Why can't nurses intubate? - page 5

Paramedics and Doctors intubate, why can't nurses?... Read More

  1. Visit  Esme12 profile page
    1
    Quote from PatMac10,SN
    I think nurses should be able to. Even if it is only when there isn't a Doc available.
    We can at certain facilities but it takes commitment on the part of the faciltiy to maintain competency. Emergency department have ED MD's available 24/7 for the major majority....there are adjunct airways that can also be used ie: LMA.....that will ventilate the patient until intubation available.

    Intubation isn't easy...it takes experience and skill...I don't think it is a skill nurses need to acquire in most instances let other focus on the airway while the nurse focuses on her multiple other duties.
    casi likes this.
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  3. Visit  PMFB-RN profile page
    0
    Quote from Esme12
    We can at certain facilities but it takes commitment on the part of the faciltiy to maintain competency. Emergency department have ED MD's available 24/7 for the major majority....there are adjunct airways that can also be used ie: LMA.....that will ventilate the patient until intubation available.

    Intubation isn't easy...it takes experience and skill...I don't think it is a skill nurses need to acquire in most instances let other focus on the airway while the nurse focuses on her multiple other duties.
    *** I agree. Can nurses intubate? Yes. Should they? Yes. That said not just every staff RN should be intubating people. Nurses can be, and are, trained to intubate but the number is kept low so that those who are trained can get enough intubations to keep their skills up.
    I have to do 30 supervised intubations a year and take a class each year to maintain my comptency. Only a handful of nurses can be trained like that in any faciliety.
    Esme12 I wanted to point out that the ER is the most common area where we (nurses on our team) have to intubate. Many of the very small rural hospital ERs are not staffed with ER physicians. Often it is a FM or IM physician, or even a PA or NP solo in these little ERs at night. Often those providers are not comfortable intubating and will avoid doing it. Some haven't even been trained to do it.
    Last edit by PMFB-RN on Apr 3, '13
  4. Visit  PatMac10,RN profile page
    0
    Quote from PMFB-RN

    *** I agree. Can nurses intubate? Yes. Should they? Yes. That said not just every staff RN should be intubating people. Nurses can be, and are, trained to intubate but the number is kept low so that those who are trained can get enough intubations to keep their skills up.
    I have to do 30 supervised intubations a year and take a class each year to maintain my comptency. Only a handful of nurses can be trained like that in any faciliety.
    Esme12 I wanted to pint out that the ER is the most common area where we (nurses on out team) have to intubate. Many of the very small rural hospital ERs are not staffed with ER physicians. Often it is a FM or IM physician, or even a PA or NP solo in these little ERs at night. Often those providers are not comfortable intubating and will avoid doing it. Some haven't even been trained to do it.
    Good point.
  5. Visit  AIR0812 profile page
    0
    I think RNs should be allowed to intubate if they're trained. 20+ years ICU-CCU and ER, both in Level 1 and 2 trauma centers. It's 3 am in ICU, you have a problem with the ET tube, you should be able to replace it. I also understand the liability associated with same. Guess it boils down to where one works. If your anesthesiologist, anesthetist is right down the hall, then call them. I don't see a need for a med-surg staff RN to do it as they lack the frequency in placement. As an RN we put in art lines. If we can put in an art line, we can put in an ET tube. I've seen some RNs who had to call the med student to replace/start an IV if they're in a teaching hospital.
  6. Visit  GrannyRRT profile page
    1
    Quote from AIR0812
    As an RN we put in art lines. If we can put in an art line, we can put in an ET tube. I've seen some RNs who had to call the med student to replace/start an IV if they're in a teaching hospital.
    If you miss an art line stick, you may have to monitor the BP or draw labs another way. A delay yes but not necessarily life threatening.

    Miss a tube and without a physician around to give you more med orders and manage the equipment to bail the patient out of the consequences, the patient is screwed.

    Not every area allows for RSI_ initiated by RNs unless in special protocols such as a code or transport team. Intubating without that ability would be stupid and irresponsible. There is so much more to consider than just putting a tube through the cords and without permanent damage.

    Most of us who do intubate have also had extensive training with alternative airways including the BVM, King, LMA, fiber optic scope and even a Cric if necessary. No one who intubates should ever rely on just "tubing". When teaching nurses to intubate, they sometimes get frustrated when they must squeeze a BVM with perfect technique for 15 minutes and review NG/OG.

    If you have a problem with an existing ETT, a tube changer is great but not fool proof. This is also not always an emergent thing to do. Just because you can does not mean you should. You can easily fix a leaky pilot balloon and some modern ventilators have adjustments which can be made to compensate for leaks. High PEEPS might be a concern but if you are running ARDS_ protocols, you probably have an Intensive st or Pulmonologist on call.
    Esme12 likes this.
  7. Visit  ♪♫ in my ♥ profile page
    2
    Nurses *can* intubate... and docs *can't* intubate... all depending on the policies and protocols of the sponsoring institution or agency.
    JustBeachyNurse and LadyFree28 like this.
  8. Visit  subee profile page
    0
    If you attempt to intubate someone with a difficult airway (and you missed it because takes some airway experience to separate the difficult airway from the normal) and you make a bloody mess, it's really difficult for anesthesia to get a tube through a bloody swollen mess. Persons who have had any radiation to the next will give you coronary constriction because you only get 1 chance to get that tube in- otherwise you've created a perfect storm.
  9. Visit  PMFB-RN profile page
    2
    Quote from subee
    If you attempt to intubate someone with a difficult airway (and you missed it because takes some airway experience to separate the difficult airway from the normal) and you make a bloody mess, it's really difficult for anesthesia to get a tube through a bloody swollen mess. Persons who have had any radiation to the next will give you coronary constriction because you only get 1 chance to get that tube in- otherwise you've created a perfect storm.

    I don't disagree but it's moot if there simply is no anesthesia provider available. This happens often in my hospital as we only have one provider at night and they are often tied up with emergent OR cases.
    azhiker96 and PatMac10,RN like this.
  10. Visit  GrannyRRT profile page
    0
    Quote from PMFB-RN
    I don't disagree but it's moot if there simply is no anesthesia provider available. This happens often in my hospital as we only have one provider at night and they are often tied up with emergent OR cases.
    Is this an accredited hospital with an emergency room? Or a private facility running on the cheap? What about hospitalists? Who gives you the orders for RSI and the necessary post intubation drugs? What about ventilator management? Yes there are protocols but you make it sound as if this hospital us running at a very dangerous level with a lack of physician oversight. I hope you do not keep intubate patients in the ICU and ship immediately. I have only heard of such places with no RT and inadequate physician staff in very small CAHs_ and they have an arrangement with the local EMS for Paramedics to respond, intubate, take over care and transfer to a higher level of care as quickly as possible.

    If this is happening frequently, the medical staff situation needs to be addressed. While you can intubate, lack of medical staff for total management could leave you hanging and the patient messed up. Don't let your ego get in the way of seeing what is best for the patients. That goes for your hospital management also. Yes it might be cool to say you are a nurse who intubates but what other responsibilities are you rushing through and how much are you taking other nurses from their patients? A newly intubated patient takes time with tube stabilization, setting up the ventilator and vent adjustments.
  11. Visit  PMFB-RN profile page
    4
    Is this an accredited hospital with an emergency room? Or a private facility running on the cheap?
    Yes, publicly owned teaching hospital. I don't deal with the ER, except when they call for help when they are overwhelmed. I am rapid response.

    What about hospitalists?
    What about them? Ours only work during the day and none of them would ever intubate. At night we have medical and surgical residents and I have never seen one even attempt to intubate. They aren't trained or privileged to intubate.

    Who gives you the orders for RSI and the necessary post intubation drugs? What about ventilator management?
    We have RSI drugs on a protocol. So in effect the orders are given by the medical director of the RRT team, same as all the other drugs we give on protocols. We don't put them on a ventilator until we get to the ICU. We have EICU so the intensivist or the ICU resident manages the vents. Same with post intubation drugs.

    Yes there are protocols but you make it sound as if this hospital us running at a very dangerous level with a lack of physician oversight.
    No I don't make it sound that way. You may have jumped to that conclusion.

    I hope you do not keep intubate patients in the ICU and ship immediately.

    Well we do keep intubated patients in the ICU but don't ship them anywhere. Where else would they be kept?

    I
    have only heard of such places with no RT and inadequate physician staff in very small CAHs_ and they have an arrangement with the local EMS for Paramedics to respond, intubate, take over care and transfer to a higher level of care as quickly as possible.
    We do not have inadequate physician staff, we are not a small CAH. The idea of paramedic coming into our hospital to intubate is totally foreign to me. Why would they do that when we have well trained people in house?

    If this is happening frequently, the medical staff situation needs to be addressed. While you can intubate, lack of medical staff for total management could leave you hanging and the patient messed up.
    Wow, you are jumping to unsupported conclusions left and right aren't you. Where was there ever a discussion of a lack of medical staff for total management?

    Don't let your ego get in the way of seeing what is best for the patients.
    I don't think it is my ego that is the problem here.

    That goes for your hospital management also. Yes it might be cool to say you are a nurse who intubates but what other responsibilities are you rushing through and how much are you taking other nurses from their patients?
    It's not cool, Its normal, common and standard. What nurse would be taken away from their patients? If required we (the RRT RNs) emergently intubate and transfer the patient to the ICU where the ICU resident or intensivist takes over their care. Totally ordinary. In my hospital the ICU is staffed to take emergent transfers.

    A newly intubated patient takes time with tube stabilization, setting up the ventilator and vent adjustments
    Oh really?
    azhiker96, Here.I.Stand, PatMac10,RN, and 1 other like this.
  12. Visit  ♪♫ in my ♥ profile page
    6
    I know one of the local NICUs... Specially trained nurses do most of the intubations.

    Regardless of *who* is doing it, it's just a skill like any other... Be it doc, nurse, or RT... whichever role is the one who does enough to be competent is the one who should be doing them.

    And let's face it, it's not rocket science.
    ajmclean, azhiker96, PatMac10,RN, and 3 others like this.
  13. Visit  GrannyRRT profile page
    1
    Quotes from PMFB-RN

    What about them? Ours only work during the day and none of them would ever intubate. At night we have medical and surgical residents and I have never seen one even attempt to intubate. They aren't trained or privileged to intubate.
    I thought you said teaching hospital. My hospital is also teaching and that is what we do. If the resident has had observed intubation training with the OR, Senior RT or the appropriate attending, they are given the chance to intubate. RT backs this up and offers more instruction on everything concerning airway and not just the "intubation". We do stress the BVM and high flow NC oxygen (during intubation) although we use a flow inflating bag for most intubations which makes it really nice. But technique is stressed for all equipment and procedures. This is just part of the teaching process. The RRT RN is also teaching the resident throughout the process about how things should go during a Rapid Response or reminding them of things which should be done. We usually have the floor resident and an ICU resident show up for each emergency. They know the role of the RRT members and see them in action which is useful for when they go out into the world as attendings.

    It's not cool, Its normal, common and standard. What nurse would be taken away from their patients? If required we (the RRT RNs) emergently intubate and transfer the patient to the ICU where the ICU resident or intensivist takes over their care. Totally ordinary. In my hospital the ICU is staffed to take emergent transfers.[

    Oh really?

    Does this mean you don't use a transport ventilator? For the past 20 years, transport ventilators been proven to be of benefit for both patient and the staff. It is even a recommendation by the AHA so much so that Paramedics are now using them to transport from the field. Several larger hospitals have an assigned RT who just transports ventilator patients from the ER, the floor, the OR and to all procedures. In some hospitals, The Anesthesia department has its own transport ventilator to bring patient to and from the OR. In some hospitals the interhospital transport team will show up at Rapid Response and Code calls to assist with transport to the ICU or what ever procedure. It is a huge safe issue since we know what even a few minutes of irregular bagging can do to a patient's pH, PaCO2 and PaO2. This also includes the chances of losing a tube when running down the hall or squeezing into the elevator which also interrupts bagging. The foot and back injuries to the staff are also noted in the data. This is costly and all avoidable. All of our X-ray machines used for RRT and Code calls have the ability to show the image immediately. We can confirm tube placement and secure it properly before rolling down the hall. We use the Hollister Anchorfast tube holder so there is no messy tape. Haste makes waste as they say.

    I am glad your standards are not standard in every hospital and definitely not in the ones which teach. We have strived for safety first and are proud to teach those who need it to be successful in their careers. When you have a well planned team, not every emergent situation has to be rushed. Our ICUs also handle emergent transfers from the floor. But, if they have to shuffle beds or staff, our team is prepared to stay put for a few minutes. The patient might need the cath lab or CT Scan instead. The beauty of it is we can take a few minutes and determine an appropriate destination first rather than just emergently running here and there or moving the patient again and again unnecessarily. We believe it to be rude to transfer the patient to the ICU bed and then say CT Scan is ready NOW. We will take the patient to CT Scan where they can be met with the bed from ICU and the nurse or we can just take them up to ICU if our backup team is still available. The patient is on a ventilator and can go just about anywhere which might be to another facility if you are at a hospital which does not have all the specialized services or piece of equipment is down. Being calm and considerate comes naturally if you are confident in your abilities and that of your team. If doesn't really matter who intubates as long as it is done safely with plans A, B and C always available for the difficult ones. The doctors in the OR and the eICU won't be of much help and your hospital seems to have neutered the hospitalists and residents as well as eliminating the RTs.

    Remember, safety first.
    icuRNmaggie likes this.
  14. Visit  GrannyRRT profile page
    1
    Quote from ♪♫ in my ♥
    I know one of the local NICUs... Specially trained nurses do most of the intubations. Regardless of *who* is doing it, it's just a skill like any other... Be it doc, nurse, or RT... whichever role is the one who does enough to be competent is the one who should be doing them. And let's face it, it's not rocket science.
    It is not rocket science until you have the difficult airway from obesity, burns, radiation, congenital anomaly, stenosis, abscesses, previous surgeries and angioedema from meds or a supraglottic airway. Some patients can only be nasally intubated with Magill forceps assist due to oral surgery or previous reconstruction from injury or CA. Very few patients are the nice 75 Kg 5'8" 25 y/o with normal anatomy and no gag reflex.

    Our transport NICU RNs share the intubation responsibility. But, just like everyone else they had to get 20 successful intubations in the unit before doing L&D. When meconium happens, that is not the time to be learning to intubate. Just like the RTs, the RNs must maintain a minimum of 20 successful intubations each year. The same for Pedi Transport RNs. Too many misses or incidents and their intubation status will be put up for review and a probationary period which also affects their team status.

    Hospitals should have a policy in place to maintain competency with live intubations regardless of who intubates and it should be strictly adhered to. All intubations should be reviewed for quality which also includes the pharmaceutical side. Giving the correct medications before and after is as important as the procedure itself. Confirming tube placement and monitoring with ETCO2 throughout and especially during transport, even within the hospital, is a must.
    emtb2rn likes this.


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