My 2 Cents

Ohio CRNAs cannot write orders for RNs and LPNs to administer medications

See the correspondence from the Ohio Board of Nursing Practice Manager to OSANA, the Ohio State Association of Nurse Anesthetists.

You will see from reading the correspondence that there was some confusion and debate as to whether this was in the scope of practice of Ohio CRNAs.

http://www.nursing.ohio.gov/PDFS/NextMeeting/M1/6.1LetterOSANA.pdf

Botox and Ohio Nurses: This is only the beginning

Thank you Pat for emailing me this link.

What are the standards in your state related to Botox administration?

Do you see this as a victory for the expansion of the nursing scope of practice, an assumption of more legal risks, a case of employers asking nurses to "do more" but not increasing salary, or something else?

http://www.dispatch.com/live/content/business/stories/2008/08/17/Botox.ART_ART_08-17-08_D1_9CB1E66.html?sid=101

Here is the cut and paste:

 

Nurses can give Botox injections

But the procedure still must be done in physician's office

Sunday,  August 17, 2008 3:46 AM

By Marcey Goulder

 

Crystal Ford gets Botox injections to deal with wrinkles. "I tell everyone I'm growing old gracefully, just cheating along the way," she said.

Botox is booming, here and abroad.

And thanks to a ruling by the Ohio Board of Nursing, the wrinkle-smoothing toxin is likely to help some Ohio medical practices improve their own lines -- their bottom lines.

Last week, Allergan Inc., the pharmaceutical company that makes Botox, said its second-quarter profit rose 6.9 percent, well above analysts' estimates, largely because of robust sales of the facial treatment overseas. Overall, Botox sales jumped 13 percent, to $315.5 million.

A survey by the American Society for Dermatologic Surgery suggests that the use of Botox and dermal fillers is up in the United States, too, in spite of -- or perhaps because of -- the sagging economy and rising unemployment. In a news release detailing the findings, the organization speculated that "baby boomers may be looking to put their best face forward on the interview circuit."

In Ohio, Botox sales could get an additional boost from the recent determination that nurses can give Botox injections, provided that they first undergo special training.

The financial advantage is obvious: By assigning the duty to nurses, medical practices that offer Botox can treat -- and bill -- more patients. And because health-insurance plans typically don't cover elective cosmetic procedures, practices can deal directly with patients and charge, for the most part, whatever the market will bear.

In 2006, the most recent year for which data are available, physicians across the country charged an average of $492 for a Botox injection, according to the American Society of Plastic Surgeons.

Because Botox is a poison, some states explicitly forbid anyone other than a licensed physician to administer the drug.

Before the nursing board ruled on the matter last month, however, Ohio's nurses were operating in uncharted territory. Some were giving Botox shots -- and even determining doses. Others thought the procedure was beyond the scope of practice for nurses and therefore could be performed only by a physician.

"There was no specific prohibition," said Lisa Emrich, manager of the board's nursing practice, education and administrative unit. "It was becoming evident that physicians wanted nurses to do this, and there were no specific guidelines."

The board's decision came in response to a request by Dr. Fernando Colon, a board-certified plastic surgeon and associate medical director of the Skin Center Medical Spa in Gahanna.

Colon argued that allowing nurses to do the procedure would enable him and his colleagues to serve patients more effectively and efficiently.

"A well-trained nurse can continue to repeat this treatment, while I'm at the office doing other things," he said. "In a well-supervised environment, I think it is safe for a nurse to administer these Botox injections."

Colon's request, submitted last year, sparked months of discussion, much of it focusing on potential complications.

"What happens in a bad outcome?" board member Eric Yoon, a nurse practitioner from Springboro, asked at one hearing. "Just call 911?"

Ultimately, the board agreed with Colon but said nurses first must complete a "preceptorship," a period of practical experience and training supervised by a physician, Emrich said.

The board also determined that Botox can't be administered in homes, beauty salons or shopping malls, she said.

Still, some Ohio physicians aren't happy with the decision.

Dr. Michael Sullivan, a board-certified plastic surgeon in Columbus and former director of facial, plastic and reconstructive surgery at the Ohio State University Medical Center, had testified that Botox injections should be left to experienced plastic surgeons or dermatologists.

In unqualified hands, Sullivan said, the drug can cause a number of problems, including muscle weakness, drooping and bruising.

"We're going to hear of more and more complications and potentially deaths, because more and more physicians want to get out of insurance medicine and look at Botox and fillers and some of these quick procedures as a way to create a lucrative practice," he said.

In February, the U.S. Food and Drug Administration reported that Botox had been linked "to adverse reactions, including respiratory failure and death, following treatment of a variety of conditions using a wide range of doses." The most serious side effects stemmed from the "off-label" use of Botox to treat limb spasms in children with cerebral palsy, the agency said.

Last month, more than a dozen people filed a lawsuit against Allergan in California, where the company is headquartered. The plaintiffs contend that Botox injured them or killed their relatives and that Allergan failed to warn them of potential dangers.

Allergan said Botox has been used safely by millions of people.

Ohio Nurses call for change in prescription drug law

See this article

http://www.crainscleveland.com/article/20070702/FREE/70628013

Here is the cut and paste:

It’s 2:30 a.m. You’re an advanced practice nurse on staff at an acute care facility somewhere in Ohio. One of your patients wakes up, crying out with pain.

Your instinct, naturally, is to alleviate that pain. But it’s Sunday morning, and the 24-hour Percocet prescription you prescribed for the patient on Friday just expired, and state law forbids a refill.

At this point, the only way you can give her the medicine is to get approval from the patient’s physician.

Some say that’s exactly how it should be, and Ohio law backs up that sentiment. Others — including thousands of nurses — believe it’s time for a change.

Leading the latter cause is Jacalyn Golden, who works for the department of advanced practice nursing at the Cleveland Clinic.

As chairwoman of the legislative committee of the Ohio Association of Advanced Practice Nurses, she’s spearheading an effort to make Ohio the 32nd state in which advanced practice nurses (APNs) have the ability to prescribe Percocet and other highly controlled substances, without going through a doctor. APNs are registered nurses who have received post-graduate education to give advanced clinical care.

Currently, APNs are allowed to prescribe such drugs, but with limitations: only in 24-hour increments and with approval from the physician who initiated the medication.

The arrangement, Ms. Golden said, is “kind of ridiculous. … People who work up in intensive care, (seeing patients) with severe pain … they have to interrupt the surgeons to be able to prescribe, even though it’s well within their training.”

The Ohio State Medical Association, a membership organization advocating on behalf of physicians, is the Ohio Association of Advanced Practice Nurses’ primary opponent.

They argue that nurses, even APNs, aren’t sufficiently trained to diagnose independently within Schedule II, the contentious class of drugs that includes potentially addictive pain relievers such as fentanyl and attention deficit disorder medications such as Ritalin. (There’s no argument over APNs prescribing less-risky drugs in Schedules III through V.)

“Having the authority to prescribe for those drugs should really be guarded,” said Tim Maglione, the state medical association’s senior director of government relations. To give APNs the authority would “blur the line between the practice of medicine and the profession of nursing.”

Mr. Maglione said there is particular concern over whether APNs could prescribe medication in retail clinics or pharmacies. As for the bill, Mr. Maglione says the association hopes to work with the nurses for a “compromise.”

Ms. Golden is devoted to promoting Ohio House Bill 253, which would remove the restrictions and make Schedule II prescriptions a collaborative process between the APN and an Ohio Board of Nursing prescriptive governance committee, composed of physicians, pharmacists and other nurses.

Contained within the bill is language empowering the nursing board’s committee to determine which Schedule II substances a qualified APN can prescribe and under what circumstances.

The Ohio bill, sponsored by Rep. Scott Oelslager, R-North Canton, is co-sponsored by several other representatives and has support from several major health care institutions around the state, including the Cleveland Clinic and University Hospitals Health System, Ms. Golden said.

The bill, introduced May 31, has been assigned to the health committee, according to the Ohio Legislative Service Commission. It will be taken up again in the fall. If approved, it would then go to the Ohio Senate.

Lisa Emrich, manager of education and practice at the Ohio Board of Nursing, said the proposed change is rather small. “(APNs) already have the ability to care for these types of patients within their own practices,” she said. “There’s already quite a bit of oversight.

Controlled Substance Administration, Documentation & Handling

If you are a nurse and you want to be investigated by the State Nursing Board or State Attorney General's office (in some states AG's office investigates complaints), this is one surefire way that will lead to an investigation.

Alot of my current cases involve the administration, documentation, handling, and wasting of controlled substances. Alot of the phone calls I receive from nurses seeking attorney representation involve the same.

Slow down, take your time, and document. You can't practice and document "willy nilly" with controlled substances. You just can't do it anymore. Why? Chemical dependency is an issue with healthcare workers. 2. Rise in drug diversion (using a drug in manner for which is was not intended) 3. Rise in Drug Theft with healthcare workers. If you are chemically dependent or impaired, you need to speak with someone.

When the shit hits the fan and it will, your employer (nursing management and human resources) will not support you. You most likely will be terminated ( 9 times out of 10), reported to the Nursing Board and/or Pharmacy Board (depending on the state), and law enforcement will be notified (depending on the state and circumstances involved).

I have worked exclusively with nursing licensure defense for 7 years and I have yet to receive a call from a nurse who remarks that his or her employer is "in my corner" in these cases. Actually, I find when employers attempt to counsel and advise nurses in these situations (you don't need to be an attorney to give a nurse advice anyway do you?) its wrong and based on inappropriate assumptions.  

PICC Line Verification in Ohio is the Practice of Medicine

See this memo from the Ohio Medical Board to the Ohio Nursing Board. http://www.nursing.ohio.gov/PDFS/NextMeeting/M2/5.4.6PICCVerification.pdf

Are nurses in your jurisdiction legally permitted to place and verify placement of PICC lines?

Recognizing an Learning Need and Acting Upon It

See http://wbjournal.com/j/index.php?option=com_content&task=view&id=3638&Itemid=139.

A very practical manual for nurses who work in cysto rooms and assist with urological procedures. It is entitled “Cysto Room Survival Manual: Guidelines for Urologic Endoscopy.” All the proceeds of the book go back to the Society of Urological and Associates. See http://www.suna.org/cgi-bin/WebObjects/SUNAMain

Is there a similiar manual available in your practice area? Should a manual be available in your practice area? What about a pocket size manual for nurses in your organization? For your specific unit on the most common patient populations and medication given?

Primary Nursing with the Nursing Shortage: Is it still possible?

See this editorial appearing in ADVANCE for Nurses.

http://nursing.advanceweb.com/editorial/content/editorial.aspx?prg=3&cc=110560.

Is primary nursing still possible in today's healthcare system? According to the editorial:

"Her primary nurses on each unit identified themselves as the persons responsible for her care, discussed goals, informed her of what to expect and prepared her for transfer to another unit or for discharge."

My nephew was admitted to Cincinnati Children's Hospital Medical Center in December and my grandmother was hospitalized at University Hospital in Cincinnati. I spent most of December 2007 in Hospital rooms and clinics and I didn't observe any form of primary care nursing. What I observed was survival staffing and the band-aid approach to nursing care.

Which is one of the reasons why anytime my nephew who has an ASD and Pulmonary Hypertension is hospitalized, someone (me, my mother, one of my sisters, or a grandparent) is ALWAYS present at the Hospital. 

What are your experiences with primary care nursing? Is primary care nursing a reality on your unit? Did you observe primary care nursing when your family, friend, or loved one is hospitalized?

CNA Speaks Out Against OHA-Supported Nurse Staffing Bill

Four nurses from the California Nurses Association and the NNOC (National Nurses Organizing Committee) spoke appeared before a legislative panel, slamming OHA, Ohio hospitals’ commitment to patient safety and an OHA-supported bill requiring hospitals to ensure a voice for direct care nurses when establishing staffing plans. See http://www.ohanet.org/healthenews/default.asp#Wednesday. 

Are you a Nurse?

My grandmother had surgery on Friday and will be hospitalized for 7-10 days. I spend most of my days at the hospital with her. My 6 y/o nephew, who was diagnosed with pulmonary hypertension and ASD is scheduled for a cardiac cath on Friday and will be hospitalized for 3-4 days. I will spend this entire week and two or three days of the following week at Cincinnati Children's Hospital and University Hospital.

When a family member is hospitalized, how do you respond when you are asked, are you a nurse? Maybe I should using legal terms like negligence, licensure defense, liability, and assumption of the risk; do you think someone will ask, are you an attorney?

What is Competency?

I am flying to Silver Springs, Maryland the American Nurses Association Congress on Nursing Practice & Economics (CNPE) meeting on Friday and Saturday. There will be over 60 nurses who practice in variety of settings (hospital, nursing education, public health, home care, nursing management, etc.) across the U.S. at this meeting.

I was elected to the Congress at the ANA House of Delegates in 2006. I am part of a subcommittee working on a definition of Competency.

How do you define competency? Are you competent? How do you measure competency in your nursing practice?

Non-Compete Clause

I reviewed an employment contract for an ARNP today. Regardless of whether you are an ARNP, RN, or LPN, if you are asked to review and sign an employment contract you should have the contract reviewed by an attorney with experience in healthcare law and nursing issues.

Why? Contracts are legally binding documents that may impact your nursing practice for years to come depending on the provisions, clauses, and terms in the contract.

Some attorneys will charge a flat fee a contract review and consultations while others may bill an hourly rate.

Does your employment contract have a non-compete clause? Is it reasonable? Is there an indemnity clause in the contract? What is an indemnity clause?

I have said it once and I will say it again....No one likes to pay attorney fees however its your nursing practice and aren't you worth it? 

LPNs & the Nursing Shortage

Have you read the article in the July 2006 American Journal of Nursing "Can the Use of LPNs Alleviate the Nursing Shortage?"

If not, its a must read regardless of whether you are a LPN or an RN. After reading the article, I wondered how my career path would have changed if a guidance counselor or my grandmother steered me towards a practical nursing program instead of RN training.

My plan after graduating from high school was to start a four year program for prelaw and then apply to law school. It was my grandmother who told me when I was eighteen "there are too many attorneys, go to nursing school", and I did. She worked in a hospital for a number of years and encouraged me to be an RN.

The authors in the article suggest that minorities should be encouraged to start in practical nursing. What do you think? Should we encourage minorities interested in nursing to attend practical or vocational nursing programs or professional nursing programs for RNs at the diploma, associate, or bachelor degree level?

This is for my grandmother. I can't thank you enough for your words of wisdom that you gave me in 1989. Little did I know how your advice and encouragement would shape and influence my career path and life choices. Thank you again for your wisdom and guidance. Thank you for encouraging me to attend nursing school. Thank you for encouraging me to attend law school when others said "you are a nurse, why would you want to be an attorney."

Licensure in Multiple States

You are a LPN who holds licensure in State A and B and you work part-time positions in each state. You work Monday-Wednesday in State A and Thursday-Saturday in State B. Can you safely assume the LPN IV therapy rules for State A are the same as State B?

I live in Cincinnati, Ohio, which borders Northern Kentucky and Southeastern Indiana. Therefore its not uncommon for nurses in these areas to have licensure in Ohio, Kentucky, and/or Indiana. Nurses who live in the Louisville, Kentucky area may be licensed in Indiana or vice versa because of the proximity of state lines and employment opportunites.

Don't assume the nursing law and regulations for State A are the same or similiar to State B. Just because you did XYZ task or procedure in State A does not mean that XYZ task is within your scope of practice in State B.

As a licensed nurse, you are accountable for your nursing practice and have an obligation to be familiar with state nursing law (Nurse Practice Act) and regulations (Board of Nursing regulations) in each state where you practice.

Chain of Command in Nursing

The chain of command in nursing exists for reason. We as nurses know what the chain of command is because we learned about it in nursing school and it was reinforced at nursing orientation as provided in the facility specific nursing policies & procedures.

A nurse contacted me this week after he was fired for not following the chain of command in a nursing home.  He had a complaint about a EMS worker and instead of discussing the issue and complaint with his immediate nursing supervisor in the nursing home, the nurse contacted the supervisor of the EMS worker directly.

What do you think based on the facts given? Is this appropriate?

For a refresher on the basics of the nursing chain of command, click here.

CPR

I completed my CPR class this week.

Did you know there have been instances in Ohio where nurses were reported to the Board of Nursing for not performing CPR correctly, not starting CPR in a timely manner, and failing to perform CPR when indicated. Are you competent to perform CPR and BLS as a licensed healthcare?

See the American Heart Association website for emergency and cardiovascular care.

Suspected Medication Error

You are a staff nurse in a facility. You suspect a fellow nurse committed a medication error that did not result in patient harm but failed to report complete an incident report. This situation is bothering you. What do you do?

Should this situation "bother" you? Do you mention your suspicions to your nursing supervisor? Do you simply approach your colleague and have a frank discussion? Do you let it ride because "its none of your business" and you don't get paid to do that? Do you consult with nursing policies & procedures to determine the best course of action?

Certification and CMSRN

Are you certified in a nursing specialty? I downloaded the information for the Certified Medical-Surgical Registered Nurse (CMSRN) exam. I am considering certification. See this article on nursing spectrum that discusses the CMSRN exam. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=12630

If you are certified, why did you become certified? What is your certification? If you are not certified, why not? Is it because we play the "alphabet soup" game with credentials and degrees in nursing?

I am a former pediatric nurse who switched to home health adult med surg and I have not looked back. I never really thought about being certified until I reviewed the American Journal of Nursing 2006 Career Guide and I have been a practicing RN since 1993.

Forensic Nursing

I am excited because I have been asked to present at the Ohio chapter of the International Association of Forensic Nurses (IAFN) meeting on May 8, 2006 in Columbus, Ohio. I will most likely present on Scope of Practice and Professional Boundaries for Ohio Forensic Nurses at the Spring Conference. 

Speaking of forensic nursing, I attended a very informative CE sponsored by the Southwestern Ohio Nurses Association (SONA) last evening on Intimate Partner Violence (IPV) that was presented by Dr. Yvonne McKoy, Ph.D., R.N. who is a nursing professor at Xavier University in Cincinnati, Ohio. The Executive Director of the Ohio Nurses Association (ONA), Gingy Harshey Meade and President of ONA, Barb Nash were also in attendance.

Practice Deficiencies

I had a meeting with a newly licensed RN today who was reported to a Board of Nursing for unsafe nursing practice. What is unsafe nursing practice? At one point does a violation(s) of an employer's policy & procedure turn into unsafe nursing practice? Is one medication error unsafe nursing practice? Is a pattern of medication errors unsafe nursing practice? Are newly licensed RNs more prone to practice deficiencies than RNs practicing for 5,10,15, or 20+ years?

Should issues related to practice deficiencies and unsafe nursing practice be dealt with "in-house" meaning inside the facility with a corrective action plan, monitoring, and supervision prior to being reported to the Board of Nursing? Where does mentoring and socializing the newly licensed RN into the professional practice of nursing fit into the equation? Should a newly licensed RN work with one, two, or more preceptors on a particular unit/floor/shift/area for orientation and competency assessment and evaluation purposes?

If you haven't done so already, read the Notes From The Field section in the December 2005 issue of Nursing Management (www.nursingmanagement.com); the article is titled Is Employee Discipline the Solution for Patient Safety?

How did you make the transition from student to professional nurse? Was it easy? How much time did it take for you to feel proficient?

Time and a Half

I am a home health R.N. and I am seeing patients on Christmas. I am per diem and decided to pick up three visits. I am embarrassed to tell you my "holiday pay" for working on Christmas.

If you are working, are you being paid time and a half for Christmas  and/or New Year's Day? Is the extra pay adequate compensation for time away from family and love one? Are you required to work this weekend/next weekend or are you picking up an extra shift?