RN intubating in the ED

Specialties Emergency

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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.

Specializes in Education, FP, LNC, Forensics, ED, OB.

Yes, you must be ACLS and/or ACLS EP certified. Staff privileges must be delineated regarding this in the ER. ALso, trauma course would be essential. But, each hospital must make own guidelines. I intubate but am a NP. Check with nurse practice act in your state, too. Check with your (individual and hospital) for this coverage.

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Specializes in ICU, CM, Geriatrics, Management.

Have only seen the docs intubate in the ED at our facility.

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well here is the deal though. We only have a total of 8 doctors at our hospital. We have 1 surgeon and 1 CRNA on call. We look at a mass casualty situation the surgeon and CRNA will be in cases most likely so that knocks out the most qualified intubator. Then you have to look at minors that will be the majority of patients you are going to need 2 or 3 docs seeing them at a off site minor care to keep congestion out of the ED. So that leaves you with 1 ED doc and 2 or 3 family practice docs. And when I talk about the ED doc we are not talking about Board Certified 10-20 year ED vets. Many times we have Moonlighting 3 year residents and family pactice docs. You must understad we are the only hospital in our state within 80 miles in three directions and 35-40 in the other. We serve a very poor county in Oklahoma. Majority of our patients in the ED are Medicaid. We usally do with what we have because we can't pay out the money ED certified docs want. We still see alot of trauma though. Agricultural accidents, ATV, motorcycle injuries, good old fashion MVC, Shottings, Stabbings, you name it. What we want to use the nurse for is another resource. We don't want to just simply say its the docs fault he can't intubate. We can say that all we want but if the patient dies because of an unsecure airway, we still loose. We don't intend to have every nurse doing it. We have several old army medic or old RN's who let para medic lapse. To say they can't do it is nuts. They've tubed more people than most doc outside of OR or the ED. And to say you can't make someone competent to do it even with training is crazy. Intubation is no more complicated a procedure to someone who understands the technique than anything else we do. And if you have ever BVM'd someone for any period of time before you intubate you increase there risk of death secondary to aspiration. Any critcal care class will tell you control of the airway is always the priority. BVM is not control. I simple ask the question " Do any of your hospitals allow RN's to intubate, and if so what competency do they require"

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Sorry above was responds

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.

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I don't see this as such a large issue. Assuming it is allowable by your BON.

Policy: Any staff member with current ACLS who has recieved training in intubation, and performed over 100 procedures, is herby granted limited privilidges to perform intuabations in this hospital.

The first 5 intubations must be performed under the immediate supervision of the physician or anesthesia staff, who must agree that the individual has the skills required. The individual must perform 10 procedures annually and maintain their ACLS to retain these privlidges.

Put your own numbers in (the numbers above were taken for OB privlidges for FPs), and those who are qualified signed off. Make sure you have evidence of their education and past experience. The above policy, as written, would also allow your ambulance paramedics (assuming they are hospital employees) to intubate.

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I dont see a problem with RN's intubating if they are trained and have maintained competency. I have seen in usually a controlled situation where the MD allows the RN to intubate. I have seen hospitals where the RN or RT can re-intubate an extubated patient if the md is not present at the time. Its a procedure not for everyone, but those with the training can perform. With so many paramedics becoming RN's, i think you'll see more of it where states allow. This is why many have taken the stance, "Most experienced Person at the bedside" for airway managment. Not always your RT.

As far as ACLS goes.....Probably 99% of the courses do not prepare you for intubation. They give you an overview of the procedure, but nothing to prepare you to do it on a real person. Some courses are more indepth, but its rare. I teach ACLS and think we do a good airway mangament station, but we make sure to let everyone know this is an exposure to airway mangement.

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I don't see this as such a large issue. Assuming it is allowable by your BON.

Policy: Any staff member with current ACLS who has recieved training in intubation, and performed over 100 procedures, is herby granted limited privilidges to perform intuabations in this hospital.

The first 5 intubations must be performed under the immediate supervision of the physician or anesthesia staff, who must agree that the individual has the skills required. The individual must perform 10 procedures annually and maintain their ACLS to retain these privlidges.

Put your own numbers in (the numbers above were taken for OB privlidges for FPs), and those who are qualified signed off. Make sure you have evidence of their education and past experience. The above policy, as written, would also allow your ambulance paramedics (assuming they are hospital employees) to intubate.

I would only add that you develop some sort of biannual exam (covering the anatomy, medications, procedures and equipment involved in the intubating experience). There would have to be case scenarios to make the person think will induction agent would be appropriate, what NMB is the right choice, etc.

Just my thoughts,

Mike

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I would only add that you develop some sort of biannual exam (covering the anatomy, medications, procedures and equipment involved in the intubating experience). There would have to be case scenarios to make the person think will induction agent would be appropriate, what NMB is the right choice, etc.

Just my thoughts,

Mike

See I'm not sure you could really include RSI or induction drugs in. Just seems like there are so many thoughts on what you use. I don't think we would include this as something our RN's could do. What we are really looking at is last resource situation. No one can get patient smith intubated after 13 tries, Sally RN you try. This would never be a Sally patient smith needs a tube get after it.

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See I'm not sure you could really include RSI or induction drugs in. Just seems like there are so many thoughts on what you use. I don't think we would include this as something our RN's could do. What we are really looking at is last resource situation. No one can get patient smith intubated after 13 tries, Sally RN you try. This would never be a Sally patient smith needs a tube get after it.

If a more experienced provider couldn't get the tube after 3 tries, I would pull out the FOB or get the trach set out. Time is of the essence. (would this be a patient decompensating rapidly or a trauma patient).

My suggestion is that if you are taking 3 or more tries, then defer to a MORE experienced provider or maintain a good BVM with cricoid until one shows up.

Mike

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If a more experienced provider couldn't get the tube after 3 tries, I would pull out the FOB or get the trach set out. Time is of the essence.

Mike

Alot of the issue is also situation dependent, can you ventilate or not, etc. The Airway algorithm would have to be included in the competency.

Mike

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Thanks for your thoughts. The more we get into it the more we really don't want to get into it.

Alot of the issue is also situation dependent, can you ventilate or not, etc. The Airway algorithm would have to be included in the competency.

Mike

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This reminds me of the days not long ago when only physicians defibrillated. How times have and continue to change.

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