Re: Hospital violations by making you wait in the hallway...

[Guest guest]

When a patient gets brought to the floor, and if the floor is staffed by both

RN's and LVN's, an RN must do

the initial assessment. An LVN can assume care after that. But you're right,

rules get bent all the time, as I am sure it happens in the ED......

Meredith

Re: Hospital violations by making you wait in the

hallway...

Actually, delegation is the assigning of tasks to unlicensed

personnel. RNs do not " delegate " to LVNs - since they are licensed,

but instead make assignments. Since the RN is responsible for

assessing the need for professional nursing tasks (those that an RN

can do but an LVN can't) before making an assignment to an LVN or

delegating to UAP, the initial assessment by definition cannot be

assigned to anyone other than an RN (how do you know whether

assignment of the assessment is appropriate unless you've

assessed?). I know - I've seen places that bend the rules, but they

do so at risk to their license.

Jen

> > Now I may be missing something or perhaps simply unaware,

but,

> > it is my understanding that in order for there to be a valid

> transfer

> > of care there must take place a face to face conversation

between

> the

> > medic and a person of same or higher level of care in the

hospital.

> > This serves two specific purposes. First, the relationship

between

> > the service's medical director and the patient must be severed.

> > Transfer of care to another physician by virtue of reception by

> > hospital staff will accomplish that end. By the way, according

to

> > JCHAO an RN must do the initial assessment and discharge

> assessment.

> > So, that person, from everyones perspective, should be an RN.

>

> What about emergency departments that staff LVNs? A registered

nurse

> could delegate the task of initial assessment to an LVN for

purposes

> of triage which they are more than qualified to do. From that

point

> of view, I would venture to say that the EMS medical directors

> relationship with the patient has been severed once the LVN has

> received a report from EMS personnel.

>

> > Secondly, it insures that ED staff is aware not only of the

> patients

> > presence but also of their triage catagory and relative

disposition

> > after your treatment. Unless I have misunderstood the advice

given

> > here, it has been suggested that the patient be left in the

hallway

> > without giving report to the hospital staff. Would this not

place

> the

> > medics in a position for abandonment issues? We have always

taught

> > that in this specific situation, as it is written in several

texts,

> > leaving a patient in the ED without a proper transfer of care

may

> be

> > grounds for abandonment, a lawsuit that would include not just

the

> > medic but the service and hospital. I'm not trying to get

> everyone's

> > feathers ruffled here. I may just be unaware of some other laws

> > pertaining to this issue that would make it OK to do this.

Thanks.

> >

>

> From what I understand of JCHAO and EMTALA, a patient who presents

to

> an emergency department, regardless of mode of travel taken, must

> have an appropriate screening examination and/or stabilizing

> treatment / transfer to a higher facility. From that point of

view,

> the EMS personnel jobs are done when the patient presents to the

> emergency department, whether or not the nurses have been given a

> report.

>

> Alfonso R. Ochoa

[Guest guest]

>

> Here's a great question though . . . if a paramedic is licensed, and

> patient assessment is taught in their curriculum and is an integral

> part of their scope of practice, then why are paramedics not allowed

> to work triage in the ERs? I've always been confused about that

> one. Is it a JCAHO standard, or ???? My personal opinion, I'd

> rather have a paramedic triage me then a RN that was floated from

> med-surg to " help out " .

>

Paramedics are not regarded as licensed by the Texas Board of Nurse

Examiners and thus fall into the category of " unlicensed assistive

personnel. "

Alfonso R. Ochoa

[Guest guest]

> Pertaining to this? How? Chapter 225 deals with " RN DELEGATION TO

> UNLICENSED PERSONNEL AND TASKS NOT REQUIRING DELEGATION IN

> INDEPENDENT LIVING ENVIRONMENTS FOR CLIENTS WITH STABLE AND

> PREDICTABLE CONDITIONS " . Now, if we're talking about an ER we're

> not talking about stable, predictable conditions in an independent

> living environment. If we're talking about the LVN situation, then

> we're not talking about delegating to an unlicensed healthcare

> provider. Or, did you mean a different chapter of the NPA? Maybe

> the link was off, because I had to piece it back together due to its

> length.

>

> I'm not trying to be rude, just not sure what you're trying to say.

>

>

Sorry, just trying to share some information. I thought that mention

was made about the fact that an RN must perform the initial assessment

of the patient. I made no mention of the LVN issue. I understand that

the document that I linked does not pertain to emergency medicine.

Just trying to point out the complexity of issues that RN's must deal

with regarding delagation. Maybe I should have been more clear or just

kept my mouth shut to begin with. I'll know better next time.

[Guest guest]

Guys, before a heated fight starts here, let me say one quick

thing. Paramedics and EMT's fall under the Texas medical practice

act, not the Nursing Practice Act. We are closer to mid-level

practicioners (PA's and NP's) in the way it works out with our

relationship with our physician oversight. Nurses as a whole will

never accept paramedic's as " licensed " personnel for their own

reasons, and hence there will always be annimositiy amongst alot of

people. Although, I now some nurses that would rather have a

paramedic at their side helping them..........There are some

hospitals which use EMT's and Paramedic's in " Triage " almost

exclusively. UTMB galveston use to use them as their " Triage "

personnel for a while, i don't know if this has changed in the past

few years. There were a few places around Houston, and the Dallas /

FW area that did it, as well as here in San . I will grant

you, it wasn't commmon place, but it does or did happen at one

time. It all boils down to trying to protect ones turf. Ex: Would

you want a nurse right out of the hospital to be able to step on an

ambulance without any EMS training and be able to do what you do?

I bet the answer is no.

Food for thought.

CB

[Guest guest]

An additional note is this......we may not accept delegation of any

orders from a nurse legally, in the hospital or otherwise. It must

be from a licensed physician in the State of Texas. So, even if

they classify us as unlicensed personnel, they can't delegate to

us. Our job functions have to be written into our job description

by the facility, or we have to act under the direction of the ER's

MD. In most cases, it is written into the job description.

CB

> Guys, before a heated fight starts here, let me say one quick

> thing. Paramedics and EMT's fall under the Texas medical practice

> act, not the Nursing Practice Act. We are closer to mid-level

> practicioners (PA's and NP's) in the way it works out with our

> relationship with our physician oversight. Nurses as a whole will

> never accept paramedic's as " licensed " personnel for their own

> reasons, and hence there will always be annimositiy amongst alot

of

> people. Although, I now some nurses that would rather have a

> paramedic at their side helping them..........There are some

> hospitals which use EMT's and Paramedic's in " Triage " almost

> exclusively. UTMB galveston use to use them as their " Triage "

> personnel for a while, i don't know if this has changed in the

past

> few years. There were a few places around Houston, and the

Dallas /

> FW area that did it, as well as here in San . I will grant

> you, it wasn't commmon place, but it does or did happen at one

> time. It all boils down to trying to protect ones turf. Ex:

Would

> you want a nurse right out of the hospital to be able to step on

an

> ambulance without any EMS training and be able to do what you do?

> I bet the answer is no.

>

> Food for thought.

>

> CB

[Guest guest]

I'm sitting with the NPA in my lap . . . can you direct me to where

the NPA states that a licensed paramedic is not licensed?

Jen

>

> >

> > Here's a great question though . . . if a paramedic is licensed,

and

> > patient assessment is taught in their curriculum and is an

integral

> > part of their scope of practice, then why are paramedics not

allowed

> > to work triage in the ERs? I've always been confused about that

> > one. Is it a JCAHO standard, or ???? My personal opinion, I'd

> > rather have a paramedic triage me then a RN that was floated

from

> > med-surg to " help out " .

> >

>

> Paramedics are not regarded as licensed by the Texas Board of

Nurse

> Examiners and thus fall into the category of " unlicensed assistive

> personnel. "

>

> Alfonso R. Ochoa

[Guest guest]

> I'm sitting with the NPA in my lap . . . can you direct me to where

> the NPA states that a licensed paramedic is not licensed?

>

http://www.bne.state.tx.us/delg_faq.htm

See Question 10.

-Alfonso R. Ochoa

[Guest guest]

> What does " requires professional nursing judgment " mean? Since EMTs

and paramedics are trained in patient assessment and triage, would a

triage decision truly " require professional nursing judgment? "

>

> Oh wait -- the nursing board makes the rules, the nursing board

interprets the rules, the nursing board enforces the rules. Sort of

reminds me of a medieval guild wanting to jealously guard its skills

and territory.

>

Sounds like you hit the nail on the head. However, the respective

state nursing boards are all in bed with JCHAO, so they get to

interpret as they please.

-Alfonso R. Ochoa

[Guest guest]

Oh well. No need for EMS to organize or for EMS to get involved with other

healthcare organizations. The fire unions will take care of us all. *rolling my

eyes*

-Wes

Re: Hospital violations by making you wait in the

hallway...

> What does " requires professional nursing judgment " mean? Since EMTs

and paramedics are trained in patient assessment and triage, would a

triage decision truly " require professional nursing judgment? "

>

> Oh wait -- the nursing board makes the rules, the nursing board

interprets the rules, the nursing board enforces the rules. Sort of

reminds me of a medieval guild wanting to jealously guard its skills

and territory.

>

Sounds like you hit the nail on the head. However, the respective

state nursing boards are all in bed with JCHAO, so they get to

interpret as they please.

-Alfonso R. Ochoa

[Guest guest]

The way I understand it is that once you are on the hospital

property, the pt. is their responsibility, besides, essentially

you've already gave a report via radio or phone p.t.a. We have this

problem a lot in Ft. worth, for example, JPS, call in a radio

report, arrive and go to " advanced triage " wait forever and a day,

give a second report to the " AT " nurse, then get assigned to an area

and give a third report to the area nurse. One report should be

enough.

> Just recently, a hospital made me wait in the hallway with my 'low

> priority' patient until they could find a room for him. Meanwhile,

> many other calls are dropping and I need to get in service to cover

> the city. The ER personnel stated that the " patient is not our

> responsibilty until we take report from you. You have to stay with

> that patient to monitor him. " What kind of violation is this in

> regards to EMTALA, RAC, or GETAC? Where can I find the literature

to

> back this to prevent me from just quoting 'hearsay'? I have a copy

of a

> March 2002 letter from the " Center for Medicare & Medicaid

Services " .

> I believe it contains too many 'coulds' and 'may's' to deliver any

> definitiveness to hospitals. Do you know the actual statutes

being

> violated? thnx. FF/P.

[Guest guest]

,

Actually, the physician doesn't have to be licensed in Texas....there was

legislation to try and make this happen last legislative session but was

defeated by many arenas....physician yes...Texas no.

Dudley

Re: Hospital violations by making you wait in the

hallway...

An additional note is this......we may not accept delegation of any

orders from a nurse legally, in the hospital or otherwise. It must

be from a licensed physician in the State of Texas. So, even if

they classify us as unlicensed personnel, they can't delegate to

us. Our job functions have to be written into our job description

by the facility, or we have to act under the direction of the ER's

MD. In most cases, it is written into the job description.

CB

> Guys, before a heated fight starts here, let me say one quick

> thing. Paramedics and EMT's fall under the Texas medical practice

> act, not the Nursing Practice Act. We are closer to mid-level

> practicioners (PA's and NP's) in the way it works out with our

> relationship with our physician oversight. Nurses as a whole will

> never accept paramedic's as " licensed " personnel for their own

> reasons, and hence there will always be annimositiy amongst alot

of

> people. Although, I now some nurses that would rather have a

> paramedic at their side helping them..........There are some

> hospitals which use EMT's and Paramedic's in " Triage " almost

> exclusively. UTMB galveston use to use them as their " Triage "

> personnel for a while, i don't know if this has changed in the

past

> few years. There were a few places around Houston, and the

Dallas /

> FW area that did it, as well as here in San . I will grant

> you, it wasn't commmon place, but it does or did happen at one

> time. It all boils down to trying to protect ones turf. Ex:

Would

> you want a nurse right out of the hospital to be able to step on

an

> ambulance without any EMS training and be able to do what you do?

> I bet the answer is no.

>

> Food for thought.

>

> CB

[Guest guest]

Look at TAC Title 22, Part 9, Chapter 197, rule 197.3 which says an EMS

Medical Director must be licensed to practice in Texas.

Lee

Re: Hospital violations by making you wait in the

hallway...

An additional note is this......we may not accept delegation of any

orders from a nurse legally, in the hospital or otherwise. It must

be from a licensed physician in the State of Texas. So, even if

they classify us as unlicensed personnel, they can't delegate to

us. Our job functions have to be written into our job description

by the facility, or we have to act under the direction of the ER's

MD. In most cases, it is written into the job description.

CB

> Guys, before a heated fight starts here, let me say one quick

> thing. Paramedics and EMT's fall under the Texas medical practice

> act, not the Nursing Practice Act. We are closer to mid-level

> practicioners (PA's and NP's) in the way it works out with our

> relationship with our physician oversight. Nurses as a whole will

> never accept paramedic's as " licensed " personnel for their own

> reasons, and hence there will always be annimositiy amongst alot

of

> people. Although, I now some nurses that would rather have a

> paramedic at their side helping them..........There are some

> hospitals which use EMT's and Paramedic's in " Triage " almost

> exclusively. UTMB galveston use to use them as their " Triage "

> personnel for a while, i don't know if this has changed in the

past

> few years. There were a few places around Houston, and the

Dallas /

> FW area that did it, as well as here in San . I will grant

> you, it wasn't commmon place, but it does or did happen at one

> time. It all boils down to trying to protect ones turf. Ex:

Would

> you want a nurse right out of the hospital to be able to step on

an

> ambulance without any EMS training and be able to do what you do?

> I bet the answer is no.

>

> Food for thought.

>

> CB

[Guest guest]

Dudley,

Pardon if I was mistaken on that point. I was explained to me a while

back by TDH that it had to be a State Licensed MD, however, you know

how DSHS is, 10 people, 10 different answers, 10 different opinions.

I thought maybe there was a change I was anaware of prior to when the

discussion in which this took place.

[Guest guest]

Lee,

I don't think Dudley was referring strictly to the physician as a

medical director of a service. I think he was making a generalized

statement that we could not accept delegation from a physician in

any form unless they were licensed in Texas. I have been unable to

find anything that says that we can't accept delegation from a

physician who is licensed to practice in good standing in another

state. As is the case in some occupational health settings, remote

medical site settings, offshore, etc. I was mainly referring to

working in a typical ER in the state of Texas in my original post

however, and I can't see where a non-Texas licensed physician would

be working as an attending in a Texas ER.

On another note, I ran across an ER here in the San area

just recently which has done away with all ancillary staff, ER techs

(EMT's and Paramedic's, Unit Clerks, etc. in the ER as of 1 year

ago. The MD's or DO's and RN's ONLY (No LVNS), are the only ones

allowed to do anything in the ER from enter orders to re-stock

supplies, to patient care, to lab draws and ECG's, etc. etc.

etc........ They believe this raises the standard of care and

increases the level of care received by the patient, whre I see it

as merely an effective cost cutting measure). Possibly overtaxing

the RN's and MD's and DO's trying to make them play unit clerk,

tech, etc. There are valid reasons for all of these positions,

although; they explained to me that Paramedic's are a liability to

the hospital (BS), and that LVN's have no place except on a floor or

in a nursing home (and never were intended to be used anywhere else

when the LVN / LPN was conceived)(BS), and that anyone can register

a patient and enter orders, so unit clerks are a waste of money.

Now, off my soapbox, except to say that their patient's take twice

to three times as long to be discharged from the ER or admitted to a

unit, or transferred, than any other facility in our RAC.

[Guest guest]

I see I may be wrong here....seems that maybe the physician has to be licensed

in Texas....but he doesn't have to live or work here. DOH!!!

Dudley

Re: Hospital violations by making you wait in the

hallway...

Dudley,

Pardon if I was mistaken on that point. I was explained to me a while

back by TDH that it had to be a State Licensed MD, however, you know

how DSHS is, 10 people, 10 different answers, 10 different opinions.

I thought maybe there was a change I was anaware of prior to when the

discussion in which this took place.

[Guest guest]

In a message dated 7/7/2005 3:16:49 A.M. Central Daylight Time,

Etlae@... writes:

Actually, I've always viewed it as the inverse (Paramedics are all licensed,

whether " licensed " or " certified " ). Certification shows proof of competency

whereas the act of licensure is the rendering of permission to engage in

occupational practice.

Mike

Mike this is much too practical of a definition for use by governments! It

makes sense what were you thinking! (tongue now stuck in cheek)

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

LNMolino@...

(IFW Office)

(Cell Phone)

(IFW Fax)

" A Texan with a Jersey Attitude "

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