LVN/LPN scope in your unit?

[pickledpepperRN]

What are the duties and responsibilities of RNs, LP/VNs, and techs or other patient care personnel in you unit?

What is safe?

http://www.calnurse.org/

For Immediate Release February 20, 2003

Contact: Charles Idelson, 510-273-2246, or Vicki Bermudez, RN 916-802-3543

CNA Sues, as Threat to Patient Safety, to Block New Rule Allowing

LVNs to Administer IV Medications

RNs Charge LVN Board Covertly Aided Dialysis Industry

The California Nurses Association will file a lawsuit in Sacramento this afternoon to stop a new

regulation that substantially expands the clinical role of licensed vocational nurses displacing RNs

and putting patients at risk.

In late January, California's Office of Administrative Law (OAL) approved a proposal authorizing LVNs

to administer intravenous medications to patients in dialysis, blood banks, and other settings. It is

scheduled to go into effect February 28.

The regulation was proposed by the Board of Vocational Nurses and Psychiatric Technicians

(BVNPT) at the request of major dialysis companies and blood banks, and backed by the Service

Employees International Union (SEIU) which represents LVNs.

The ruling was seen by many in the health care industry as a foot in the door to extending the LVN

scope of practice - the legal authority that governs what a health professional can and can not do - to

other essential medical services now provided by RNs.

'Dangerous and unwarranted expansion'

CNA is seeking a temporary restraining order against the BVNPT to block the decision which CNA

President Kay McVay, RN called a "dangerous and unwarranted expansion of role of LVNs

regardless of the harm to patient safety."

Last April, the OAL threw out a similar BVNPT proposal ruling that the board exceeded its authority

to enlarge the scope of LVN practice, the proposal was "inconsistent" with California law, and that

patients would be jeopardized.

None of those concerns were addressed when the BVNPT resubmitted its proposal with only

perfunctory changes, says CNA. Two factors probably influenced the abrupt U-turn by the OAL,

according to CNA:

* Intense political pressure by the health care industry and SEIU. Three major multinational dialysis

companies that operate in California, for example, Fresenius Medical Care, Gambro Healthcare, and

DaVita, Inc. combined for $17.3 billion in sales and $373 million in profits in 2000-2001.

* Back door assistance provided to the dialysis industry by the BVNPT staff.

In its 2002 Legislative Highlights, the California Dialysis Council, the industry trade association,

described how "we worked throughout the year" with the "BVN staff (which) suggested the adoption

of a new set of regulations." Then, "we worked closely with staff at the BVN in an attempt to get a

favorable position from the Department of Consumer Affairs (the consumer protection agency over

the BVNPT) and the Office of Administrative Law."

After the initial proposal was rejected by the OAL, noted the Council report, "We then worked

closely with the staff at BVN to provide additional information to consider and use in connection with

the resubmitting of the regulations."

Dialysis Council: 'We worked closely with the BVN staff'

"We sent out a request that all CDC members provide information to the BVN," the CDC reported.

"We have been working closely with the BVN staff in an effort to be sure they have sufficient

information and support to maximize our potential for success on this important issue."

"It is scandalous and outrageous," said McVay, "that an agency created to protect consumers, the

BVN, would be in open collusion with large corporate health care corporations that make greater

profits by employing lesser skilled staff."

Notably, in its first ruling last April, the OAL had held that "consumer protection is an issue of the

utmost importance when administering intravenous therapy. Hemodialysis medications are

circulated rapidly through the patient's system and may cause potentially lethal reactions."

Yet nothing had changed in the BVNPT proposal to address that concern, says McVay.

Growing numbers of patients receive medication through IVs, "which requires a substantial amount

of clinical skill and pharmacological knowledge and the continual monitoring of its effect on the

patient."

"Dialysis patients are seriously compromised, often with complications of diabetes, severe cardiac

disease and other serious ailments. The administration of medications through an IV involves

pumping them directly into the vein or through a catheter in the neck directly into the heart - and

mistakes are irreversible," McVay said.

McVay noted that RNs are only permitted to administer medications under an order from a physician

and only after conducting a direct physical assessment of the patient.

An LVN, who has far less scientific knowledge and clinical expertise than an RN and in all other

settings can only work under the direct supervision of an RN, will be permitted to administer

medications as long as an RN is in the "immediate vicinity." The regulation does not define

"immediate vicinity" leaving it to the company to determine. "An RN may never see the patient before

the medication is given by the LVN," said McVay.

"Again, a consumer agency, the BVNPT, with the approval of the DCA and the OAL, are allowing the

health care corporations to set all the parameters for a crucial patient care decision - and they are

doing so through a regulation rather than the public legislative process," McVay said.

In minutes of its meetings, the Dialysis Council noted that it sought to carry out the change through

the regulatory process rather than the legislature due to the vocal opposition of CNA. "Our best

chance for success is via this route as Michael (Arnold, the CNC Legislative Advocate) feels we will

have little chance if we face off with the CNA in the legislature," state the June 21, 2002 CDC

minutes.

Most 'egregious example of regulatory abuse'

"Sweeping changes in scope of practice that have such a significant effect on the quality of patient

care should only occur through the legislature, the arena where the public can directly participate in

hearings and hold their legislators accountable," said McVay.

That is also one of the points raised in the CNA lawsuit. CNA charges the BVNPT lacks legal

authority to promote the regulation which violates all existing laws and repudiates the legislative

history of statutes governing LVN practice in California. "There couldn't be a more egregious example

of regulatory abuse," McVay said.

SEIU: 'the proposed regulation is necessary'

While CNA fought the proposal, SEIU campaigned for the ruling in testimony by the SEIU Nurse

Alliance and a legal analysis by the SEIU attorney who wrote that since the duties of LVNs in those

settings were "not covered by any other statute or regulation ...the proposed regulation is

necessary."

In its October 18 minutes, the CDC, the industry council, also noted the contrast. "The California

BRN (Board of Registered Nursing) and CNA both still oppose the concept. However, the Service

Employees International Union, which is trying to organize LVNs, may be supportive."

"Eroding RN scope of practice has long been a major goal of the health care industry," said McVay.

"Now, regrettably, they have the assistance of a major union and a state agency whose mission is

to protect public safety."

The lawsuit will be filed in State Superior Court in Sacramento.

(Copies of the CDC minutes and the letter from the SEIU attorney to the BVNPT in support of the

proposed regulation are available to the media by calling 510-273-2251.)

[jnette, ASN, EMT-I]

WOW !!! Can't believe I'm reading this!!!

I've been at our dialysis clinic 6 years, and for the first 3, the only RN we had was our DON ! There were three LPN's and two techs.. (one of which was me). I'm now an RN myself as of very recently. We currently have 3 RNs and 2 LPNs. There has NEVER been any question about the capabilities of our LPNs.. htey have been there 10 years and do a SUPERB job !

They draw and give all the routine dialysis meds.. epo, ferrilicit, zemplar, the occas'l vanc or tobra.. everything ! Nor did an RN even have to be in the building...which has since changed. We MUST have an RN on duty at all times, but this is only recent. But they do not overlook the LPNs as they give their meds. The ONLY thing I can think of that the LPNs do not do, is hang blood when needed. Wow, I can hardly believe what I just read here ! I know our company last year went through a big deal of trying to phase out the LPNs in favor of more techs and RNs, or to keep their jobs, coerce them into going back to school for RN. But a nation of LPNs reared up on their hind legs and refused, so they dropped it in the end.

I don't know what to think here. Our LPNs have been at this so long, and know EXACTLY what they're doing, and do a MARVELOUS job ! They know far more than many of our newer RNs. They also do the precepting of new staff.

Basically, our LPNs do everything our RNs do, but blood products. They order all the meds, and keep our clinic running tip-top ! They do all the assessments (but as of now, the RNs have to sign behind them), but other than that, there's no differences. I couldn't imagine our clinic without them ! Hmm..mmmm....

[niteshiftnurse]

check with SBN. In florida LPN's are not allowed to hang blood or give ANY pushes, except heparin flushes. SBN says "its not in your scope of practice

[jnette, ASN, EMT-I]

The way I understand it, is that the company sets it's own policies... our policy states that LPNs are permitted to give the meds, including the pushes,etc. I do know that if this were not the case, then we certainly would be in violation. But I'm sure this has been looked into by both the company, our DON, and the docs...

I believe Dialysis facilities have more leeway regarding certain procedures... will ask tomorrow about the specifics.

[pickledpepperRN]

What concerns me is:

1. There is no list of medications considered routine. It says only," Including but not limited to anticoagulants and antibiotics."

2. Each facility may create a different training program and Standardized procedures.

3. The greedy owners of these clinics have already tried to use nurses not properly trained for dialysis.

4. Deaths have occured during routine dialysis in for profit clinics at a higher rate than not for profit centers. The VA and county centers have the least deaths of patients during outpatient dialysis. They also have the highest percentage of RN staff.

Experienced LVNs are usually very competent in their area. What about the new grad?

[Juanay]

Our unit does not allow LPN's to give any IV meds even if they are IV certified. ALL meds are given by RN's. However they are allowed to give initial heparin boluses when cannulating grafts and mid treatment heparin to graft patients only. Catheter patients are for RN's only. LPN's are not allowed to give mid treatment heparin to catheter patients and they are not allowed to "rinseback" catheter patients. We do not use heparin pumps in our unit.

[Hellllllo Nurse, BSN, RN]

At my unit, LVNs give all IV push meds, just as the RNs do. The only difference I've seen is that an RN must co-sign any careplan written by an LVN. And, although we don't give transfusions in my unit, when I worked med-surg in a hospital, LVNs could hang blood and do IVP meds.

It kind of freaks me out that techs, with only 6 weeks OTJ training can give intra-aterial heparin pushes!

[hemoLPN]

HI!!

I am new to this board, but not to dialysis. I have been working in hemodialysis for almost 10 years as an LPN. In the unit I work for the LPN is responsible for giving Zemplar, epo and the heparin boluses. But we are not allowed to hang antibiotcs or blood. We are also not allowed to push hypertonic or benadryl, this I do not understand, but each unit is different. When I first started working in dialysis I was not permitted to push anything, so I guess that is a step in the right direction.

[babs_rn]

Our LPNs can do anything the RNs can do except charge and give blood products. Our techs cannot touch the caths, do assessments (other than v/s), draw up or give heparin, make the baths. All they can do is stick, pull needles, monitor, and give saline boluses (co-signed, of course).

[pickledpepperRN]

Article from Allnurses.com site:

https://allnurses.com/news/jump.cgi?ID=2080

[pickledpepperRN]

Article from Allnurses.com site:

https://allnurses.com/news/jump.cgi?ID=2080

[jnette, ASN, EMT-I]

Interesting, how each facility differs. Even as a tech, I accessed the caths, did the cathcare and dressings, gave the hep bolus, saline boluses, etc. Our one remaining tech still does the same. Our saline boluses do not have to be co-signed at that time, but rather the charge nurse co-signs the flowsheet at the bottom after txs. are completed. Our LPNs give all the same meds as the RNs, and redo the meds after labs have come back, following the algorythms provided by our nephrologist. Techs do not assess the pt. or give meds of course. But they do prepare the baths..unless K+ has to be added to the acid bath to increase it to a K+3 bath. LPNs and RNs do this.

Again, our LPNs are invaluable to us.