Recently, this standing order set was suggested to my hospital’s ER (after some discussions with another ER’s director of nursing about ways to raise patient satisfaction scores):
“STANDING MEDICATION ORDERS
Emergency Department nurses may administer the following medications for pain or fever at
their discretion before an ED patient has been evaluated by a physician.
§ Acetaminophen 1000mg (or approx. 15mg/kg), or ibuprofen 600mg (or approx. 10mg/kg),
po x1 prn pain or fever.
§ Percocet-5, or Vicodin, 1 po prn moderate pain to a patient ≥ 40kg; may repeat once prn.
§ Fentanyl 50 mcg IV q 5 min. prn moderate to severe pain to a patient ≥ 40kg, to a
maximum of 250 mcg.
The nurse will consider such factors as the degree of pain, medications recently taken by the
patient, likelihood of the patient needing to go to the OR, and whether or not an IV may be
necessary for other reasons. Generic equivalents are acceptable.”
Excuse me. Did I just hear FENTANYL IV can be given to a patient in triage by a nurse with no provider evaluation?!?!?!?! To a maximum of 250 mcg?!?!?!And then they can just go back to the waiting room and sit there until they are called in?
W…..T…..F…..!!!!!
This is the stupidest thing I have ever heard. Not only is it totally dangerous (people being given super high strength narcotics IV are then going to sit out in the waiting area with no monitoring at all – I can see having at least one to two respiratory arrests per month), but it creates a perfect situation for drug seekers. They can just come in, get their fix and elope from the waiting room! Probably with the IV still in place! Hell, even if they just get pain pills like Percocet, that is bad enough! I bet they’ll never even get registered! They’ll get their drugs and leave!
I don’t give a crap if my hospital started this policy, I would absoultely refuse to follow it and would document on every chart that the RN gave these drugs expressly without my knowledge or approval. Thankfully my director thinks the same way and there is no plan to go in this perverted direction.
Agreed. WTF indeed. Why not just put the patches in a vending machine out front and save everyone the hassle?
Gee, when I was in nursing school they made it pretty clear no narcs w/o doctor’s orders. I wouldn’t want to administer fentanyl freely. Just MHO.
Drug-seekers aside, the contrary view is that there are acutely painful conditions that may still require a long wait when the ED is busy. I wish I’d been given a shot of Fentanyl or even a percocet when I presented with a traumatic anterior shoulder dislocation and fracture…especially once the spasms started. I know I wasn’t going to die, and did not whine about waiting a couple of hours, but it was not a pleasant experience.
If someone is so painful that they need emergent Fentanyl, they’re a “2″ on the ESI scale and need to come back right away.
I am not saying the Nurses should never medicate people before I see them. I authorise on a case by case basis meds that can be given. Anything IV though has to wait til they are in the dept on a bed.
“ways to raise patient satisfaction scores”
Well, I’m sure this insanity will raise the drug seekers’ satisfaction scores! This idea can only come from someone who doesn’t work on the ER front regularly. Insanity!
*headdesk*
We don’t start IVs on people in the waiting room, period. Even if we had such a doofus policy I can’t see (m)any nurses giving fentanyl without involving the doc. I’d be happy if we just had some standing orders for ordering xrays! Oh, and aspirin for cardiac chest pain – that would be nice.
What are perocet and vicodin called generically?
Given that 100ucg of fent forms part of my standard “stop you breathing” anaesthetic, this is a bloody crazy protocol. Besides, if someone is in that much pain, they need bumping up the triage queue and parking on a trolley with monitoring.
We start IV’s in the waiting room on a case by case basis for example A pt with a severe low bg with N/V and they sit in the extra triage room till we can get them into the back since we are always out of beds. But never not one in a million yrs would we dare give A narc by mouth or IV in triage without a doctors order period that being said we are lucky because we have an extra doc on shift and his job is to help with the triage and treat immed. while the others are sent to the waiting room to wait their turn.
I’m not really a fan of standing orders. Even tylenol can be a bad idea. What if the patient has liver problems and the nurse is a new grad?
However, I have been advocating a Valium mist to be sent through the ventilation ducts- for patients, families and staff for quite some time. It hasn’t gone through yet. :)
I’m ok with giving Tylenol/Ibuprofen (although they should have just taken it before they came in, but whatever)…but fentanyl??? A patient complains of a headache, so you start an IV and give fentanyl?? That is just.. I don’t know… crazy??
In one place where I worked, we called ideas like this “an idea of such breathtaking lunacy that it could have originated only in management.”
The brilliancy of the idea, twisted though it is, is that now all those who just wanted medication could be billed for sitting in the waiting room and leaving without seeing a doctor. The hospital could probably reduce staffing in the ED as well since the triage staff would be administering treatment. (Note my heavy sarcasm but I may not be too far off here.)
@whitecap nurse – x-ray techs should be triaging for the x-rays if anyone does. I can’t tell you how many times the ER asks us to reverse the charges on studies we did that nurses ordered that were not necessary or incorrect.
I am surprised no paramedics have mentioned anything on this. While reading the protocol, I notice one thing, it doesn’t state the pt has to get bedded right away or not. I would assume (using the more experienced nurses in triage) that if a nurse implemented this protocol, if he/she gave fentanyl, the pt would immediately be put in a bed and they could not be returned to the waiting room. Further, If you are looking giving a patient a vicodin or percocet and letting them putting them back in the waiting room, it is no different than what they will probably be getting on discharge. You won’t have many addicts going through all the hastle of getting 1 percocet in triage and darting, they are likely dependent anyway and will want more.
I see no difference between this and what a paramedic does. As a paramedic, I can give my patient 10mg of Morphine on standing orders to take care of their pain for many conditions before they are ever seen by a physician, what is the difference?
I guess I am a little disappointed in your reaction to this ERP. I think if you trusted your nurses and put simple rules on how it is implemented, it would go a long way. Pain is detrimental, it should be every health care provider’s goal to treat pain just as they treat any other illness.
I bet if you had a dislocated shoulder you would appreciate some pain management while waiting for the doctor.
I’m not going to even touch the subject of the medications but…
Why are we creating standing orders based on PATIENT SATISFACTION SURVERYS rather than EVIDENCE BASED PRACTICE?
We recently implemented treatment protocols- Standing Orders being outlawed. We have always been able to order certain xrays, medicate for fevers, order simple labs, etc…
Now, we have some freedom (supported of course) to dose a patient with zofran, and in very certain instances we can give toradol. Most of us talk to the docs if we get as far as wanting pt to have pain meds before doc sees them. We can place lab orders if pts meet certain criteria.
Fentanyl? No way. Also, no IVs and out to lobby. Bad things waiting to happen.
I would have to find a new job if I was asked to start placing IVs and administerning narcs to the waiting room pts. No way, no how am I giving fent IV to someone who is not in a position to be adequately monitored. I can just see the line up of seekers trailing out the door once word of this brilliant idea gets around!
Our hospital recently removed many of our protocols and standing orders, no way could I see this starting.
When presented with stuff like this we always reply, “The RN should never be placed in the position of prescribing.” This is only ok with much more clear indications of when to give what, and personally I wouldn’t allow anything controlled…
Almost Jesus. Big difference when medics give IV narcs. First they have ONE patient they are monitoring and then can easily intervene. Second, the patient is on the gurney and can’t go anywhere.
I am actually one of those medics that can give up to 20 mg (gasp) of morphine or up to 200 mcg (double gasp) of fentanyl without a physician order. Of course the patient has to fit within the protocol that I am using.
What is it about the word or medication FENTANYL that scares the baJesus out of everyone? When we started carrying this drug in 2005, the RNs in the ED could not even administer it yet! The truth is, Fentanyl is well proven to cause less respiratory depression and less side effects (in pain management doses) than morphine does. Besides, it wears off in an hour or less.
Beyond all of that, if you want to argue the safety of doing this in the waiting room, I’m with you. I totally understand. But when the reason is, “oh, well, the drug seekers will have a field day”, I guess it just speaks volumes as to where our priorities now fall.
Evidently its okay if legitimate patients in pain continue to suffer just so long as drug seekers don’t get narcs from the ER. Reading many of the comments above, that is what it clearly has come to.
Guess you’ve never given pain meds to someone and then watch their BP or O2 sat crash.Even tiny doses can cause it in some people.
I’m all for pain control – in fact, I might criticize ER docs who seem to think practically everyone is a drug seeker.
But even I think iv fentanyl in the waiting room is nuts.
I’ve watched someone get pain meds and have their BP crash. Waiting room would be a bad place for that.
Hueydoc and Tracy – you both state “pain meds” can cause BP to crash and I agree. However, if you look at the literature, Fentanyl seems to be much less likely to do this – again at lower doses. I’ve likely not treated as many patients as either of you but I am yet to witness or Q/A a single case of hypotension or resp. depression due to 100 or 150 mics of fentanyl. But don’t take my word for it, study after study seems to show the same thing. Just sayin.
Jeff, I’m not so worried about BP. I’m worried about respiratory depression and subsequent hypoxia and aspiration risk in an unmonitored setting.
I guess I just want to be clear, I don’t agree all too much with IV pain meds in the waiting room either. I just don’t. Handing out a percocet or vicodin is another story. My main points are:
A. Fentanyl is not nearly as “scary” as some people think or claim.
B. Many studies clearly show that Fentanyl (in pain doses) does not cause nearly as much resp. depression or hypotension as morphine and other drugs do.
C. We should never veto anything where drug seekers getting drugs is at the top of our reasons list for the veto.
Fentanyl is one drug of choice used for conscious sedation, and everywhere I’ve ever worked that means 1-On-1 RN monitoring as per conscious sedation guidelines. Sorry, but I have seen many a pt drop a BP and O2sats with IV Fentanyl.. No way is this safe- or sane!!
Hello, kids…What is the purpose of triage? The purpose is to figure out sick/not sick and determine the order in which people are seeing the physician/PA/NP, essentially.
In addition to 250 mcg of Fentanyl in triage w/little to no monitoring just being silly and likely dangerous, you’re taking time away from seeing that the little old lady in the corner of the waiting room who has a vague “headache” and is looking a lot more sleepy and is starting to kind of stumble around a bit. Putting in a quick order for a foot XR or a wrist XR or something is a different story. This take 10 seconds and helps others to get back faster = Win.
You have to be on the lookout for changes to patients’ conditions more than making people happy with narcotics and re-evaling all those people for iatrogenic respiratory depression. This in and of itself is very time-consuming, if you have time at all.
You’re taking time away from finding these people beds or bringing them back or whatever. You’re giving Fentanyl to someone while a chest paineur with unstable angina is in the queue to be triaged…what’s more important, kids? Sally’s “severe” chronic low abdomen pain or Gramps with the chest pain who is waiting patiently and not complaining and would never think to write a complaint letter to a hospital?
If you make narcotics in the lobby an expectation, well, you’ll get more complaints and your triage nurses will have to defend triaging to all these people. It’ll get annoying and distracting.
If your only issue with your care is that you had to wait for a physician eval to receive pain medicine for an otherwise non life-threatening issue, well, boo-hoo. Life sucks.
For otherwise normal (not drunk) patients with deformed ankles/wrists and other such painful issues likely to result in a longer wait, you can get an order for a courtesy Vicodin after speaking with a doctor. Big deal.
Fentanyl is a great medication. I have no issue at all with fentanyl. And sure, respiratory depression is more likely with opoids. But I think it’s a bit more gradual, and someone might notice before it’s a disaster. In the waiting room, of course, that is *might*. BP crash can be sudden and spectacular however, by the time someone noticed the patient might be dead. Hence my horror at the waiting room idea.
Fentanyl is also quite a *big gun* – I’m trying to figure out why they’d go straight to that. But that’s not really the big issue – IV opioids in the waiting room – eek.
I’m actually curious as to how many nurses actually stopped for fifteen minutes to evaluate a patient that they’d given IV fent to? The idea of pushing it to a patient that walks away is kind of scary but I don’t get ERP’s defense that you get to watch a patient, etc. On heme/onc, we easily push 50-100 mcg/hour PRN for non-dying patients. Hate to disappoint ERP but nobody’s standing over the patient for fifteen minutes, etc. when this happens.
Hannah, your patients are not in a waiting room. Also they generally not narcotic naive. Finally, you are not triaging twenty other patients while supposedly watching a patient that got IV fent.
Glad Jeff doesn’t work in my hospital.
Anaesthetics gives you a healthy respect for opiate analgesia. Yeah, it works, but if there’s nobody around to administer the jaw thrust at the right time, you’ve just put yourself in a hole you’re not going to be able to dig yourself out of.
I take issue with the onset being “gradual”. 100ucg of fent is enough to take an opiate-naive or sensitive person from breathing to not in about 45 seconds: I speak from experience in a nice, quiet anaesthetics room, with all the kit to hand and 3 people watching the patient.
This is not about being “scared” of opiates. It is negligent and indefensible to provide a drug you know can cause respiratory depression and loss of consciousness without adequate monitoring.
I love the standing orders for pain meds, so long as the patient is going to be evaluated by a doc before a second dose is needed. Anyone needing IV pain control gets triaged a 2 where I work, and they are lying on a stretcher before we give it.
Here in Oregon us EMT Intermediates can give Fentanyl as standing order/protocol hell, training to the level of EMT I is a TOTAL of four terms at a community college.
@ almost jesus: We can give it because we stay with the patient until they are transfered to the ED. In case of a reaction or resp depression we can counter it with a lil narcan. This is different than loading them up and sending them on their way back to the waiting room with little/no monitoring.
It would be like letting a pt sign a refusal after giving morphine dose to ease pain while loading them up.