RN Role in ACLS

[joeDO2]

so the other day while instructing an acls class to a group of nurses, i was asked about the medico-legal issues surrounding an RN providing acls care in the absence of a physician. i did not gave a good answer but thought i would bring this and a few other curiosities of mine up to this forum....

one of the groups of nurses worked in a hospital setting and stated "we do what we can if we get there before the docs arrive".... they described providing cpr, defib, and epi prior to the arrival of a physician.

another group who worked in a rehab/vent weaning hospital provided all acls care and ran their own codes under "standing orders" since there was not a physician in house overnight.

my question to you all is what are you comfortable allowing RNs to do under standing orders in these situations? are there legal issues with this? where is the line of scope of practice in regards to decision making, procedures, and medication delivery during resuscitation in the absence of a physician?

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[xaelia]

Since pretty much nothing in cardiac arrest in ACLS has any evidence that it works, I don't care what RNs do in that case.

As far as the rest of the protocolized ACLS for non-arrest situations - it was designed to be used without the presence of a physician (hence, protocolized), so it's fine for the RNs to do what they can autonomously while calling for backup.

 

[EctopicFetus]

Agreed. If someone needs ACLS and no doc is around it is better to get things going than wait for the guy to turn blue/gray and go into rigor.

 

[BADMD]

so the other day while instructing an acls class to a group of nurses, i was asked about the medico-legal issues surrounding an RN providing acls care in the absence of a physician.

The patient is dead. I don't think there can actually be any liability in following a nationally recognized resuscitation protocol, assuming they also call for help.

I would argue that ACLS was designed for nurses and non-physicians. For physicians, it is a guideline.

 

[pseudoknot]

At one hospital where I've been, ICU patients were generally admitted with PRN orders for ACLS meds. I always thought it was silly but I guess some lawyer slept better at night.

Xaelia, you must mean the medications only, right? CPR, defibrillation and hypothermia have certainly been shown to benefit cardiac arrest patients.

 

[joeDO2]

thanks for your replies so far. it seems that consensus is that RNs giving acls meds without specific orders in this situation is acceptable. what about parts of acls that maybe are not so protocol driven, i.e. correcting h's & t's. also, any comments on procedural components, for example advanced airway etc.

 

[pseudoknot]

what about parts of acls that maybe are not so protocol driven, i.e. correcting h's & t's. also, any comments on procedural components, for example advanced airway etc.

If correcting the H's and T's involves doing something that is part of an individual's scope, then I don't think there would be any fundamental legal issue. Certain providers may need a protocol for giving certain meds (like, give calcium if you suspect hyperkalemia, or give bicarb if you want to ward off evil spirits). That's no different from the rest of it.

As for procedures, again, it's just a matter of the individual's scope. I don't think RNs can intubate in most states, but paramedics can, so presumably they could do so during a code if a hospital had a protocol allowing that.

(That would be a bad hospital to arrest in, of course, since you really shouldn't be intubating in the first 6-8 minutes of a code, and hopefully a physician would have responded by then, but I digress…)

 

[AbbyNormal]

I would argue that ACLS was designed for nurses and non-physicians. For physicians, it is a guideline.

Absolutely agree.

Simply taking an ACLS course does not authorize a nurse or paramedic to provide ACLS. There must be written protocol and the providers cannot exceed that protocol without communication with a physician.

 

[jbar]

I would say that there should be some sort of document from the hospital that ACLS is standing orders for all certified nurses. I'm sure you could argue if the hospital requires their RNs to have taken ACLS, and that there be crash carts around, they have implied that their RNs can do it. But from a CYA standpoint, if I were a nurse I'd feel a little better.

I think it usually doesn't matter. The codes that I've been at the time from the code being called overhead to the first MD being there is about 1 minute. Add another minute for the page operator to get the call and page it out. The RNs are usually still in the process of getting the code cart to the bedside and getting the monitor on the patient when we get there. So it is rare that the RNs are in a position to start pushing drugs or defibrillating before an MD is there. Not that they shouldn't be doing everything as if we aren't going to be there for awhile, and not that they shouldn't ensure that the hospital recognizes that they can provide that care. But they shouldn't be stressing out that they are going to be running these codes by themselves for half an hour.

 

[deleted109597]

I think it usuall@y doesn't matter. The codes that I've been at the time from the code being called overhead to the first MD being there is about 1 minute. Add another minute for the page operator to get the call and page it out.

Your n=1 is mostly irrelevant. As has pointed out here multiple times, the vast majority of hospitals are not residency training centers. So when they call a code and I'm single coverage, it may be up to 10 minutes before I can get to the other side of the hospital. The RTs have usually made a couple poor attempts at intubating by that point and they're on their third round of drugs. ACLS is what keeps people from standing there with their thumb up their ass.
Although I still think the hospital requiring me to take it is ridiculous.

 

[southerndoc]

Our cardiologists have authorized standing orders for ACLS. It's really not needed though since they have 24/7 in-house PA's. There should be no delay for defibrillating VF or VT without pulse or in initiating amiodarone for VT with a pulse. This is critical in patients who recently were stented for MI and are at risk for reperfusion arrhythmia.

 

[jbar]

Your n=1 is mostly irrelevant. As has pointed out here multiple times, the vast majority of hospitals are not residency training centers. So when they call a code and I'm single coverage, it may be up to 10 minutes before I can get to the other side of the hospital. The RTs have usually made a couple poor attempts at intubating by that point and they're on their third round of drugs. ACLS is what keeps people from standing there with their thumb up their ass.
Although I still think the hospital requiring me to take it is ridiculous.

Hmmm, good point.

 

[Hamhock]

There should be no delay for defibrillating VF or VT without pulse or in initiating amiodarone for VT with a pulse.

Really?

(I am not referring to the "defibrillating VF or pulseless VT" part...just the "amio" part).

As I have said before, ACLS is not the answer, it is just a simple algorithm for folks who aren't trained in resus and for folks who are trained but need something to fall back upon when needed.

There are certainly reasons for delaying amio when there is VT with a pulse. I'll give you one to get you started: hypotension.

Please don't follow ACLS blindly and please don't believe that ACLS is built on good evidence and please don't believe the best management for even the majority of resuscitations is ACLS.

HH

 

[southerndoc]

Amio is indicated in VT with a pulse with hypotension. Synchronized cardioversion is also indicated, but you don't just shock and not give amio do you? That's against how I was trained, how our cardiologists (and my group) practices, and how ACLS teaches.

 

[Hamhock]

Amio is indicated in VT with a pulse with hypotension. Synchronized cardioversion is also indicated, but you don't just shock and not give amio do you? That's against how I was trained, how our cardiologists (and my group) practices, and how ACLS teaches.

Who says amio is indicated in VT with a pulse and hypotension?

On what evidence?

"...but you don't just shock and not give amio, do you?"

Indeed, I do! I would and do shock without amio.

I am not interested in what ACLS teaches (without evidence) and I am certainly not interested in what a few regional cardiologists think...especially wben they are likely only see reperfusion "arrhythmias" (which, I am not sure are true 'arrhhytmias') and channelopathies.

When they spend a similar amount of time in the ED working with undifferentiated VT with pulses due to such things as tox and unidentified metabolic abnormalities, I'll consider their OPINION.

HH

 

[southerndoc]

Who says amio is indicated in VT with a pulse and hypotension?

On what evidence?

"...but you don't just shock and not give amio, do you?"

Indeed, I do! I would and do shock without amio.

I am not interested in what ACLS teaches (without evidence) and I am certainly not interested in what a few regional cardiologists think...especially wben they are likely only see reperfusion "arrhythmias" (which, I am not sure are true 'arrhhytmias') and channelopathies.

When they spend a similar amount of time in the ED working with undifferentiated VT with pulses due to such things as tox and unidentified metabolic abnormalities, I'll consider their OPINION.

HH

What year resident are you?

 

[joeDO2]

Really?

(I am not referring to the "defibrillating VF or pulseless VT" part...just the "amio" part).

As I have said before, ACLS is not the answer, it is just a simple algorithm for folks who aren't trained in resus and for folks who are trained but need something to fall back upon when needed.

There are certainly reasons for delaying amio when there is VT with a pulse. I'll give you one to get you started: hypotension.

Please don't follow ACLS blindly and please don't believe that ACLS is built on good evidence and please don't believe the best management for even the majority of resuscitations is ACLS.

HH

hmm, i'm not sure i'd agree with the statement that acls is primarily designed for those not trained in resus. as with all protocols/guidelines/etc there are always situations where deviation is indicated and necessary, however- i think acls is far more evidence based than "expert opinion" which many would use in its absence. each guideline is rated by level of evidence and a listing of the studies from which each recommendation is made is available.

 

[UnderwaterDoc]

I have not looked this up, but every time we talk about ACLS we are told that the only interventions for which there is positive evidence are CPR and electricity, the drugs have no evidence supporting them, although we are still trained to use them. Is this not true?

 

[southerndoc]

I have not looked this up, but every time we talk about ACLS we are told that the only interventions for which there is positive evidence are CPR and electricity, the drugs have no evidence supporting them, although we are still trained to use them. Is this not true?

Try explaining to a jury that you didn't think there was enough evidence to warrant meds for a cardiac arrest, VT with pulse, or Torsades when the plaintiff's lawyer presents ACLS guidelines that were agreed upon by experts after analyzing the research.

 

[UnderwaterDoc]

Try explaining to a jury that you didn't think there was enough evidence to warrant meds for a cardiac arrest, VT with pulse, or Torsades when the plaintiff's lawyer presents ACLS guidelines that were agreed upon by experts after analyzing the research.

Good point 🙂 I wonder if they will keep dropping drugs with every revision, seeing how they dropped atropine from asystole/pea pathway last time.

 

[joeDO2]

I have not looked this up, but every time we talk about ACLS we are told that the only interventions for which there is positive evidence are CPR and electricity, the drugs have no evidence supporting them, although we are still trained to use them. Is this not true?

i think most of the value is in using the interventions for the management of the patient prior to cardiac arrest. as was said a million times prior, cpr/defib/hypothermia/correction of reversible causes is really all that has been proven useful after that point.

 

[Hamhock]

What year resident are you?

OK - I was a bit flippant...so I'll tone it down a little.

It's just that I get frustrated by people trained in resuscitation nearly blindly following ACLS and believing it is based on good evidence.

Just a few posts above JoeDO2 stated, " i think acls is far more evidence based than "expert opinion" which many would use in its absence. each guideline is rated by level of evidence and a listing of the studies from which each recommendation is made is available."

This kind of misconception results. I strongly suggest reviewing the "evidence" that is given before agreeing with the AHA's "rating". Frequently I think readers will be surprised how incredibily weak the "evidence" is and occasionally find flat out misreprestations, misinterpretations, and even unrelated studies.

A few days ago we had an arrest come in with ROSC obtained and lost again three times in the field....Once on the monitor in the ED, the patient slowly became more and more bradycardic and then arrested...chest compressions, epi, and calcium chloride resulted in sinus tach that slowed and was going in and out of VTach. The potasssium was 9.2.

Even knowing this, there were multiple calls for amio during the code that had the ED pharmacist running to grab amio for VTach with a potassium of 9 instead of calcium, bicarb, IVF (ideally cold; which was unavailable), albuterol, sugar/insulin.

And some time during the code when the patient was bradycardic there were calls for transcutaneous pacing.

I later found out (debriefing) that folks were insistent on amio for VTach with pulses because that is "what ACLS says"!!! 😱

I think this is a good example of why I think ACLS sometimes hinders those of us who are trained in or are training in resuscitation.

And I think this is a good example of why I disagree with statements like, " There should be no delay ... in initiating amiodarone for VT with a pulse."

I would argue there should often be a delay and there are many times when it is just not indicated. (even if cardiologists - who are NOT the gods of resus! - think it should be a standing order...I am about to get flippant again, so I'll stop here😀)

HH

 

[UnderwaterDoc]

OK - I was a bit flippant...so I'll tone it down a little.

It's just that I get frustrated by people trained in resuscitation nearly blindly following ACLS and believing it is based on good evidence.

Just a few posts above JoeDO2 stated, " i think acls is far more evidence based than "expert opinion" which many would use in its absence. each guideline is rated by level of evidence and a listing of the studies from which each recommendation is made is available."

This kind of misconception results. I strongly suggest reviewing the "evidence" that is given before agreeing with the AHA's "rating". Frequently I think readers will be surprised how incredibily weak the "evidence" is and occasionally find flat out misreprestations, misinterpretations, and even unrelated studies.

A few days ago we had an arrest come in with ROSC obtained and lost again three times in the field....Once on the monitor in the ED, the patient slowly became more and more bradycardic and then arrested...chest compressions, epi, and calcium chloride resulted in sinus tach that slowed and was going in and out of VTach. The potasssium was 9.2.

Even knowing this, there were multiple calls for amio during the code that had the ED pharmacist running to grab amio for VTach with a potassium of 9 instead of calcium, bicarb, IVF (ideally cold; which was unavailable), albuterol, sugar/insulin.

And some time during the code when the patient was bradycardic there were calls for transcutaneous pacing.

I later found out (debriefing) that folks were insistent on amio for VTach with pulses because that is "what ACLS says"!!! 😱

I think this is a good example of why I think ACLS sometimes hinders those of us who are trained in or are training in resuscitation.

And I think this is a good example of why I disagree with statements like, " There should be no delay ... in initiating amiodarone for VT with a pulse."

I would argue there should often be a delay and there are many times when it is just not indicated. (even if cardiologists - who are NOT the gods of resus! - think it should be a standing order...I am about to get flippant again, so I'll stop here😀)

HH

Dumb question, but could you elaborate why you would not use amio in the case you provided? Is it because of the hyperkalemia?

 

[chemist157]

Amio is indicated in VT with a pulse with hypotension. Synchronized cardioversion is also indicated, but you don't just shock and not give amio do you? That's against how I was trained, how our cardiologists (and my group) practices, and how ACLS teaches.

Wouldn't the hypotension (depending on the degree) characterize it as "unstable" v-tach and make CV the first line? Wouldn't amio potentially bottom out the pressure more? Are you just suggesting amio after the shock to prevent further arrhythmia or amio before?

 

[southerndoc]

Wouldn't the hypotension (depending on the degree) characterize it as "unstable" v-tach and make CV the first line? Wouldn't amio potentially bottom out the pressure more? Are you just suggesting amio after the shock to prevent further arrhythmia or amio before?

Amio after to prevent further arrhythmia (or concurrently with cardioversion) if the patient is hypotensive.

Hamhock, it's nice to have labs back when you're running a code. In a situation like that, it's not indicated. What was the rate? The reason I ask is wide complex tachycardias can often be thought of as VT when in fact it's just wide complex that is nearing a sine wave.

 

[deleted109597]

Had to argue with a floor nurse at a code the other night who kept wanting me to give amio to someone with sinus tach and a RBBB. Her rationale was that it looked like VT on the defibrillator, but the monitor at the head clearly showed a sinus tach.
My favorite part was when she tried to overrule me because "I wasn't practicing ACLS".

 

[joeDO2]

OK - I was a bit flippant...so I'll tone it down a little.

It's just that I get frustrated by people trained in resuscitation nearly blindly following ACLS and believing it is based on good evidence.

Just a few posts above JoeDO2 stated, " i think acls is far more evidence based than "expert opinion" which many would use in its absence. each guideline is rated by level of evidence and a listing of the studies from which each recommendation is made is available."

This kind of misconception results. I strongly suggest reviewing the "evidence" that is given before agreeing with the AHA's "rating". Frequently I think readers will be surprised how incredibily weak the "evidence" is and occasionally find flat out misreprestations, misinterpretations, and even unrelated studies.

A few days ago we had an arrest come in with ROSC obtained and lost again three times in the field....Once on the monitor in the ED, the patient slowly became more and more bradycardic and then arrested...chest compressions, epi, and calcium chloride resulted in sinus tach that slowed and was going in and out of VTach. The potasssium was 9.2.

Even knowing this, there were multiple calls for amio during the code that had the ED pharmacist running to grab amio for VTach with a potassium of 9 instead of calcium, bicarb, IVF (ideally cold; which was unavailable), albuterol, sugar/insulin.

And some time during the code when the patient was bradycardic there were calls for transcutaneous pacing.

I later found out (debriefing) that folks were insistent on amio for VTach with pulses because that is "what ACLS says"!!! 😱

I think this is a good example of why I think ACLS sometimes hinders those of us who are trained in or are training in resuscitation.

And I think this is a good example of why I disagree with statements like, " There should be no delay ... in initiating amiodarone for VT with a pulse."

I would argue there should often be a delay and there are many times when it is just not indicated. (even if cardiologists - who are NOT the gods of resus! - think it should be a standing order...I am about to get flippant again, so I'll stop here😀)

HH

some great points brought up here. certainly i agree that evidence is lacking in most parts of resuscitation science. i make it a point to review the evidence for each guideline i practice. unfortunately, sometimes we must practice on the available evidence which in many cases is small. every few years we end up doing things completely different in resuscitation based on new information.

in the above example case, you could treat the hyperkalemia and still be within the realm of the guidelines. there is no statement that restricts you to following rigidly to the flow chart and, in fact, you are encouraged to consider and correct reversible causes such as this at every juncture. i don't think the problem here is the acls guidelines, but rather how many are taught to use them.

using debriefings like the one above are a great way to take time and explain why each intervention was performed as it was, however team-based resuscitation training before the fact would be ideal. including several scenarios where the docs must deviate from the basic algorithm into correction of reversible causes can avoid confusion during the actual resuscitation.

 

[chemist157]

Amio after to prevent further arrhythmia (or concurrently with cardioversion) if the patient is hypotensive.

Hamhock, it's nice to have labs back when you're running a code. In a situation like that, it's not indicated. What was the rate? The reason I ask is wide complex tachycardias can often be thought of as VT when in fact it's just wide complex that is nearing a sine wave.

Gotchya. That makes sense.

 

[Hamhock]

Had to argue with a floor nurse at a code the other night who kept wanting me to give amio to someone with sinus tach and a RBBB. Her rationale was that it looked like VT on the defibrillator, but the monitor at the head clearly showed a sinus tach.
My favorite part was when she tried to overrule me because "I wasn't practicing ACLS".

Exactly!

HH

 

[Hamhock]

Dumb question, but could you elaborate why you would not use amio in the case you provided? Is it because of the hyperkalemia?

I'll try to answer this question honestly and with care. Please don't mis-read my answer for irreverant sarcasm: I am being serious.

"could you elaborate why you would not use amio in the case you provided?"

(asked by 'underwaterDoc')

...for the same reason you wouldn't use amio for unstable VTach with no lung sliding on the right side!

HH