ACLS question

KneKno · Jul 17, 2009

Does your hospital have any standing orders to cover these situations? Most of our tele- and ICU patients have a signed "Arrhythmia Orders" form in the chart, based on ACLS--pretty much covers the first few minutes of a code. First doses of amiodarone (push and IVPB loading), atropine, epi. These are also included in the Rapid Response team standing orders, so they can be implemented while the MD is being contacted.

thursmo · Jul 17, 2009

It would depend on hospital policy. We had somone who was a paramedic who also worked in the cath lab. He is very capable of intubating pts. but would get spanked if he did it in the lab because he was not covered if anything went wrong wit the pt. not just with the tubing

GilaRRT · Jul 17, 2009

As stated earlier, much will depend on facility policy and procedure. Some facilities may have protocols or standing orders in place to cover specific interventions in cases of emergencies. Actually, I think such a plan should be in place in most facilities.

Having nurses provide immediate protocol based interventions such as; defibrillation, basic airway management and use of rescue/alternative airways, and perhaps the administration of medications in cardiac arrest may be helpful.

Of course, one could argue the current evidence base really does not support administering medications in cardiac arrest; however, special situations such as hyperkalemia and overdose may apply.

Otessa, BSN, RN · Jul 17, 2009

You need to follow the policy and procedures of your place of employment and scope of practice. You may know how to do something-doesn't always mean you are legally covered.

otessa

Medic/Nurse, BSN, RN · Jul 17, 2009

i can appreciate the confusion of the op when asking the questions - if i understand correctly

1. was it "legal" for a nurse to give atropine or lidocaine to a patient that was experiencing a clinically significant arrythmia?

most likely yes. the most likely presumes that there are "standing orders" that physicians write in advance that, in fact, are the same as any other physician order. these standing orders (prn) usually cover certain patients in many clinical units - icu/ccu, pacu, ob, cath lab. most all units that i am familiar with have "routine" unit orders that cover common clinical presentations and usually include acls drugs and interventions.

i.e. acls may be initiated in an emergency situation by a rn with acls/demonstrated unit competencies prior to a physician being present bedside. symptomatic bradycardia should be treated with atropine at 0.5 mg ivp ....

imagine the outcome if these orders were not available and a patient went into v-tach with a pulse or bradycardia with hypotension and hypoxia. without immediate intervention these conditions will likely have deadly consequences. it may take time to contact a md that the patient does not have - even rapid response teams take time to respond. having good standing orders and well prepared clinicians are hallmarks of good patient care. your yearly unit competencies are important - know your stuff - know your equipment - be prepared as if life depends on it - it does!

the key to acls is not just in a "code" situation. the ability to avoid a patient "coding" is often what differentiates excellence among clinicians. any monkey can be trained to "run" a cookbook code - but, it is the astute clinician monkey that will keep the patient from coding. sometimes there is no substitute for experience. :monkeydance:

2. does having acls allow any acls nurse to administer acls anytime, anywhere?

no. nurse operate on orders - verbal, written, standing. any nurse that chooses to takes matters into their own hands - will have handfuls of troubles. i understand the desire and drive to help and save a life. the life you will put at risk when you "freelance" will be your own - regardless of outcome.

i encourage you to be familiar with your state nursing practice, your facility policy and procedure manuals and unit specific standing orders and competencies. these will guide you.

practice safe!

Editorial Team / Admin · Jul 18, 2009

As pointed out by others, certification does not qualify anyone to "push drugs". It is simply a certification given once satisfying the AHA written examination and "megacode" checkoff.

Facilities should have in place written protocols for "codes" with and without physician presence.

In the situation outlined by the OP, the stent "shutting down" is not even covered in ACLS protocol. And, the ACLS protocol dosage for symptomatic brady isn't Atropine 1 mg. - it is 0.5 mg.

This nurse was practicing medicine w/o a license and if this is his/her normal behavior, will be seeing the inside of a courtroom one day.

Meriwhen, ASN, BSN, MSN, RN · Jul 18, 2009

They told us in ACLS that though each one of us will get to do everything in the megacodes, in real life we all have to stay within the scope of our practices. So if ordering drugs or pushing drugs w/o an order isn't within your scope of practice, then you shouldn't be doing it.

GilaRRT · Jul 18, 2009

Also know, ACLS is NOT a certification. AHA does not certify you. No where on the provider card does AHA say you are certified to perform ACLS.

Cinqly, BSN, RN · Jul 18, 2009

So, even if the hospital writes a policy doesn't the state nursing practice act still govern the practice of the nurse? I understand standing orders can be written, but isn't a policy just a policy? Hospitals can write policies for anything, but it doesn't necessarily mean we can DO all the things written in a said policy? Just wondering...

GilaRRT · Jul 18, 2009

True; however, find a state BON that does not allow a RN to administer front line cardiac medications in an emergency situation.

RNKPCE · Jul 18, 2009

Where I work tele, standing orders cover us. On med-surg hopefully a rapid response will be called first( they have their own standing orders) if not it is likely you are already in a code situation and then cover by the standing order/hopsital policy of a code.

The only in house doctors we have consistently are the ER doctors it can be several minutes before they arrive to assist in a code. At our hospital it would be negligent to not defib, pace or administer atropine while waiting for the doctor to arrive.

A doctor once told us that he worked at a hospital that would only let staff defib a patient if an MD was present. He had a patient who was rescued by a lay person using an AED in the airport then admitted to this hospital =. He was furious to think his patient was safer in an airport than in a hospital. He got the policy changed.

dyaryan · Jul 18, 2009

Thank you everyone for your input. In the situation where the RN pushed atropine, she indeed pushed 0.5mg. When it was brought to the attention of the physician who had performed the procedure on the pt...she said "you should have pushed 1.0mg" Scary...huh...the RN was better prepared to address this pt's bradycardia. With 0.5mg, the pt immediately jumped to the 70's-80's, and needless to say felt SO much better. In the case of my patient, I work in a small unit. Everyone was doing something...getting an EKG, replacing the fluid that was almost out, I was on the phone with the cath lab/Dr.when the RN pushed the lidocaine. I'm really torn...she probably prevented that patient from going into V-tach/fib by her quick thinking. I realize the significance of "preventing" a code and she is far more experienced at dealing with cath lab situations-gone-sour than I am. My experience is tele..more "floor" nursing. I'm used to calling a pre-code(ACAT) team or a code, starting CPR and having the team arrive and run it with a doctor ordering what and how much to push. This hospital has few protocols or standing orders. A frustration I tried to remedy on Tele before I left...to little avail. I feel sometimes like there is little in place to protect me ..the RN. This entire experience has been a huge learning experience. I've spent a lot of time picking them apart and analyzing why, what, when. Now I need to research what was "legal" according to hospital and our state board of nursing. Thanks again everyone.