LVN scope with ventilators?

riquelle · Jun 2, 2019

I did email the board for clarification, they are in discussions with the Respiratory Care Board because a lot of questions have arisen. It has been over a month and they haven’t gotten back to me yet. It seems there may have been a little bit of an uproar and they’re reconsidering?

Gr8LVN12 · Jun 2, 2019

Good job! I still can’t imagine what or if anything happened to prompt this. These meetings on June 7 may clarify, hopefully.

BreatheDeep · Jul 19, 2019

As someone who works very closely with the CA RCB, and who was also involved in the negotiations between the RCB and BVNPT, allow me to expand a bit on what this means, and why it happened.

Also, just for the record, some of this might be upsetting to some of you. Please keep in mind I'm merely relaying the information as I received it or was involved with it - none of this is my own personal take or beliefs on the matter.

First and foremost, a couple people have stated that the RCB was dictating things to the BVNPT. This is not true. The RCB and BVNPT arrived at this decision together, after spending over a year working on it. Even if that wasn't the case (which it was), in California the practice of Respiratory Care and regulation thereof lies solely with the RCB. In practical terms this means the RCB can make unilateral decisions regarding what is/isn't respiratory care, and who gets to practice it (to everyone except the BRN). In reality, the RCB, BRN, and BVNPT all work very amicably together, so this hasn't ever, and shouldn't ever, actually be an issue.

Secondly, this ruling came about because it was discovered that in a number of facilities LVN's were performing ventilator assessments beyond data collection, and were manipulating and managing ventilator care based on these assessments.

Initially the BVNPT said this was fine, so long it was only basic assessments and interventions being performed, while the RCB said it wasn't. The RCB responded by saying that LVN's lack the necessary educational background to perform such advanced functions within their scope.

At this point, the educational standards of RCP's and LVN's were explored, and it was eventually mutually agreed upon that LVN's do in fact lack the educational background in comparison to RCP's to perform functions relating to ventilator management. **A side point, but related. In CA, RN's can, in certain circumstances, provide and bill for certain RT related services. To do so requires them to take additional classes/certifications to be considered a "competent" provider. Competent in this case meaning "above and beyond the skill and knowledge level of a traditional RN". In relation to this ruling, it was determined that LVN's, as they do not possess the same educational background as an RT or RN (which are considered to be equivalent with one another), are not able to adequately be brought to this same level due to the nature of their original nursing education.

So, what does this actually mean for LVN's?

Well, most importantly, LVN's can still care for mechanically ventilated patients. There's nothing in this statement that says they can't. LVN's can still do the following:

Collect assessment data/Basic Assessments
Administer medications that do not require manipulation of the vent circuit
Patient and family education
Oral care and hygiene, including ET/Tracheal suctioning

LVN's can not:

Change any setting on a ventilator, under any circumstance
Change inner Tracheostomy cannulas
Reconfigure/manipulate ventilator circuits
Troubleshoot ventilator-related controls or alarms
Assess a patients response to ventilator settings or adjustments
Assess for placement or place a PMV or trach plug
Transport patients receiving mechanical ventilation

In short, LVN's can still care for ventilated patients, but they cannot troubleshoot, assess, or manage the ventilator itself - those practices fall solely within the scope of an RN or RCP.

If anyone actually managed to read to the end of this, I hope it was useful for you. I'm also more than willing to answer any questions anyone may have regarding this as well.

Cherry Aims · Jul 19, 2019

Breathe Deep all of the points listed in your response to what LVNs CAN’T do with a ventilator is EVERYTHING THEY MUST DO in Homecare. In many of the homes I visit there is only the patient and their nurse. Vent alarm, occluded teach CALL RT, what a joke with their 24 hour response turn around time. Have the RN do it-I live an hour away from some of my patients AND there is no funding for the amount of RN visits that would be needed. This change in practice will mean our patients can not remain in the home. I find it interesting that you’ve been working on this for a year but your members, the RTs and LVNs I spoke with knew nothing about it.

caliotter3 · Jul 20, 2019

An excuse for home health agencies to decrease the per hour pay for the LVNs who work with vent dependent patients in the home, as if they are going to get those who really are allowed to perform all those forbidden interventions to come to the home, even when there is an emergency. Already I have noticed that agencies are shying away from paying LVNs more for vent experience.

Cherry Aims · Jul 20, 2019

What BreatheDeep related is that now matter how skilled the LVN becomes they may never change inner cannula, respond to ventilator alarms, “break the circuit “ to transfer a patient from one device to another, or put a nebulizer treatment in line- it would be out of the scope of practice.

I went to the RT board meeting here in San Diego county. The room was packed! People on ventilators and their families discussed their concerns. I don’t think anyone expected the number of people who came. I also don’t think either board took in to account what this decision would mean to those living at home. Again I have to ask what prompted this decision. I have been in the field of homecare for more than 30 years. Many of my patients have been ventilator dependent. LVNs have been providing their care. Now it’s not good enough, safe enough! Why?

Cherry Aims · Jul 20, 2019

By the way this decision was not prompted by the Homecare agencies. Reimbursement drives wages. MediCal, finally, increased reimbursement in July 2018 after many years of stagnation.

Crash_Cart · Jul 20, 2019

On 5/31/2019 at 11:20 PM, Crystal-Wings said:
Why on earth is the respiratory board trying to suggest things to the nursing board?!

Respiratory Board vs. Nursing Board...

riquelle · Jul 20, 2019

So is the decisión final? I’ve been in communication with the BVNPT and they said they have been in meetings and trying to work some things out and may just require an additional ventilation certification. Are the meetings and discussions over?

Crash_Cart · Jul 20, 2019

Respiratory is very protective of their domain. I recall being "put on report" one time for responding to a code blue and since respiratory wasn't there at the time, I ended being the individual who was bagging the patient. Well they weren't there at the time and the patient needed to breathe right? Apparently, it seems that's RT's job and not mine, but do you really think I cared about that at the time?

So I was written up for being the bad guy. Seems when reports are written they have absolutely no idea how things work in the real world of everything.

Perhaps, if I had followed proper protocol, I should have done things differently and should have just waited for RT to arrive and just let the patient suffocate and die.

I was raked over the coals in my nursing supervisors office for my actions.

Apparently, RT are the only persons who are responsible for conducting any such activity or action.

Gr8LVN12 · Jul 20, 2019

8 hours ago, Cherry Aims said:
Breathe Deep all of the points listed in your response to what LVNs CAN’T do with a ventilator is EVERYTHING THEY MUST DO in Homecare. In many of the homes I visit there is only the patient and their nurse. Vent alarm, occluded teach CALL RT, what a joke with their 24 hour response turn around time. Have the RN do it-I live an hour away from some of my patients AND there is no funding for the amount of RN visits that would be needed. This change in practice will mean our patients can not remain in the home. I find it interesting that you’ve been working on this for a year but your members, the RTs and LVNs I spoke with knew nothing about it.

Extremely well put, Cherry Aims!! Could not have said it better!!

BreatheDeep · Jul 20, 2019

17 hours ago, Cherry Aims said:
I also don’t think either board took in to account what this decision would mean to those living at home. Again I have to ask what prompted this decision. I have been in the field of homecare for more than 30 years. Many of my patients have been ventilator dependent. LVNs have been providing their care. Now it’s not good enough, safe enough! Why?

You're correct, home care wasn't what prompted this decision from the Boards. This whole decision is the unfortunate sequelae of events stemming from the practices of various SNF/LTAC facilities.

The unfortunate truth is that their actions, specifically, encouraging LVN's to act outside of their scope of practice (in particular, making ventilator changes based on their own assessments, and assessing the patients response to those changes), are what caused this to happen.

Objectively speaking, the position of the BVNPT and RCB is that LVN's do not receive enough formal education in ventilator management and the necessary related subjects to appropriately assess and manage the machine and the patients physiologic response to it.

Of the 15 or so LVN schools who's curriculum's I personally had to assess, a number of them did not cover ventilators in any sort of meaningful depth. The ones that did covered, in totality, about as much information as your average RT school covers in a day. When you consider that in the context of RT's having, on average, 6-8 months worth of dedicated didactic training related to solely to mechanical ventilation, it becomes easier to see why the Boards came to this position.

Now, going back to the main point - By these facilities having LVN's act in a function which was legally restricted to only RN's or RCP's, the Board was unfortunately forced to intervene.

Either way, the outcome of this intervention, i.e. the letter which started this whole thread, is the logical outcome of what happens when a state agency uncovers widespread misbehavior. It is also a good example of why Board intervention is undesirable - because statewide mandates are blunt instruments, the effects of which always catch innocent people in them.

On a personal note, I actually have no problem with LVN's working with ventilators in the home setting. Hell, I've taught family members how to care for vents in the home...so obviously training a nurse to do so wouldn't be an issue.

For what it's worth, I thought that an exemption should have been made for home care LVN's who have received the appropriate training. I also suggested that home care companies that are involved with ventilators should be legally required to have an RCP on staff for training/competency/consultancy/oversight. It's kind of perfect actually - because now you have an expert to initially train the nurses, to help maintain their competency, and to be available for them should questions arise while they're in the home. It also would maintain the current workforce without disruptions. Unfortunately, this would require actual legislation and isn't something that any of the boards can mandate. Still, it is something I've been working on. Whether it will actually amount to anything though, that I couldn't tell you.