Question about RN's removing Chest Tubes...

[kurtzmobile]

Hello everyone,

Just wanting a little feedback on how you guys feel about the removal of chest tubes on a post-CABG/Valve pt via an RN. I previously worked @ a hospital were on the Tele/Stepdown Unit I and the other RN's removed chest tubes all the time. The requirements were that you had to have successfully completed ACLS, be an RN, completed a basic critical care course, and be witnessed by a trained person in chest tube removal 3X's prior to being able to remove them yourself. I recently reviewed on the states BON website that it is contraindicated for RN's to remove chest tubes. The hospital that I worked for was the only REGIONAL medical facility in the state and us nurses regularly removed chest tubes as we were given both verbal and written orders by the cardiac surgeons to do so. I guess what I would like is a little feedback on this topic b/c looking back if anything would have went wrong I could have been in some serious trouble in a court of law. I would have been found guilty of practicing a skill outside of a nurses scope of practice. How can a large REGIONAL medical facility allow this to happen when it is clearly stated in the BON?

Thanks-Jen, RN, BSN

[Tweety, BSN, RN]

I would definately look into this with your educators. It sounds like they had a clear written policy, and as you say I wonder how they would write such a policy that was against the BON.

I'm not sure what our BON says, however, where I work only MDs and ARNPs can remove chest tubes, not staff nurses.

[KatieBell]

The removal of chest tubes may be listed as a category two skill by your BON. Thus, it would normally be not permitted, but under certain circumstances (appropriate training etc), certain nurses are allowed to do these things. When I worked in ICU, I was trained to do several category two skills which were not in the normal scope of RN practice. However, on the BON website, there was a clear deliniation of category one and category two skills and the requirements of Category two. (which included appropriate training prior to doing those skills).

[jmgrn65, RN]

Our staff nurses remove, chest and plueral tubes all the time. We have a competency that everyone has to demonstrate before pulling chest tubes on thier own. We have pulled chest tubes for many many years. There was a short time the PA's pulled plueral tubes and they found the incidence of pneumo' s increased. As far as I know it is within our scope of practice ohio bon.

[Larry77, RN]

As a policy the hospital I work in does not have RN's remove chest tubes...

[rt2crna]

Reply by Larry77 raises a (maybe silly) question. Can a hospital policy supercede a BON directive? i.e. BON says you can but hospital, or med staff, says you can't or vice versa- hospital says you can, but BON says no. Which would hold up in court? Probably the more restrictive, but what does everyone think?

[Larry77, RN]

I hope that a hospital policy would not be able to over-ride any BON guidelines or limitations. You would think that if so this might and should be discovered by a JCAHO survey?

This same type of question came up the last time I did ACLS when the paramedics asked if RN's can intebate. All of us RN's quickly answered "No", but then an older RN who has experience in other states said she has seen ICU nurses with special training intebate when necessary.

Larry (a non chest-tube pulling, non intebating, plain ol' RN)

[Tweety, BSN, RN]

Reply by Larry77 raises a (maybe silly) question. Can a hospital policy supercede a BON directive? i.e. BON says you can but hospital, or med staff, says you can't or vice versa- hospital says you can, but BON says no. Which would hold up in court? Probably the more restrictive, but what does everyone think?

If a hospital policy is an RN can't remove a chest tube, but the BON says an RN can, and an RN removes a chest tube in the hospital, it still won't hold up in court if sometime bad happens. The main reason being since there is no policy, then there's no documentation of your competency in this task and a good lawyer will jump all over that, and the hospital will let you fry.

Maybe a legal nurse can say it better, but that's how I understand it. You can't violate hospital policy just because the board allows you do.

Visa versa - We are responsible for knowing what the BON says, so if a hospital asked us to violate the BON, we still are in trouble in a court of law. So if the BON says we can't remove a chest tube, and the hospital says you can, you're still in trouble. In this case a good lawyer will go after the hospital (where the big bucks are). Ignorance of the law is no excuse for breaking it. (But in this case, if I'm going down, I'm getting my own lawyer and bringing the hospital down with me.)

Having a license to pracitice nursing is a serious business. :)

[HappyNurse2005, RN]

Uh, no. RN's don't pull the chest tubes post cardiac surgery in my pcu. PA's or doc's do it.

[NYNewGrad]

Question - how do I find my state's BON policy on RN responsibilities? I live in NY and havent had much success searching online....

[rstewart]

I hope that a hospital policy would not be able to over-ride any BON guidelines or limitations. You would think that if so this might and should be discovered by a JCAHO survey?

This same type of question came up the last time I did ACLS when the paramedics asked if RN's can intebate. All of us RN's quickly answered "No", but then an older RN who has experience in other states said she has seen ICU nurses with special training intebate when necessary.

Larry (a non chest-tube pulling, non intebating, plain ol' RN)

Registered Nurses are licensed by the state. Your state's nursing practice act defines your scope of practice. If you practice outside of your scope of practice then your state's board of nursing can discipline that RN. This is true regardless of whether or not a physician or your hospital "gives permission" to exceed your scope through an order or a policy.

Unfortunately, whether or not a specific procedure is outside the scope of nursing practice may not be entirely clear. Some states offer specific advisories/directives regarding certain procedures. However many do not, essentially pleading that to define all procedures as permissable (or not) would be overly cumbersome for the board and the nurse alike. Typically, they provide a decision tree to aid the nurse in determining whether a procedure is permitted under the act. Usually the decision tree requires that the procedure is not specifically prohibited by the board, that the facility's nurse executive has blessed the procedure, that a policy/procedure exists for its performance, that the individual has had the education/skills checked off to perform the procedure safely etc....... So be aware that even though a procedure may potentially be within the scope of nursing practice, if your facility has no relevent written policy/procedure, you are subject to be found practicing outside of your scope of practice should an adverse event occur.

As mentioned above, the completion of a course in ACLS in and of itself does not bestow immunity from the above facts. But some RNs can and do perform intubation-----not because they have completed ACLS but rather because their employer has a policy permitting same, they have verified/documented the nurse's training and proficiency etc.

My advice: If your facility does not have a policy regarding a procedure....don't perform it until one is formulated/approved. If you have any doubts regarding whether or not a procedure is within the scope of practice ask for a determination from the board; they might provide a straight answer to your inquiry or refer you to a prior determination they have made------or likely as not refer you to one of those damn decision trees.

[DutchgirlRN, ASN, RN]

No one other than the doctors pull the chest tubes. I'm not even going there. Talk about your liability. YIKES !