I recently encountered yet ANOTHER incident whereby big Pharma/Medical Device Companies are re-writing hospital policy and procedure and even going against nurse practice acts, in order to sell more wares.
Case in Point:
New epidural pump being introduced within hosp. by two RN's representing a well known medical device/medical supply company. This new pump has a BOLUS feature. These RN's were teaching all participants to use the pump, including the bolus feature, which, was taught as INITIAL BOLUS......I questioned this right away. I was ALWAYS taught that ANY epidural infusion was to be bolused only by a DR.....esp. INITIAL BOLUSES, because RN's are not trained to know epidural placement, etc.....it isn't like getting a blood return on an IV and knowing that you are "in the vein"....not to mention all the very very bad things that can go wrong...ie, dura rupture, cath migration, resp. arrest, too high of anesthetic action, paralysis of extremities, cardiac arrest, etc....
SOOO, when I asked, "Isn't this supposed to be done by a DR?, the two RN's said, "well, in some places, it is true, but we teach this feature anyway." When asking what the nurse practice act states for our state, neither of these RN's could tell me what the position was by the BON on this issue.....when asked further, "what does hosp. policy and proced. say?", they were equally unsure.
After some investigation, the dusty policy does not even ADDRESS INITIAL BOLUSING....it only vaguely speaks of increasing the continuous dosing "per doctor's orders."
What are your thoughts on this, and what does your institution say about vendors who come in and teach through inservices something that is counter to acceptable practice or written policy?
New epidural pump being introduced within hosp. by two RN's representing a well known medical device/medical supply company. This new pump has a BOLUS feature. These RN's were teaching all participants to use the pump, including the bolus feature,
OMG! This exact senario happened at our hospital. Our educators (whom were absent during the presentation) were freaking out when they heard that the vendors taught us to bolus!!
I blamed the educators. They should screen all vendor presentations prior to staff education. Another fabulous implementation which required reactionary, mandatory re-education. We all have time for this.
We also had a vendor doing education on a triple lumen dialysis catheter (extra port for IV infusions). He was calling the extra port a PICC line. Please! The educator was right there letting him say it. AHHHH!!!
We NEVER give initial boluses where I work. What we can do is bolus Astromorph when ordered (this came under question for a few months when it was found that we were the only hospital in the state doing it, so we stopped until the BON said it was acceptable practice), titrate per orders, and we've always been able to d/c epidurals when ordered (I've been there 7 years, never knew different). I didn't receive any special competency for it, they just trained me. But initial boluses? Never. Policy covers all of these points. :)
Specializes in ICU;CCU;Telemetry;L&D;Hospice;ER/Trauma;.
to jmgrn: Would you mind sharing what your competencies are for your state and what is required of you yearly for your epidural catheter maintainence, etc.? I am curious what is required because it is something that is so varied from state to state....thanks.
In our hospital our anesthesiology dept wrote their own set of policies regarding epidurals and such. I work in PACU and we do not start the initial infusion, they do. They connect the actual tubing to the catheter port. We can and do prime the tubing and set the infusion rate as ordered by them. We can titrate based on established(by them again) protocols. We can D/C catheter with an order and have been trained to do so(by another RN in our dept). I am concerned when I see so many agency nurses on our floors who do not know how to work the pumps and yet are assigned these patients.
Also, we never bolus the infusion. This is per the anesthesia protocol again and while they whine and complain, we tell them these are THEIR protocols and if they want to re-write them and inservice us, we will talk about it.
We always D/C epidural caths with another RN to check the catheter tip and the site for bleeding and hematoma.
Training was given by an Anesthesiologist, we took a test, a competency and demonstrated pulling the epidural. WE do check INR if patient is on anticoags. We are well educated. And why do you seem to be attacking me? for our hospital policy. There isn't much we don't pull or d/c. We have had proper training. We are a teaching hospital, and a magnet hospital (well I know that doesn't mean anything) But we are good hospital.
As far as intial bolus all of our patients come with them already in place. I don't know if they do intial bolus in L&D or PACU. But I wouldn't be surprised if we do.
It's not really an inappropriate question. It sounds like you are well covered but as a traveler I've found nurses frequently performing function specifically not within their scope per their Bd. of Nsg. simply because they were told to. I always check the regulations of the state board when I go to a new one. Some of these more naive "young" nurses actually still believe they will be covered in an adverse event "because the had an order"!
Specializes in ICU;CCU;Telemetry;L&D;Hospice;ER/Trauma;.
to jmgrn: I was not attacking you, and I am sorry you took my questioning that way.....I am mostly just trying to find out from you how you obtained your competencies, who certifies you to do what you do with epidurals, and if your state encompasses this within your scope of practice through your own BON.....THE reason I am asking this is because this is a VENDOR who is generating the policy and how it is to be followed in a hospital, as opposed to what is the BON"S mandate on it....all in the name of selling more product and at the expense of nurses who are naiive or ignorant of the BON's regulations....I am happy that you seem to have received more than just a small inservice, and that you have received competencies in this situation....my concern is that when VENDORS come in to a hospital and start TEACHING a procedure to nurses that may not be in their scope of practice, both a PATIENT and a NURSE will be put at risk....
When I asked you who taught you, I was hoping you weren't going to say, "well, the RN from Company A taught us for an hour, and then left...." one of those deals.....
I think the other writers here understood my line of questioning, because they have traveled enough to understand that NOT ALL PLACES are the same....yet, that drug rep, or company vendor isn't going to teach you from the perspective of what is within your scope of practice, nor are they too much concerned what effect this may have on a patient....they are mostly concerned with their commission....which isn't a great support system for patient and nurse safety....
So, if my questions seemed to rub you the wrong way, mea culpa....
I started this thread because I wanted to know if anyone else in the nursing universe has ever encountered some of this....
I believe we are going to see more and more of this....where vendors are allowed to come in and teach staff...not according to THAT hospital's policy, but according to their bottom line.....and if there is a chasm between what the hospital says in policy and procedure and what is taught to the nurse, it will fall on the NURSE to understand the difference....I also find it troubling that I see vendors pretty much generating what the hospital policy will say...ie, THEIR product is written into the policy, so that issues of concern, like patient safety, or nurse safety, are just secondary concerns....
This was my point and my agenda in asking you. I hope you are better able to understand this now. Thanks....crni
Specializes in ICU;CCU;Telemetry;L&D;Hospice;ER/Trauma;.
And to answer your question of "no, I don't know what that is or what it has to do with pulling epidurals"....
My questions have to do with understanding the level of teaching you received, as you indicated earlier, in a previous post that you didn't see what the big deal was....or something to that effect....
I wanted to know if you really understood epidural anesthesia as related to dermatome levels....(these are basic teaching tools used to help nurses monitor the level of anesthesia and how deep the anesthesia is...ie, you don't want an epidural dermatome level to get too high anatomically on the body, say, over the chest area, because it can affect respiratory status....) Since you also stated that you regularly pull these, I was curious to know whether or not you understood through your competencies the things that can go wrong, and the things for which many nurses have been sued....
ie, not reporting neurological changes....ie, "I can't feel my legs"...."I have a terrible headache"....etc....."only one side of my body is numb...I can feel the other side" (unilateral anesthesia)....
I think it's good that an anesthesiologist inservices you on this device....but again, my concern is that the teaching that is happening in some hospitals comes from VENDORS,not anesthesiologists, and many nurses taught this way, will not know cardinal signs of trouble to watch for....they will just bolus their patient and think they are doing the right thing, because, by golly, they went to A INSERVICE on it!! THey won't know what their BON says, because they foolishly believe that because their hospital is a Magnet hospital, or because it was an RN trained by a company, working for a company, selling a device, "that it just must be okay!!".....and sadly, THAT ISN"T THE WAY IT IS!!
The place I work at right now, is also a magnet status hospital....but they still let the vendors in to teach initial bolusing....which isn't in our scope of practice here....
To me, THIS IS A BIG DEAL....because it's my license on the line....and mostly, it's my patient's safety on the line....
I work in Pacu and we are allowed to program in a bolus on our pumps as dictated by the anesthesiologist. We can also change rates, etc.. But this is not allowed on the floor. As far as the initial bolus... if you assist in epidural insertion you know the initial bolus is done at time of insertion per the anesthesiologist. He assures placement at that time. Our anesthesiologist see all patients with epidurals daily. I don't think you are that interested in what others do about epidurals though. I think your problem is with Vendors dictating hospital policy. Hopefully your hospital takes more care than you think when allowing vendors to do inservicing for not only are you liable, so are they.
Specializes in Spinal Cord injuries, Emergency+EMS.
several issues here
1. systems design - within reson it's actually logical to make the epidural as unlike the IV system as possible to give a good check against cock ups like confusing IV pumps and epidual pumps ... if they are the same or simialr - as one poster suggested the pump the bag and the line needs to be marked - people have called me obsessive compulsive for marking arterial + cvp lines in 5 places (at the cannula/line exit, each side of the transducer, on the transducer and at the drip chamber )
but then tell me you didn't realise which line was which...
2. techncial training vs operational training - a balance needs to be struck between tchnical raining, delivered by whoever from the manufacturer / vendor and operational training of how the kit is going to be used in that facility / organisation .
3. local policy and the vagueries of Nurse practice acts - again a matter for the people writing the policies for that place at that time...
Specializes in ICU;CCU;Telemetry;L&D;Hospice;ER/Trauma;.
{hopefully your hospital takes more care than you think when allowing vendors to do inservicing for not only are you liable, so are they. }
the current facility i work in depends upon it's systems that are in place to assure proper teaching of it's employees.....however, on more than several occasions, with vendors teaching staff, i have run into unbelieveable stuff....so it isn't "what i think' it's what i know that is happening.
here are some of the lurid examples:
the vendor for a device being used with arterial lines gave an inservice to all of the nurses in icu/pacu/er who may have an arterial line in a patient....her (the vendor) new mousetrap was a device that is supposed to be a closed system whereby the wasted blood is pulled back into a provided syringe that is connected to the arterial tubing and then after the sample is pulled from the also provided stopcock device, the wasted blood is then re-fed into the arterial flow of the patient.....this is supposed to assist with patients who have borderline blood counts, and don't have that much to spare, etc. for blood sampling.
the device is a good thing.....but
at our facility, if the arterial line is already in place, and then it is decided that this device should be added on to the existing tubing, there is truthfully no safe way to add it on....if you disconnect the pressure line, and try to insert this hub, you have arterial blood squirting everywhere, because there isn't a clamping device between the patient and where you would have to put this blood saver device....
the vendor's solution was to haul out a pair of kelly's and clamp the end of the pressure tubing (no kidding!!!) and then connect up your device....
of course, these are probably sterile kelly's that you have in your pocket, and you have been carrying them along with your pen, flashlight, gum, and locker key just for this moment!! of course, the arterial line won't crack...it is hard after all, but a little pressure from a kelly won"t crack it!!!....and, well, a momentary break in an arterial feed shouldn't compromise a patient's well being....what's a little spurt here and there to save blood for crying out loud!!
no one seemed to question this vendor....all the seasoned, (and yes...they are good nurses) affixed their eyes on this person as if they were the newest evidenced based great kahona.....and no one from clinical education was there to say, "uh...wait a minute...."
i did, say something...and it was decided that unless the doctors, when inserting the line, didn't attach this device from the get go, we would not be mucking with it....duh.
so, you see, i don"t believe that hospitals will watch out for me while watching out for their own liability....because they apparently don't watch what is being taught....so how can i depend on that one???
this is completely the issue here....vendors who are allowed to present their wares, and teach nurses to use them, whether or not their methods are within our scope of practice via bon's and hospital policy....
if something goes wrong....which side of the fence do you think the bedside nurse is going to be on??? and how much backing do you think the hospital is going to give that nurse....hmmmm???? crni
jmgrn65, RN
1,344 Posts
yes I agree the vendors should take the time to find out what the facilities policies are.