Should OR RN's be ACLS/PALS certified?

shodobe · Jun 13, 2004

Mostly I meant that to stand around and do nothing implies one has no clue on what to do during a code. I am lucky in that the RNs I work with do know what to do and we do have a great anesthesia team. I do what I am told to do and do not go beyond that. We do have to call a house code because it is policy. Most of the time the code team comes and usually leaves right away. I do agree the more you know the more your going to be responsible for. This is why I let my ACLS expire. I have no reason to have it. IF I had to use my knowledge on a pediatric patient, then something is wrong in my book. Where is your anesthesiologist or the surgeon? It is their responsibility to direct any problem that occurs with the patient. On the other hand, patients that are in PACU, be it adults or peds, don't always have the luxury of anesthesia's presence or the surgeons. This is why these certs are essential in the PACU and not for the OR. I also agree that the mandatory requirement of these certs for OR personel is just another way for the hospital to save money and "kiss up" to the surgeons. The scenario being, the patient hasn't been NPO long enough and the surgeon doesn't want to wait, nurse manager say "that's OK I'll just have my nurses give a little sedation". I don't mind giving sedation for adults but WILL NOT do it for anyone under the age of 18, no exceptions! I always have an anesthesiologist in house so there is my back-up. I have also found out that smaller rural hospitals make it mandatory for their OR staff to be ACLS cert, Why? Because they not only make the staff do the procedure they also make them recover the same patient. This is an economical reason, they are to "cheap" to hire real PACU nurses. If there are two cases, the second one has to wait until the first patient is recovered and sent to their room. Poor use of time. I don't think it is a dumb policy to not have the OR nurses certified. I have have been doing this for 27 years and have found not one time where I actually needed any ACLS knowledge. Why, because as I said before I always have had a proven MD in the room for ALL codes I have been involved in. Sorry to rant, I think I put more than my 2 cents worth in. Mike

sharann, BSN, RN · Jun 13, 2004

I don't think you are ranting at all Mike. I appreciate your input, and it has actually given me reason to re-think my position(though I wasn't really sure of it which is why I posted the question!). I worked for a plastic surgeon for about a week and quit as soon as he tried to get me to circulate, push sedation/twilight meds AND then recover(which is why he wanted me to be ACLS certed....that guy was a schmuck). Anyhow, thanks everyone for all the input and info :)

shudokan-RN · Jun 13, 2004

I am signed up for ACLS, in Sept, and PALS in Oct. My incentive is $1.00/hr

pay raise.

marci

sharann, BSN, RN · Jun 13, 2004

I am signed up for ACLS, in Sept, and PALS in Oct. My incentive is $1.00/hr
pay raise.
marci

HA!

I am REQUIRED to take ACLS and PALS b/c I work PACU, but no pay incentive PLUS I take them on my time with no pay or reimbursement. Yay for me.

stevierae · Jun 13, 2004

You have to keep in mind that most codes in the OR are not the chaotic, high drama situations they can be in other departments--because when we have a code, we usually have some warning of it--the patient starts to crash before our very eyes--and we already have a protected airway. Our patient is intubated, and if he is not, he soon will be. In other codes, chaos occurs during multiple attempts to establish the airway; we don't have that problem---it's a very controlled, relaxed environment, or it should be.

I faithfully renewed my ACLS every 2 years for probably 15 years, and finally let it lapse. There are few codes that the circulator and anesthesiologist cannot handle, even if the circulator is not ACLS certified. In fact, all these busybodies running to the room to "watch" or "help" just get in the way.

I have been in more than one situation where the anesthesiologist asked the charge nurse, desk person, or whoever among management (or staff RNs and anesthesia) showed up to leave--they just get in the way. They usually just look up and quietly but assertively say, "My circulator and I can handle it." Normally, if need be, the surgeon or even the scrub can give CPR, and the circulator can charge the defibriilator and defibrillate. Truthfully, in all the years I have worked in ORs, nobody ever came and recorded, as they do in ER and on the floors. Anesthesia just charts when the code is over, and we chart what took place in our nursing notes--it does not have to be overly detailed, so as not to be redundant. If I need additional help, I am capable of asking for it.

I was not aware that one had to be ACLS certified to give code drugs. I have pushed or given IM succs, Lidocaine, Epi, Atropine; Bretylium and Verapamil when those were in vogue, or whatever else needed to be given over the years whether I was certified or not--after all, the circulator assists with induction and gives drugs when the anesthesiologist's hands are tied up for any other reason--why should it be different in a code? We are a team, we function as a unit, and we all trust each other. I think I would have a problem with another nurse coming in uninvited and taking over care of my patient.

I agree with Shodobe in that, if the OR management knows you are ACLS certified, they expect you to give conscious sedation. I refuse to do an anesthesia provider's job just so they--the suits in management-- can open an extra room. They do not pay me enough to do an anesthesia provider's job, and I think every patient deserves an anesthesia provider at the head of the table in charge of his sedation and his airway--not a nurse. I know what I don't know.

Also, the "reward" for getting done early here (in Oregon) is either getting sent home early without pay, or getting stuck doing the add ons, which, more and more, are elective cases that should be scheduled on another day. What's the point of busting a** for that? I know in CA people rarely, if ever, get sent home early--CNA considers that an involuntary layoff and worthy of filing a grievance and getting paid for the lost hours--but here, it is very much a reality.

squeek · Jun 14, 2004

ditto to the protected airway and the cool and controlled environment!

only code I had trouble with was an anaphylaxis to Abs prior to induction ... couldnt get an airway for that one!

we never call the code team ...

I only have BLS certification.

i work as a team with my anaesthetist ... and scrub team if necc.

Squeek

stevierae · Jun 14, 2004

only code I had trouble with was an anaphylaxis to Abs prior to induction ... couldnt get an airway for that one!
Squeek

That's where Benadryl, Epinephrine, possibly Decadron and a trach tray standing at the ready come in handy! Also a Fast-Trach and the fiberoptic laryngoscope! You can call out for somebody to bring the difficult intubation cart, and then it's your call, or anesthesia's, whether they stick around to "help" or not. Or just an oral airway while you wait for the laryngotracheal edema to subside after the Benadryl or, more probably, Epi.

Or, often a patient layrngospasms and bradys down. Atropine and succs break the laryngospasm, and you can proceed. The anesthesiologist will be busy masking, so the RN will be the one giving the Atropine and succs--ACLS certified or not. Doesn't matter to me-- when seconds count between progression from bradycardia to cardiac arrest, who is going to stand on ceremony? When the laryngospasm breaks, he will be able to intubate.

What happened in your situation, squeek?

Often in the OR, a "code" is usually a transient vasovagal reaction and is treated immmediately with O2, Trendelenberg, speeding up the IV fluid, and, if need be, Ephedrine or Atropine. By the time all the busybodies run to the room, we have proceeded with the case.

"Show's over! Nothin' to see here, people!!" is what you feel like saying.

I think it makes some of management, especially, feel important to be there--now they can go to one of their endless meetings and tell everybody there was a "code," and they singlehandedly saved the day.

squeek · Jun 14, 2004

we were about to start a nephrectomy,

triple Abs before start ... NKA ...

registrar was pre oxygenating pt,

anaesthetist gave Keflin ..

patients face just got bigger and bigger!

we tried everything, every drug....

bougie, trachlight, LMA, guedells ... but we couldnt get any air movement.

finally cut down trachy .. her neck was so swollen by then it was difficult to find landmarks. got the tracheostomy in but it was too late.

I have an anaesthetist who swears never to give Abs pre op ... wait til the tubes in .. I say whats the rush.

doesnt matter how many other people were there .. the outcome would have been the same. we were prepared, it didnt help. we knew what we were doing. just real bad luck :stone

squeek :angryfire

stevierae · Jun 14, 2004

we were about to start a nephrectomy,
triple Abs before start ... NKA ...
registrar was pre oxygenating pt,
anaesthetist gave Keflin ..
patients face just got bigger and bigger!
we tried everything, every drug....
bougie, trachlight, LMA, guedells ... but we couldnt get any air movement.
finally cut down trachy .. her neck was so swollen by then it was difficult to find landmarks. got the tracheostomy in but it was too late.
I have an anaesthetist who swears never to give Abs pre op ... wait til the tubes in .. I say whats the rush.
doesnt matter how many other people were there .. the outcome would have been the same. we were prepared, it didnt help. we knew what we were doing. just real bad luck :stone
squeek :angryfire

Dang! That was bad luck. I am betting she was one of those rare people who has a cross sensitivity to BOTH Penicillin and Cephalosporins. She may have just forgotten she was allergic to PCN; maybe she had not had it since childhood.

We don't use Keflin anymore here--at least, I have not SEEN it used in years. We use Kefzol (Ancef.) We always give a test dose to see if the patient has anything resembling an anaphylactic reaction; then, if not, give the rest of the dose.

hypnotic_nurse · Jun 15, 2004

In my research group, we are required to have both ACLS and PALS by our federal funding -- but if there's a problem, we are to call 911 stat...we have a crash cart with all the meds, but we are not to use it unless the MD is in house.

It's not a waste, really, it's nice to know, but the likelihood of me ever using it is next to nil unless I happen to be near an AED when someone's heart stops.

jwk · Jun 16, 2004

Not required here. I did go through the ACLS and let it expire because no reason to have it. I have been around long enough if my gas passer drops dead I think I know what to do. Mike

Glad you have such a high opinion of yourself in case your "gas passer" drops dead.

Can you mask a patient? Adequately?

Can you intubate a patient or place an LMA?

Are you aware that Lidocaine is NOT a first line drug?

Do you know what Vasopressin is, when it's used, the dose?

Are you aware that Bretylium isn't even available anymore?

ACLS standards change over the years. The move is to base the recommendations much more on "science" than just doing things "the way we've always done it". 25 years ago, one of the first drugs we gave was two amps of Bicarb on everyone who arrested, even if it only lasted 30 sec.

Our hospital doesn't currently require ACLS for OR nurses. However, they don't stand around during a code either. Each person in the room has an assignment during a code so no one stands around wondering what to do. Anesthesia is generally in charge since they control the A/W and drug administration during the case anyway. The scrub usually does chest compressions, the circulator gets the crash cart an at least an additional RN to help. One of the RN's keeps track of each event - drug, defib, start/stop compressions, etc. Those notes/records are compared and combined with the anesthesia record to produce accurate records of the entire code. If you think an accurate record isn't important, you're dead wrong, because particularly if the patient dies, some attorney will be looking at it sooner or later.

RN's certainly may push IV medications during a code. They do not have to be CERTIFIED in anything. It certainly is not outside their scope of practice - it might conceivably be against hospital policy.

jwk · Jun 16, 2004

anaesthetist gave Keflin ..
I have an anaesthetist who swears never to give Abs pre op ... wait til the tubes in .. I say whats the rush.

For those wondering about cross-allergy with PCN and cephalosporins - it is certainly not rare. It's on the order of 10-15%.

However, severe anaphylactic reactions are unusual. And not all cases get an ETT, so your anesthetist's assertion is somewhat ridiculous.

Finally - the latest recommendations for antibiotic usage in surgery recommend that the antibiotics be given not less than 30 minutes prior to skin incision. That's easy for drugs like PCN and Cephs, which can be given fairly rapidly after a test dose. Others like Vanco and Cipro need to be given much more slowly, so we try and start them 1 hr prior to going to the OR so that they will be fully infused by the time of the incision. The timing does make a difference in post-op infection rates.