What do ICU nurses do with ventilators in USA?

[StevenSwife]

Hi to all my new neighbours as we're moving from Australia to my husband's home, the USA! I'm coming equipped with a post grad & hopefully I finish my Masters in Crit Care by the time we arrive.

I'd like to ask a question with regards to the way RN's work in the ICU's... I have been advised that respiratory therapists actually look after the ventilators?

Don't the RN's do anything with them? In Australia, the vents are the RN's responsibility, as is the patient's washes, medications, turnings, dressings,ETT positioning & cleaning/auctioning etc and altering the vent settings as required when the patient's requirements change. The only thing we don't do, is the physiotherapy which the physiotherapists do during two round during the day (and more if required).

We also ever only have one vent ratio, unless we are covering for breaks.

How will my career change when I arrive? I love working with the vents and will hate to not be responsible for them.

[Do-over, ASN, RN]

I can only speak for my place, but RTs have the primary responsibility for changing vent settings and giving treatments. RNs do the suctioning, care of the tubes/trachs, etc. RTs draw ABGs, although I will do it if I am drawing other labs from a line anyway.

[ICUNurseG]

It's different at every hospital. Where I work they do everything, including intubation and insert art lines. The only part of the vent the nurses touch is the silent button and "O2 breaths" (gives pt 100% o2 for two minutes). We also suction but other than that they do it all! Nurses don't do art sticks either. Our RTs rock!

[Penelope_Pitstop, BSN, RN]

It's different at every hospital. Where I work they do everything, including intubation and insert art lines. The only part of the vent the nurses touch is the silent button and "O2 breaths" (gives pt 100% o2 for two minutes). We also suction but other than that they do it all! Nurses don't do art sticks either. Our RTs rock!

This is a similar set up at my hospital, although physicians do art lines (and anesthesia does difficult intubations).

The OP states the ratio for a vented patient is 1:1, which is a big difference. I typically have two patients on vents, and I think most of the US is like that.

[Do-over, ASN, RN]

We generally will have 1 vent, 1 non-vent if the census and staffing allows.

[turnforthenurse, MSN, NP]

Where I work, RTs generally manage the vents. They are responsible for changing the vent settings and giving treatments. They suction and care for the ETT/trach. RNs also do suctioning and ETT/trach care, draw ABGs (along with RT, usually we call them after an unsuccessful ABG attempt), and we know how to hyperoxygenate for 2 minutes, lol. We need to know how to trouble shoot the ventilators, too - high pressure vs. low pressure alarms. When in doubt, take them off and bag them with 100% O2 and call RT. Overall it's a team effort.

[TraumaSurfer]

In the US, a "vent" comes with a complex list of other skills and responsibility. The RTs are responsible for the alarm systems and doing their own cleaning and decontamination as well as set up for the next use. This can get time consuming and it is rare an RN will have an extra 30 minutes or more to get a machine back in service especially if the pre-use test is not going well.

Some hospitals also have a little policy about tubes. Don't mess with what you can not put back in or don't have the time to bag until someone comes to put it back in. If an RT loses a tube while retaping, they can either re-intubate or they will bag until someone who can arrives which could be several minutes or many, many minutes if the patient is stable with the BVM.

There is also the setup of, monitoring and changing of the other gases such as Nitric Oxide, Heliox, Nitrogen and Carbon Dioxide. Few RNs can take the time to go to the loading dock for more tanks and do all the change outs with the pipe wrench especially on night shift. Even switching out all the machines on one patient can be time consuming if first BiPAP was trialed, then intubation and a regular ventilator and then HFOV. Add another gas or two or setting up a continuous medication drip like flolan as well as cleaning all the equipment can be a pain. In some places it is nice if the RT also has the responsibility of the IABP and the A-lines. They will usually have their protocols so you don't have to wait for a physician to come in the next day and make time to insert an arterial line.

RTs in the US have a minimum of an Associates degree with many having a Bachelors degree and some have a Masters if they are involved in education, research or management. Much of the advancement in ventilation/oxygenation science have come about and changed by the research done by this group.

Respiratory Care

Canadian Respiratory Journal, Home

A hospital can run a lot of different ventilators and in a variety of modes. Most RTs work off protocols as long as they get the desired results. The RN may also have protocols just for keeping the patient stable for the various modes. If a patient is not tolerating a ventilator well or deteriorating fast and needs to be stabilized, it is really easier to work with someone else on the other side of the bed as a team instead of thinking you can fly back and forth across the best trying to titrate 5 drips and make several ventilator changes all the while making sure your alarms are also in compliance. It just takes one mistake on either team member to have a disaster on top of what might already be a train wreck.

But, with all that being said, many hospitals and LTC facilities are cutting back on RTs. If you want the total responsibility of "managing" a ventilator, you can go to one of the many subacutes. Or, you can allow the RTs to train you on everything about ventilators and join a flight team. If you want to do all of you own treatments, just work med surg or the ER in some hospitals. But few RNs want or can spend 30 - 60 minutes with one patient just doing a treatment protocol like for a spinal/neuro or CF patient.

Hospitals also do not get reimbursed for "therapy" if done by a nurse and it is not cost effective to add more RNs who make at least 2x what an RT makes. The choice was made to give up a lot of floor treatments but in the long run we are now seeing a problem with that decision.

At your hospital in Australia, did you make all the ventilator decisions for choosing the machine and mode changes as well as gas/drug titration on your own?

[07302003, ASN, RN]

Where I was (and it may depend on state / hospital) RN's don't touch the vent except for oxygen breaths, however, there is a lot of collaboration if the patient needs settings changed, etc. RT's cannot take verbal orders from a doc, so the RN does. Also, because the RN is at bedside monitoring the patient closely, and the RT may have a large assignment, we identify the need for setting changes. We take and send ABG's. It depends on your hospital, hopefully you'll be somewhere with a large teaching hospital - make sure you're somewhere where you have a lot of autonomy to manage your patient if that is what you're used to.

[JonM_RN]

I won't get into what the role of the respiratory therapist is in NJ because the above posts summarize it well. In terms of what you can expect to have in your assignment, you will definitely have two vented patients on a regular basis, whether they be ETT's or trach airways, and possibly a third non-vented patient depending on your unit's acuity and staffing. In NJ there is no mandate like California for nurse-patient ratios, so it is not uncommon to have a 3 patient assignment in the ICU. I would say 2 is the norm, and one to one nursing only for new codes, IABP's, CRRT, or a severely unstable patient.

[brypoli]

Here in north africa we nurses usually change the vent settings depending on the pts need and after that you will inform the intensivists