RN intubating in the ED

perhaps you should also check with your state board of nursing to see if this is permitted or do you require state mandated higher level of education?

an example would be- nps can but staff rn cannot suture in our state. i don't know about intubating in pa, i'd have to reasearch that one.

anne

Well we do have RT that intubates at times. we have checked with our state board and there is nothing in our practice act that is against it. And it is not something we want to occur routine. Our problem is we are a rural hospital. We have a 10 bed ED that at peak times only has 3 RN and 1 MD or DO. At other times we fall down to 1 RN 1 MD or DO. This presents problem if we have a bad MVC with multiple victims come in or just multile codes at once. What we are trying to do is cover our RNs that are capable if the ned arises. We have many who have worked in other areas in the past where intubation was routine duty(we have some former army combat medics and such). Don't get me wrong if the doctor or CRNA can do it they will. We just want to cover those mass casualty situations you hope you plan for so it never happens.

perhaps you should also check with your state board of nursing to see if this is permitted or do you require state mandated higher level of education?

an example would be- nps can but staff rn cannot suture in our state. i don't know about intubating in pa, i'd have to reasearch that one.

anne

after speaking to the obn intubation doesn't seem to be forbidden. competency must be determined though. i just want to get a feel of what other hospitals and nurses think. i don't think it is something any nurse should do but i don't feel it should exclude all nurses. in relation to sutures, depending on the wound and area it is located there can be many problems. now i also understand intubation is not without risk. but one thing does distingish the two. one is very emergent and the other usualy is not. the cases we would use a rn in would be very rare and only in those cases where there is no other option. we would also most likely limit it to those who are cen or setting for the cen soon. they would also likly need to do competency with one of our crnas. thanks for your thoughts

matt- sounds like you are trying to put together a good plan- if you do train in intubating- make sure your education includes what needs to be done to maintain competency, as this is a skill that is not routinely done by your nurses- maybe include your anesthesia department in the training and maintainence of competency-

example- the nurses who are trained must do so many supervised intubations in a 3-6 month period to maintain competence.

emt-ps also are an excellent resource for intubation- maybe you could include them in your disaster chain- some of them can tube anything!!! :) they may already be there if it's a mass casualty event.

good luck with your planning!

anne

We've sort of looked into it, too. We have determined that the nurses simply need supervised training. This is something that can be accomplished easily with anesthesia or a CRNA in OR. If you have a fairly busy OR. We generally have someone around who can intubate (I'm in ICU) but there have been occasions where the ER doc was busy, the particular RT present wasn't capable, and we had to bag for up to 30 minutes waiting for anesthesia to get there. The EMTs stationed at the hospital would occasionally do it (against our wishes), depending on the doc in ER that night, but we have had multiple problems with them, and have since found out that they are not authorized to intubate within the hospital (excluding ER). Good luck, I think your plan is great.

In our Hospital the Medics Intubate all Pts. No nurses intubate.

In a mass casualty you would be calling in docs from all over anyway, possibly someone would be in house to help too. You would have the medics as backup, plus bagging with an airway is usually sufficient for a short time. In worst case scenario the doc goes from room to room intubates and moves on to the next. He/she doesn't have the luxury of staying in one room if there are multiple victims anyway, right?

Yet another issue- if this is a doc problem why is it up to the nurses to solve their staffing issues? Do they need closer backup? If we need more nurses we don't look to the CNA's to cover. They don't get enough practice even if they did go through special education.

I recently found myself in a situation where a patient was intubated due to respiratory distress and was found on CT to have a huge subdural bleed. His wife expressed that the patient had always told her that he never wanted to be kept alive on a ventilator. The admitting physician came to the ER and told the family that she would extubate the patient and he would be moved to a room so that the family could freely come and go to the bedside until the time of his death, which could be seconds or hours. The patient was intubated in the ER. He lived approximately 10 minutes. We allowed the family to be at the bedside even when the tube was removed. I would not have been comfortable doing this without the physician present. Since there is a physician always on duty in the ER, I feel that they should be utilized in situations like this.

Do any of you work at hospitals where RNs intubate patients in the ED under certain situations? We are looking at this at our hospital. What training do you require of these nurses. I've heard some say ACLS, but I teach ACLS and don't feel it rovides enough training to set someone loose even with a doctor or paramedic with them.

Do any of you work at hospitals where RNs intubate patients in the ED under certain situations? We are looking at this at our hospital. What training do you require of these nurses. I've heard some say ACLS, but I teach ACLS and don't feel it rovides enough training to set someone loose even with a doctor or paramedic with them.

I have to agree...I've been a nurse for 10 years, and had ACLS all 10 years....there is a difference when you take ACLS, and you "practice" getting a dummy intubated vs actually doing it and learning the proper way to do it...I am a PH-RN so I did learn how to intubate, and let me tell you that those 10 years of ACLS did nothing to teach me how to do it for real. It takes more than a five minute "playing around" once a year to be able to do it in the real world...There would definitely have to be more of a learning process and a competency in it...The concept sounds easy, but throw in an emergent situation and not having done it frequently and trust me, its not as easy as it sounds...Is it impossible, no, not by a long stretch, but like I said, it would have to be more teaching and a more structured competency for it...Even the medics in my area have yearly skills lab.

It's just a skill like any number of skill we perform each day. It' s not rocket science. If you only started 1 IV a year, I would prefere someone else try if I needed one in an emergency. The same with the tube.

ACSL in itself isn't enough. AHA says that right up front. If you facility want's RN's to intubate, then just like adding any other skill to the list, they need to establish competencies and go from there.

I only allow 2 of my RN's to intubate, THe others are allowed to utilize Combutube when there is a delay in a member of the medical staff getting there.