Found out how much stroke nurses are allowed to do - and oh my god my jaw is dropping

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Making initial assessments, deciding which MRI's to order, interpreting MRIs....... seriously can't believe this.

What's up with that???
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curiousneuro said:
Umm...what? Never seen this before.
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They are basically like residents. They do assessments, order stuff, make decisions, and then tell the attending about it. The attending makes the final call for the extremely important decisions such as TPA.
 
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Yes, nurse practitioners in any field do these sort of things. It's not surprising. They still need attending oversight though.
 
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Midlevel creep and implications to patient safety have been discussed ad nauseam on this site multiple times in the past. No point in creating another thread to keep beating the dead horse. We all know about it, and we are all aware, but what are we doing about it?
 
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RNs or NPs? Be clear

Although I oppose the NP creep, them acting autonomously is nothing new.
 
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HipiMochi said:
Even with attending oversight - don't you think it harms patient care?
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Yes. It harms patients. I’ve seen failures to diagnose, wrong prioritizations, real endangerment and harms. Also: Because NPs cannot diagnose, they look to scans and consultants to tell them what’s wrong. Overutilization naturally follows. So they harm the system.

Meanwhile there is such a dire shortage of bedside nursing that there’s nursing scope creep as nursing assistants are being asked to do more and more nursing tasks.

Hospital admins love NPs because they over order, make less money, and aside from being walking HR nightmares are compliant with whatever illegalish scams big hospitals are pushing, like avoiding “leakage.”
 
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DrStephenStrange said:
Midlevel creep and implications to patient safety have been discussed ad nauseam on this site multiple times in the past. No point in creating another thread to keep beating the dead horse. We all know about it, and we are all aware, but what are we doing about it?
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Be aware. Get involved with PPP. Fight it locally. Stand up for patients and safety.
 
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Also: Because NPs cannot diagnose, they look to scans and consultants to tell them what’s wrong. Overutilization naturally follows. So they harm the system.
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Have seen this first hand. If they order an MRI or CTA/whatever study and it doesn't come with a diagnosis but a differential, they flounder. If the radiologist is non-committal and doesn't say what's going on what follows is inevitably more scans and shotgun testing. I had an MRI where the radiologist described a hemorrhage, the NP was going down the ICH path but when opening the image the "hemorrhage" was in the exact curvilinear shape of a cortical vein. Patient had a CVT.

If by deciding "which MRIs to order" you mean following the flowchart for a stroke admit? Sure. Anyone can do that. Interpretation of imaging? Not likely. Initial assessment? In non emergent situations, yeah, sure.

Basically, you can pick your jaw back up.
 
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I thought you were referring to nurses, not NPs. Yeah they are certainly worse, but I've never seen them independently interpret imaging and/or diagnose, especially in the acute setting. They've essentially acted as a triage system for the stroke team. But maybe that's just been my experience.

Still bad an inappropriate, but I guess just slightly less so.
 
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Its propaganda to cut hospital cost (1 MD with multiple NP cheaper than multiple MD).
 
NP= residents at our institution. Same privileges from an autonomy perspective.
 
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Our stroke NP is better than 99% of our residents because she's smart and has been with us for almost 10 years. She takes telestroke call with us as backup for the complicated cases. I think it's highly dependent on the NP, but we've had a good experience and she definitely extends our abilities.
 
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Better than PGY2? Sure. But by PGY3 or 4 at the latest they should be better.
 
Hank Rearden said:
Our stroke NP is better than 99% of our residents because she's smart and has been with us for almost 10 years. She takes telestroke call with us as backup for the complicated cases. I think it's highly dependent on the NP, but we've had a good experience and she definitely extends our abilities.
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This seems to be more reflective of the lack of quality of your program
 
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IMO stroke is not particularly difficult and would be easy for an NP to become very skilled in by 10 years. My only worry would be whether they can adequately diagnose stroke mimics or rather be anchored to stroke vs seizures vs vasovagal syncope. I've seen a stroke code by a resident called functional only for me to go back to see this poor lady 3 days later and diagnose her with AIDP. I definitely see subspecialists tend to bias their differential towards their area.

If you're a hammer, everything is a nail.
 
Hank Rearden said:
Our stroke NP is better than 99% of our residents because she's smart and has been with us for almost 10 years. She takes telestroke call with us as backup for the complicated cases. I think it's highly dependent on the NP, but we've had a good experience and she definitely extends our abilities.
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I have my vascular boards. I've been a PI on over a dozen stroke trials. I've given tPA hundred(s?) of times and been involved in the care of many hundreds more. Some of the hardest calls have been tPA decisions.

Yes, @DrSatan - easy cases are easy. How about the hard ones? How about the ones where you're pretty sure of the onset, but not entirely. How about the ones confounded by intoxication, elaboration, hypoglycemia, MI, or seizure? How about the ones with non-compliance for their anti-coagulant? How about conversion or complicated migraines? How about a gyral calcification vs. tiny SAH on head CT? You gave a really difficult case of AIDP, which might be obvious 24-48 hours later, but how about under the gun of door to needle pressure?

@Hank Rearden - a character based purely on intellect and excellence - come on dude. An NP? This is so far outside the scope of an NP it would make a personal injury lawyer by a beach home. I wouldn't feel comfortable getting a hangnail clipped at an institution where an NP makes tPA calls. In fact, this is something that's likely illegal outside huge institutions (NP scope varies state by state, but the nature of tPA means that there's no possible physician oversight). Dubious in terms of ethics as well. Good luck.
 
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neglect said:
I have my vascular boards. I've been a PI on over a dozen stroke trials. I've given tPA hundred(s?) of times and been involved in the care of many hundreds more. Some of the hardest calls have been tPA decisions.

Yes, @DrSatan - easy cases are easy. How about the hard ones? How about the ones where you're pretty sure of the onset, but not entirely. How about the ones confounded by intoxication, elaboration, hypoglycemia, MI, or seizure? How about the ones with non-compliance for their anti-coagulant? How about conversion or complicated migraines? How about a gyral calcification vs. tiny SAH on head CT? You gave a really difficult case of AIDP, which might be obvious 24-48 hours later, but how about under the gun of door to needle pressure?

@Hank Rearden - a character based purely on intellect and excellence - come on dude. An NP? This is so far outside the scope of an NP it would make a personal injury lawyer by a beach home. I wouldn't feel comfortable getting a hangnail clipped at an institution where an NP makes tPA calls. In fact, this is something that's likely illegal outside huge institutions (NP scope varies state by state, but the nature of tPA means that there's no possible physician oversight). Dubious in terms of ethics as well. Good luck.
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NPs cannot make tPA calls though, but neither can a pgy2 resident in our institution without attending verification. In that sense the training level of an NP is considered about the same as junior residents, and I think that’s what they were trying to communicate. Both have similar levels of oversight.
 
A good NP that rounds with every attending on the stroke service for 10 years and is up to date on the trials is going to be better than the vast majority of residents at any institution. I don't know why you all are so bent out of shape. The vast majority of the things NPs do are things you don't want to do. Many of us don't enjoy stroke clinic. Guess who does stroke clinic? At many institutions the NPs see the less acute cases and write their notes with the MDs supervising so the MDs can focus their efforts on the more acute/ICU patients. Do you all enjoy telestroke call? I would much rather have the NP screen and only get called for the complicated cases - though most of our telestroke shifts are covered by MDs. I've not heard of NPs covering telestroke being a problem from a medicolegal standpoint - if you have specific examples of such cases please cite them. Do you all realize what a shortage of Stroke Neurologists there is around the country? There are nearly as many people having strokes as MIs and Cardiologists outnumber us like 10:1. Trust me, the NPs aren't stealing our jobs.
 
Hank Rearden said:
A good NP that rounds with every attending on the stroke service for 10 years and is up to date on the trials is going to be better than the vast majority of residents at any institution. I don't know why you all are so bent out of shape. The vast majority of the things NPs do are things you don't want to do. Many of us don't enjoy stroke clinic. Guess who does stroke clinic? At many institutions the NPs see the less acute cases and write their notes with the MDs supervising so the MDs can focus their efforts on the more acute/ICU patients. Do you all enjoy telestroke call? I would much rather have the NP screen and only get called for the complicated cases - though most of our telestroke shifts are covered by MDs. I've not heard of NPs covering telestroke being a problem from a medicolegal standpoint - if you have specific examples of such cases please cite them. Do you all realize what a shortage of Stroke Neurologists there is around the country? There are nearly as many people having strokes as MIs and Cardiologists outnumber us like 10:1. Trust me, the NPs aren't stealing our jobs.
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They don't need to steal it if you give it to them. Ever heard of the field of Anesthesiology?
 
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Hank Rearden said:
A good NP that rounds with every attending on the stroke service for 10 years and is up to date on the trials is going to be better than the vast majority of residents at any institution. I don't know why you all are so bent out of shape. The vast majority of the things NPs do are things you don't want to do. Many of us don't enjoy stroke clinic. Guess who does stroke clinic? At many institutions the NPs see the less acute cases and write their notes with the MDs supervising so the MDs can focus their efforts on the more acute/ICU patients. Do you all enjoy telestroke call? I would much rather have the NP screen and only get called for the complicated cases - though most of our telestroke shifts are covered by MDs. I've not heard of NPs covering telestroke being a problem from a medicolegal standpoint - if you have specific examples of such cases please cite them. Do you all realize what a shortage of Stroke Neurologists there is around the country? There are nearly as many people having strokes as MIs and Cardiologists outnumber us like 10:1. Trust me, the NPs aren't stealing our jobs.
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I've heard of particular instances where acute stroke patients could have received life altering tPA, but because of the NPs bad history taking about LKN, they didn't.
 
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Hank Rearden said:
A good NP that rounds with every attending on the stroke service for 10 years and is up to date on the trials is going to be better than the vast majority of residents at any institution. I don't know why you all are so bent out of shape. The vast majority of the things NPs do are things you don't want to do. Many of us don't enjoy stroke clinic. Guess who does stroke clinic? At many institutions the NPs see the less acute cases and write their notes with the MDs supervising so the MDs can focus their efforts on the more acute/ICU patients. Do you all enjoy telestroke call? I would much rather have the NP screen and only get called for the complicated cases - though most of our telestroke shifts are covered by MDs. I've not heard of NPs covering telestroke being a problem from a medicolegal standpoint - if you have specific examples of such cases please cite them. Do you all realize what a shortage of Stroke Neurologists there is around the country? There are nearly as many people having strokes as MIs and Cardiologists outnumber us like 10:1. Trust me, the NPs aren't stealing our jobs.
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You get paid for telestroke call. Do the job or don't.

An NP practicing medicine without a license is likely insurance fraud, but that's for their boss to deal with. Your concern will come when there's a bad outcome. You'll find that there are actually no legal standards of care for nurses, so it is very difficult to sue them. The lawyers will sue her supervising doctor instead.

Personally I wouldn't be able to sleep knowing that I have that much exposure (or that I'm complicit in a system that permits an NP to practice with this degree of risk). Best luck.
 
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“I've not heard of NPs covering telestroke being a problem from a medicolegal standpoint - if you have specific examples of such cases please cite them”

Probably because there are few places that would actually take such a huge risk! There are enough difficult variables in telestroke for specialized neurologists. Huge huge lawsuits waiting to happen for NPs in telestroke…

Not saying that a very experienced NP couldn’t do it, but I think that would be a very tiny minority of NPs even in neurology. I would never ever “supervise” a NP in that role but clearly some do.
 
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Spinothalamic said:
“I've not heard of NPs covering telestroke being a problem from a medicolegal standpoint - if you have specific examples of such cases please cite them”

Probably because there are few places that would actually take such a huge risk! There are enough difficult variables in telestroke for specialized neurologists. Huge huge lawsuits waiting to happen for NPs in telestroke…

Not saying that a very experienced NP couldn’t do it, but I think that would be a very tiny minority of NPs even in neurology. I would never ever “supervise” a NP in that role but clearly some do.
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Hospitals don't care about the risk. They have a physician name on the nurse to take the hit. And nurses cost so little they can easily make up the difference.
 
neglect said:
You get paid for telestroke call. Do the job or don't.

An NP practicing medicine without a license is likely insurance fraud, but that's for their boss to deal with. Your concern will come when there's a bad outcome. You'll find that there are actually no legal standards of care for nurses, so it is very difficult to sue them. The lawyers will sue her supervising doctor instead.

Personally I wouldn't be able to sleep knowing that I have that much exposure (or that I'm complicit in a system that permits an NP to practice with this degree of risk). Best luck.
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New grads have lots of loans and need jobs. They will supervise. And they've been indoctrinated that everyone is equal.
 
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ne.neurology.org

Neurology APP Residency Training Programs

The current need for improved access to health care spans all specialties including neurology. To improve access to care, our healthcare teams are increasing their complement of advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs).[1][1],[2][2] The
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Neurology APP residency incoming. Maybe this will help:chicken:
 
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Seems like it’s time to cancel my AAN membership
 
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Ibn Alnafis MD said:
Seems like it’s time to cancel my AAN membership
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The AAN's interests diverged from their member's interests LONG ago. With Sacco dead there's really no need to support them. Also, their conference sucks. It's just a big reunion.

Med students and residents should still go.
 
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neglect said:
Med students and residents should still go.
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I was starting to get very bummed about my airfare to Boston… Also if I was to back out now, I feel like I’d be screwing over my AirBnB host, Hank the homeless guy who’s cardboard box I’m renting out…
 
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