Any ICU ACNPs???

lifelong · Mar 15, 2010

You raise a great question. My graduate NP program included the use/benefits etc., but the program did not include individual training (landmarks, anatomy) or return demonstration. But found in my ICU practice we used it enough my collaborating MDs wanted me using it for therapeutics only. I had to go to a specific training (local medical school and SCCM class) and then have my docs demonstrate and observe me perform 7 of them before they would check me off. Then I added those to my SCA, DOP & credentials at the hospital.

But every program is different...yours might have included it. My program had skills days specific to suturing, lines, intubation, para and thora but not bronchos. Hope this helps.

Tracey

Harmonynurse · Mar 15, 2010

Working in ICU, I have encountered many times the ETT balloon were ruptures. What can we do? we can't removed the ETT and replaced another one. This patients are prone to get pneumonia because all the saliva goes to the lungs. Frequent oral and deep suction and keep head of bed up will buy some times. Marty6001 - do you mean put the bronchoscopy down throught the EET or trach? I don't think that's a good idea, it probably cause more long term damage than benefit. Unless the pulmonologist very gentle, careful and uses extra soft and small bronch tube.....

ukstudent · Mar 15, 2010

Working in ICU, I have encountered many times the ETT balloon were ruptures. What can we do? we can't removed the ETT and replaced another one. This patients are prone to get pneumonia because all the saliva goes to the lungs. Frequent oral and deep suction and keep head of bed up will buy some times. Marty6001 - do you mean put the bronchoscopy down throught the EET or trach? I don't think that's a good idea, it probably cause more long term damage than benefit. Unless the pulmonologist very gentle, careful and uses extra soft and small bronch tube.....

What do you mean, it can't be replaced? Of course it should be replaced if the ET tube ballon is ruptured. Can the bedside nurse do this, NO. But this is a forum for NP's. They should be able to do this. You must work in a very different ICU than mine if you dont change out ET tubes and don't bronch your intubated patients? :eek:

To the OP, if you are allowed to bronch will probably come down to the nurse practice act in your State and if insurance companies will let you bill for it.

Advanced Practice Columnist / Guide · Mar 15, 2010

Hey all you acute care NPs.. This one is for you..
I recently took on a position as an ACNP in a small community ICU. I am the first to be hired, and in the last year we were successful enough in lowering length of stay, ventilator days, and hospital acquired infections that a second ACNP has been hired and we are looking for a third...
Here's my question. I have a great collaborating doc who together we have mapped out what our practice agreement is. Intubations, central lines, alines, chest tubes, para and thora's in a code.. all ok.. Admitting without signout, discharging, declaring patients also ok. The question comes with using the bronch scope. I've used it successfully several times in patients with difficultly ventilating, going down the ETT I've found one ruptured balloon and one dislodged ETT. A third time I found a migrated new trach in a patient.
My attending was concerned that it may not be in our scope to use the bronch on patients. Anyone have any input on this??

Look into your state NP scope of practice and see if there are limitations. I would assume there wouldn't be any as long and as you're covered by your hospital's credentialing comittee and is checked off that you are trained to perform bronch's you should be OK. If your state requires standardized procedures then that's how you can be allowed to do procedures. I am an ICU NP as well and used to work in an ICU where the NP's did quite a few bronch's for BAL's. The attendings trained us to do bronch's and we also had a sim lab to practice the skill on. It's pretty much like playing a video game - a lot of hand-eye coordination (looking at the video screen while moving your dominant wrist in different directions while changing the direction of the probe with your thumb to advance it).

meandragonbrett · Mar 15, 2010

We can't removed the ETT and replaced another one. Frequent oral and deep suction and keep head of bed up will buy some times.

If you have a ruptured ETT balloon you have to replace the tube. Otherwise you are not going to achieve adequate ventilation. Orally suctioning the patient has nothing to do in regards to buying time.

Marty6001 - do you mean put the bronchoscopy down throught the EET or trach? I don't think that's a good idea, it probably cause more long term damage than benefit. Unless the pulmonologist very gentle, careful and uses extra soft and small bronch tube.....

Yes, the broncoscope is placed into the lumen of the ETT or Trach. How is that going to cause more damage than benefit?

I'm not sure most of us follow your line of thinking.

marty6001, EdD, EMT-P, APRN · Mar 16, 2010

Hmm, 2 interesting points brought up here?? Who doesn't replace the ETT when the balloon ruptures?? In fact, its quite easy using a tube changer to do, can get it down in less than 20 seconds...

As to the bronch, yes I mean going down the tube.. The few times I've done it I've gotten great visualization through the lumen of the tube and the chords... It's not to enter the lung, but to visualize the tube with the small lumen bronch. Nothing in the practice act either way and the hospital has basically said credentialing is at the discretion of my collaborating doc and myself... I'll let you know how it goes...

Advanced Practice Columnist / Guide · Mar 16, 2010

As to the bronch, yes I mean going down the tube.. The few times I've done it I've gotten great visualization through the lumen of the tube and the chords... It's not to enter the lung, but to visualize the tube with the small lumen bronch. Nothing in the practice act either way and the hospital has basically said credentialing is at the discretion of my collaborating doc and myself... I'll let you know how it goes...

Well, if you're just grabbing the bronch cart in order to pass the scope and visualize where the ET tube is in relation to the carina, that techically does not constitute a full bronchoscopy (i.e, the risks of complications are definitely not the same as full bronch and you may not be able to bill for this procedure as it is not a formal bronch). I think you shouldn't have to deal with any hassle to be allowed to do just this procedure.

I'm wondering though, since you were finding these problems with the ET tubes in your unit, shouldn't this alert the managers (or you as an APN) for a possible need for some kind of process improvement on ET tube care involving NP's and RT's (maybe loose tape jobs, need for a securing device other than tape for long-term ET tube patients). Our RT's routinely check pressure on the pilot so we are sure that our cuffs are inflated appropriately. RN's are also quick to alert us if they hear a leak around the ET tube or can hear a sound from the patient's vocal cords. I would hate to be the first one finding these things via a bronchoscopy.

marty6001, EdD, EMT-P, APRN · Mar 16, 2010

Well, if you're just grabbing the bronch cart in order to pass the scope and visualize where the ET tube is in relation to the carina, that techically does not constitute a full bronchoscopy (i.e, the risks of complications are definitely not the same as full bronch and you may not be able to bill for this procedure as it is not a formal bronch). I think you shouldn't have to deal with any hassle to be allowed to do just this procedure.
I'm wondering though, since you were finding these problems with the ET tubes in your unit, shouldn't this alert the managers (or you as an APN) for a possible need for some kind of process improvement on ET tube care involving NP's and RT's (maybe loose tape jobs, need for a securing device other than tape for long-term ET tube patients). Our RT's routinely check pressure on the pilot so we are sure that our cuffs are inflated appropriately. RN's are also quick to alert us if they hear a leak around the ET tube or can hear a sound from the patient's vocal cords. I would hate to be the first one finding these things via a bronchoscopy.

I think my question got mixed with someone's response. In my case, the two that I did were for loss of volume and increased pressures with inability to ventilate. So using the bronch I found the reason. I wouldn't go past the distal end of the ETT as there is no need. If I didn't find a quick reason in the tube, then of course, xray for placement and looking for other reasons (ptx, etc) would be looked into.

My question is have other APN's found issue at institutions with using the bronch scope for this reason. Not to bill for a full bronchoscopy, but for the in the moment need to assess a patient??