Why can't nurses intubate?

[natnat122]

Paramedics and Doctors intubate, why can't nurses?

[chare]

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

Which state is this?

[ICUNurseG]

We have some awesome RTs that intubate. They have to be critical care trained and do a certain number each year to maintain. Nurses don't intubate where I work because of that, other than the flight nurses. In the ER the docs typically do it (and life flight nurses). Inpatient or RRTs and codes it's usually the RT. They are better than most of the hospitalists.

[PMFB-RN, RN]

We have some awesome RTs that intubate. They have to be critical care trained and do a certain number each year to maintain. Nurses don't intubate where I work because of that, other than the flight nurses. In the ER the docs typically do it (and life flight nurses). Inpatient or RRTs and codes it's usually the RT. They are better than most of the hospitalists.

I am sure they are. Until this discussion the idea of a hospitalists, or a non-anesthesia resident intubating was outside my experience. Sounds dangerous to me. How many intubations can a hospitalist get to maintain proficiency?

[ICUNurseG]

Not sure about hospitalists. RTs have to do 5 per quarter I believe. Most hospitalists have to hand it over to the rt when they try. That makes me think they don't have any required competency. Scary.

[GrannyRRT]

I am sure they are. Until this discussion the idea of a hospitalists, or a non-anesthesia resident intubating was outside my experience. Sounds dangerous to me. How many intubations can a hospitalist get to maintain proficiency?

Since hospitalists are in house 24/7 in many hospitals now they can be the primary intubators on the floors in non teaching hospitals. They have a better opportunity to train and stay current on intubation skills than nurses. If they don't meet the required number per quarter, I doubt if anyone in the OR is going to protest these doctors be there for a few tubes. They can also intubate in the ER while admitting the patient. But, in the hospitals which I have seen utilize hospitalists, each one might get at least one intubation per week working 3-4 12 hour shifts. That gives them at least 50/year. It would be more difficult for a nurse to leave patients and run to the floor where there might be an intubation.

GrannyRRT, you seem to be hung up on the idea of a nurse performing intubations.

In every setting, the people who should (and, in my experience, do) perform the intubations are those who the system has directed to do so and are those who do it most often.

In five different hospitals, in settings from m/s, NICU, ED, OR, and high-risk delivery I've seen it be MDs, RNs, RTs, CRNAs, and medics... and this includes RSI.

To the OP's point: Trained and qualified RNs, can and do perform intubations... so do MDs... so do RTs...

In none of the five hospitals have I seen it be a hospitalist... I'm sure there are ones where they do but there are many where they don't.

[GrannyRRT]

You miss the point.

[GrannyRRT]

GrannyRRT, you seem to be hung up on the idea of a nurse performing intubations.

In every setting, the people who should (and, in my experience, do) perform the intubations are those who the system has directed to do so and are those who do it most often.

In five different hospitals, in settings from m/s, NICU, ED, OR, and high-risk delivery I've seen it be MDs, RNs, RTs, CRNAs, and medics... and this includes RSI.

To the OP's point: Trained and qualified RNs, can and do perform intubations... so do MDs... so do RTs...

In none of the five hospitals have I seen it be a hospitalist... I'm sure there are ones where they do but there are many where they don't.

You've repeated what I stated before. I am also going to restate it so you can understand my point.

I am not hung up about nurses intubating. I have my intubation skills and I help the transport nurses get theirs. But, if I didn't intubate, and haven't at a couple of hospitals, do you think I am less of an RT without that skill?

Intubation is not a merit badge and the skill should not be taken lightly. Only those who can adequately trained and in a small enough group to be adequately monitored for quality should be doing intubation. They should also have the ability to leave their patients to respond quickly to an emergency anywhere in the hospital.

What's with the low opinion of hospitalists? A hospitalist is an MD or DO. You said yourself that an MD can intubate. They also manage the ventilators, place central and arterial lines and run things in the ICU until an intensivist shows up. You have only seen 5 hospitals. My city has 5 hospitals on just one side of it and at least 5 on the other side. It all depends upon the size and makeup of the hospital. Why should a critical access hospital have to call 911 to intubate if there is a hospitalist in the sleep room? Don't say a nurse could do the intubation since CAHs have very limited staff and someone has to do all the other tasks for the patient before, during and after the intubation as well as watch the other patients. Haste makes waste when you try to do too many things at once. Usually it will be the patients who suffers the most Use resources wisely.

But, let's explore the possibilities others doing what you do. RTs could easily be giving your medications when you are off the unit. We do on transport and in the bronchoscopy suite. RTs have an ACLS card and the same college pharmacology plus specialized ones for cardiopulmonary. PTs also have pharmacology and could give the medications to the patient in the gym instead of a nurse. Exercise Physiologists should also be giving all the meds instead of a nurse.

There are a lot of things in my scope of practice which I could do but don't always get a chance to do them in every hospital such as A-line insertion, central lines including PICCs, IABPs and chest tube management. But, there are plenty of things which I can do and master them to see the patient get the full benefit of my training and education. Skills come and go depending on the leadership of the hospital for that moment. In nursing school they should have told you that intubation would not be a primary skill for you. The ACLS instructors should not have mislead some into believing all you need is that card to be able to intubate.

If you really want to intubate, join a flight team. Even some flight teams only have the Paramedic intubating and not the RN. But, that does not show poorly towards the RN who has many, many other things of importance to do. Some flight teams also require the RN to get the Paramedic cert for training in intubation and scene calls.

You could get the Paramedic certificate and work on an ambulance. You could go back to school and be an RT and find a hospital which allows them to intubate if this skill is really that important to you. Just remember that not even all Paramedics can intubate because it is difficult to get enough live intubations to maintain proficiency. Maintaining proficiency is a big issue regardless of the title. As a nurse you do have some really valuable skills and intubation should not have to be one of them to make you feel complete. You are usually responsible for several patients at one time. Even for the nurse at the immediate bedside to be tied up for 1 - 2 hours for a difficult intubation can tax the other nurses taking care of his or her other patients. Now if you have 2 or more nurses tied up for that intubation, others will have to go without care or breaks.

Some hospitals are considered lucky if they have an nurse for Rapid Response and to relieve the staff for breaks.

My main points here are:

Hospitalists are doctors and can intubate.

Intubation is not a merit badge. It is a huge responsibility to not be taken lightly as is the prep and the post intubation care. You are not less of a nurse if you are not allowed to intubate. No need to get upset if a mere hospitalist intubates and you can't.

I'm not upset at all. If I had some burning desire to intubate then I'd go get a job where that was included. I'm quite content where I am.

I'm simply pointing out that intubation privileges are not a matter of one's license but rather the policies of the facility or agency... Sometimes it's a nurse, sometimes an RT, and sometimes a doc... Just depends on where you are.

And unequivocally... The hospitalists where I've worked do not intubate patients...

[calivianya, BSN, RN]

We had a nurse get fired at my job for trying to intubate a patient. It did not happen while I was there, but one of my coworkers told me about it later. RT was unsuccessful, the patient was desatting, the nurse pushed RT aside and intubated the patient... and the nurse lost her job. It's a scary world when we have to make the decision to let people die to save our jobs...

[azhiker96, BSN, RN]

Hospitalists are doctors and can intubate.

Not all doctors should intubate. If they have the training and practice that's fine but whoever intubates should be someone who practices and is proficient with that skill. Consider the death of a famous pop star who hired a cardiologist to manage anesthesia. If a hospitalist has the experience and practice to be proficient then sure, he should intubate. If not then he should not let ego compromise good patient care.

At my last hospital, there were intensivists on duty at all times. They handled emergent intubations in the ICU and responded to rapid response and code calls on the floors. Honestly, if there are a large number of intubations on the med/surg floors then patients are not being managed properly. Questionable airways should always be assigned a higher level of care.

At my current teaching hospital we have anesthesia providers on staff 24 hours a day. They respond and manage airways everywhere in the hospital from the ED to codes. On many occasions anesthesia has traveled to the ICU to intubate or assist with the intubation of patients. That doesn't mean the ICU docs can't intubate, they can and often do. However, they realize that patient care and safety are more important than ego. It also frees the intensivists to concentrate on other areas of patient care as a non-patent airway is usually not the only issue.