Non anesthesia provider providing anesthesia

[EMS/ICU/SRNA]

I overheard an ED attending discussing a policy regarding the administration of propofol w/ an RN at work today. Apparently the policy states that propofol or any other medication may be administered to a non-intubated pt if an attending ED/Pulmonary physician is in the room. This would be done for a procedure ie: reduction of a fx....etc. I asked him why anesthesia personnel would not provide the anesthesia. He responded that the ED/Pulmonary physician is able to provide all services that anesthesia could. What do you guys think about this?

[MmacFN]

Hey

Ive already been in grad school :)

In anycase, i know what you mean about p/n. The p value will also will tell you if there is a statistically signifigant negative as well. Such as H = cheerios will decrease cholesterol but the P = high cholesterol in a large subset of patients. So you would expect the p to also be associated with negative outcomes as well (assuming the research is pure), yet in the majority of the studies this isnt the case.

All studies in medicine will benefit someone economically, just look at drug studies. However, that dosent mean the data or the variables were tampered with. The validity of any study is often proven by independantly reproduced results in a similar study.

I understand what you are saying. I'm not suggesting the practice is right, what im saying is that the research done, on the whole, seems to support the use which is why it continues. Until there is a proven negative outcome for patients (a rash of lawsuits or research) I dont see it changing in the least.

Hey Mike, don't take this personally but it's just my U of Pitt education wanting to say something. In previous threads you kept throwing out the n numbers and the p values of the studies that you cited as proof that they were well conducted pieces of research. Just the edu talking: the p value is simply indicative of the statisical significance. The more subjects that are enrolled in your study,(n) the greater chance that you would detect a statisically significant difference (ie: cheerios reduce you cholesterol). These numbers speak nothing of the internal or external validity of the study. What everyone here was saying was that, depending on your motivation (read: pt turnover and $), there are numerous oppurtunities to skew the results. While I do not have the time or interest to critically appraise the studies that you cited, I do raise an eyebrow when such a large sample size is used and those conducting the research will benefit directly if their "findings" are what they had crossed their collective fingers for. Just wanted to let you know that there is quite a bit more to quality research than the n's and p's.

PS: Don't worry, you'll learn this in grad school

[yoga crna]

This is an abstract from the ASA Closed Claims Study. It is interesting to note the data with sedation being administered by professional anesthesia providers. Wonder what it is with other medical professionals?

Injury and Liability Associated with Monitored Anesthesia Care: A Closed Claims Analysis.

Anesthesiology. 104(2):228-234, February 2006.

Bhananker, Sanjay M. M.D., F.R.C.A. *; Posner, Karen L. Ph.D. +; Cheney, Frederick W. M.D. ++; Caplan, Robert A. M.D. ; Lee, Lorri A. M.D. [//]; Domino, Karen B. M.D., M.P.H. #

Abstract:

Background: To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990.

Methods: All surgical anesthesia claims associated with MAC (n = 121) were compared with those associated with general (n = 1,519) and regional (n = 312) anesthesia. A detailed analysis of MAC claims was performed to identify causative mechanisms and liability patterns.

Results: MAC claims involved older and sicker patients compared with general anesthesia claims (P

Conclusions: Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries. Awareness and avoidance of the fire triad (oxidizer, fuel, and ignition source) is essential to prevent on-the-patient fires.

© 2006 American Society of Anesthesiologists, Inc.

[KeithEMU]

All studies in medicine will benefit someone economically, just look at drug studies. However, that dosent mean the data or the variables were tampered with. The validity of any study is often proven by independantly reproduced results in a similar study.

I really am not attacking you Mike...lol

This brings to mind an interesting question for me. Concidering the economic gain that could be made for the drug company, if there are so many studies that say it is ok for RN's in the ED to push propofol why wouldn't the drug company try to change the insert as they have been asked to do. I think it shows that the company does not beleive it is safe and will eventually hit the fan. If they thought it was safe they would be all over trying to expand their base of sales. They like money too.

[MmacFN]

hey keith

I didnt think you were !

I agree with what you are saying. After all, it seems pretty clear that the GI people have a vested economic interest. I dont believe the ER docs really do but the faster turn over might be a benefit to the hospital, though the procedure is rare enough that i dont know that it really would be. It is also possible the ER docs might have an economic interest depending on their contract (increased pay for procedural sedation?) I dont really know if thats the case?

I think the company knows that people will use it for whatever they like, regardless of the insert. Not so uncommon to use off label uses (thats how wellbutrin became a smoking cessation drug), but the company is protected legally by putting that on their insert (which is smart!).

In anycase, i havent a clue how this will all cash out. I have seen/heard of diprivan being used in the ER for the last 7 years myself, but apparently its been occuring for 10 in some places. It cant be long before we hear about litigation!

I really am not attacking you Mike...lol

This brings to mind an interesting question for me. Concidering the economic gain that could be made for the drug company, if there are so many studies that say it is ok for RN's in the ED to push propofol why wouldn't the drug company try to change the insert as they have been asked to do. I think it shows that the company does not beleive it is safe and will eventually hit the fan. If they thought it was safe they would be all over trying to expand their base of sales. They like money too.

[Just a CRNA]

It's pretty sad when you use the presence or threat of litigation as a factor in deciding what is right. It has been pretty well demonstrated in this thread that you are indefensible when it comes to administering general anesthesia in the ER, GI lab, or outside the hospital. You seem satisfied to base your practice on bad advice and risky habit. You do not have the education to be practicing anesthesia; and in a rare case of cohesion, both the AANA and ASA are lined up foresquare against you. The drug company who stands to profit from your practice has said, in every package of drugs, that they do not stand behind this practice of non-educated individuals using their drug in the fashion you describe. Still, you are happy to continue on, until a catastrophe occurs. When it does, you will stand alone, because you will find the hospital does not have any record of your training and wants to settle, no professional association will step up to support you, and any future you might have in anesthesia will evaporate. In the ashes of this scenario will be a patient who is either dead or disabled. Yes, your BNE supports this practice, but only in the specific areas of emergency intubation and central line placement. Your full stomach patient for a closed reduction is not covered, and this will be the time it will strike. Still, you don't agree, and none of us with experience seem to be able to sway your thinking. Over and out.

[2luvnsg]

This is my first posting to this site. I would like to add that the "we do this all the time" attitude exists in just about all the ICU's I've worked.

My story with Propofol is that while re- intubating a cardiothorasic surgical intensive care patient, a nurse pushed 100mg instead of 10mg as ordered by the Physician's assistant at the bedside prior to intubation. The Patient cardiorespiratory arrested. Not to worry, CPR, fluids, pressors helped this patient out. I confronted this nurse and the charge nurse and got the "we do this all the time" thingo. In this new setting where I'm working, my manager was responsive to my written suggestions I provided with citations from the literature. My past experience in other settings was that anesthesia managed the airway.

It seems for this population, this drug is too risky. Also, and in the wrong hands near fatal.

As far as I am aware of, Propofol may be taken out of this setting. Don't get me wrong, I respect the wonder of this drug and have managed many patients on propofol drips safely. The above senario may have even occurred even if the patient recieved the proper dosage as these types of patients are in tenuous states.

[indapinda1]

You need to read the nurse practice act for the state you are in. In Vermont propofol has to be given by an anesthesiologist unless it is in a critcal care unit.

[deepz]

You need to read the nurse practice act for the state you are in. In Vermont propofol has to be given by an anesthesiologist unless it is in a critcal care unit.

Given by a WHO????

?

[athomas91]

:)

go deepz.... :)

[EMS/ICU/SRNA]

Hey

Ive already been in grad school :)

You really are all things Mike......

[MmacFN]

Het Justa

As i said before i dont agree with the practice and since i no longer work in the ER often I probably havent done it in over a year. However, allow me to answer some of the questions.

It has been pretty well demonstrated in this thread that you are indefensible when it comes to administering general anesthesia in the ER, GI lab, or outside the hospital.

No it hasent. It has been suggested that this may be the case, there is no evidence for this claim (even if i believe it to be true). In one of my posts i mentioned how risk management, the hospital lawyer and the nsg board all agreed.

in a rare case of cohesion, both the AANA and ASA are lined up foresquare against you.

ACEP and the ENA would suggest this is an economic motivation by both groups as there isnt signifigant research to back the claims. Afterall, if only an anesthesia provider can push the diprivan then they also bill for it. Again, i agree with the statement. However, it is important to also understand how it can be percieved.

When it does, you will stand alone, because you will find the hospital does not have any record of your training

I do not know what the common practice at hospitals are, but the one i worked at did a training session for it on annual competancies. So there is a documented intitial training and a documented recurrency training every 6 months (along with various other ED meds/procedures).

no professional association will step up to support you,

That may be true, however, the joint statement made by the ENA and ACEP suggest this is not the case. It carries the weight in the emergency room as the ASA/ANNA statement carries the weight in the anesthesia setting. The regulatory bodies for each specialty do not regulate the other.

Yes, your BNE supports this practice, but only in the specific areas of emergency intubation and central line placement.

I dont believe you have read this thread but simply decided at one point to post. The nsg board allows for the use of diprivan when performing concious sedation. The RN cannot push a bolus, cannot initiate a drip on an un-intubated patient. The ED doc must do both of these. The RNs job is to support the ED Doc, chart and monitor the drip by titrating to order of the physician. When it comes right down to it, i believe any and all liability would lie with the physician since he orders, initiates and is present until the sedation has worn off. Now if done in a different way, i could see it being wholly different.

Your full stomach patient for a closed reduction is not covered,

Sorry, your wrong.

Still, you don't agree, and none of us with experience seem to be able to sway your thinking.

I did agree a week ago and still do. What i am saying is that my opinion that diprivan isnt safe for anyone to use in the ER is not backed up with sufficent evidence to suggest the contrary. Since the evidence dosent exist (currently), as with most things in medicine, litigation will most likely be what turns the tide in this practice. It is unfortunate, i agree, that it has to be this way, but thats how it is. None of the RNs in the ER have ever refused to give the diprivan, this is more than likely because of an education deficit. However, as it currently stands, an RN who refused to give it would be in the same boat as one who refused to give any other drug approved for use in the ER (which it is). It is not my thinking that that needs to be swayed my friend, ultimately it is ACEP which must be convinced as they drive policy in the ER, not RNs or any other groups.

So would i give diprivan again tommorrow when i work in the ER? The answer is no. Based on everything i have learned here i would feel unsafe giving it (with the exception of intubated pts). Before this forum I would have continued realizing the risks, but following the policies where i work and the associations ruling them. Now, with the perspective of my future mentors, I would suggest we use a different agent. I would suspect that I would be written up for it and another rn would simply do it.

Have a good one

[MmacFN]

Hey :)

Im a bit of a nerd when it comes to school, i love it. All the grad classes i have taken (only 4 classes) have been either night school or online via a university. One nice thing about my job is that i have inet and time to get them done, which is a large obstacle for many. I knew i was going to do something else, but didnt know what so i figured heading toward a masters degree couldnt hurt.

quote=EMS/ICU/SRNA]

Hey

Ive already been in grad school :)

You really are all things Mike......