First dose antibiotics

Sitric

Hi,

Has anyone ever come across any research about the increased morbitity due to the first dose of antibiotics rule/practice? I can't find anything. It may be that this would be research into the bloody obvious but sometimes that's exactly what's needed to change something.

resus

No research WHAT SO EVER. Actually the 2nd dose is most likely to cause issues!

If you REALLY want to talk risk... what is the risk of a spanking-brand-new intern mixing drugs they've not really learnt that much about yet, for the very first time, not having a fecking clue how to do it properly as never really been taught.....

vs

a nurse who does it every day


It is THIS sort of issue, just like the farmers not able to grit their side roads that needs to be addressed in the New Ireland

SomeDose

There's plenty of evidence which supports the prompt administration of IV antibiotics in managing patients with sepsis, and is a key intervention in improving mortality:

http://www.survivingsepsis.org/Bundles/Individual_Changes/Pages/improve_antibiotic_time.aspx

So the daft "rule" of insisting docs come and administer the first dose would seem to fly in the face of internationally-agreed best practice.

Sitric

Thanks guys,

I know about the importance of timely administration of the first dose in sepsis, meningitis etc, with mortality and morbidity increasing with every hour delayed. I just wondered if anyone had actual numbers about the situation in Ireland. I know it's accepted best practice (internationally) but is the any sign of the rules changing in Ireland? The impression I get is the doctors saying the nurses won't do it and the nurses saying the doctors won't let them. What's is actually the case?

sam34

Sitric wrote: »

The impression I get is the doctors saying the nurses won't do it and the nurses saying the doctors won't let them. What's is actually the case?

i know of no doctor who would object to a nurse giving first dose antibiotics.

there is no valid scientific reason why this should be done by a doctor. it's simply another example of someone else's job being done by a doctor

SelmaB

It's not that nurses don't want to give the first dose, it would save time if they could administer it instead of waiting for a doctor. In most hospitals, it's policy that prevents nurses from giving first dose. I agree that it's absurd and lacking any scientific basis, but it's definitely not a case of nurses "refusing".

resus

Time to change policy then. I feel my head would be bounced off a brick wall though!

ZYX

SelmaB wrote: »

It's not that nurses don't want to give the first dose, it would save time if they could administer it instead of waiting for a doctor. In most hospitals, it's policy that prevents nurses from giving first dose. I agree that it's absurd and lacking any scientific basis, but it's definitely not a case of nurses "refusing".

In many cases however it is not policy. It is habit. In other words it is not written down anywhere the habit is simply passed from one nurse to the next.

Dr Galen

I can only talk from my own experience, but in one hospital I worked in, this was not common practice at all, and had been done away with. In another, it was still in common practice.

tbh, most of us nurses think its a fcuking stupid rule, and agree with there being no clinical basis for it. In fact, its more of a pain in the ass. You just want to get the thing hung up there so you can get n with things.

I've asked before, and twaddle about "reactions", "patient safety" etc are what I've been told. Not sure how any of those things could be affected tbh, and no disrespect, but if patient A has a reaction to antibx 1, the intern is going to be ringing the same bloody person that I would be.

Bella mamma

ZYX wrote: »

In many cases however it is not policy. It is habit. In other words it is not written down anywhere the habit is simply passed from one nurse to the next.

Hi ZYX, it's not habit, it's hospital policy depending on the hospital you work in. For example - James hospital policy is doctors have to give the first dose, but in Tallaght (opened about 11 years now) it's hospital policy for nurses to give the first dose. Makes no sense! (as you know)

Pastafarian

Bella mamma wrote: »

Hi ZYX, it's not habit, it's hospital policy depending on the hospital you work in. For example - James hospital policy is doctors have to give the first dose, but in Tallaght (opened about 11 years now) it's hospital policy for nurses to give the first dose. Makes no sense! (as you know)

James's Hospital Policy DOES NOT state that doctors must give first dose. In fact it states cleraly in section 3.2 that nurses may give first dose. You can find it under Policies-> nursing admin. Forget the document name but its quite far down. This document is signed off by senior medical and nursing staff. Nurses on some wards are refusing to do so in clear breach of the hospital policy.


An Bord Banaltrais opinion on the matter:

The Nursing Board does not have a policy or practice standards for "first dose administration of intravenous medications".

http://www.nursingboard.ie/#faq6


Liam Doran's opinion on the matter (President INMO)
http://www.thepost.ie/story/ojcwkfojsn/

ZYX

Bella mamma wrote: »

Hi ZYX, it's not habit, it's hospital policy depending on the hospital you work in. For example - James hospital policy is doctors have to give the first dose, but in Tallaght (opened about 11 years now) it's hospital policy for nurses to give the first dose. Makes no sense! (as you know)

I am afraid Pastafarian is right and that is the point I was trying to make. Most hospitals do not have a policy of nurses not giving first dose antibiotics. Nurses think they do and tell other nurses the same. This then is claimed to be "policy" when it is not.

Bella mamma

Sincerest apologies Guys! Am a bit gobsmacked! I am pretty sure that most doctors don't know this. Emmmmm..............so why on earth have we got these 2 hospitals (using them as an example) - let's say 5 miles apart - doing different things? And why are doctors/med admin/medical directors standing for it? And, most importantly, we all know (nurses included) that we all working for the benefit of the patient and clearly it is in the patient's best interest that prescribed IV antibiotics are given ASAP, so why would nurses not just spend the time they spend bleeping doctors/making doctor's 'to do lists' when they could just give them themselves???!!!

For the record, this is not a general complaint about nurses.

SelmaB

Ok, I accept that some hospitals don't have this policy, but many do. The fact that all hospitals don't follow the same guidelines and (lack of) evidence based practice makes even more ridiculous.

If it's the case that it's not hospital policy, why don't nurses give the first dose? They're more than willing to give the second, which is when a reaction is more likely to occur.

Also, why don't the doctors refuse to give first dose in hospitals where the policy doesn't exist? I'd imagine a few feathers would be ruffled initially, but it is a total waste of time for all involved... doctor, nurse and patient.

Sitric

Thanks for the links Pastafarian, reading the rest of it, An Bord Altranais does seem to be generally supportive of nurses giving first doses.

http://www.nursingboard.ie/en/medication_management.aspx?article=d450dba9-e7a8-4368-a58e-586a9d4fe148

Liam Doran's quote "‘‘Of course all nurses should be doing that, but we have a fixation on a medical model of care. The doctor initiates everything. Therefore, we have an undue reliance on doctors, and under-utilise other health professionals," would seem to imply that the INO feel that nurses can and should be doing this but that the "undue reliance on doctors" prevents this. Who exactly is relying unduly on doctors?

Pastafarian

Well my understanding of all this is that the was a move a number of years back to bring in nurses giving first dose, and the INO dug there heels in and put the kybosh on it. Apparently they wanted extra money for taking on the extra duties such as giving first doses and doing cannulation. I mean this really is the root of all this. THe question is at what level has all this happened in the INMO ? Liam Doran's comments are interesting - either he is talking out both sides of his face.....or the internal communciations at the INMO are lacking since it is only them that are preventing this from happening now.

Personally I wager, this is one example of a public sector union resisting an efficiency measure unless they get something out of it. This is the sort of **** that is not supposed to happen anymore.

Hmmm what I think is an interesting perspective thou is this: if the hospital guidelines say nurses can give first doses, and An Bord Balantrais are in favour of nurses giving first doses, but the INMO are saying nurses cannot do that as it is an 'extra duty' - does this not mean that nurses refusing to give first dose on union instructions are in fact, unbeknownst to themselves, engaging in a strike or industrial action ??? drkpower I'd be very intersted on your legal take on that one.

See sooner or later this idiotic practice is going to result in someone suffering serious complications or even death thru delayed treatment. And when that happens someone, or someones, are going to take the blame for it. Who do you think that will be ? The doctor following the hospital protocol which says nurses can give first dose, or the nurse refusing to give first dose and breaking the hospital protocol ?? In all likelihood both would take the blame....but would you like to be a nurse in this position.

If you are a nurse reading I think you need to give serious consideration to these issues. For example lets take two scenarios which are entirely possible:

What if a patient seizes but a nurse won't give prescribed IV lorazepam as its never been given before and whilst the doctor is making the ten minute trek from the other side of the hospital the patient vomits, blocks their airway and then can't be revived ?

Alternatively what if a patient has an adverse drug reaction and even thou IV hydrocortisone is written up, the nurse won't give it because the union telles her not to, so instead bleeps a doctor, but by the time he gets there the patient has gone into full blown anaphylaxis and arrests, gets resusitated and then is left a paraplegic thereafter?

Would anyone of you reading like to be the nurse who subsequently gets hauled up in court to explain why exactly, she had gone against the hospital policy which says nurses can give first doses ? Oh your union says otherwise in what is essentially an industrial dispute ? You mean to say this person is a dead/paraplegic because you want more money ??

These stories may seem far fetched but frankly I've seen real life examples just as bad. I've had nurses assertively tell me they won't give first dose IV lorazepam if someone is seizing as it was a breach of hosptial protocol (it isn't) :eek: I've regularly had to give first dose hydrocortisone even thou hydrocortisone is the treatment for what the supposed first dose policy is there to prevent:eek:

I think this is something nurses need to start thinking about before bleeping the overworked intern at 4am to give the meds the reg has just prescribed. I also think nurses (and doctors) need to actually read their local policies on these things. I further think if you are a nurse and you are concerned about these issues, you need to contact your INMO rep and tell them about your concerns, ask them is this all part of an industrial relations dispute the beginnings of which are lost in the mysts of time, and you need to tell them if you want to be able to give these meds and you don't want to be the one held accountable should something happen to someone as a result of a union imposed 'first dose' policy

Jane5

Excellent letter written about this nonsensical negligent carry-on here:

http://www.imt.ie/opinion/2011/03/first-dosing-rule-is-farcical-for-over-stretched-nchds.html

Twoweeksonatrolley posted about this awhile back too....:D

http://twoweeksonatrolley.blogspot.com/2009/03/inefficiencies-in-irish-health-service.html

As one of the commenters on the IMT article suggests, and it sounds like an excellent idea, we should all get very vocal about this, online, in the media, everywhere, and highlight it to the general public. Too many things are dangerously wrong with healthcare in practice in Ireland, and we are charged with the responsibility to advocate for better, safer practice, as doctors.

Even typing in "first dose rule/policy nurses Ireland" into Google, repeatedly, gets it more hits and makes it appear first on search engines, if you want to be really passive about it

take everything

(Yet another) interesting article in today's Irish Medical Times on this.
http://www.imt.ie/opinion/2011/03/first-dosing-rule-is-farcical-for-over-stretched-nchds.html#comments

When you sit back and think about it objectively, the burden of work is so ridiculously skewed towards NCHDs.
NCHD on call: 1 in 100 patients.
Nurse: 1 in 6 patients.
Yet if you can't fulfil this often superhuman workload don't be surprised to get abuse.

I wonder how much the "medicine is a vocation" line actually guilt-trips/blinds NCHDs from actually looking at the conditions objectively and saying this is just bull****

Someone here made the point a while back in another thread (i think it was Tallaght01) that if nobody knows whose job it is, then it must be the NCHD's. I think this sums it up.
And that's all apart from not being properly trained to do the job.


Edit: the letter above is the same as in Jane5 post (only got my IMT today).

sam34

take everything wrote: »

Someone here made the point a while back in another thread (i think it was Tallaght01) that if nobody knows whose job it is, then it must be the NCHD's. I think this sums it up

and dont forget the other one that if nobody else wants to do it, it then becomes the NCHDs job.

drzhivago

sam34 wrote: »

and dont forget the other one that if nobody else wants to do it, it then becomes the NCHDs job.

Was working in a small hospital surgical SHO 1/3 going to 1/2 when people on leave

On a long weekend, got bleep at 2 am to ward, get up there to find a pool of water on floor and nurse asking me what was I going to Do

My puzzled look spurned her on to quote "you are the only man here"

At that stage with tail between legs had to admit that plumbing in the non vascular sense was not my thing