Propofol IV push by non-CRNAs in non-intubated patients--allowed in Oregon

[stevierae]

i know we've discussed this issue to death, both on this forum and on the gastroenterology forum.

as an rn and operating room nurse, i have very, very trong feelings against this practice, which is now allowed in oregon, via our own nurse practice act.

i wrote to the board twice expressing my feelings. i will post the most recent reply i received. note the reference of the writer to "the anesthesia community" (and her apparent disregard for their viewpoints) and the references to meetings and discussions, and requests for input, that were never, apparently, widely circulated (except on their website.)

if any of you harbor feelings as strong as mine--that, i believe, would be most of you--please let them be known to the oregon board of nursing. if you reside and/or practice here, or in wa or idaho, possibly you can arrange to be at the next meeting, or to make your feelings known via mail or emails. i just think that this decision was wrong, and is a recipe for a sentinel event that could easily be avoided.

without input, your own state could be next---other states; other hospitals, other free-standing endoscopy facilities, interested in using rns as cheap labor as an excuse to avoid paying or benefitting anesthesia providers, are probably well aware of this decision and anxious to jump on the bandwagon--anything to save a buck--safe patient care be damned.

here's the reply i got by someone who identified herself as a "nursing practice consultant" of the oregon state board of nursing: (my own letter to which she is replying is below it:

"i am a member of the board's staff and the staff member who led the task force that developed this policy. here's the history:

at the november 17, 2005 board meeting, the draft policy guideline, nursing scope of practice for the use of sedating and anesthetic agents was first introduced as a non-consensus document for the board's consideration. work on this policy guideline was ongoing from the first task force meeting on march 28, 2005 until policy adoption in february 2006. the initial impetus for this work was in response to a december 13, 2004 letter from carla harris, vice president of patient care services for legacy health system, who requested clarification from the board about the role of the rn in the administration of anesthetic agents for varying levels of sedation, the task force consisted of 22 members from a variety of practice, health systems and geographical settings around the state. it included rnss, cnss, an fnp, 2 crnas and an ed physician. a literature search was done, and articles reviewed by task force members.

during the november 17th meeting, stakeholders had the opportunity to speak to concerns they had regarding adoption of this policy. there was significant discussion regarding the use of anesthetic agents (particularly propofol) by the rn, np and cns for moderate procedural sedation. at that meeting, the draft policy was largely supported by those stakeholders with the exception of the anesthesia community.

the board determined that additional feedback from the nursing community around the state would be useful, and directed that the policy be posted for comment on the website. the draft policy was posted shortly after the november 17th meeting, and comments were collected. e-mail comments that were received were reviewed at the board meeting on february 9, 2006. in addition to e-mail comments, dr. john walker sent a notebook filled with information for each board member including his personal statement from the november 17, 2005 board meeting, questions and answers regarding nurse administered propofol sedation (naps), a chronology of naps since november 2005, and 3 papers on naps. feedback that was editorial in nature was also received over the telephone and communicated to the board.

the february 2006 meeting was videostreamed and videoconferenced into more than one location, so there was additional opportunity for public comment at that time. the information that you have pointed out in your e-mail was taken into consideration by the board in their decision-making. ultimately, based on the evidence and information in existence, the board determined that nurses may safely engage in sedation as long as the safeguards outlined in this policy are followed.

as you can see, this was an extensive and thoughtful process. many safeguards were put into place. the decisions that were made, were not made lightly or without support in the literature. hopefully, this information gives you a clearer picture of the process that was followed. at this point in time, due to the fairly recent consideration of this same information, it is not my intent to forward your concerns to the actual board of nursing. if you believe that you need to pursue your concerns further, you are welcome to bring them to the board's open forum which is held during each board meeting. it is usually at 1 pm on the day of the meeting. the board next meets on february 15, 2007. you will want to check the website a couple of weeks ahead for the specific time. it would be helpful for me to know ahead of time, if you plan to be there. for your information, this is an opportunity to bring an issue forward, but any consideration of that issue must be given at a future meeting.

if you want to discuss this matter in the meantime, please feel free to call."

________________________________________________

attention: oregon state board of registered nursing

can you please clarify your position on rns who are not crnas giving iv push propofol to non-intubated patients? are you of the opinion and supportive of the position that this practice is acceptable as part of moderate sedation in free-standing surgical centers, ers, ors and gi labs (endoscopy suites?)

i read the position statement in its entirety http://www.oregon.gov/osbn/pdfs/policies/sedation.pdf

that appears to have been updated as of 2/2006.

i am deeply concerned about your response to the rn (page 7) who states that she has been offered a job in an endoscopy suite, and will be giving propofol as part of conscious sedation.

i do not believe that any rn, other than a crna, should be giving iv push propofol to a non-intubated patient--particularly an adult who is categorized as an asa 3, or a pediatric patient who is categorized as an asa 2.

i am absolutely certain (check their position statements) that both crnas and anesthesiologists nationwide are in agreement with my position. aaaafs does not support this practice in free-standing surgery centers.

you do realize that, at endoscopy labs such as the one in medford, or,

nurse assisted propofol sedation

that these patients are not intubated, correct?

do you also realize that the package insert for propofol specifically states that it is to be administered (for anesthesia purposes) on non-intubated patients only by an anesthesia provider? do you realize that gastroenterologists petitioned the drug's manufacturer to remove this wording from the package insert--and were unsuccessful?

i feel very, very strongly that the non-crna rns at this facility (and others like it) are putting their patients at unnecessary risk by administering propofol iv push.

just the comments some of them make on various nursing bulletin boards shows that these people truly do not understand the pharmacology alone behind propofol, as they continually refer to giving their patients "a pain free experience." (propofol has no analgesic properties.)

i do not think rns who are not crnas should be used as "cheap labor" by any facility as a way of getting around paying properly trained personnel--crnas or anesthesiologists----who deal with difficult airways and anesthetic complications everyday; multiple times a day. even healthy pediatric patients can laryngospasm and desaturate--and even arrest-- very, very rapidly.

down syndrome children, for example, often have multiple co-morbidities and can become bradycardic and desaturate in the blink of an eye--yet they are the children entrusted to non-anesthesia rn providers in ambulatory surgery centers for "moderate sedation" when they need dental restorations or extractions done. they are the ones who often get assigned (and who is doing the assigning? the rn doing moderate sedation?) an asa 2 status.

(why do you think that there are anesthesia providers who are specifically trained in pediatric anesthesia? these children are often medically fragile, and deserve a designated anesthesia provider--crna or anesthesiologist--managing their anesthetic regimens. they are trained in pals----most or nurses are only acls certified--not pals certified.)

asa 3 adult patients--some of whom are smokers; some of whom have cardiac or vascular disease or other co-morbidities; some of whom are obese, have beards and short, thick necks, and even sleep at home with cpaps due to sleep apnea--are often difficult to "bag" (and intubate) by the most experienced anesthesia provider.

endo lab nurses, and even operating room nurses and er nurses---and i am an operating room nurse with nearly 30 years of experience----simply do not have the advanced education, training or experience that crnas have.

why should any of us be expected to function as "cheap labor" and endanger the lives of unsuspecting patients? these endo lab gastroenterologists and er physicians--as well as surgeons---should be able to focus their complete attention on their procedure---not on having to intubate a patient who has slipped into deep sedation--or even general anesthesia-- by a non crna rn and thus needs to be "rescued." many simply have little experience or skills even giving cpr (other than on a mannekin, at annual bls certification)--let alone intubating.

please rethink your position. i know of no other state that allows non- crna rns to administer iv push propofol on non-intubated patients.

it's simply not within the rn's scope of practice anywhere (other than in icus, where the patients already have protected airways.) those patients are intubated, on ventilators, have easy access to rt, intensivists, and pulmonologists, as well as anesthesia providers, and usually have arterial lines from which to draw stat blood gases (as well as other hemodynamic monitoring lines and devices.)

i will be anxiously awaiting your reply. (i have actually written you in the past, as well as the orana (the oregon organization of nurse anesthetists,) about my concerns surrounding this issue.)

i am passionate about my responsibility as a patient advocate, and will not rest as long as this is accepted practice in the state in which i reside--or anywhere, for that matter. this issue comes up all the time among legal nurse consultants such as myself.

[paindoc]

This may be one of the few areas the majority of CRNAs and MDAs actually agree with one another.

[P_RN, ADN, RN]

I'm not a crna by a long shot, but I have been chastised by physicians in the past for refusing to give IV propofol for post op hiccups! I am happy to see that my stance is supported. Thank you. Is Oregon the only state that's approving this? Or are other states going to follow?

[AnnieOaklyRN, BSN, RN, EMT-P]

In NH nurses can push propofol and hang a drip on patients who are intubated already. There are equally dangerous drugs that nurses push everyday. The major effects of Propofol, that I have noticed is obvioulsy that the patient becomes obtunded and may become hypotensive. I do not see what the big deal is really, obvioulsy they cannot tie you down and force you to push a drug you are uncomfortable with.

Swtooth

[London88]

SWtooth key word in your post is the pt is intubated already. As for the hypotension ask yourself what causes the hypotension? I personally have no problem in a situation where the physician can intubate such as in an ER, but I have not come across many GI docs who can intubate a pt. Last week a colleague of mine gave propofol during a TEE, the pt became apneic and my colleague ended up intubating the pt and the procedure was completed w/out any problems. Bottom line is that she is an experienced CRNA and even in trained hands propofol can be unpredictable.

[deepz]

........ I have not come across many GI docs who can intubate a pt. .........

As I often say, moving from a light Versed/Demerol combo into bolusing propofol is like a fully qualified Cessna pilot jumping into the cockpit of an F-16 jet. Expect trouble.

!

[jwk]

In NH nurses can push propofol and hang a drip on patients who are intubated already. There are equally dangerous drugs that nurses push everyday. The major effects of Propofol, that I have noticed is obvioulsy that the patient becomes obtunded and may become hypotensive. I do not see what the big deal is really, obvioulsy they cannot tie you down and force you to push a drug you are uncomfortable with.

Swtooth

There has NEVER been a debate about propofol use in intubated patients. Why do people keep bringing this up?

[zrmorgan]

oregon rn,np, cns beware, you are accountable for making these decisions...read the fine print in the practice act the oregon sbn has given you a very narrow scope...take the following quotes into consideration before agreeing to use this drug:

"...the oregon state board of nursing affirms that it is within the role and scope of practice for the rn, np and cns to administer sedating and anesthetic agents to produce moderate and deep procedural sedation...under the direction of a lip"

"'deep sedation / analgesia' is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated or painful stimulation....cardiovascular function is usually maintained."

(*reflex withdrawal from painful stimulus is not considered a purposeful response).

"...licensed independent practitioner...(lip) - an individual permitted by law and the individual's employer to independently provide care, treatment and services that are within the individual's scope of practice and consistent with clinical privleges granted by his/her employer"

it seems as if the sbn is authorizing the practice, but in fine print excluding most cases where propofol is used. how many patients have you seen who cannot be easily aroused, but they can respond purposefully?

cardiovascular function maintained? how is this defined? not asystolic? almost all of my patients will drop their blood pressure when i give propofol..especially during deep sedation.

how many "lips" want their patients to maintain purposeful movement when subjected to repeated painful stimulation (purposeful meaning the patient pushing away the painful procedure that is at the hand of the operator)?

i would strongly urge the oregon sbon to follow up on these guidelines to make sure they are being followed. i highly doubt if they are followed there will be more than 3 or 4 cases a year in oregon that fall within the printed scope of practice.

to those of your practicing under this scope. be sure that the lip you are working with is comfortable handling airway emergencies.

[needsmore$]

Stevierae--your letter was perfect. I hope you don't mind but I would like to borrow it for use in our ED setting-- some of our docs want the ED nurses to PUSH Propofol for moderate sedation --not for pre-intubation but as a procedural sedation med. I feel like I am banging my head against a wall trying to get some of my colleagues to recognize the dangers of this practice

Your letter was well thought out, and included many if not all of the points I have been trying to make, and stated more eloquently as well.

I have been an ED nurse for 26 years, and I find that its the less experienced nurses who seem to think-- "no problem" regarding doing new procedures, administering meds that they have very limited experience with. They read it about in in their reference book and think they're competent

Thank you again

[TXCRNA]

In Texas propofol may only be administered by CRNA or anesthesiologist to a nonintubated pt. If pt intubated & ventilated an RN may administer. If the RN is acting as the CRNAs or MDs "hands" and administering propofol while the anesthesia professional mans the airway this is also allowed by RN practice act in Texas. Although some RNs dont know their own scope of practice and simply do as theyre told by MDs (esp the newbies). I recently responded to a code where an RN was giving propofol to a nonintubated patient for MRI because she had an order from the physician to do so. Pt had a respiratory arrest in MRI and when we responded to code the propofol was STILL infusing. Beware....MDs have no clue what is and what is not in the scope of practice for a RN. Look out for yourself and know your own states nurse practice act.

[subee, MSN, CRNA]

I do a lot of endoscopy (CRNA) and Stevierae - I'm just so impressed with the eloquence of your presentation and your concern for the patient. BECAUSE I use Propofol ALLDAY, EVERYDAY, I have a profound respect for its ability to create havoc. All kinds of patients who don't belong in outpatient endoscopy wind up there anyway. Some are so blatently obvious that the MD makes the arrangement to send them up the road to the tertiary center (to have the procedure that same day). We still get an occasional aspiration that wouldn't have happened if the patient were not sedated with propofol. Only people who have day to day experience with propofol should be using it in non-intubated patients. With only a modicrum of patience, endoscopic procedures can be done comfortable with conscious sedation.