The situations when nurses are starting drips is when there are NO physicians around and in an emergency, you need to do something or the patient will die. There have been days when the physician teams are nowhere to be found and are not responding or the pages are not going through. Its either act and save the patients life or let them die because you are waiting for the MD. That is pretty much the only time when we will start drips on our own. We don't just decide oh this patient needs a cardizem drip lets hang it up. In some hospitals the rotating residents are not on the floor for up to 12 hours. The nurses don't want it that way either, they want the MD's there, but if they aren't, they have to do what they can.
As far as extubation goes, it's not that difficult. If the patient meets criteria based on ABG and clinical stability the tube gets pulled. If it doesn't meet criteria, than we leave it alone until the MD evaluates the patient and he/she decides if the patient can in fact be extubated or if it should wait.
The nurses know what each particular attending wants and doesn't want for their patient, and what they are comfortable with us doing. We are never going against the attending, its more like we are acting on his/her behalf when they are not around in order to keep the patient stable. That's what it is, and its been working without a problem so far.
I totally get you. Talking about doing what you're doing when a hospital system is so dysfunctional that residents aren't on the the unit for hours at a time and attendings are remote, is very different that what I perceived you to be talking about.
In my unit, there are multiple residents at any one time. They are NOT permitted to leave en masse for any reason. If they go for lunch, at least one stays on the floor. If they're all at academic conference, then I don't leave the unit (attending). In THIS environment, it would be wholly unacceptable for a nurse or mid-level, in my opinion, to make unilateral decisions on gtts, extubations/intubations, etc. In YOUR environment, at least as you perceive and describe it, it obviously is not only acceptable but it sounds like you've saved some lives. Well done. And I mean that sincerely.
Your comment about extubation... I get what you're trying to say, but I just disagree, and least in my unit where people are sick sick sick. I'll try being more constructive and less bombastic and explain why.
First, for the vast majority of extubations, you're right, the intellectual reasoning to extubate isn't that hard, and the technical side even less (hell, I can't remember the last time I actually did the physical motions of extubation). However, while most patients can be extubated based on a "pathway", or some combination of clinical gestalt and data (if you're relying on blood gases) it's the patients that fall in the grey area that matter.
And WORSE, some that don't even fall in the grey area at first blush will definitely be so! You're not judged solely by how many people you successfully extubate. You're judged by how you handle the ones who crash thereafter.
Plus, what about the patient that doesn't meet your criteria? Some will need to be given the chance... do you have in your toolbox the ability to decide what other factors are relevant? Maybe you do, I don't know. Most mid-levels and nurses don't. Maybe you're different.
Plus, even if you do have the toolbox, and you make a sound decison... SOME WILL FAIL ANYWAY! So you need to be able to rapidly rescue them if they fail. The alternative -- to leave them on the vent longer until they meet "criteria" -- just predisposes them to pneumonia (and frankly, some folks will NEVER reach "criteria"... pull the tube and run is (sometimes) the only strategy left
You know what I mean.
Plus, what criteria are you actually using? The f/Vt is really the only parameter ever been shown to correlate with extubation success, and even that was when something like 20-30 parameters were basically thrown into the mix via logistic regression. You throw 20 random parameters in, significant testing says at least one of 'em will be helpful! Plus, the f/Vt cut off is 105... you gonna tell your nurses that anything under 105 on minimal settings should be extubated? In truth, most folks are in the 20 - 40 range. But it takes clinical judgement, beyond interpreting a pathway, to pull the tube on the folks with higher rapid shallow breathing indices (f/Vt).
Also, relying on an ABG is fraught with danger, both theoretical and practical. It takes some knowledge to know that the PO2 on a blood gas of 60 isn't necessarily concerning. Can you walk me through the nuances of oxygen delivery and how O2 content is different that Sat% O2, and is different than PaO2? Can you rank their relative importance? Can you discuss the role of Hgb as it pertains to O2 content (and delivery)?
Can you tell me the difference between extubating a POD 1 CT Surgery patient vs. a single lung transplant vs. a double lung transplant? Did the single lung have restrictive or obstructive disease?
Look, maybe you, NYRN, know the answers and can discuss. And, if you can, you're welcome in my unit anytime, and I'd be lucky to have you.
But without exception, no mid-level I've ever worked with or nurse has consistently displayed all these knowledge components. And I take umbrage with the fact that many in hospital administration circles (to say nothing of the aggressive mid-level National Organizations) think otherwise. This thread wasn't a thread about whether or not you, as an individual nurse, can feasably extubate and start drips in a crashing patient when the residents are nowhere to be found and your attending is absent. This was a thread about the place of a mid-level in the unit, and it degenerated into a mud-slinging competition (which I had an incendiary role in) about what a nurse could/couldn't do.
But legally, a lot of what you said you could and have done is only so because you're attendings are lazy, fraudulent, or both. Your comment that you were "acting on his/her [attending's] behalf when they are not around in order to keep the patient stable. That's what it is, and its been working without a problem so far" is both telling and flawed.
Flawed in that it really isn't relevant, because in such a system, you have no control arm. You don't know what would be happening if you had a real 24/7 intensivist around! And telling, because to have you functioning as the de facto attending, whether or not you're acting as they would or not, means that your attendings are either leaving a lot of deserved compensation on the table or they're billing fraudulently. CMS is very clear that to bill for critical care time, you must be physically on the unit. You don't have to be at the bedside, but you have to be ON THE UNIT i.e. if he/she is in their office, the office has to be part of the unit. The situation you describe is not consistent with this.
, I must ask:
