Coming Soon? Will Nurses be Taking Over the Lab?

[Nerd eNurse]

It sounds crazy but a vague ruling but the Center for Medicare and Medicaid Services could be interpreted that way.

I have been discussing, with Clinical Laboratory Scientist's, what current communication between nursing and the lab is like and how we can improve this relationship. I have been working on trying to standardize blood collection across the continuum. During my research I found out that the Center for Medicare and Medicaid Services (CMS) recently ruled that a Bachelor of Science in Nursing is the equivalent to a Bachelor of Science in Biological Science.

Here is an excerpt from that ruling:

Quote

"Bachelor Degree in Nursing: A bachelor's degree in nursing meets the requirement of having earned a bachelor's degree in a biological science for high complexity testing personnel. The laboratory may show a PSV report verifying that a bachelor's degree in nursing was earned, a diploma with the type of degree earned, or transcripts as evidence of meeting the education personnel requirement. An associate's degree in nursing meets the requirement of having earned an associate's degree in a biological science for moderate complexity testing personnel. The laboratory may show a PSV report verifying that an associate's degree in nursing was earned, a diploma with the type of degree earned, or transcripts as evidence of meeting the education personnel requirement. "

I don't understand why this was done and would like to learn more. Where better to gather information than here on allnurses? Therefore, I am asking for you to help me in identifying what this all means. Can we wear any more hats? Is this going to put more stress on a career that is already overloaded with responsibility? Does this mean a BSN can be a lab director? Does this mean that a BS in Biological Science can be a CNO, or ICU director? Is this another way of dealing with shortages by trying to combine resources? Doing more with less? Both nursing and the laboratory science field are experiencing shortages. This is a very confusing ruling. (view attached pdf)

I can tell you that the Clinical Laboratory Scientist community is not happy and would like our support. The American Society for Clinical Pathology (ASCP) is encouraging everyone that has an interest to sign a petition to get the CMS to reconsider its decision. For starters the ASCP says a biological science degree requires three to four times more academic science than does nursing. This CMS ruling seems to be a very broad ruling and deserves to be scrutinized. This can cause a rift between nursing and the lab if the reasons for the ruling are not spelled out.

The ASCP Board of Certification (BOC) has been talking with staff from the Centers for Medicare and Medicaid Services (CMS) about this decision. The CMS memo does not provide a rationale or justification regarding this decision. The BOC communications are on behalf of the Board of Governors (BOG), whose member institutions include:

• ASCP (American Society for Clinical Pathology)
• American Association for Clinical Chemistry (AACC)
• American Association of Pathologists' Assistants (AAPA)
• Association of Genetic Technologists (AGT)
• American Society for Clinical Laboratory Science (ASCLS)
• American Society of Cytopathology (ASC)
• American Society of Hematology (ASH)
• American Society for Microbiology (ASM)
• AABB
• Clinical Laboratory Management Association (CLMA)
• National Society for Histotechnology (NSH)

They are taking this very serious so it makes me think it deserves a good looking at. I wonder what the impact will be for nurses. With your help we can formulate what this ruling may mean to nursing and what potential impact this will have. In my limited research I can't find where the American Nurses Association, Nursing Boards, Nursing Unions etc. have weighed in on this subject. I don't think this subject matter has been exposed enough and may not be on their radar yet.

Have you heard about this? Has this affected your job? What do you think?

Survey-and-Cert-Letter-16-18.pdf

[Nerd eNurse, ADN]

CMS does not really say that the BSN and the BS Bio or so are equivalent meaning they are the same. Of course they are not. Though there is the word "science" in BSN .... CMS put out that they view the BSN as a science for the purpose of lab testing , which would mean that nurses are technically allowed to perform certain tests in certain categories that were limited to staff the has studied a science science and have the lab experience.

Thank you for all of the information. I don't know who is upset but I am not. Yes, I did make a couple of provocative comments but that was to get attention for a subject that on the surface is not of great interest to nurses. As far as the impact of the CMS ruling goes.... what lab testing is a BSN not allowed to do? I am probably wrong but it looks like a BSN can do any testing a lab scientist is certified to do. I don't see why the ruling had to be so broad. I would like to know the intent of the ruling. I don't think nurses are going to flock to the lab but I wonder if nurses are going to be expected to take on more responsibility.

[catsmeow1972, BSN, RN]

Hmmm...I have done trauma, transplant, big orifice complicated surgeries, etc. as an OR nurse. I've also dabbled in critical care (just not my cup of tea). I can draw out of a central line, I can run an arterial blood gases given to me by anesthesia. I can do I-stats. Great. I can look at the results and make a quickie assessment on it. FINAL decision on it comes from the surgeon/doctor OR the lab. I've taken a bunch of classes for my BSN. They were not so much watered-down as they were focused on NURSING, not LAB.

I love and appreciate my lab folks from the phlebotomist (some of those folks can draw from a rock and still get 4 tubes of blood) all the way to those running and managing the equipment and the seemingly infinite number of various specialties. No way in h*** could I do that.

No folks, Laboratory management cannot be filled by a BSN regardless of what asinine ruling has come from CMS. Just like another blooming discussion here on AllNurses, a BSW in Social Work does not qualify a person to do physical assessments, as a BSN does not qualify a person to do therapy for behavioral issues (just an example). A BSN qualifies me to be a nurse and take care of my patients. Also to know when to utilize my colleagues. Just because we all have a BS-something, in no way makes us interchangeable.

[Nerd eNurse, ADN]

Hmmm...I have done trauma, transplant, big orifice complicated surgeries, etc. as an OR nurse. I've also dabbled in critical care (just not my cup of tea). I can draw out of a central line, I can run an arterial blood gases given to me by anesthesia. I can do I-stats. Great. I can look at the results and make a quickie assessment on it. Just because we all have a BS-something, in no way makes us interchangeable.

Great comments. The more responsibility we have the less we can spend thinking about giving the best care we can too our patients. If there is a need to have nurses do specific lab testing then CMS should spell it out or identify a BSN with what other requirements(science classes etc.) are needed. I think we need to keep these fields separate. If we don't pay attention to this ruling we may find that down the road they will rule that phlebotomist will be allowed to draw blood off of central lines.

[Julius Seizure]

if all units adopted iSTATs nurses would take over a much greater responsibility in running and interpreting basic, frequently ordered labs. I'm sure the machines and cartridges are expensive, but they can't be more expensive than staffing the lab.

So, in my ICU, we aren't allowed to use the iSTAT for labs without a specific order from the physician that it is warranted.

The reason isnt because it costs more exactly....but the cost isn't billable to insurance in the same way. It is still about money, however you look at it.

Now, seeing as this memorandum came from CMS, perhaps it is aims at allowing bedside POC testing like the iSTAT to be billed equivalently. That wouldnt mean that nurses were taking over the lab, but would potentially expand the use of iSTAT testing which, especially in ICUs, could be a very helpful thing.

[adventure_rn, MSN, NP]

So, in my ICU, we aren't allowed to use the iSTAT for labs without a specific order from the physician that it is warranted.

The reason isnt because it costs more exactly....but the cost isn't billable to insurance in the same way. It is still about money, however you look at it.

Now, seeing as this memorandum came from CMS, perhaps it is aims at allowing bedside POC testing like the iSTAT to be billed equivalently. That wouldnt mean that nurses were taking over the lab, but would potentially expand the use of iSTAT testing which, especially in ICUs, could be a very helpful thing.

Very interesting insight! I read a couple of cost analysis articles which found that iStat labs cost less than standard labs to run, but I hadn't considered the billing issue. I'm sure that hospitals don't give jack squat about the cost effectiveness of iStat testing if they aren't getting reimbursed for it at an equivalent rate. I definitely agree that patient care could benefit from increased POC testing utilization. Perhaps this new policy will help make that possible.

[Nerd eNurse, ADN]

The reason isnt because it costs more exactly....but the cost isn't billable to insurance in the same way. It is still about money, however you look at it.

Now, seeing as this memorandum came from CMS, perhaps it is aims at allowing bedside POC testing like the iSTAT to be billed equivalently. That wouldnt mean that nurses were taking over the lab, but would potentially expand the use of iSTAT testing which, especially in ICUs, could be a very helpful thing.

Good point but why don't they just say that in the ruling?I don't know if the ruling is good or bad but it definitely is broad. Thanks for the comment.

[RiskManager]

Speaking as someone who looks at these issues from an enterprise risk management perspective, I would be concerned about putting a BSN into a lab role. Unless they meet the qualifications for a MT/MLT/CLS, I would not think that a BSN has the training, experience or competence to do many of the lab tests in the lab. POC testing is another matter.

CMS does not establish the standard of care, and if my BSN/lab tech makes an error in a test with adverse results to a patient, they will be held to the standard of care of a lab professional. I would imagine that the plaintiff could find lots of MT/MLT/CLS willing to testify on the lab standard of care and how a BSN, without additional training or experience, is not qualified and therefore breached the lab standard of care. I would also seek clarification from the state BON that working in a lab would be within the scope of practice and licensure for a BSN.

[Nerd eNurse, ADN]

CMS does not establish the standard of care, and if my BSN/lab tech makes an error in a test with adverse results to a patient, they will be held to the standard of care of a lab professional. I would imagine that the plaintiff could find lots of MT/MLT/CLS willing to testify on the lab standard of care and how a BSN, without additional training or experience, is not qualified and therefore breached the lab standard of care. I would also seek clarification from the state BON that working in a lab would be within the scope of practice and licensure for a BSN.

Thank you for the comment. CMS does not establish the standard of care so this interpretation can mean many things to many people and they could all be right just dangerous. The BON is on my radar but my experience is that they prefer to be vague also. I had questioned them about the liability of nurses pushing certain medications and I was told that the facility determines the scope of what drugs nurses are allowed to push or not. The comments that I have been getting on this article have been very helpful. Thanks again!

[la_chica_suerte85, BSN, RN]

The only thing I'm aware of is, at my facility, they are relying less and less on lab for bedside draws. We also had something implemented in terms of being survey-ready that our state's regulatory body requires to do a urine dip and spec grav a minimum high school diploma is needed. To train someone on said machine, a minimum BSN is required. Our hospital needed copies of everyone's diplomas to show who was who and who had what. It's weird. I don't know what they want in terms of POC but there is something in the air. As far as nurses taking over the lab? Lol, ain't no one got time for that!

[WKShadowNP, DNP, APRN]

As an ER RN I use POC testing often. The i-Stat for creatinines and lactic acids come to mind. I also use the FSBS, UA and urine HCG for POC. However, we have to annually pass a test and be signed off by the senior MT to be able to use that equipment.

[nutella, MSN, RN]

Thank you for all of the information. I don't know who is upset but I am not. Yes, I did make a couple of provocative comments but that was to get attention for a subject that on the surface is not of great interest to nurses. As far as the impact of the CMS ruling goes.... what lab testing is a BSN not allowed to do? I am probably wrong but it looks like a BSN can do any testing a lab scientist is certified to do. I don't see why the ruling had to be so broad. I would like to know the intent of the ruling. I don't think nurses are going to flock to the lab but I wonder if nurses are going to be expected to take on more responsibility.

No - I do not think that the purpose is for nurses to engage in complexity lab tests.

It seems to me that you wonder a lot about this whole issue. The ones who are highly upset is the personnel that works in labs as they feel that nurses could take their jobs - they feel that nurses are not sufficiently prepared.

Since we are mostly nurses here and I guess most of us would not be interested in working in a lab perhaps you need to ask folks for a lab organization or such.

[nutella, MSN, RN]

Good point but why don't they just say that in the ruling?I don't know if the ruling is good or bad but it definitely is broad. Thanks for the comment.

It seems that you are not dealing with regulatory stuff on a daily basis. Not only CMS but generally all regulation language is somewhat difficult to understand for the person who is not working in that area every day or has more extended knowledge. Which is the reason why usually there are "comments" to a memo.... which often clarifies how something is interpreted.

Regulations often seem "broad" but when addendums and comments come out after that to clarify the language it is not always that broad.