Paramedics in the hospital setting

[Ellekat2]

Our facility, a twenty-two bed Critical Access Hospital, has hired two paramedics to work in-hospital. When asked what they can do, the DON said, "Everything, under the supervision of an RN". I am an RN.

I have not been able to find any verification of the Paramedic Scope of Practice in the hospital setting through the Kansas Board of Nursing or the Kansas EMS site. Where can I find their Scope of Practice? I am comfortable working with them. I am just wanting verification of what a Paramedic can/cannot do in the hospital setting. Our facility has two Paramedics working, but is still writing the policy.

[Susie2310]

I do not live in your state, but if I could not find an answer to such a question on my state Board of Registered Nursing web site, I would telephone my state Board of Registered Nursing and ask my question.

[Ellekat2]

Thanks for your response. I think you're right.

[nurse2033, MSN, RN]

This is from National Registry of EMTs http://www.nremt.org/nremt/downloads/Scope%20of%20Practice.pdf. I'm not sure if your state is a National Registry state but it will give you an idea. Remember that paramedics have a certification and always work under the license of a physician. You have a license and work under the license of you. In my opinion your DON was a bit glib. Paramedics are great at tasks, patient assessment, especially IVs, and performing under stress. You should just ask them what they can do for you, and what you can do for them. They don't think like nurses so are usually a bit light on the nurse-feely stuff. Paramedics work in ERs here in Colorado and take their own patients- usually the less involved cases. (I'm both a paramedic and RN BTW). Their medication knowledge will be much less than yours, but if you have an real patient emergency they will be a great asset.

[sgrondahl]

I think that in CA they increased their ability to do more here now. In our area we have EMTs that work in the ER now. Great resources.

[akulahawkRN, ADN, RN, EMT-P]

California's rules for Paramedics working as Paramedics in the ED are a little different. In "small and rural" hospitals, they can function as Paramedics and their full scope of practice can be utilized. They're not nursing staff and they don't replace nursing staff. They compliment the nursing staff, but function under the ED MD's license. Larger and non-rural hospitals may hire them as UAP staff, with titles such as "ED Tech" or "PCT" and they may be allowed to perform certain skills that aren't usually thought of as OK for PCT staff to do, though it won't be their full Paramedic scope of practice.

Just as an aside, Paramedics once inside the hospital itself, aren't usually allowed to utilize their full scope of practice, and that's probably true even at the small & rural hospitals where they have Paramedics in the ED.

Just remember, like one of the posters above said, Paramedics don't think like nurses and they don't function under your license. They may have their own license, but much of what they can do is delegated to them by the MD, under the MD's license. Their med knowledge is going to be not as broad as an RN's is, but for what they do know how to do, they're usually very good at it.

[BR157]

No nurse should ever be supervising a Paramedic. That should just not happen. Paramedics do not work under a nurse's license. Only a doctor should be giving us orders.

As Akulahawk pointed out, Paramedics don't think like nurses. Paramedics use critical thinking skills in the field where we don't have a doctor or many doctors telling us what to do every step of the way. Akulahawk is wrong in that the Paramedics' scope of practice is much more broader than a nurse's. We can do many more things they can't and will never be able to do. It is a shame we are restricted in the ERs by nurses as to what we can do.

[Esme12, ASN, BSN, RN]

No nurse should ever be supervising a Paramedic. That should just not happen. Paramedics do not work under a nurse's license. Only a doctor should be giving us orders.

As Akulahawk pointed out, Paramedics don't think like nurses. Paramedics use critical thinking skills in the field where we don't have a doctor or many doctors telling us what to do every step of the way. Akulahawk is wrong in that the Paramedics' scope of practice is much more broader than a nurse's. We can do many more things they can't and will never be able to do. It is a shame we are restricted in the ERs by nurses as to what we can do.

We both follow strict protocols dictated by the state and under medical control. While there are tasks that are not usually performed by RN's in the hospital setting...there are no tasks that the medic performs that a nurse cannot do after training. However there are tasks and patients that nurses can care for that medics cannot as they are restricted from certain equipment and meds (depending on state protocol)....unless critical care training has been established.

We are both critical care givers with high levels of education in our specialty. To discredit one over another is just counter productive.

Nurses intubate at facilities that I have worked and can perform other tasks that medics are trained for. Do we do them? no. There is no reason to do these tasks as there are other medically trained personnel who are experts at our disposal.

Medics are not restricted by the nurses.....they are restricted by the physicians/medical control, hospital policy, and state statute.

I am curious however....how is the medic scope of practice broader than the RN's.

the Paramedics' scope of practice is much more broader than a nurse's.

[BR157]

We both follow strict protocols dictated by the state and under medical control. While there are tasks that are not usually performed by RN's in the hospital setting...there are no tasks that the medic performs that a nurse cannot do after training. However there are tasks and patients that nurses can care for that medics cannot as they are restricted from certain equipment and meds (depending on state protocol)....unless critical care training has been established.

We are both critical care givers with high levels of education in our specialty. To discredit one over another is just counter productive.

Nurses intubate at facilities that I have worked and can perform other tasks that medics are trained for. Do we do them? no. There is no reason to do these tasks as there are other medically trained personnel who are experts at our disposal.

Medics are not restricted by the nurses.....they are restricted by the physicians/medical control, hospital policy, and state statute.

I am curious however....how is the medic scope of practice broader than the RN's.

Here you are just wrong.

Many states restrict a nurse from intubating. Some restrict nurses from central lines and arterial line insertion. The medical director for a Paramedic just has to inform the state there is a necessity for a skill to be added. This is how Paramedics manage ventilators including setup, balloon pumps, ECMO patients and just about anything else that must be transported. Paramedics also work in cardiac cath labs, ERs and ICUs with the exact same scope as an RN along with their own which makes them more valuable in many ways. But, nursing unions are always bickering about this just like they tried to stop Paramedics from expanding in Minnesota and a few other states like Maine and Colorado. Finally they loss and Community Paramedics can do what occupational therapists, physical therapists, respiratory techs and nurses do in the home care setting.

I can't imagine the nurses who intubated held their license very long. I don't know of any hospitals would allow nurses to intubate unless they are flight nurses but even then Paramedics usually do the intubations as their partners. Not very many nurse/nurse flight teams around.

In the state of Texas, Paramedics do not have a defined scope of practice. It is whatever the medical director for that agency says it is. Nurses are very restricted in that state. I would imagine there are other states like that also or they just have to ask their scope to be expanded. Doesn't work that easy for nurses.

[Esme12, ASN, BSN, RN]

Here you are just wrong.

Many states restrict a nurse from intubating. Some restrict nurses from central lines and arterial line insertion. The medical director for a Paramedic just has to inform the state there is a necessity for a skill to be added. This is how Paramedics manage ventilators including setup, balloon pumps, ECMO patients and just about anything else that must be transported. Paramedics also work in cardiac cath labs, ERs and ICUs with the exact same scope as an RN along with their own which makes them more valuable in many ways. But, nursing unions are always bickering about this just like they tried to stop Paramedics from expanding in Minnesota and a few other states like Maine and Colorado. Finally they loss and Community Paramedics can do what occupational therapists, physical therapists, respiratory techs and nurses do in the home care setting.

I can't imagine the nurses who intubated held their license very long. I don't know of any hospitals would allow nurses to intubate unless they are flight nurses but even then Paramedics usually do the intubations as their partners. Not very many nurse/nurse flight teams around.

In the state of Texas, Paramedics do not have a defined scope of practice. It is whatever the medical director for that agency says it is. Nurses are very restricted in that state. I would imagine there are other states like that also or they just have to ask their scope to be expanded. Doesn't work that easy for nurses.

Show me a nurse practice act or state statute that the prohibits nurses from intubation. I have flown with a couple of crews and worked with many...I have always seen nurse /medic crews.

Here is an example of a state statute that states nurses may intubate.....http://www.azbn.gov/Documents/advisory_opinion/AO%20Intubation-Endotracheal%20%26%20the%20Use%20of%20Advanced%20Airway%20Devices-The%20Role%20of%20the%20RN.pdf

[Esme12, ASN, BSN, RN]

By the way paramedics do have a scope of practice.

The rules governing EMTs and Paramedics are located in Title 25, Texas Administrative Code, Section 157.2. This rule limits the scope of practice of EMTs/Paramedics to performing duties in the "pre-hospital and inter-facility transport" settings. Therefore, whether certified or licensed, the BON delegation rules view EMTs, Paramedics, or other similarly trained staff as "unlicensed assistive personnel" (UAPs) when working in acute care settings, such as the ED.

Each

RN

decides on a case-by-case basis what nursing tasks may be delegated to unlicensed personnel in accordance with Rule 224 (relating to

RN

delegation in acute care settings or for patients with acute conditions). It should be noted that position descriptions developed by employing institutions can neither mandate

RN

delegation, nor force

RN

delegation by facility policy or physician order.

The BON's delegation Rule 224 is not prescriptive to specific procedures or tasks that may or may not be delegated. Rule 224 permits a

RN

to delegate starting a peripheral IV saline lock to an unlicensed person providing all of the delegation criteria are met. The applicable section of Rule 224 in delegating this task is 224.8(b), Discretionary Delegation Tasks, under (2)(A), Sterile Procedures. Section 224.8©(5) does prohibit delegation of administration of IV fluids, so an unlicensed tech in the ED could not connect and administer a bag of IV fluid under

RN

delegation.

Other laws outside of the BON's jurisdiction may prohibit performance of certain tasks by unlicensed personnel, even if a physician is willing to delegate a task. Under physician delegation, the physician must willingly make the decision and delegate the task(s) and such delegation must be permitted by hospital/facility policy. BON staff cannot speak as experts on the Texas Medical Board's (TMB) rules; however, Rule 193 of the TMB Rules addresses "physician delegation." You may wish to contact the TMB at [phone], or check their web site at

Texas Medical Board

for more information on this law.

The delegation rules also address the

RN

who may be supervising an unlicensed person to whom the physician has delegated tasks. The

RN

always has a responsibility to protect client safety [217.11(1)(B)], so the

RN

has a duty to intervene if he/she sees something being done incorrectly by the unlicensed person, and to notify the delegating practitioner of the incident. For additional information on EMTs and Paramedics in the pre-hospital and interfacility transport setting, check the Texas Department of State Health Services web site at

Home - DSHS EMS & Trauma Systems

, or, to access applicable laws, see Texas Legislature Online at

TLO

.

Texas Medical Board language of 22 Texas Administrative Code, Section 197.1. Medical personnel with specific training and competencies may be able to perform skills outside the bounds of traditional practice if their medical director evaluates, provides additional training, authorizes them accordingly and develops protocols to match

[akulahawkRN, ADN, RN, EMT-P]

Yes, Paramedics and EMT's have their own scope of practice and each state regulates what it is and where they may practice and in some cases, their scope of practice can be very restricted and in others, not. In each state, there is usually a pretty clear demarcation as to when a Paramedic or an EMT is UAP or functioning under their own scope.

For nurses that want to find out what the field personnel can do, look up your state's EMS statutes and regulations. You might be surprised at what their scope is, what their service levels are, and how different their scopes of practice are. That has implications for arranging transport between facilities.