Dermabond Scope Situation (CA)

[240zRN]

I am caught in a dilemma here. I work in a triage area within a prison facility that operates similarly to a rural ED. We receive a patient who was involved in an altercation and presents with multiple lacerations to the face including a 3cm long superficial and well approximated lac to the R side of the forehead. I am working with another nurse under an NP (who is attending). Upon receiving the patient I perform my initial full body assessment, get my vitals, and begin to clean and irrigate wounds. Usually for fine well approximated superficial lacerations we successfully use dermabond to close them-the RN can apply them with the order of a provider. The NP leaves the room while I continue to clean the wound and prep the one wound for dermabond--the other lacerations will require sutures based on side, depth, and location. She comes back in the room sees me preparing the dermabond and doesn't say anything more than "don't worry about it I can take care of it" (I didn't know what this really meant at the time). In an effort to be efficient, I finish dermabonding the forehead lac and it came out great. She comes back in the room and tells me "What are you doing? Is dermabond in your RN protocol? I didn't order that!" And pretty much tells me off in front of officers and the patient--my partner takes over at that point.

Long story short, she refuses to sign the dermabond order and accused me of practicing out of my scope; she also states she will look to inform the board that I am practicing out of my scope. A doctor who I have a good relationship that works with us often signed off on my dermabond verbal order, however, the chief physician got involved and we had a conference that pretty much came down to my actions being disrespectful and a breach to patient safety.

Mind you, I will admit to fault for assuming that all of the providers that step foot in out treatment-triage area will adopt the culture and style that we operate in. I have learned a valuable lesson to be more careful and read providers more carefully rather than make assumptions about clinical pathways.

My main concern is keeping my license healthy and strike-free. How bad could this get for me? Could this situation potentially cause a bad mark on my record? I have been worried sick for the past day just thinking about it. I have also come to find out that California doesn't really have defined guidelines for RNs and their scope when using dermabond; also, my facility doesn't specifically define whether dermabond is something to be used within out RN protocols even though it recognizes it as an intervention in RN training literature.

Any input would be appreciated.

[Sassy5d]

I love it when people's initial reaction is to report you to the board.

IMO, such action is best to be kept when malice or plain ignorance is used to carry out a task. For example, giving all your Pts lactulose so the next shift gets literal crap on them.

That sounds like more of an internal compliance issue and not a board issue, but if they report you, they report you. I would not stress out about it until you get to that point. A lot of work is involved in reporting someone

[240zRN]

I emailed the board and this was their response:

Dear ****, the application of Dermabond is covered under b&P 2725 (b)(1), direct and indirect patient care services that ensure the safety, comfort and personal hygiene and protection of patients. An order is not required, and the RN must of course be competent in the procedure. the institutional policy covers the RN for this intervention. **************NEC

****staff note: name of board employee removed per ToS****

[mish_RN]

I have used dermabond in our ED in fast track. Our mid-level practitioner had no issues about it.

[SweetMelissaRN]

That really sounds like someone on a stupid power trip, especially if it's a new person or someone who doesn't work there frequently. Honestly I wouldn't worry about it too much. The board will not find you at fault for anything, the only issue that may arise is within your facility. Sorry you're having to go through this, let us know how it turns out for you!

[240zRN]

Yes, I didn't want to mention the politics behind it, but there are definitely personality issues behind this situation.

I have asked the board more about clarification regarding the need for an order, this was their response:

****,

You are asking about whether an MD order is needed for the registered nurse to apply the Dermabond. Although this procedure is within the SOP of the RN, the facility can require an order - should be clarified by your facility to address your concern.

I hope that helps.

Sincerely,

*************

Nursing Education Consultant

------------------

The problem I have is that, looking through my protocols, my institutional policy recognized Dermabond and liquid adhesives for the closure of superficial lacerations that do not go past the epidermis, but there is no mention for the need of an order. I am waiting to hear back from the board about whether an RN can face disciplinary action for applying dermabond without an order, given the nature of the current institutional policy.

I'm not sure why I've become so obsessive with this, because if you read my first post I actually got the verbal signed by another MD, but I suppose its the principle of the matter. I'll keep you all posted.

[canoehead, BSN, RN]

It sounds like a misunderstanding to me. If other providers like it one way and she prefers another, and apology should have done it. And you can just peel the Dermabond off if she wants to suture the thing. What did your employer say? (Surely she spoke to your supervisor before going to the BON.)

[HikingNinja, BSN, MSN, DNP, RN, APRN, NP]

OMG! This is almost EXACTLY what happened to me a couple of years ago. Basically, I dermabonded a very small lac per my physicians verbal order. In my case however another nurse saw me doing it & said "that's not in our scope of practice... You shouldn't be doing that" I let her know that indeed it was in my scope, finished the job I had started, & went about my business. Weeks later I get a very serious write up & sit down meeting about going outside my scope with this. I was so mad I not only contacted my state board but also contacted nearly all other BONs in the US. Not one said applying dermabond was outside our scope. Several had board decisions stating it was within our scope. I was so mad! After I got the union involved I ended up with a warning for doing something that our facility had no specific policy addressing. I didn't know it at the time but we did have a written policy, it was just common practice for those of us trained to use skin adhesive to do it. The warning was removed from my HR file after 6 months per policy.

To show you how utterly stupid the whole affair was I interviewed for a per diem job at another facility & they asked if I had any disciplinary action in the last few months. I honestly answered about the dermabond debacle & the manager laughed so hard she started crying. Her exact words were " We don't waste our resources pursuing petty things like that here." True to her word I've never gotten harassed, written up for things at there even when I did things they had differing policies on than I was used to. They simply educated me on their policy & we all moved on about our business.

To the poster, let me know if you need anything. I wrote a paper which included survey results from the state BONs and a draft RN skin adhesive application policy for my facility. Yes I know, a bit over the top but they had me flaming mad. In the end they did not adopt the policy because MDs, NP , PA could bill for dermabond application as a wound repair but you could not get $$$$ for an RN doing it. Oh and on a side note I also had the NP who taught me home & when to apply dermabond properly write a statement saying he trained me & watched me apply it many times before he said I could go it alone (which he did - no one wants to accidentally glue an eye shut :)

D

[ezgreazin]

Prep it next time and simply ask,

"um, can you assist and hold the wound closed? thanks."

[rn619]

The clown with the red wig on lovekin misses you.

[Kidrn911]

Do you have a standing order in your ER that covers that? If you do, no worry, if you don't then don't do it without getting a standing order. Either way talk to your manager. That should never have been brought up in front of a patient.