears that our residents missed that day in class. So they get the call.

While I rarely agree with the dog/tractor/child-posting Asberger-esque Happy Hospitalist, in his post about Call Parameters…blah, blah, blah he lays out a plethora of standing orders that would basically end calls to him. Call it extreme protocoling. But it has the under-pinnings of a decent idea. Give the nurses the tools they need so they can treat the patient instead of spending time on getting orders. There are issues with that though.

First, there is the issue of control. Some physicians tend to be a little on the control-freakish side, liking to micromanage care, which I get. Letting protocols run free deprives them of the minute control some need. I turn to say that it frees them to be more efficient with their time and reduces the amount of time spent on hold waiting to talk to the nurse who paged them. Win-win, right?

Which brings up the second issue: lack of nurse follow-thru. This can be an issue if you have lazy nurses. Lack of this follow-thru is what dooms it on my floor. Many of our nurses don’t even draw off scheduled labs, like cardiac enzymes q6, when the patient has a central line. How are these nurses gong to have the follow-thru to manage an electrolyte replacement protocol? They’re not. Probably what would happen is the patient would get the first dose and redraw, but odds are good that anything further won’t happen. I know this as I’ve seen it happen, so it’s not pure cynicism on my part to doubt it would be done right. There are some nurses that are very cognizant and would do well with such a protocol, but they are way out-numbered by those that aren’t. So we end up with the myriad and endless game of phone tag.

There are places where this works, critical care comes to mind, but it could work on the floor. All that is needed is staff buy-in, but in my milieu, that’s dreaming. So, I’ll just be calling the docs and making all of our lives inconvenient. There’s a protocol for that too…

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4 Comments

  1. I love protocols. It helps me get the important work done without all the hassle. I wish all ICU patients had electrolyte replacement orders. It definately simplifies things.

    Reply

  2. The nurse fielding the order for the Lasix drip should have done the rest of you “a solid” and asked for the replacement protocol on the spot…

    Reply

  3. Here in OncologyLand, protocols are SOP (although we never have near enough). My nights go EVER so much better with protocols. The alternative? That the patient does a ‘tell-tale’, be it VS, labs, or other stinky finding just before they crash, and the on-call is, well let’s say, bearishly unhappy. And frankly, this happens way too often.

    Sorry I missed this earlier. Short-staffed and all that.

    Reply

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