Solution for PAC problem advances role of NC nurses
Qualified nurses win right to advance PACs
The ICU nurses at FirstHealth Moore Regional Hospital in Pinehurst, NC, had a problem that’s not uncommon for smaller community hospitals. Patients with inaccurately placed pulmonary artery catheters (PACs) often had to wait for a physician to advance the line.
Because the hospital has no interns or residents, and its physicians are in private practice, misplaced PACs resulted in inaccurate assessments and delays in treatment until a physician could be called from home or had completed a surgery, recalls Cheryl Batchelor, RN, MSN, CS, CCRN, director of clinical practice at the hospital. "We were looking for a way for nurses who are properly credentialed to do this without calling a physician."
At the suggestion of John F. Krahnert, MD, FACC, FACS, director of the cardiac surgery, Batchelor and Cindy Mooney, RN, Med, CCRN, CN, clinical educator at the hospital, started a project that took more than a year of research, lobbying, and testing. But in the end, nurses who meet strict credentialing standards at Moore Regional as well as all hospitals in North Carolina have the authority to advance the catheters.
In most states, advancing a PAC is taboo for nurses. The key to changing that is to work closely with your state nursing board and make sure your staff have the necessary expertise, says Mooney. Here are the three primary criteria that Moore Regional Hospital nurses must meet before doing the procedure:
r They must be able to assess whether the catheter is located in the right ventricle or the pulmonary artery and will not wedge.
r They must be able to assess the chest X-ray to make sure the catheter is not kinked when they advance it.
r They must be able to assess the 12-lead EKG to ensure there’s not a pre-existing left bundle branch block.
But getting to the point of setting those standards involved a lot more. It started when Batchelor and Mooney contacted the state board of nursing to gauge its attitude about expanding the role of nurses. The board was supportive, says Batchelor, and suggested a search of the literature. That search turned up mostly information about the current debate over use of PACs but little about nurses advancing the lines.
At the board’s suggestion, Batchelor and Mooney then designed a pilot study which began in the fall of 1994. Their initial focus was on developing a means of validating the skills of the nurses who would take part in the test and creating a strong policy and procedure for advancing PACs. (For a copy of the policy and procedure, see p. 5.)
During the six-month pilot study, Batchelor and Mooney monitored every PAC that was advanced by nurses, looking especially for lethal and minor dysrhythmias. They found none of the former and only a few of the latter. They also checked for nurses’ documentation of conducting standard troubleshooting procedures before advancing the line.
When the results were presented to the state nursing board, Batchelor and Mooney had effectively expanded the role of nurses throughout the state.
"To be honest with you, I think the staff initially were scared to death," says Batchelor. "We selected only our veterans to participate in this because, obviously, we didn’t want any adverse outcomes. In the beginning, they were very nervous because we were letting them do something they were told never to do. But now that they’ve been doing it for awhile, it’s like riding a bike; they don’t think twice about it. They just follow the criteria and do it."
Currently, 14 nurses at Moore Regional are certified to advance PACs, and they welcome the new authority, says Mooney. "The staff who can advance the PA caths see this as a step up on the clinical ladder. They see it as an autonomous role and a way to avoid delays in patient care. And management certainly has supported the staff," she says.
The line advancement currently is permitted only in the cardiac and cardiovascular units, but training is under way to expand the program to the medical intensive care unit.
The PAC advancement procedure also may catch on elsewhere. When the duo presented their project at a recent National Teaching Institute conference for critical care in Orlando, FL, about 25 people requested copies of the policy and procedure with an eye toward changing their states’ rules, says Mooney.
"What we found during poster presentation is that many nurses told me they already do this even though they know it’s illegal," adds Batchelor. "But that’s only because no one’s taken the bull by the horns and pushed forward through the politics."
For anyone who sees other areas where nursing skills could be advanced, the key is to work closely with nursing officials on the state level, says Batchelor and Mooney.
"First, call your state board of nursing and find out where they’re coming from, especially the practice consultants," says Batchelor. "If you tell the practice consultants upfront what it is you’re aiming to do and get their support, I think it goes a lot smoother because they can help guide you through the process."
Mooney says the project she and Batchelor undertook went smoothly because they had a strong competency validation program and a solid policy and procedure for advancing the PACs. She suggests others plan to spend a lot of time upfront on the policy and procedure, reviewing literature and getting comments from the medical staff. "That is why we haven’t had to go back and revise the policy and procedures," she adds.
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