LVN scope with ventilators?

Nurses LPN/LVN

Updated:   Published

Hi guys! So I work at a small group home, kind of like a SNF but it’s just 6 patients and they all have muscular dystrophy. So everyone is on a vent. We just got some mail from the BVNPT and Respiratory Care Board clarifying the LVN scope as opposed to an RT scope. They basically say we can’t do anything with the vent, not even administer a nebulizer through it or change a cannula, or transfer with the client if they need to go somewhere. Does anyone know more about this? Trying to find the exact scope of practice on the BVNPT website is difficult, but this just seems incorrect so I wonder if I’m reading it incorrectly or missing something? Thanks! This is in California btw.

Specializes in Respiratory Therapy.
10 hours ago, Crash_Cart said:

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.

I think the real monsters here were your supervisors.

If an RT wrote you up for bagging a patient (which, by the way, is probably the most absurd thing I've ever heard before, and the person who wrote that complaint should find a new career field), once they saw the complaint they should have thrown it away.

Hell, they probably should have filed a complaint against the RT for being so insufferable.

The only exception I could see to this would be if the RT's at your facility intubate. I always do the physical bagging prior to intubation so that I can better assess the mouth, airway, chest wall compliance, etc. before I start trying to stick a tube down there. Even then, I'm more than happy to let the nurse take over once I'm comfortable anyway.

That whole situation you had to deal with sounds absurd, and your supervisors in particular should never have been upset about you doing something to help keep a coding patient alive. Ridiculous.

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41 minutes ago, BreatheDeep said:

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.

So since you’re involved, I’m asking again has a formal decision been made? Will they send another letter addressing this? Or respond to emails that have been sent multiple times? Thank you

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Specializes in ER OR LTC Code Blue Trauma Dog.
1 hour ago, BreatheDeep said:

The only exception I could see to this would be if the RT's at your facility intubate. I always do the physical bagging prior to intubation

No it wasn't even that... Just plain old lifting the jaw and tilting the head back, making a good seal with the mask, and then bagging the patient on high flow O2. Dirt simple kind of stuff.

It seemed like when RT arrived at the code, they were horrified to see what was going on or something, but to me it didn't make any sense.

During the coal raking session in the the Nursing supervisors office, I was questioned about my "formal training" and qualifications in the area of advanced airway management. The supervisor also said it was reported that I was "reluctant" to let RT take over the bagging, which I thought was just plain nonsense to further exacerbate the claims.

Perhaps I appeared "hesitant" because my body was jammed between the head of the bed and the wall, and with all the surrounding jungle of IV's, pumps, electrical cords and other equipment in the way, yes I suppose it was somewhat difficult to do the "hand over" to the RT from that position.

Witch hunt or something? RT trying to cover their own tracks for something? I dunno... I still haven't figured it out. One thing was clear though, RT didn't like it and thought it wasn't within our scope of practice for some apparent reason. I didn't really understand all the hoopla they were making out of it all, but of course I had to take the reported complaint seriously anyways.

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Specializes in Respiratory Therapy.
59 minutes ago, Crash_Cart said:

No it wasn't even that... Just plain old lifting the jaw and tilting the head back, making a good seal with the mask, and then bagging the patient on high flow O2. Dirt simple kind of stuff.

It seemed like when RT arrived at the code, they were horrified to see what was going on or something, but to me it didn't make any sense.

During the coal raking session in the the Nursing supervisors office, I was questioned about my "formal training" and qualifications in the area of advanced airway management. The supervisor also said it was reported that I was "reluctant" to let RT take over the bagging, which I thought was just plain nonsense to further exacerbate the claims.

Perhaps I appeared "hesitant" because my body was jammed between the head of the bed and the wall, and with all the surrounding jungle of IV's, pumps, electrical cords and other equipment in the way, yes I suppose it was somewhat difficult to do the "hand over" to the RT from that position.

Witch hunt or something? RT trying to cover their own tracks for something? I dunno... I still haven't figured it out. One thing was clear though, RT didn't like it and thought it wasn't within our scope of practice for some apparent reason. I didn't really understand all the hoopla they were making out of it all, but of course I had to take the reported complaint seriously anyways.

Well then that's just even more ridiculous!

One thing I've noticed is that there's often an inverse relationship between how territorial an RT is and how good of a therapist they are.

The strong ones know their own skills and knowledge, know they don't need to defend/justify themselves or their existence to others, and typically get along better with people too (which also leads to less people having or trying to step on their toes anyway).

Almost without fail, it's always the trash therapists who blow up whenever an RN does something they "shouldn't have". And usually, because they're trash, they have to hide behind policies and rules to justify their being there, because otherwise in most cases they could completely disappear and no one would notice.

I remember once I was getting slammed in our CVICU, so the RN changed our patient over to spontaneous so we could get the weaning going before it was too late. Oh my god! He touched my ventilator!! Super against every rule and policy we have at our hospital.

And I didn't actually give a sh*t. Because I trusted him, and he trusted me, and the world somehow kept spinning. Now, when I went to look at the machine I did notice that the settings he picked were crazy wrong, but still, it was fine. I fixed what he did wrong, told him what was incorrect and why, and then we went on and handled business. Because that's how strong clinicians who are good coworkers handle themselves.

Anyway...To the point, I'm absolutely insinuating that your RT in question is crazy insecure about something, because there's no logical reason to get so crazy about something so small.

As for those supervisors? You should have told them that your qualification to use a BVM was having a pulse and enough brain power to tie your shoes. Then followed that up with a, "if you consider a basic BLS skills to be 'advanced', are you sure you meet those qualifications?"

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Specializes in ER OR LTC Code Blue Trauma Dog.
9 minutes ago, BreatheDeep said:

As for those supervisors? You should have told them that your qualification to use a BVM was having a pulse and enough brain power to tie your shoes. Then followed that up with a, "if you consider a basic BLS skills to be 'advanced', are you sure you meet those qualifications?"

Exactly what I was thinking, (but not actually saying) to the nursing supervisor at the time lol.

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This is going to boil down to money again, whether we like it or not. Everyone knows that nurses in home health don't make any money as it is, (thats why we're chronically short staffed), and that definitely goes for our RN case managers. Office staff make minimum wage, if they're lucky. Where is the money going to come from to hire these RCP's?

Having the legal scope of practice without working knowledge and experience as well as vice versa is a debatable topic.

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It is not home health caring for ventilator dependent patients, it’s home care. The state of California paid $29.43 per hour reimbursement for LVN shift care until July of last year. Wages are dependent on reimbursement. Take into account the cost of doing business here in this state: , payroll taxes, the cost of documentation, instituting the new Conditions of participation etc. I am a clinical supervisor for homecare here in San Diego. My coworkers and I don’t make close to what the case managers do in home health. LVNs left homecare, as have RNs because wages in this field are low. My agency is fighting to attract experienced, competent nurses. Most of the agencies in San Diego, LA, San Francisco have many cases that go unstaffed due to lack of nursing.

The issue under discussion is the very poor decision by these two boards limit LVNs scope of practice,across the board, not taking into account persons who live at home dependent on ventilators.

The LVN board will hold hearings on this topic in August. I hope everyone shows up to advocate for our patients.

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It is not home health caring for ventilator dependent patients, it’s home care. The state of California paid $29.43 per hour reimbursement for LVN shift care until July of last year. Wages are dependent on reimbursement. Take into account the cost of doing business here in this state: , payroll taxes, the cost of documentation, instituting the new Conditions of participation etc. I am a clinical supervisor for homecare here in San Diego. My coworkers and I don’t make close to what the case managers do in home health. LVNs left homecare, as have RNs because wages in this field are low. My agency is fighting to attract experienced, competent nurses. Most of the agencies in San Diego, LA, San Francisco have many cases that go unstaffed due to lack of nursing.

The issue under discussion is the very poor decision by these two boards limit LVNs scope of practice,across the board, not taking into account persons who live at home dependent on ventilators.

The LVN board will hold hearings on this topic in August. I hope everyone shows up to advocate for our patients.

Riquelle a decision has not yet been made. The LVN board still has to meet in both Northern and Southern California.

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My company states Home Healthcare Services after their name. Is that the same thing then?

Will we all have to go to Sacramento for that meeting then?

Thanks.

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