can nurses intubate?

LilPeanut, MSN, RN, NP · Apr 1, 2006

Personally, and I'm just a student, so grain of salt and all, but it really sounds like the nurses are practicing outside their scope at that hospital.

I can't imagine that a hospital is keeping vented kids and doesn't have an NNP, resident or attending there at all times. Most of the hospitals around me are cosidered "2+", they have NNP housestaff who are there 24/7, then attendings and residents who round. They will keep vented kids, but if the kid is really sick, they'll send them to us. Of course, our official other lvl III in my city is more like a 2+ as well, because they still send us all their really sick kids and they don't do any surgery over there.

They really need to revise the levels.

KK7724 · Apr 1, 2006

We're a Level III

LilPeanut, MSN, RN, NP · Apr 1, 2006

You can't be a lvl III if you don't have docs there round the clock, at least this is my understanding. This is what prevents most of our II+s from being considered IIIs, they have NNPs, but they don't have attendings in-house.

I could be wrong though.

Edited for less bluntness and clarification :)

KK7724 · Apr 1, 2006

We're a regional Level III...so we do transports and pick up babies that are as far as two hours away. I looked some stuff up:

"Although the TIOP designations provide a general framework for classification of NICUs, both interpretation and application vary widely within the United States, and no national definition exists."http://pediatrics.aappublications.org/cgi/content/full/114/5/1341

Gompers, BSN, RN · Apr 1, 2006

We're a regional Level III...so we do transports and pick up babies that are as far as two hours away.

I am in utter shock right now. I cannot believe that a regional transport center does not have an MD on the unit at all times. It's my personal opinion that any nurse working in a level III NICU without a doc or NNP there 24/7 is risking his or her license.

I would never want to be in court someday, trying to explain why a baby died or had a bad outcome because I was the one expected to intubate, change vent settings, run a code without a doc, diagnose NEC on an X-ray...

With the exception of specially trained transport nurses, none of those things are within an RN's scope of practice. At least, not as far as I know.

KK7724 · Apr 1, 2006

I'm sorry. I forgot to post that we do have transport nurses. We have an on-call Neo and a backup.

Gompers, BSN, RN · Apr 1, 2006

I'm sorry. I forgot to post that we do have transport nurses. We have an on-call Neo and a backup.

Right, but it's still not safe to have a level III unit with critically ill babies, and not have a doctor or NNP physically on the unit at all times. Maybe I've been sheltered and this is the norm in some places, to only have a doc on call. But I still don't think it's a nursing responsibility to analyze lab results and x-rays, and to change treatment (vent setting, etc.) accordingly. I mean, it's nice to have autonomy, and there are times when I wish I could write the orders instead of the docs...but in the end, I don't think any of this is legal.

BittyBabyGrower, MSN, RN · Apr 1, 2006

I have to agree with Gompers...I'd have to ask what the legal department of the hospital has to say about all this. You are diagnosising and prescibing from what I read. I would just be very careful, esp in my documentation. I think that asking multiple opinions isn't right....and if this is what you do, then you should be documenting exactly who you went to and what they said, just like if you went to the doc. I have never known of a level 3 that didn't have a doc on 24/7. But, as a transport nurse myself , I still have to defer to the fellow I go with. I pick up kids from other states, but that doesn't make me the one to diagnosis and treat! I just have a few other skills....anyone can transport.

I would be very concerned, esp with the reading of the xrays....what if 3 of you say the lines look good and you end up infusing into the mesentaric or portal? Esp if it has been infusing for hours...nothing like a good liver abcess or clot in the mesentaric to make a baby good and sick. And do you really think the hospital would cover that? No. You could kiss your license goodbye. And when you have a kid code, what if it needs a chest tube or needle aspiration immediately, and no one can do that, and the kid dies. Please don't tell me that you guys do chest tubes too, or I am going to faint! I am just having a million scenarios running thru my head right now.

Autonomy is a great thing, but what they are asking you all to do is bordering on malpractice. Just opinion.

KK7724 · Apr 1, 2006

The neos do come in for admits and they insert their lines. They wait for the x-ray to come back. They're called if we have to do a code...they have to pronounce the baby dead in that unfortunate event.

I agree with you about the too much autonomy thing and if I didn't feel comfortable in what my charge nurse told me, I would go over her head and call the neo. I have done that before. I chart books on my babies! Very very defensive charting.

Everything we're doing is legal. We do have legal teams at the hospital. We are joint commission certified and they have been in the area, so we're probably due soon to be surveyed.

I do have a lot of issues with the unit, but I just have to be very careful. Afterall...I get to move out of state soon and go to a university children's hospital (hoping there are NICU positions open). I have only been out of school for 10 months, so I question everything and I chart extensive notes.

Supposedly...from what I got from Education when I went through NICU Hospital Orientation (this is before going to orient in the unit). We were told about needle aspiration of the chest in an Emergency situation. Basically, the state covers you if it's an emergency only and absolutely no physician around or NNP....(like a transport for example). I know I never ever want to have to needle a chest. That is 100 miles beyond our scope! I think I have only heard of a transport nurse having to needle a chest en route and that was her only one ever.

Gompers, BSN, RN · Apr 1, 2006

I have to agree with Gompers...I'd have to ask what the legal department of the hospital has to say about all this. You are diagnosising and prescibing from what I read. I would just be very careful, esp in my documentation. I think that asking multiple opinions isn't right....and if this is what you do, then you should be documenting exactly who you went to and what they said, just like if you went to the doc. I have never known of a level 3 that didn't have a doc on 24/7. But, as a transport nurse myself , I still have to defer to the fellow I go with. I pick up kids from other states, but that doesn't make me the one to diagnosis and treat! I just have a few other skills....anyone can transport.
I would be very concerned, esp with the reading of the xrays....what if 3 of you say the lines look good and you end up infusing into the mesentaric or portal? Esp if it has been infusing for hours...nothing like a good liver abcess or clot in the mesentaric to make a baby good and sick. And do you really think the hospital would cover that? No. You could kiss your license goodbye. And when you have a kid code, what if it needs a chest tube or needle aspiration immediately, and no one can do that, and the kid dies. Please don't tell me that you guys do chest tubes too, or I am going to faint! I am just having a million scenarios running thru my head right now.
Autonomy is a great thing, but what they are asking you all to do is bordering on malpractice. Just opinion.

Great post.

I forgot about pneumos. That is another very good point - when a preemie on a vent gets a pneumo, they don't have time for a doctor to come in from home to decompress it. They have minutes before they start coding. We don't have codes very often anymore, but when we do, half the time it's because of a pneumo. Say that a nurse analyzed a blood gas herself, upped the vent settings (even by 1 on the pressure), and the baby blows a pneumo...what happens then? If the case ever went to court, the nurse is going to be blamed for changing the vent settings without first consulting an MD. Even if there are "standing orders" that doesn't mean that the nurse is going to be protected. If a baby's lungs are fragile enough to blow a pneumo, then they're too fragile for a nurse to be responsible for prescribing vent changes. Just my opinion.

Now I'm very curious, so here's a question:

POLL: How many of you work in level III units where there is NOT a doc or NNP on the unit at all times? If so, are you allowed to make changes on babies (vents, meds, feedings, etc.) without calling the on-call doc first for orders?

Gompers, BSN, RN · Apr 1, 2006

I do have a lot of issues with the unit, but I just have to be very careful. Afterall...I get to move out of state soon and go to a university children's hospital (hoping there are NICU positions open). I have only been out of school for 10 months, so I question everything and I chart extensive notes.

I'm glad that you're going to be moving on soon and I think you'll really like the children's hospital. If there are no NICU positions available, try PICU. If you don't like it, you can always put in for a transfer when NICU positions open up. Most hospitals will do in-house transfers first before hiring from the outside. You've only just begun your nursing career, and we all want you to have a long and happy life in this field. That's why we're so scared for you!

Good luck, and let us know how things go when you move and get your new position. How soon until the big move?

KK7724 · Apr 1, 2006

Thanks Gompers,

I'm glad to hear you said try PICU..because that's what happened! The NICU was completely staffed (it must be good!)...and I applied for a PICU position. The nurse manager called and she is wonderful! She was thrilled that I had ACLS...but things didn't work out...I was supposed to be moving in June...but my DH's job won't let us move until the end of August now.....I emailed her to let her know...she said something about possibly being able to "overhire" and that she could be selective about filling the positions. That sounds good huh?? :)