Shot Time
At every ER where I've ever worked, there is a rule that must have been passed down through generations of nurses, a requirement with such authority that its justification is rarely questioned, a guideline that is so ingrained in nursing practice that only a fool would speak out against it, and then only in passing, because everyone knows that this policy is as important to nurses as their midshift break. I'm referring to the dogma that patients must remain in the ER for 20-30 minutes after receiving a tetanus shot before they are allowed to leave the premises.
Nurses will occasionally bend the "only 2 visitors in a room" rule, they might fudge on putting both of the siderails up on your stretcher, they aren't always precise about how quickly they push certain drugs through an IV, and they definitely don't reach 100% compliance when it comes to making you change into a gown prior to my evaluation, but if you try to leave too soon after receiving your tetanus shot, you'd better be prepared for a struggle, or at least a tongue-lashing. By the nurse, that is. I don't really care.
I've ordered literally thousands of tetanus shots, and not once have I needed to re-assess a patient afterwards. But most of those patients have complained at least a little bit about the wait, and many of them have become quite upset. Is it really worth it? Call me a heretic, but I say let them go. The evidence seems to support my anecdotal experience: "The risk of death from anaphylaxis following DT, Td, or tetanus toxoid (is) extraordinarily low (page 110). No cases of death...were reported through MSAEFI (the CDC's Monitoring System for Adverse Events Following Immunization) between 1979 and 1990. During that time, approximately 1.3 million doses of DT and 29 million doses of Td were distributed (page 109)."
Nurses will occasionally bend the "only 2 visitors in a room" rule, they might fudge on putting both of the siderails up on your stretcher, they aren't always precise about how quickly they push certain drugs through an IV, and they definitely don't reach 100% compliance when it comes to making you change into a gown prior to my evaluation, but if you try to leave too soon after receiving your tetanus shot, you'd better be prepared for a struggle, or at least a tongue-lashing. By the nurse, that is. I don't really care.
I've ordered literally thousands of tetanus shots, and not once have I needed to re-assess a patient afterwards. But most of those patients have complained at least a little bit about the wait, and many of them have become quite upset. Is it really worth it? Call me a heretic, but I say let them go. The evidence seems to support my anecdotal experience: "The risk of death from anaphylaxis following DT, Td, or tetanus toxoid (is) extraordinarily low (page 110). No cases of death...were reported through MSAEFI (the CDC's Monitoring System for Adverse Events Following Immunization) between 1979 and 1990. During that time, approximately 1.3 million doses of DT and 29 million doses of Td were distributed (page 109)."
Labels: defensive medicine, questioning authority
posted by scalpel at 4:41 PM
23 Comments:
Yeah, but imagine if they did let them leave and they were one of the exceedingly low cases of anaphylaxis post tetanus shot... the patient would sue, the hospital would fire the nurse, she'd lose her license and you'd ... come in to work the next day, I guess. LOL
Yeah, no way they would ever think about suing the doctor. Keep studying.
0 deaths/30,000,000 patients
I'm with you Scalpel, and crap!! why should you have to be a babysitter when there are more "Emergent" things going on in the ER. you wouldn't catch me waitin there, cos I am not one for needles PERIOD!!!LOL,,,, Stacy..
Don't be silly, I fudge shot time all the time. You can document the shot a little earlier or the discharge a little later. I figure if anaphylaxis is coming -it will probably come in the first 5 minutes anyway. I don't want those patients waiting around any more than you do. However, the best way to avoid the whole issue is to give them their Td EARLY in their visit, like before getting sutured. Now why can't docs learn the difference between Td and DT?
-whitecap nurse
I'm not one of those nurses. Actually nor are most that I work with.
The watch for 15 minute policy was part of our immunization education. I asked my pharmacology instructor how often she'd seen anaphylasis following an immunization. She was a public health nurse for years and never had. She did however, cite cases that she had either heard or read about.
With flu shots- which we don't do in the ER- we ask them to stick around for 15 minutes. At flu shot clinics we even offer them coffee and tea following their shots. Some of the elderly enjoy the outing, however, the majority leave before 15 minutes are up. We inform them, they leave, oh well. Far be it for me to chase them down.
We give a tetanus shot and seldom ask them to stay. An empty waiting room is a good waiting room.
I communicate with the docs. I get to know them and learn what they are comfortable with. Some docs are text book, others let me use my judgment.
As for the gowns.. I use my judgment for that too. Gowns use resources like time and money. Also most people would rather be in their clothes if possible. Again, something I've discussed with the docs.
And.. I wish we had a 2 visitor per room policy. Good grief how I get frustrated nursing around crowds of well wishers.
"Yeah, but imagine if they did let them leave and they were one of the exceedingly low cases of anaphylaxis post tetanus shot... the patient would sue, the hospital would fire the nurse, she'd lose her license and you'd ... come in to work the next day, I guess. LOL"
Priceless commentary. What part of less than 1 in 30,000,000 did you not understand? You're almost 150 times more likely to get hit by LIGHTNING. And while I'm sure you're taught how important nurses are, they don't teach that to lawyers, who will be going after the MD every time.
My goal isn't really to impugn all nurses, I'm just using hyperbole to make a point. If a patient's only complaint is a stubbed toe or conjnunctivitis, by all means let them be comfortable in their street clothes. I want nurses to use their judgment and not be bound by policies that are not based upon evidence. I know plenty of nurses that will cut a couple of minutes off of the shot time, but that doesn't change the fact that the shot time is an unnecessary policy to begin with, at least with regard to tetanus shots.
Cranky student nurse.. chill
We nurses really don't carry the weight of the whole world on our shoulders.
You'll be fine. You'll give shots, you won't be sued. You'll go to work the next day and so will the doctors.
Breath in...breath out.
I don't care if patients leave either, but my BOSS says re-evaluate for allergic reaction.
Funny though, on the floors we give flu and pneumovax shots at discharge, but don't re-evaluate.
Go figure.
I try to give the tetanus shot like right away if I know they're going to need one, even before they're sutured, so it's never really an issue for me. If you're not ordering the shot until after you sew, then WTF, order it right away.
The only thing where I'm militant about holding people is with antibiotics, like for the pills/IM with STDs for instance.
I HATE that crap. Thank God we don't have that one in our ER. Even more stupid is "wait one hour after getting a Benadryl, Percocet, or Valium". This is so dumb I can't stand it. I mean, let them leave right when the drug kicks in!!!! What about when they take them at home - do we have to send a nurse there to observe them?!?!?!? A constant source of argument between me and the RN's.
Luckily, there are nurses that bend these rules since they think they are as stupid as I do.
Ok so wow, I have never even heard of waiting following the administration of Benadryl, Percocet, or Valium.
Sheesh, we'd need a holding room with a nurse assigned just to observe and assess post med administration pts.
I'm a bit of a rebel and this would get a rise out of me for sure.
This reminds me of a fun time I had with one of my horses when I was a kid. It was typical back them for oweners to give IM injections of penicillin if the animals came down with respiratory infections and green, nasty discharges.
Big giant needle that you could see through. You inject either in the butt and run the risk of getting kicked or in a trigenl in the neck between the vertebre, windpipe, and shoulder. It is like ten inches of flat muscle.
This was all very routine and my mom stuck the mare and started injecting the stuff in the neck.
Within about three seconds this 800 pound horse rolls to the ground and goes into seizures. This lasts for about two minutes while my mom rushed into call the vet.
He said it could have been an allergic reaction or injection into a vein but wasnt sure.
that mare was never quite right after that.
Geez.
CDC is the source who recommends the 15-20 minute observation time.
Hospitals have policies that clearly state this.
Nurses who don't follow hospital policy get fired.
Give the Td as soon as you know they are going to need it, like Nurse K says.
Also, you should be using Tdap (when age criteria met)
"CDC is the source who recommends the 15-20 minute observation time."
I call bullshit and request that you prove your assertion with a link. The CDC makes no such recommendation.
I'm aware that hospitals have such policies, but I'm suggesting that these policies are not based upon current evidence and should be reconsidered.
Certainly if triage nurses always correctly identified patients who required tetanus vaccination at the initial point of contact and administered it at the beginning of the visit, this issue would be less important. But it is unfortunately quite common for this issue to be identified at the end of a visit, and the patient to suffer an unnecessary delay.
Not at any of the South African or English hospitals I have worked at do we keep patients waiting for 30 minutes .
I had to stay after my tetanus shot last year (not at the ER), but it was due to the my latex allergy, not fear of anaphylaxis from the shot itself.
As it was explained to me, the thing on top of the bottle was latex so I had to sit around the waiting room for 20 minutes. Apparently I would have been free to go immediately if I didn't have the allergy.
But it is unfortunately quite common for this issue to be identified at the end of a visit, and the patient to suffer an unnecessary delay.
It's your job to order it, so order it at the same time you see the patient for the first time if they need it.
ERP--Waiting one hour after Percocet etc is silly, but this goes back to my give first dose in ER pet peeve which is doctors that order a single dose of a PO medication prior to discharge instead of just writing a script for it and sending them on their way. Really, unless all you're doing is the single dose with no script, then just write the script and send the patient on their way.
You guys are always welcome to send off an email to the nurse manager to see what the actual "holding" policy is. If the nurses are mistaken, then they should be told to not hold the patient for an hour.
Nope, it's a protocol drug, like aspirin with a STEMI or Tylenol for a fever.
I sometimes give a dose of one of those drugs before they go if it is late and or a pharmacy is not likely to be open to fill it. The whole concept of waiting after you give most drugs is asinine unless someone has a prior history of drug allergies/reactions like when I give Keflex to someone with a PCN allergy. And Tetanus vaccination? I mean WTF, that is a stupid as they come.
There are times I give the drug myself instead of the RN if they give me a hard time about them leaving right afterwards. I'll take the heat for the near-nil chance of complication no problem.
A while back, I was in the ER and they gave me a shot of Toradol, the Nurse told me I had to wait for about 15 minutes, she then left and closed my door, ( my thought was she was busy doing other things( more serious)and would come back to discharge me when she got finished with the other things, I really didn't mind because I respect them in their workplace and she may have been really busy or went back into the "linen"closet to finish her cell phone conversation,LOL, nonetheless,it wasn;t up to me to decide, and now since I read this blog have added another reason behind it, I am allergic to Demerol, so that may as well have been the most popular reason. (:Stacy
Scalpel,
"Yeah, no way they would ever think about suing the doctor. Keep studying. 0 deaths/30,000,000 patients"
No crap, people sue MDs? Geez, I never would have known. I know lawyers go after doctors, but many of my professors and clinical instructors have told us students that hospitals protect doctors over nurses all the time, and that we're mostly-- not always-- the ones to bear the brunt of a fuck up by getting fired and losing our license. Sad tales abound at my school "Oh, I know nurse so and so that called a doc at 3am because the orders said hold medication if whatever vital is below whatever value, the doc told her to push the meds, the patient died, and the family sued, and the nurse ended up getting fired and losing her license."
I dunno if they're trying to scare us into compliance or what, as I have no basis for comparison. I haven't been a nurse but one semester so far, and most of my first was learning bed baths, moving folks, yadda yadda. mWhatever.
But ultimately, as evidenced by the LOL in my original post, I was joking. So no need to be a crabby MD.
BTW? 0 Deaths / 30,000,000 patients? Okay, so no deaths. Great. But now many cases of anaphylaxis? Last I *studied* anaphylaxis doesn't result in death 100% of the time. Obviously anaphylaxis happens sometimes, albeit rarely, otherwise there wouldn't be so many case studies about it:
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Search&Term=tetanus%20toxoid:%20anaphylaxis:%20case%20report&itool=QuerySuggestion
So I suppose the wait time is to stave off any doctors or nurses who say "fuck it, it never happens, let them go home" and they have an anaphylactic reaction in the car. That's all I'm saying. I'll say no more because obviously you think I'm out of my league or something. Have a nice one.
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