Why can't nurses intubate?

[natnat122]

Paramedics and Doctors intubate, why can't nurses?

[GrannyRRT]

I don't disagree but it's moot if there simply is no anesthesia provider available. This happens often in my hospital as we only have one provider at night and they are often tied up with emergent OR cases.

Is this an accredited hospital with an emergency room? Or a private facility running on the cheap? What about hospitalists? Who gives you the orders for RSI and the necessary post intubation drugs? What about ventilator management? Yes there are protocols but you make it sound as if this hospital us running at a very dangerous level with a lack of physician oversight. I hope you do not keep intubate patients in the ICU and ship immediately. I have only heard of such places with no RT and inadequate physician staff in very small CAHs_ and they have an arrangement with the local EMS for Paramedics to respond, intubate, take over care and transfer to a higher level of care as quickly as possible.

If this is happening frequently, the medical staff situation needs to be addressed. While you can intubate, lack of medical staff for total management could leave you hanging and the patient messed up. Don't let your ego get in the way of seeing what is best for the patients. That goes for your hospital management also. Yes it might be cool to say you are a nurse who intubates but what other responsibilities are you rushing through and how much are you taking other nurses from their patients? A newly intubated patient takes time with tube stabilization, setting up the ventilator and vent adjustments.

[PMFB-RN, RN]

Is this an accredited hospital with an emergency room? Or a private facility running on the cheap?

Yes, publicly owned teaching hospital. I don't deal with the ER, except when they call for help when they are overwhelmed. I am rapid response.

What about hospitalists?

What about them? Ours only work during the day and none of them would ever intubate. At night we have medical and surgical residents and I have never seen one even attempt to intubate. They aren't trained or privileged to intubate.

Who gives you the orders for RSI and the necessary post intubation drugs? What about ventilator management?

We have RSI drugs on a protocol. So in effect the orders are given by the medical director of the RRT team, same as all the other drugs we give on protocols. We don't put them on a ventilator until we get to the ICU. We have EICU so the intensivist or the ICU resident manages the vents. Same with post intubation drugs.

Yes there are protocols but you make it sound as if this hospital us running at a very dangerous level with a lack of physician oversight.

No I don't make it sound that way. You may have jumped to that conclusion.

I hope you do not keep intubate patients in the ICU and ship immediately.

Well we do keep intubated patients in the ICU but don't ship them anywhere. Where else would they be kept?

I

have only heard of such places with no RT and inadequate physician staff in very small CAHs_ and they have an arrangement with the local EMS for Paramedics to respond, intubate, take over care and transfer to a higher level of care as quickly as possible.

We do not have inadequate physician staff, we are not a small CAH. The idea of paramedic coming into our hospital to intubate is totally foreign to me. Why would they do that when we have well trained people in house?

If this is happening frequently, the medical staff situation needs to be addressed. While you can intubate, lack of medical staff for total management could leave you hanging and the patient messed up.

Wow, you are jumping to unsupported conclusions left and right aren't you. Where was there ever a discussion of a lack of medical staff for total management?

Don't let your ego get in the way of seeing what is best for the patients.

I don't think it is my ego that is the problem here.

That goes for your hospital management also. Yes it might be cool to say you are a nurse who intubates but what other responsibilities are you rushing through and how much are you taking other nurses from their patients?

It's not cool, Its normal, common and standard. What nurse would be taken away from their patients? If required we (the RRT RNs) emergently intubate and transfer the patient to the ICU where the ICU resident or intensivist takes over their care. Totally ordinary. In my hospital the ICU is staffed to take emergent transfers.

A newly intubated patient takes time with tube stabilization, setting up the ventilator and vent adjustments

Oh really?

I know one of the local NICUs... Specially trained nurses do most of the intubations.

Regardless of *who* is doing it, it's just a skill like any other... Be it doc, nurse, or RT... whichever role is the one who does enough to be competent is the one who should be doing them.

And let's face it, it's not rocket science.

[GrannyRRT]

Quotes from PMFB-RN

What about them? Ours only work during the day and none of them would ever intubate. At night we have medical and surgical residents and I have never seen one even attempt to intubate. They aren't trained or privileged to intubate.

I thought you said teaching hospital. My hospital is also teaching and that is what we do. If the resident has had observed intubation training with the OR, Senior RT or the appropriate attending, they are given the chance to intubate. RT backs this up and offers more instruction on everything concerning airway and not just the "intubation". We do stress the BVM and high flow NC oxygen (during intubation) although we use a flow inflating bag for most intubations which makes it really nice. But technique is stressed for all equipment and procedures. This is just part of the teaching process. The RRT RN is also teaching the resident throughout the process about how things should go during a Rapid Response or reminding them of things which should be done. We usually have the floor resident and an ICU resident show up for each emergency. They know the role of the RRT members and see them in action which is useful for when they go out into the world as attendings.

It's not cool, Its normal, common and standard. What nurse would be taken away from their patients? If required we (the RRT RNs) emergently intubate and transfer the patient to the ICU where the ICU resident or intensivist takes over their care. Totally ordinary. In my hospital the ICU is staffed to take emergent transfers.[

Oh really?

Does this mean you don't use a transport ventilator? For the past 20 years, transport ventilators been proven to be of benefit for both patient and the staff. It is even a recommendation by the AHA so much so that Paramedics are now using them to transport from the field. Several larger hospitals have an assigned RT who just transports ventilator patients from the ER, the floor, the OR and to all procedures. In some hospitals, The Anesthesia department has its own transport ventilator to bring patient to and from the OR. In some hospitals the interhospital transport team will show up at Rapid Response and Code calls to assist with transport to the ICU or what ever procedure. It is a huge safe issue since we know what even a few minutes of irregular bagging can do to a patient's pH, PaCO2 and PaO2. This also includes the chances of losing a tube when running down the hall or squeezing into the elevator which also interrupts bagging. The foot and back injuries to the staff are also noted in the data. This is costly and all avoidable. All of our X-ray machines used for RRT and Code calls have the ability to show the image immediately. We can confirm tube placement and secure it properly before rolling down the hall. We use the Hollister Anchorfast tube holder so there is no messy tape. Haste makes waste as they say.

I am glad your standards are not standard in every hospital and definitely not in the ones which teach. We have strived for safety first and are proud to teach those who need it to be successful in their careers. When you have a well planned team, not every emergent situation has to be rushed. Our ICUs also handle emergent transfers from the floor. But, if they have to shuffle beds or staff, our team is prepared to stay put for a few minutes. The patient might need the cath lab or CT Scan instead. The beauty of it is we can take a few minutes and determine an appropriate destination first rather than just emergently running here and there or moving the patient again and again unnecessarily. We believe it to be rude to transfer the patient to the ICU bed and then say CT Scan is ready NOW. We will take the patient to CT Scan where they can be met with the bed from ICU and the nurse or we can just take them up to ICU if our backup team is still available. The patient is on a ventilator and can go just about anywhere which might be to another facility if you are at a hospital which does not have all the specialized services or piece of equipment is down. Being calm and considerate comes naturally if you are confident in your abilities and that of your team. If doesn't really matter who intubates as long as it is done safely with plans A, B and C always available for the difficult ones. The doctors in the OR and the eICU won't be of much help and your hospital seems to have neutered the hospitalists and residents as well as eliminating the RTs.

Remember, safety first.

[GrannyRRT]

I know one of the local NICUs... Specially trained nurses do most of the intubations. Regardless of *who* is doing it it's just a skill like any other... Be it doc, nurse, or RT... whichever role is the one who does enough to be competent is the one who should be doing them. And let's face it, it's not rocket science.[/quote']

It is not rocket science until you have the difficult airway from obesity, burns, radiation, congenital anomaly, stenosis, abscesses, previous surgeries and angioedema from meds or a supraglottic airway. Some patients can only be nasally intubated with Magill forceps assist due to oral surgery or previous reconstruction from injury or CA. Very few patients are the nice 75 Kg 5'8" 25 y/o with normal anatomy and no gag reflex.

Our transport NICU RNs share the intubation responsibility. But, just like everyone else they had to get 20 successful intubations in the unit before doing L&D. When meconium happens, that is not the time to be learning to intubate. Just like the RTs, the RNs must maintain a minimum of 20 successful intubations each year. The same for Pedi Transport RNs. Too many misses or incidents and their intubation status will be put up for review and a probationary period which also affects their team status.

Hospitals should have a policy in place to maintain competency with live intubations regardless of who intubates and it should be strictly adhered to. All intubations should be reviewed for quality which also includes the pharmaceutical side. Giving the correct medications before and after is as important as the procedure itself. Confirming tube placement and monitoring with ETCO2 throughout and especially during transport, even within the hospital, is a must.

[applesxoranges, BSN, RN]

I know in my state it is not in the nurse's scope of practice.

[MereSanity]

Get a paramedic....they can intubate.

[PMFB-RN, RN]

I

thought you said teaching hospital. My hospital is also teaching and that is what we do. If the resident has had observed intubation training with the OR, Senior RT or the appropriate attending, they are given the chance to intubate.

(shrug) What your residents do or do not do is not of any concern to me. However I do know that having residents, or really anyone who doesn't get a chance to practice regularly is a bad idea and will lead to patient harm.

Other than anesthesia residents, and possibly the occasional ER resident I am not used to seeing residents intubate anyone. None of them would want to. They know who the experts are.

RT backs this up and offers more instruction on everything concerning airway and not just the "intubation". We do stress the BVM and high flow NC oxygen (during intubation) although we use a flow inflating bag for most intubations which makes it really nice. But technique is stressed for all equipment and procedures. This is just part of the teaching process. The RRT RN is also teaching the resident throughout the process about how things should go during a Rapid Response or reminding them of things which should be done. We usually have the floor resident and an ICU resident show up for each emergency. They know the role of the RRT members and see them in action which is useful for when they go out into the world as attendings.

So it's the floor residents who intubate emergently? That sounds dangerous to me.

Does this mean you don't use a transport ventilator?

No, the RRT team does not use a transport vent when intubating emergently in a code or RRT situation. If the code goes on for a while a transport vent is brought to the scene by the respiratory therapist. Usually by the time he arrived the patient is already on a vent in the ICU.

For the past 20 years, transport ventilators been proven to be of benefit for both patient and the staff. It is even a recommendation by the AHA so much so that Paramedics are now using them to transport from the field.

Yes no kidding. We used one on the transport service I worked for before I got the RRT gig. I think you are pointing out the obvious.

Several larger hospitals have an assigned RT who just transports ventilator patients from the ER, the floor, the OR and to all procedures.

Yes, having worked in a number of different hospitals I am well aware of this.

In some hospitals, The Anesthesia department has its own transport ventilator to bring patient to and from the OR.

So you are saying that is NOT the case in some hospitals? I was unaware of that and assumed it to be the standard of care.

In some hospitals the interhospital transport team will show up at Rapid Response and Code calls to assist with transport to the ICU or what ever procedure.

Yes I know.

It is a huge safe issue since we know what even a few minutes of irregular bagging can do to a patient's pH, PaCO2 and PaO2. This also includes the chances of losing a tube when running down the hall or squeezing into the elevator which also interrupts bagging.

"running down the hall"? the idea is foreign to me. Under what conditions would anyone un down the hall with a patient? Anyone doing so in my hospital would be immediately corrected. No reason to squeeze into an elevator either unless the facility is old. We have plenty of elevator space.

The foot and back injuries to the staff are also noted in the data.

Foot and back injuries? I suppose those occur when you guys are "running" down halls? Safe patient handling equipment should be readily available and used. If you are seeing foot and back injuries in your facility at codes or RRT calls then I would imagine a review of your equipment and procedures is in order.

This is costly and all avoidable. All of our X-ray machines used for RRT and Code calls have the ability to show the image immediately. We can confirm tube placement and secure it properly before rolling down the hall. We use the Hollister Anchorfast tube holder so there is no messy tape. Haste makes waste as they say.

How nice for you. I assume that you mention this because these measures are new for your facility?

I am glad your standards are not standard in every hospital and definitely not in the ones which teach.

What standards are those? What do you possibly know of our standards?

W

e have strived for safety first and are proud to teach those who need it to be successful in their careers.

So in other words you are pretty normal. Good for you.

When you have a well planned team, not every emergent situation has to be rushed.

Quite obviously. I think you need to be very concerned with your practice of running down halls and squeezing into elevators. Not sure if you are in a position to effect changes but I would urge you to consider it.

Our ICUs also handle emergent transfers from the floor.

Hmmm, are their ICUs NOT prepared to handle such transfers?

But, if they have to shuffle beds or staff, our team is prepared to stay put for a few minutes. The patient might need the cath lab or CT Scan instead. The beauty of it is we can take a few minutes and determine an appropriate destination first rather than just emergently running here and there or moving the patient again and again unnecessarily.

So in other words your team is pretty much like other teams and is doing the normal, standard stuff, like most of the rest of us? Good for you I guess.

Being calm and considerate comes naturally if you are confident in your abilities and that of your team.

Again not sue what you gain by pointing out the obvious.

If doesn't really matter who intubates as long as it is done safely with plans A, B and C always available for the difficult ones.

Naturally. Again pointing out the obvious.

The doctors in the OR and the eICU won't be of much help

The doctors in the OR are surgeons and thus would be of no help anyway. EICU intensivists are very effective and managing ICU patients. This is well supported by EBP.

and your hospital seems to have neutered the hospitalists and residents as well as eliminating the RTs.

Resident practice is regulated by the university, not by us. However despite having worked in numerous teaching hospitals in a number of states I have never observed where medicine and surgical residents are depended on to preform intubations. Usually such things are left to the trained experts who get enough practice to be effective. We haven't eliminated the RTs. I have no idea where you got such an idea. We have a highly skilled RT who responds to all codes and respiratory RRT calls.

Remember, safety first.

Please take your own advice an work to eliminate the running down the halls situation you described before.

[PMFB-RN, RN]

Get a paramedic....they can intubate.

Yes, like trained nurses. Our transport services run with an RN / medic team. Both are trained and qualified in a variety of airway management skills, including intubations. With the exception of certain drugs there is a lot of overlap in their skills.

[PMFB-RN, RN]

Hospitals should have a policy in place to maintain competency with live intubations regardless of who intubates and it should be strictly adhered to. All intubations should be reviewed for quality which also includes the pharmaceutical side. Giving the correct medications before and after is as important as the procedure itself. Confirming tube placement and monitoring with ETCO2 throughout and especially during transport, even within the hospital, is a must.

Everything you mention above is normal and standard. Are there hospitals not using ETCO2? Are there hospitals where providers without a competency are counted on to intubate? Are there hospitals where emergent intubations, including the pharmaceutical side, are not reviewed and monitored for safety?

If so I am unaware of any. All of that is standard of care stuff.

[PMFB-RN, RN]

I know in my state it is not in the nurse's scope of practice.[/quote

So there are no RNs working on transport rigs like helicopters and ambulances in your state? Or if there are they can not intubate? I understand if you don't want to tell us but I would be interested to know what state that is.

[applesxoranges, BSN, RN]

The teams are RN (who usually is a paramedic), paramedic, and an EMT driver. Sometimes there are other levels too such as a respiratory therapist, resident, or physician depending on the case. I know they have residents in one of the helicopters. I know one of the flight services in my area used to advertise that they had to get their paramedic within a year (local bridge classes is about 3 months).

Oh, advance practice RNs are different and I don't know what their scope is. We're also a weird state and let LPNs teach.