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Any NPs Administering Propofol?

MarylouNP MarylouNP (New) New

Specializes in general, interventional card and ep.

Hi, I am an NP in the Cardiac Services Dept (mostly Cath Lab/EP service for now). My administrator has proposed an addition to my responsibilities---administering propofol for our Electrophysiologists during DFTs/ICD implants/cardioversions.....I have been assured this is legal and within my scope of practice, but I will be looking into this myself. I plan on speaking with the NY State Board of Nursing tomorrow.....just wondering if any one else out there is doing this, what you did to become credentialed, any tips etc.....Thanks in advance!

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU.

I think you are wise to take it up with your state BON.

I think you are wise to take it up with your state BON.

.... and get their response in writing.

love-d-OR

Specializes in Transplant/Surgical ICU.

I am confused, as an ICU RN it is within my scope of practice to administer propofol. So, why can't you (an NP)? Is it because in the EP lab it would be used as an anesthetic? Are nurses only allowed to administer propofol to vented patient with a secure airway?

cardiacRN2006, ADN, RN

Specializes in Cardiac.

Are nurses only allowed to administer propofol to vented patient with a secure airway?

Bingo. We are only allowed to give it in pts with protected airways.

In addition, we are only allowed to give it as an infusion, not IVP. Whearas for conscious sedation/procedures it's given as an IVP.

I am confused, as an ICU RN it is within my scope of practice to administer propofol. So, why can't you (an NP)? Is it because in the EP lab it would be used as an anesthetic? Are nurses only allowed to administer propofol to vented patient with a secure airway?

The difference is that a RN follows orders and a NP gives them, just like a doctor. You can't even begin to compare our scope of practice or the liability associated with it. A NP may be a RN, but a RN is NOT a NP.

MarylouNP

Specializes in general, interventional card and ep.

Bingo. We are only allowed to give it in pts with protected airways.

In addition, we are only allowed to give it as an infusion, not IVP. Whearas for conscious sedation/procedures it's given as an IVP.

That is exactly the situation--I am being asked to administer bolus dosesfor moderate(deep?) sedation IVP. I can't find anything on the NYS Dept of Education/Board of Nursing website about NPs administering, only that RNs cannot administer or monitor pts receiving propofol without protected airways....

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU.

In IL, there must be an MD in the room and/or CRNAs can give in the OR (where full intubation/resuscitative equipment is readily available). There must also be someone present (in the room) that is trained and able to immediately intubate.

MarylouNP

Specializes in general, interventional card and ep.

In IL, there must be an MD in the room and/or CRNAs can give in the OR (where full intubation/resuscitative equipment is readily available). There must also be someone present (in the room) that is trained and able to immediately intubate.

How would it work if the MD in the room is the doc implanting the ICD (the operator)? Could an NP give the propofol and monitor the patient? Thanks for taking the time to respond here. :up:

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care.

We always have an anethesia resident and attending to administer anesthetics to non-intubated patients in the ICU during procedures that require some form of conscious sedation such as elective cardioversions. However, hospital policy only allows personnel from anesthesia to intubate in the ICU and us ICU NP's are not credentialed to intubate. I've ordered conscious sedation medications to already intubated patients in the ICU for bedside procedures such as bronchoscopies and thoracenteses that we can do on our own. I should try to find out what the protocol in our EP Lab is from our NP's in Electrophysiology.

How would it work if the MD in the room is the doc implanting the ICD (the operator)? Could an NP give the propofol and monitor the patient? Thanks for taking the time to respond here. :up:

Illinois is unusual as it is the only state (as far as I know) to regulate conscious sedation by CRNA's. The nurse practice act there has pretty explicit regulation of conscious sedation. It then goes on to lay out the educational requirements for the physicians (ie how much CME they must have to supervise CRNAs doing cases under their supervision). The requirements are different for general anesthesia.

In most other states conscious sedation is not addressed in the NP practice act. There are generally rules about anesthesia being the domain of the CRNA. Part of the issue comes from the PI of Propofol which states it should only be given by an anesthesia provider. However, off label use of a drug is common. There are a number of studies that show that it is safe when given for procedural sedation by trained RNs. Given that it should be fairly easy to show that it can be given by a trained NP.

The other issue deals with the RN license. I'll defer to the experts but if a procedure (ie Propofol administration) is specifically prohibited for an RN is it also prohibited to an NP (as the NP license derives from the RN license)? Assuming of course that it is not addressed in the NP rules.

The reason that this is probably germane is that Medicare issued rules last year allowing NPs (and PAs) to bill for conscious sedation. This can add between $3-900 dollars to a practice income for a sedation. As a number of others have mentioned only the BON can answer this question. The state law does not specifically answer it. However I not a number of red flags that may indicate they are not so inclined.

1. NPs in NY must operate under a practice protocol. I doubt any of the protocols are sufficiently new to address conscious sedation (specifically Propofol sedation). The ACNP book may address it. Caveat I have not read all of the books listed.

2. NY is very restrictive on who it allows to give anesthesia in an outpatient setting. For example on physicians are allowed to give GA in an office based setting for Podiatrists.

This is an interesting area for NPPs. Good luck

David Carpenter, PA-C

At one of the hospitals that I have privilages propofol is on the list of medications for moderate sedation that nurses can give. I am not credentiled for independant sedation, but I could give it as a RN under the RN protocol. Suprising the codes for sedation provide decent reinbursementm, not great but not bad.

Jeremy

MarylouNP

Specializes in general, interventional card and ep.

We always have an anethesia resident and attending to administer anesthetics to non-intubated patients in the ICU during procedures that require some form of conscious sedation such as elective cardioversions. However, hospital policy only allows personnel from anesthesia to intubate in the ICU and us ICU NP's are not credentialed to intubate. I've ordered conscious sedation medications to already intubated patients in the ICU for bedside procedures such as bronchoscopies and thoracenteses that we can do on our own. I should try to find out what the protocol in our EP Lab is from our NP's in Electrophysiology.

I would be interested in what your EP NPs do. Thanks for the info.:up:

MarylouNP

Specializes in general, interventional card and ep.

Illinois is unusual as it is the only state (as far as I know) to regulate conscious sedation by CRNA's. The nurse practice act there has pretty explicit regulation of conscious sedation. It then goes on to lay out the educational requirements for the physicians (ie how much CME they must have to supervise CRNAs doing cases under their supervision). The requirements are different for general anesthesia.

In most other states conscious sedation is not addressed in the NP practice act. There are generally rules about anesthesia being the domain of the CRNA. Part of the issue comes from the PI of Propofol which states it should only be given by an anesthesia provider. However, off label use of a drug is common. There are a number of studies that show that it is safe when given for procedural sedation by trained RNs. Given that it should be fairly easy to show that it can be given by a trained NP.

The other issue deals with the RN license. I'll defer to the experts but if a procedure (ie Propofol administration) is specifically prohibited for an RN is it also prohibited to an NP (as the NP license derives from the RN license)? Assuming of course that it is not addressed in the NP rules.

The reason that this is probably germane is that Medicare issued rules last year allowing NPs (and PAs) to bill for conscious sedation. This can add between $3-900 dollars to a practice income for a sedation. As a number of others have mentioned only the BON can answer this question. The state law does not specifically answer it. However I not a number of red flags that may indicate they are not so inclined.

1. NPs in NY must operate under a practice protocol. I doubt any of the protocols are sufficiently new to address conscious sedation (specifically Propofol sedation). The ACNP book may address it. Caveat I have not read all of the books listed.

2. NY is very restrictive on who it allows to give anesthesia in an outpatient setting. For example on physicians are allowed to give GA in an office based setting for Podiatrists.

This is an interesting area for NPPs. Good luck

David Carpenter, PA-C

Thank you for all the information and points you have raised; you have given me some more great starting points to research, and I really appreciate it.:up:

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care.

I would be interested in what your EP NPs do. Thanks for the info.:up:

I looked through our Pharmacy Drug Protocols and found that it does not specify which medical staff are allowed to administer Propofol. All it says is that the drug "should be administered in a monitored environment and by staff who are skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management. Facilities for maintenance of a patent airway, artificial ventilation, oxygen supplementation and ciruclatory resuscitation must be immediately available".

However, this is the email response I received from one of the NP's who work in EP:

"We use anesthesia department services in certain cases (pulmonary vein ablations, patients with severe COPD or heart failure, etc.). We use RN administered conscious sedation on other cases. We use Propofol on certain cases (generally these would be with anesthesia services).

How it works here is anesthesia provides personnel to cover one of our three labs everyday from Mon-Thurs. We schedule cases that must have anesthesia services in that lab. On Fridays and in the other two labs, we schedule cases that can be managed by our RN staff (pacemaker implants, defibrillator generator changes, SVT ablations, etc.). When RNs are administering conscious sedation, the drugs would be ordered by the EP fellow or staff attending on the case."

I have to remind you, though, that our hospital system is under a single and closed medical group model. All physicians are employees under this one medical group and revenues generated by each department go to that group. In this environment, competition for revenues between departments does not become an issue.

I looked through our Pharmacy Drug Protocols and found that it does not specify which medical staff are allowed to administer Propofol. All it says is that the drug "should be administered in a monitored environment and by staff who are skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management. Facilities for maintenance of a patent airway, artificial ventilation, oxygen supplementation and ciruclatory resuscitation must be immediately available".

However, this is the email response I received from one of the NP's who work in EP:

"We use anesthesia department services in certain cases (pulmonary vein ablations, patients with severe COPD or heart failure, etc.). We use RN administered conscious sedation on other cases. We use Propofol on certain cases (generally these would be with anesthesia services).

How it works here is anesthesia provides personnel to cover one of our three labs everyday from Mon-Thurs. We schedule cases that must have anesthesia services in that lab. On Fridays and in the other two labs, we schedule cases that can be managed by our RN staff (pacemaker implants, defibrillator generator changes, SVT ablations, etc.). When RNs are administering conscious sedation, the drugs would be ordered by the EP fellow or staff attending on the case."

I have to remind you, though, that our hospital system is under a single and closed medical group model. All physicians are employees under this one medical group and revenues generated by each department go to that group. In this environment, competition for revenues between departments does not become an issue.

This is a different situation. The OP was asking about state law. Credentialing is a whole different matter. Even if something is allowed by state law it may be prohibited by staff bylaws. There were two hospitals where I worked that only allowed Propofol to be used by BC EM and Critical care physicians (and then only in the ER and ICU) and anesthesia of course. No chance of a NPP using Propofol there.

David Carpenter, PA-C

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care.

This is a different situation. The OP was asking about state law. Credentialing is a whole different matter. Even if something is allowed by state law it may be prohibited by staff bylaws. There were two hospitals where I worked that only allowed Propofol to be used by BC EM and Critical care physicians (and then only in the ER and ICU) and anesthesia of course. No chance of a NPP using Propofol there.

David Carpenter, PA-C

Right, but I was responding to the thread where she said "I would be interested in what your EP NP's do".

MarylouNP

Specializes in general, interventional card and ep.

This is a different situation. The OP was asking about state law. Credentialing is a whole different matter. Even if something is allowed by state law it may be prohibited by staff bylaws. There were two hospitals where I worked that only allowed Propofol to be used by BC EM and Critical care physicians (and then only in the ER and ICU) and anesthesia of course. No chance of a NPP using Propofol there.

David Carpenter, PA-C

It is a different take than my original question but I did ask what the EP NPs in his hospital do. I am being asked to administer Propofol during ICD (defib) implants when they test the device by putting the pt into VT/VF then defibrillate the patient. Anesthesia at our hospital is not providing timely service, delaying cases (inpatient and outpatients) for hours!

MY hospital administrator is telling me that I am allowed to do this but I can't find anything myself is the NYS Scope of Practice that clearly states whether or not I can. I want to talk to one more manager at my hospital to see what documentation her and the administrator have before I call the BoN myself for clarification.

Credentialing is a whole separate mess. I started what I was told was the credentialing process for my institution. I am already ACLS certified. So I went to the moderate sedation class they told me I needed. It turns out it was the moderate sedation class that was part of our critical care orientation!!! What a joke! I talked to one of the EP docs who is recently certified--he had to take his ACLS (yes many docs are not ACLS certified) and be observed and signed off on airway management in 5 cases by an anesthesiologist.

Any and all comments are welcome. This is all going on in New York state.

love-d-OR

Specializes in Transplant/Surgical ICU.

"The difference is that a RN follows orders and a NP gives them, just like a doctor. You can't even begin to compare our scope of practice or the liability associated with it. A NP may be a RN, but a RN is NOT a NP"

Who was comparing scope of practices? I never did. My statement basically said --If RN's can give it, then NP's must be able to do it too. Because they have a wider scope of practice. Anyway, this was before CardiacRN2006, kindly explained the rationale behind all this. I think you might want to read the article I posted, you will see that "the difference is not because a RN follows orders and NP gives them". Yep, there really is more to that...

An RN is not an NP??? What really???? No waayy!!! ----> I can't read the tone of your post, but it sure sounds harsh!

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