Critical Care Nursing

“Public Hospitals could save $430m by getting nurses to do some doctor tasks: report” – My Thoughts

My eye was caught today by an article in on the ABC news website.

 

Public hospitals could save $430m by getting nurses to do some doctor tasks: report – ABC News (Australian Broadcasting Corporation)

 

The gist of the piece is that “routine” procedures can be easily carried out by nurses at less cost. The author suggests endoscopies, colonoscopies, and sedating patients for low risk procedures.

The author appears to be an economist and public policy academic. This perspective is the only one in current Australian culture that the report makes sense. The Grattan Institute (http://grattan.edu.au/about-us) states that “it is an independent policy think tank providingindependent, rigorous and practical solutions to some of the country’s most pressing problems.”

I don’t have issue with the article per se (although at no point has anyone thought to ask any nurses what they think…) but I am riled by some of the more obvious comments attached below.

None of the Users commenting actually seem to understand the point of the original report or what the people in the modern health system actually do.

 

 

 

Comments all seem to follow a small number of themes:

  1. Just plain bitchy (“… our definition of a colonoscopy was “six feet of fibre optics with an ar*ehole at each end” … Modern nurses are well qualified to replace the current proceduralists” – User discus49, retired anaesthetist) Let he who casts the first stone, sir. You’d know, maybe having been one of the ar*eholes at some point. And I hope I never worked with you.
  2. The “I nearly died from an anaesthetic and I’m not going to let a nurse near me” response. I’m not even going to address this User’s concerns directly, they obviously had a bad experience which has hopefully resolved. They do suggest that nurses “are not trained specialtists” and several other claims not bearing scrutiny. Although I guarantee that what ever happened it was not fixed by doctors alone.
  3. The “perhaps vocational training at a hospital level (as it was 25 years ago) would be a good way to save resources instead of insisting on degree level training” – User cynical wasp, no occupation listed) line of thought. This comment unfortunately represents a large proportion of the general population who don’t understand what we actually do.

Further comments reflect the original article’s assertation that the RN duties of bathing and feeding could be passed on to vocationally trained nursing assistants.

So I suppose what this post is really about is a rebuttal to the “let’s train nurses as we always have” mixed with some thoughts about why nurse sedationists are a bad idea in modern Australia. If neither of these topics interest you, please read something else (really, my opinions aren’t going to change yours…come back though, there’ll be something else later more your style…)

The obvious response is why do we let the public have a say regarding nurse education anyway? Other professions don’t do this. We tend to invite “consumers” onto our Nursing Boards of Registration (the now defunct QNC used to have two such representatives) and as nurses we engage the community with position statements from Nursing Colleges and policy organisations.

In doing so we may educate a percentage of the population regarding the reality of modern healthcare and nurses place within it, but I believe that is the absolute minority. I feel that the vast majority of society only meet nurses when they find themselves in the unfortunate position of needing nursing care.

So should we go back to the old days of signing our (mostly female) young adults over to a regime of residential curfews, administration spies and vocation (read task focused) based training? Should we remove the rights of junior nurses to go “out” for social events (on own time) without the employers permission? Should we leave them without the ability to advocate for their patients, subservient to the requirements of the medical profession, with all the job satisfaction of knowing that if they keep going and achieve another poor pleb will come and relieve them of the burden of the bedpan?

Rather than answer in the manner in which I normally would (No! with references)…

Would we ever expect that surgeons give responsibility for their education back to barbers?

Would we ever expect that in order to save money, the health system sack all the anaesthetists in favour of good, strong sticks for patients to bite?

Would we ever expect that modern dentistry return to the “everything can be fixed with a good extraction” days of the past?

I could go on…(architects? airline pilots? rocket scientists?)

 

Society has changed. Nursing has changed. There is no real correlation between “what a doctor used to need to know and what a nurse needs to know now” but the body of knowledge involved in both professions does intersect and cover the same ground. One complements the other, not replaces it.

Nurses do and will likely always look after the patient as a person in an attempt to return that person to the best functional state they can achieve. That does involve feeding, and toileting, and bathing. These aren’t things that can always be passed off to another with vocational training. They are further opportunities to assess, to look closely, and they may be the only time available to do so. The fact that these things are not done is not always an indictment on the nurse but a comment on the current conditions in which we work: doing more with less.

The public perception that the nurse is more interested in completing the paperwork (computerised or not) couldn’t be further from the truth to the average nurse. Most could easily have gone for an administration job (without night shift) if that is what they wanted to do. The paperwork is devoted to justifying the hours costed for staffing the ward, and ultimately the costs spent by government in looking after the patient.

Part of my thinking in working in my chosen specialities was the potential for the nurse practitioner role in anaesthetics: the nurse anaesthetist. As alluded to by the Grattan Institute’s report and the ABC article, the role does exist in several countries. One of the prime impediments to adopting such a role in Australia is one of culture.

In the US, nurses have administered anaesthetics (or anesthetics, in American) since the earliest surgeries. Medicine only took responsibility for sedation relatively recently, in the 1960’s or thereabouts (with few exceptions, the people administering drugs to patients during surgery in M*A*S*H* were nurses).

In Australia we followed the English model. Thus doctors have always had responsibility of anaesthesia, and even the anaesthetic nurse role is defined by hospital policy rather than codified by any particular legislation (ANZCA, the College of Anaesthetists recommend that a staff person be provided by the hospital to assist the anaesthetist as required, they shall not be answerable to the surgeon, and shall have 18months ‘suitable’ educational preparation).

In practice, this means that the anaesthetic assistant is a former wardsperson, or some one off the street, or any other background deemed to have satisfied the 18 month rule (no specification is made of what the 18 months should include). Or if you are lucky, the hospital has a preference for Registered Nurses, with their Bachelor of Nursing (3 years) and a Graduate Certificate in Anaesthetic Nursing (1 year). This still isn’t an “I’m better than you are” argument: I can train an anaesthetic nurse in a shift and a half (that was all I recieved at the time) but it’ll take about two years before you really know what you’re doing.

After all that, I could keep someone asleep during surgery whilst the Anaesthetist went to the toilet, I could anticipate, I could intubate and assess, I was handy in an emergency, understood and could administerl all the medications, all the things you would want in an assistant. Once I came to ICU I learned a lot more, all relevant. I have all the experience I need to apply to a US-style program (they call them Certified Registered Nurse Anaesthetists, or CRNA’s).

The US model requires the equivalent of a Masters degree preparation, AFTER the background and preparation and education I currently have. I could do that. But I won’t. Even if we followed the Grattan Institute’s ideas and adopted the system here.

The CRNA model requires supervision. It has been a part of the system since the beginning and the nurses undertake ALL anaesthetics during ALL the procedures a hospital offers. All of them. Patients aren’t always given the choice, and the literature shows there is not a difference in the care from a nurse as from a doctor.

We simply do not have that culture in Australia. Nursing has an image problem (as demonstrated by the comments above indicating a lack of understanding with the staus quo) and the public likely won’t accept nurses in the role (imagine the outcry!!!)

As a child of cost cutting measures, the CRNA model in Australia would be a hard pill to swallow. There are not enough training positions for the doctors, never mind the CRNA’s requiring supervision. It is easy to foresee a potential future where should the adoption of CRNA’s be successful (against all odds) the newly minted CRNA’s are required to fill the backlog of vacancies in rural centres…

Aargh

As a nurse, my interest is in the patient as a person. Not in cost cutting for Government. That’s what the Grattan Institute is for.

 

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The team leader isn’t always the senior registrar (or the Director of ICU)

About four years ago I took some leave from my position and worked in another department for 6 months or so. I didn’t do this because I wanted to, I did it because I had to. That will be a much later post, and is a much different story from this one. I mention it here because the story from this post happened in the midst of the worst week of my career that forced me away for 6 months and nearly out of nursing…

 

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The team leader isn’t always the senior registrar (or the Director of the ICU)…

At the start of our night shift we had an admission. She was a pillion passenger on a motorbike and had gone from the motorbike into a window, which had been thoughtfully opened by the rider of the bike who had been jettisoned though the glass head first, milliseconds earlier. He had died at the scene.

She had a head injury and severe liver damage and multiple long bone fractures and that night would require two operations in theatre and two trips to CT, as well as activated factor VII and the Massive Tranfusion Protocol. We couldn’t bring her ICP below 50mmHg, and she quite frankly had us all concerned.

All that was to come.

Right now she had just arrived in our ICU and had been too unstable for the emergency department to do a head scan, so our job was to stabilise her and get her to radiology on another floor and then back to our floor to OT.

A large team of nurses and junior doctors gathered at the bedside, ready to do what was required. The Director of ICU was the consultant and was standing back, arms casually folded, making decisions and guiding the team. Sometime over the next half hour the night shift doctors started drifting in, taking over from their day shift counterparts so they could prepare for the medical handover round.

Eventually, the consultant decided that if she was going to get to radiology now was the time. I was the ACCESS (or Bay nurse, or float nurse) in the area. He nodded towards me and I started delegating nurses to collect equipment, medications, transfer monitors and test transport ventilators, which is the kind of thing an ICU consultant might not know about. Keeping an eye on our activity and the patient the consultant started filling in the details for the night shift senior registrar.

I work with a truly wonderful team. Most of the senior nurses are interchangeable within roles, although we all have unique approaches to problems and situations. Right now, senior nurses and spare staff were completing delegated tasks, reporting to me and awaiting the next objective. I had people undertaking several steps of the process at the same time. Admittedly, this was before tabards clearly stating “Team Leader” or “Airway Nurse”…

Having been nominated to transfer the patient to CT, the oncoming senior registrar quickly looked around and asked the team at the bedspace if he could have some medications, (he seemed to ask everyone, or no-one, but not any one person) and proceded to list propofol (running already), noradrenaline (also running), vecuronium (infusing due to ICP), morphine (check) and midazolam (you guessed it, also being given) and then added mertaminol (something new).

Not only did he request those medications, he yelled those requests, with strengths and concentrations, and he yelled them over the quiet that had characterised our efforts so far.

Naturally, no-one much paid him attention. Certainly no one dropped what they were doing and ran to the medication room.

In the relative quiet after the senior registrar had stopped yelling, the Director of ICU quietly turned to the senior registrar and said “I don’t think you’re in charge just at the minute, do you?” And pointed in my direction.

A look of understanding crossed the registrar’s face, (the force was strong with this one) and he asked me for his preferred medications. I quickly ran him through what he currently had, and asked two nurses to ensure adequate supplies had been made up for the trip.

The patient was out the door and on the way in less than 10 minutes from the time the decision to go had been communicated.

At the recent smaccGOLD 2014 conference on the Gold Coast, several presenters addressed issues surrounding “tribes”: nursing, medical, ICU, Emergency, Anaesthetics, Pre-Hospital and specialities. (Big shout out to @Socratic_EM, @cliffreid et al.) All presenters promoted a blurring of the “tribes” for the betterment of patient care.

Similarly, recent practice changes and coronial investigations have promoted readily identifiable clothing, tabards of stickers identifying roles in resuscitation or intervention situations, especially when teams are ad hoc and staff capabilities are unclear.

All of these ideas and practice changes are valuable. But that isn’t what this post is about.

When we do know our staff, and we do know our own capabilities, we shouldn’t be afraid to cede responsibility to another with more knowledge of a process or procedure. We don’t lose power or respect, rather we empower others and ourselves.

The Director of ICU wasn’t any less in charge of the situation, and wasn’t any less of a decision maker. He knew what his role was and so did everyone else there. But it had been a long time since he had actually prepped a patient for a trip to radiology.

Even without identifying markers, everyone else knew their roles as well. And amongst the senior staff, any one of us could have coordinated the transfer. It was just via allocation that it was me.

Similarly, if the senior registrar had taken a moment to assess the situation, breathe in, and look – he wouldn’t have been at a disadvantage when it came his turn to lead the team to and from the radiology department, either. We learn these lessons in first aid, in PHTLS, ALS, ATLS and all the other courses we do. Sometimes it is a matter of safety, and sometimes just to ease the wheels of communication and teamwork.

Midazolam Does Not Work Until it is Given

Midazolam Does Not Work Until It Is Given

Most of us have seen patients on midazolam. Some of us might’ve had some for minimally invasive procedures. The patient doesn’t remember anything and it’s possible they have the same conversation over. The patient doesn’t remember anything and they have the same

oh.

Right.

Anyhow, we had a gentleman who went into VF. He kept his output (he was monitored with both arterial line and ECG) but it was fading. He DID keep his alertness, however. We were very fast with the defibrillator. A senior registrar (who was on scene) proceeded to do what you do…charged, apologised “I’m very sorry sir…!”

And Zapped.

Followed by a cry of “SOMEBODY GET HIM MIDAZOLAM!!!”

And Zapped again.

He reverted, we got him the midazolam, can’t actually remember whether he needed to be intubated…but he remembered everything…and the first thing he did say was “CAN YOU PLEASE NEVER DO THAT AGAIN?”

In anaesthetics, we had a patient who had had his induction dose of proposal, suxemethonium, and fentanyl. We intubated him reasonably promptly, and as the anaesthetic nurse I set out to help the scout nurse with positioning the patient. The anaesthetist answered his telephone. The patient didn’t like us moving him. Pressure alarms went off on the ventilator…the whole thing. The anaesthetist gave more propofol, we positioned the patient, the surgeon started the procedure…the patient jumped, the anaesthetist rapidly sedated the patient with more propofol and told the surgeon “it was OK, they’ve had some midazolam”.

Except the patient hadn’t yet been given any.

Hence the tip: MIdazolam does not work until it has been given.

Midazolam is wonderful drug in for use in critical care. In small doses, it is relatively short acting. It is painlessly administered intranasally (equivalent dosage for I.V.  – good for kiddies) and usable IV or via deep I.M. (obviously not as painlessly). It has a small number of incompatibilities in solutions and is good for procedural sedation, long term ICU sedation and as a second line treatment for status epilepticus.

It’s not perfect – it can cause respiratory depression or arrest and should be used with caution with intoxicated patients – it is metabolised in the liver via CYP3A4 (of the CYP450 family of oxidising enzymes) so drunk patients may have a prolonged duration of action.

This is NOT an administration guide for a medication. Clinicians should use their own judgement and adhere to relevant policies.

Magill Forces Are Supposed To Be Bent…

Paediatric Magill Forceps

Paediatric Magill Forceps

Magill Forceps Are Supposed to Be Bent.

This was the Original Tip that started them all…

Magill Forceps are a useful tool will a many and varied uses, sort of like a one-trick pocket knife. Primarily designed for assisting the movement of the Endotracheal or Nasotracheal tube into the chords during laryngoscopy, they come in different sizes for different sized patients.

One hospital I worked in kept a couple in the draw of the anaesthetic machine, a small one and an adult one (we never used the two for the intended purpose unless it was an emergency). We’d use them for extending our reach for things, passing trachy tape under a large patient’s head after intubation, for instance.

One day, in a complete fluke (honest) the paediatric one got “straightened” in the closure of the draw. Now it was completely useless for its intended purpose and always getting in the way.

Ivan Magill was an Irishman and prolific inventor whose assistant (see who gets the credit!?) invented the Endotracheal Tube and what we know as the “Patient Piece” (in ICU) or “Liquorice Stick” (in Anaesthetics). Magill invented the connector that fits between, amongst many other things, including his “bent” forceps.

He was an Anaesthetist in the RAMC during WW1 and worked after the war with one of the other great medical inventors, Captain Gillies (a WW1 surgeon who also has a forcep to his name).

http://en.wikipedia.org/wiki/Ivan_Magill

Thanks to CoCo for going on holiday.