Frankly, I have never understood why some operating room nurses feel honored to be able to sit up at the head of the bed and administer conscious sedation, especially during elective cosmetic surgery procedures (in which the patient could afford the services of a CRNA or anesthesiologist.)
I think it is a power trip for them--makes them feel oh-so-important.
OK, here come the flames from those who consider it "an expansion of their role as a perioperative nurse" and apparently aren't concerned about not being trained--or compensated--in the same way a CRNA or anesthesiologist would be for doing the same thing.
I truly believe that this is a classic example of the saying, "A little knowledge can be dangerous."
Yes, I am ACLS certified--I am good at starting IVs--I know the conscious sedation drugs and the drugs to reverse them---and hey, I have even had to do a stab trach or two with a jelco to ensure an adequate airway and prevent imminent death----but that was as a Vietnam era corpsman, when there was no other option.
There was no MD or CRNA to call on--as an independent duy corpsman, I was it. Oh, and the situation was trauma--NOT elective cosmetic surgery.
Today, there are plenty of other options--those include staff CRNAs and anesthesiologists who are PAID for their skills at airway management and conscious sedation (as well as far more complicated anesthesia situations.)
Yes, times have indeed changed. Personally, I do not feel they pay me enough to take on this role and the extra responsibility it entails--especially when CRNAs or anesthesiologists are sitting around with nothing to do--simply because hospital management, or cosmetic surgery patients who are paying out of pocket, do not want to reimburse those people (or bill the insurance) accordingly.
This often happens in elective cosmetic surgery cases where insurance ISN'T picking up the tab. Rather than pay the person who is trained--and welll compensated--to do this job--we are supposed to do it.
Why are we allowing ourselves to be exploited as a source of cheap labor?
I actually worked registry a few times at a hospital where, in my opinion, the "queen bee" RNs who fought for the chance to give conscious sedation were waayyyyyyyy over their heads--they were allowed by certain plastic surgeons to simply give drugs in the increments they (the nurses) saw fit--usually Fentanyl and Versed--and more than once they got into trouble and had to slip in an oral airway, bag the patient, and reverse the Versed with Romazicon or the Fentanyl with Narcan to end up with (eventually!) a spontaneously breathing patient.
Forget about having anesthesia nearby to come bail them out--they had long since gone home--none covering OB, either, as this small hospital had no OB unit.
I expressed my concern to their supervisor about this--with some trepidation--I knew it would not be well received since I was not staff. Her answer? "We do it all the time--and anyway, if they run into trouble, they can call the ER doctor."
Right. Like he is going to drop whatever he is doing (perhaps handling his own code!) and rush right over to bail someone out of a situation they should not have been doing in the first place.
(When I voiced THIS, I was given a blank and hostile stare--and, not called to work there again, surprise--as if I would have wanted to return to this hotbed of sentinel events in the making.)
What do the rest of you think? Why are nurses taking on this role? If you have no other objection, just consider this one---they just do not pay us enough to do it.
Specializes in O.R., Endo, Med-Surge, Mgtmt., Psyche.
We don't use Propofol. It is against the Oklahoma Nurse Practice Act for a registered nurse to give Propofol for moderate sedation. Propofol is high in lipids so you have to be careful infusing it as well. Propofol falls into the same category as Sodium Pentothal and Amidate and I don't care to use those either.
I know what I can and can't do as well. I have never had a patient too deep to need intubation. Our patient's breathe spontaneously and respond to commands. You are right about the fine line between moderate and deep sedation and until it is changed and we choose to work in areas that require moderate sedation, we can only do the right thing and that is stand up for your patient, be safe, and stay educated. I agree that intubating a manequin is not the same as intubating a person.
Unfortunately, anesthesia shortage is horrible in Oklahoma and I'm sure in Oregon as well.
You state that you have been hearing nursing is changing for a long time. Well it is and will continue to do such. I can't agree that all changes are for the better. I'm not a manager. I'm not trying to get anybody to do more work. It's a fact.
LVN's have no business giving moderate sedation. New graduate nurses have no business giving moderate sedation. My training on moderate sedation consisted of a 3 day course that was extremely beneficial.
If I were consistently being placed in the situation to where my license would be put at risk, I would have to consider another area of expertise. I did not leave the O.R. due to any of those reasons. I left for a job with better benefits, no w/ends, or call so I could be with my family. 10 1/2 years of call and lack of management was burning me out.
The nurses don't do housekeeping where I work either.
Who was to know you weren't a "he" with a name like stevierae. Sorry for the misconception.
Unfortunately, anesthesia shortage is horrible in Oklahoma and I'm sure in Oregon as well.
This is not our problem to deal with. Why should we enable management--or ANYBODY--to use this as an excuse to pay US less to do more work and take on extra responsibilty? Let them offer a lucrative benefits package to find and KEEP qualified anesthesia personnnel. Or, they can use traveling or locum tenens anesthesia personnel.
Management has always tried to use the "nursing shortage" as an excuse to utilize unlicensed personnel to do patient care that really should be done by Registered Nurses. In truth, there is no nursing shortage---there is simply an ever increasing population of RNs who are starting to say "No, I will not give suboptimal patient care, and, no, I will not take on tasks that are well outside the scope of nursing practice to save you money and ensure you (management) a bonus."
For this reason, I now do OR nursing as a traveler--when I feel like it-- and work as a legal nurse consultant the rest of the time. Far too many cases I have reviewed involve nurses stepping outside the parameters of their state's nurse practice act because they were afraid to simply speak up to management and say, "No. That is dangerous patient care, and I will not do it." Our job is to be patient advocates, first and foremost. It would not bother me one bit to say to a patient, "Mr. so-and-so, I want you to be aware that although there are anesthesia providers in house, the front desk here, in order to open more rooms, wants me instead of an anesthesia provider to give you conscious sedation. While I am ACLS certified, my training does not in any way equate with the training of an anesthesia provider, and I want you to be aware of this situation and feel free to speak up and demand that your anesthesia be provided by a CRNA or anesthesiologist, who does this all the time and is board certified to do it." I would be more than happy to get the hospital administrator on the phone for him, if it required going that far up the chain of command.
I feel the same way for patients who are under the impresssion that a board certified surgeon is doing their procedure, when in reality it is being done by a resident. I don't want my operation done by a resident--why should they settle for less?
It's not my job to make management's job easier. This is the reason they also like to give for trying to force people to stay overtime, "Oh, there's a nursing shortage, and we just don't have enough staff, so "we" (Notice that "we" never includes management...) all have to pitch in..." Oh, no, "we" don't. I want to do my 8 hours and go home. If you can't attract qualified staff, then call registry. That's what management gets paid the big bucks for--to troubleshoot and plan for adequate staffing levels and recruit and retain qualified staff. My job is to deliver nursing care--PERIOD. My job is NOT to deliver anesthesia care--there are CRNAs and anesthesiologists who are experts at doing that job.
People will only do to you what you allow them to do to you. I think that we as patient advocates need to speak up both for our patients and for ouselves in the name of safer patient care to ensure that professional nursing is done by RNs and anesthesia is done by licensed and board certified anesthesia providers ONLY.
Now I like this line of responses, everyone is seeing each others point of view and there is no personal attacks. I can see each others opinion and get a little out of both. As both point out, I know what I know and avoid all others, is the best way to approach CS. I just hate it when all surgeons think this is the easy way out. I feel for all GI nurses because they are put into situations everyday by their MDs and there are times I'm sure they don't want to do what they are instructed to do. Luckily, the majority of procedures I deal with are "pure" local cases that don't require any CS or very little. The first time I am asked to give a little Diprivan, I'm yelling for anesthesia!They should know better. Mike
I feel the same way for patients who are under the impresssion that a board certified surgeon is doing their procedure, when in reality it is being done by a resident. I don't want my operation done by a resident--why should they settle for less?
That situation is a little different. The surgeon is supposed to be present, or at least stopping by. Anesthesia isn't around when OR or GI nurses do CS. Also, the resident is learning his or her specialty and may actually be quite skilled, especially if they are nearing the end of their training. The nurse is not training to be an MDA or CRNA, she/he only knows what has been taught at the hospital inservice or whatever.
I'm in agreement on all points about nurses administering anesthesia/sedation when an expert should be doing it. Not okay.
Cecumseeker, I dont know if you noticed but in one of your last threads, changes in perioperative nursing you speak of "we" doing lap chole's, appys, changes in anaesthetic gases. I dont know what you have been up to out there but "we" have never done lap anything or gassed anything. Those are all changes which have affected the medical profession. I know there are RN's who take on extended roles however I dont personally believe they are extended roles within the nursing profession. I simply believe that there are nurses who are crossing the boundries into another profession for which they will get neither the financial or professional recognition.
That situation is a little different. The surgeon is supposed to be present, or at least stopping by. Anesthesia isn't around when OR or GI nurses do CS. Also, the resident is learning his or her specialty and may actually be quite skilled, especially if they are nearing the end of their training. The nurse is not training to be an MDA or CRNA, she/he only knows what has been taught at the hospital inservice or whatever.
I'm in agreement on all points about nurses administering anesthesia/sedation when an expert should be doing it. Not okay.
My point is, it's dishonest when informed consent is given to state that the surgeon is doing the operation when the whole thing is actually done by a resident. In some places, particularly in some university settings, the attending does not even scrub IN--he is floating between 2 or 3 rooms, "supervising" other residents. Not OK in my book. I don't care HOW skilled a resident is--he is NOT a board certified surgeon. When I need surgery, I want a board certified surgeon--not a resident--performing my operation. That is my RIGHT, and is the right of ANY patient--EVEN those in teaching hospitals, and even those who are uninsured.
Smae thing goes for anesthesia. I want a CRNA or anesthesiologist performing my anesthesia, even if it's simply local with sedation, or a colonoscopy. What if I have an unrecognized condition like malignant hyperthermia or pseudocholinesterase deficiency that rears its ugly head and puts me in crisis? I want someone who can deal with it IMMEDIATELY--NOT someone who has to be bailed out of a situation he or she should NOT have been in in the first place! I don't want to be assured that someone can "RESCUE" me---I don't want to get into a situation where I NEED to be RESCUED in the first place!!!!
After reading this thread I am amazed. . . amazed at what my previous hospital had asked us to do. . .
It was a smaller community hospital that had been bought out by a bigger non-profit hospital group but they had some thinking there I objected to.
The telemetry floor was preparing to deal with the increased population of cardiac cath patients we were expecting as the hospital expanded cardiac services. Part of our preparation (we being the telemetry floor nurses, some of us actually had ACLS), was this pitiful poorly put together xeroxed packet of information on GIVING & RECOVERING conscious sedation patients!! I was required to read and fill out the test but I asked why we were getting these packets, were we expected to do these things? I didn't mind receiving cardiac cath patients after they had been recovered but this? I never got a straight answer but one of the scarier answers was that we could "help out" by being able to give the CS if someone needed to be cardioverted at the bedside or we could be available to recover a nighttime cath patient so the cath lab staff could go on home after the procedure was finished. SCARY!! I copied a whole bunch of information off about who was qualified to give CS and stapled that to the packet to hand back in. I left that position shortly after that. This CS thing was one of the many reasons for me leaving.
Been giving cs for the last four years. We do not administer propofol.
The first hospital I administered cs required much training and testing before actually doing it.....and then under the direct supervision of a crna until the RN was comfortable with it. I have refused to do cases based on the patients health status. I also comunicate my thoughts to the surgeons if I feel they are asking me to give more than I am comfortable with.....thoughts such as patients age, size, respiratory status, blood pressure, meds, mentation ect. I have somewhere along the lines accepted that this is a practise that is not going to go away and am trying to make the best of it in the most professional way I can. I do believe comunication between the surgeon and the nurse is of upmost importance. I do not wait for him to tell me to give more sedation before I tell him that there has been a drop in sats... or to report to him that his patient appears comfortable. Yup, I agree that nurses are doing more and more all of the time. Not always happy with it either. Certainly fought against the ideal initially. So much for how much clout I have :chuckle
"Saying that it has received several reports of adverse events, including the death of a cosmetic surgery patient, after RNs improperly administered propofol, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) is rushing to ensure that only those trained to give general anesthesia or rescue from general anesthesia administer propofol in its 1,100 or so accredited facilities. The AAAASF announced last week that facilities that want to continue to use propofol -- even if only for "conscious sedation" -- must either upgrade to a Class C facility (where all anesthesia must be administered by an anesthesiologist or CRNA) or promise to always use an anesthesia professional to administer the drug. Facilities must comply by May 1.
"We decided that we need to get our standards in line with the manufacturer's recommendations," says Jeff Pearcy, executive director of the AAAASF. "The easiest way to do that was to require those facilities that want to continue to use propofol to become Class C facilities."
For Class B facilities that would like to continue to use propofol but won't use other types of general anesthesia, complying with the new standard is simple. These facilities must fill out a form certifying that they have a dedicated anesthesiologist or CRNA administering the sedative-hypnotic. They also must have neuromuscular blocking agents available in the facility. No on-site inspection is necessary. There will be no additional charge, says AAAASF.
Those facilities that are upgrading to a C and plan to use general anesthesia (inhalational) in addition to using propofol must comply with all Class C criteria, says AAAASF.
AAAASF President Michael F. McGuire, MD, a board-certified plastic surgeon, says the major motivation for making the change was that "administration of propofol by a non-anesthesia provider is really not appropriate."
Dr. McGuire adds that the new standard has caused quite a bit of confusion and concern, mostly among Class B facilities that don't give inhalational anesthesia and misread the standard to mean they couldn't administer propofol unless they bought an anesthesia machine and CO2 monitor. Part of the confusion, he says, lies in the nature of the propofol.
"Is propofol a general anesthetic or a sedation agent? It's both. Really, truly, it is both," says Dr. McGuire. "At a certain level and in a certain individual, it is a sedation agent. In other individuals or at higher does, it becomes a general anesthetic agent. It's so unpredictable, which is not a problem if you're an anesthesiologist but can be if you're a surgeon trying to do surgery and supervise a nurse giving the medication."
Cecumseeker, I dont know if you noticed but in one of your last threads, changes in perioperative nursing you speak of "we" doing lap chole's, appys, changes in anaesthetic gases. I dont know what you have been up to out there but "we" have never done lap anything or gassed anything. Those are all changes which have affected the medical profession. I know there are RN's who take on extended roles however I dont personally believe they are extended roles within the nursing profession. I simply believe that there are nurses who are crossing the boundries into another profession for which they will get neither the financial or professional recognition.
I would like some clarification on your above post please. Are you implying that CRNAs are "nurses who have crossed the boundary" outside of the "nursing profession" or are you saying that non-anesthesia nurses providing aggressive sedation just to please a surgeon are stepping outside the nursing model? Thanks for the clarification.
I work in oral surgery with non intubated patients. The oral surgeons I work with are anesthesia providers and what do you think they think about what the makers of Diprivan, the ASA or the AANA are saying? They may as well tell them to smoke their position statement because oral surgeons across the US are still doing surgery and using propofol every single day with excellent patient outcomes.
We use Versed and Fentanyl for most procedures and occasionally Propofol
if needed. With the proper training and experience and a nurse practice act that allows it, an RN can administer this drug safely. Quite frankly, I've seen more complications with other IV drugs, like ritodrine or mag sulfate, I have administered than I have ever seen with any of the sedation drugs I just mentioned. Those RNs who are administering Propofol just need to publish their patient outcomes related to the safety of RN administered Propofol.
SuperSGirl
53 Posts
We don't use Propofol. It is against the Oklahoma Nurse Practice Act for a registered nurse to give Propofol for moderate sedation. Propofol is high in lipids so you have to be careful infusing it as well. Propofol falls into the same category as Sodium Pentothal and Amidate and I don't care to use those either.
I know what I can and can't do as well. I have never had a patient too deep to need intubation. Our patient's breathe spontaneously and respond to commands. You are right about the fine line between moderate and deep sedation and until it is changed and we choose to work in areas that require moderate sedation, we can only do the right thing and that is stand up for your patient, be safe, and stay educated. I agree that intubating a manequin is not the same as intubating a person.
Unfortunately, anesthesia shortage is horrible in Oklahoma and I'm sure in Oregon as well.
You state that you have been hearing nursing is changing for a long time. Well it is and will continue to do such. I can't agree that all changes are for the better. I'm not a manager. I'm not trying to get anybody to do more work. It's a fact.
LVN's have no business giving moderate sedation. New graduate nurses have no business giving moderate sedation. My training on moderate sedation consisted of a 3 day course that was extremely beneficial.
If I were consistently being placed in the situation to where my license would be put at risk, I would have to consider another area of expertise. I did not leave the O.R. due to any of those reasons. I left for a job with better benefits, no w/ends, or call so I could be with my family. 10 1/2 years of call and lack of management was burning me out.
The nurses don't do housekeeping where I work either.
Who was to know you weren't a "he" with a name like stevierae. Sorry for the misconception.