Scope of practice in surgery

[Ag15]

Hello I am traveling on my third assignment as a Surgical Tech and had some questions regarding scopes of practice in different states, any advice/info is much appreciated! I'm from Kansas City and that's where I went to school and worked at a few area hospitals and was a private scrub for a group of surgeons. Around there, the techs are expected to assist (with some limitations) unless it is a complex case that requires a second surgeon.

I've been to DC where the techs don't assist....they barely are allowed to even hold a retractor or do normal assisting duties (or what I thought was normal). Docs have a PA on every case or student/resident.

I've also been to Kentucky where they use the techs as assistants on every case. When I say assist I mean they literally do the surgery lol. Inject local, make incisions, put in trocars, fire staplers, etc. They also make two techs and one nurse be on call at the same time, one tech to assist and the other to do the passing. The techs here also do most of the circulating duties.

My question is, why is it so different everywhere? How can I find out what the scope of practice is in different states? There seems to be a lot of grey area. Again, thanks for any suggestions!

[Rose_Queen, BSN, MSN, RN]

As surgical techs are only licensed/registered in a few states, there isn't really going to be an official scope of practice. However, what many surgical technologists may do is going to be influenced by facility policy. It could be that in your experience, some facilities were more liberal with what could be delegated to STs. However, as this is a nursing site, the Association of Surgical Technologists may be a better place to help you with your question.

[Ag15]

Thank you for the reply! I will definitely post on that site too. In my searches before, this site came up a lot so I decided to join. It's always nice to get a nurses point of view on things along with techs :)

[NedRN]

Nurses have a scope of practice limited by the state licensure act. Scrub techs do not have any such limitation. The general rule (modified in some circumstances by law or insurance) is that anyone can do anything under a physician's direct supervision and sometime indirect supervision - at least at a physician's private practice. The reality in most hospitals is that you are limited in what you can do by hospital policy and/or practice. Techs or nurses can practice as first assistants per individual hospital whether certified or special training or not. While I don't know the laws of every state, it is unlikely that the state you work in will matter in deciding what you may or may not do in any particular facility.

I've worked in hospitals in perhaps 15 states now as well as surgery centers and private ORs and I've never seen any limitation on first assisting in surgery by techs or nurses except by hospital policy and practice. Opening is unusual, but I've seen that as well (scary in open hearts without the surgeon in the hospital yet). Closing, retracting, cauterizing is commonplace everywhere regardless of credentials.

In brief, it is the facility that accounts for the differences you have seen, not the state.

[Ag15]

Ned, thank you for the information! The place I'm at seems completely shut off from the real world. The nurses/OR staff were unaware of what is included in a "time out". What do you say in your time out process? I look like the bad guy here when I'm insisting on basic safety measures be taken.

[Rose_Queen, BSN, MSN, RN]

Our time out policy mandates the inclusion of:

Patient name/DOB

Procedure to be performed- including laterality if applicable

Surgeon performing said procedure

Site marking (surgeon initials) visible in surgical field

Allergies

Antibiotics ordered and if they were given (surgery not to start if not given unless emergent)

Any necessary imaging studies are available

Any potential implants are available

Blood products available if applicable

Any medications on the sterile field (most of us get around this one by not dispensing our meds until after the time out)

Fire risk score

This whole procedure takes a fair amount of time, and I'm of the opinion that more is not better. By the time I get to the end of this spiel, most people aren't even paying attention anymore. Too much red tape! I really wish they'd simplify it a little- name, DOB, procedure, surgeon, pertinent allergies (seriously, who cares if the patient is allergic to bee venom? it's not an apiary, it's an OR!), and antibiotics. By the time we start our time out, the surgeon has already viewed the films, our normal fire risk score is high (minimal procedures in my specialty), and some of the other stuff is just no brainer we don't bring a patient back to the OR without having available completed (implants, site marking).

[Ag15]

I agree that the time outs have gotten out of control on too much info....like you said, by the time they get done with it I don't even remember what we are doing lol. At this hospital here is how the time outs are done..."time out this is John Doe 4/5/1900 we are doing a knee replacement on right side". Their "site marking" is an arrow (no initals). This is not okay to me!

[NedRN]

Ned, thank you for the information! The place I'm at seems completely shut off from the real world. The nurses/OR staff were unaware of what is included in a "time out". What do you say in your time out process? I look like the bad guy here when I'm insisting on basic safety measures be taken.

As a tech and a traveler, you are the bad guy here! I wouldn't try to change practice dramatically here unless asked for input. The surgeon, circulator, and even the anesthesia provider have a much higher level of liability than you do. Small things are OK: Confirm with the nurse what the procedure is, and ask to see the consent and xrays (I always bring them up if available when I circulate, it makes a difference in what we pick/open) if the facility is still in the dark ages. You can also verbally ask the surgeon before you hand them a knife to confirm the surgery, or inform him/her what procedure and side you are set up to do. That should wake the surgeon up and probably elicit some sort of time out. Fire risk is sort of interesting, but allowing alcohol based preps to dry fully (three minutes) before allowing draping, and ensuring fluids are on field before incision. Otherwise, all you really care about is right patient, right surgery.

[Ag15]

They do not wait for Chloraprep to dry!

[NedRN]

That is a real problem, but not much you will be able to do about it until they have a fire.

[Ag15]

Speaking of that....they actually did have a fire there about 6 months ago! I feel so bad for the staff here, the doctors are so terrible to them and have been allowed to act this way. Thank you for listening and your advice!

[NedRN]

The hospital I'm at had a fire two years ago while I was there (not in that room). I'm now back and in my absence they developed a fire risk score and there is a three minute timer in every room.