The Advanced Practice Registered Nurse Role Clarity in the

CICU at CCHMCApril 2013

CICU APRN Role Clarity Project

• Objectives: – Provide tools to initiate discussion of advanced

practice registered nursing (APRN) role in the CICU at CCHMC.

– Identify common advanced practice questions that exist in regards to the role in the CICU

History of the CICU APRN

First APRN started in December of 2010.

APRN’s started to manage patients in March 2011 in collaboration with attending MD.

The APRN’s are NOT limited to managing a certain cardiac anomaly or diagnosis.

APRN’s are able, but do not currently bill for services they provide.

It is projected that as of July 2013 there will be a total of 6 fully oriented practicing APRNs in the CICU

– Lindsey Justice and Amy Donnellan are CICU APRN Leads

– APRN patient coverage is currently 7 days a week

– Plan to increase coverage to provide 24/7 coverage

– The CICU APRN group continues to actively recruiting APRN’s 4 positions are currently listed.

Meet Our CICU APRNs• Lindsey Justice, CICU APRN December 2010

– Obtained here MSN from Rush University and was certified as an Acute Care PNP. Started the CICU NP program in December 2010. Prior to working as an APRN she was a CCHMC CICU RN for 3.5 years.

• Amy Donnellan, CICU APRN March 2011– Obtained her MSN from the University of Pennsylvania

as an Acute Care PNP. Worked at St. Jude Children’s Hospital PICU as an PNP-AC for a year. Then worked at Duke Children’s Hospital CICU for 2 years before joining CCHMC CICU in March 2011. Prior to working as an APRN, she worked as RN for Memphis Cardiovascular Surgery Clinic for nine years, adult CICU for 2 years and St. Jude PICU for 2 years.

• Robyn Stamm, CICU APRN November 2011– Obtained her MSN from the University of Cincinnati and

is dually certified as Acute and Primary Care PNP. Worked as a CT surgery APRN for 3 years and then transitioned to the CICU NP position in November 2011. Prior to working as an APRN, she was a CCHMC CICU RN for 4 years.

Meet Our CICU APRNs• Melissa Magness, CICU APRN March 2013

– Obtained her MSN from the University of Cincinnati as an Acute Care PNP in June of 2012.  Previous to her Acute Care PNP degree worked as a care manager and bedside RN in the CICU, PICU RN and general care floor RN for a total of 20 years.

• Liz Moore, CICU APRN May 2013– Obtained her MSN from the University of Cincinnati as

an Acute Care PNP in June of 2012. Worked as a bedside nurse/ECMO Specialist in the NICU at CCHMC for five years prior to receiving MSN. Prior to becoming a nurse, worked as a Board-Certified Music Therapist for ten years at Drake Center. Additionally provided therapy for children with special needs, including Autism spectrum, multiple disability and visual impairment through her private practice.

• Louann Smith, CICU APRN July 2013– Obtained MSN from the University of Cincinnati June

2012. Prior to working as APRN, worked 3 years as RN in Special Needs Clinic, 5 years in RCNIC as RN/ECMO specialist, 5 years at Good Samaritan Hospital NICU as RN, and 5 years as RN working adult home health.

Definition of Advanced Practice

• APRN’s are clinical nurse specialists, nurse practitioners, nurse midwives or nurse anesthetists who are registered nurses with specialized, advanced education. In Ohio, APRN’s have a master’s degree and have met the licensing criteria for the state. They practice under the rules and regulations of the State’s Nurse Practice Act.

APRN’s provide many healthcare services in CICU which include

• Management of acutely ill patients admitted to the Cardiac Intensive Care Unit

• History & Physical Exams• Daily rounds, rounds presentation, and plan of care formulation • Facilitating and/or executing the plan of care• Interpretation of test results• Prescription of medications within the guidelines of state laws• Patient and family education• Care coordination and case management• Patient/Family education

APRN Practice Scope of Care in the CICU includes performing procedures:

– Intubation– Chest tube placement/removal– CVC placement/removal– Arterial line placement/removal– Lumbar Puncture– Removal of intra cardiac lines– Procedural sedation

* In order to perform any procedures all APRN’s are required to fulfill education requirement regarding the procedure and demonstrate correct technique with an experienced provider on three separate occasions.

In the CICU APRN’s are NOT limited to which patients they manage. In the CICU multidisciplinary team model, the patient case load is divided among Cardiology Fellows, PICU Fellows, and the APRN’s equally and may include:

– Newborn with congenital heart disease– Post-operative patients with congenital heart

disease– Post-cardiac transplant patients– Patients with congenital or acquired heart disease

in need of medical management

What type of test may an APRN provider order in the CICU & do they need to be co-signed by a physician?

• X-ray• Ultrasound• CT• MRI• Echo• Labs/Cultures

All of the above do NOT need to be cosigned by a physician.

What type of services may an advanced provider NOT order in the CICU?

An APRN in the CICU MAY NOT place an order for Home health care: currently only MDs & DOs may order this service in the State of Ohio.

An APRN may transport an intubated patient off the floor for a procedure.

The CICU APRN’s ARE able to transport intubated patients off the floor for procedures, appropriate discussions with the CICU Attending occur prior to transport.

May an APRN admit patients to the hospital?

No - Under Ohio Law (ORC 3727.06) only a physician, dentist or podiatrist may admit a patient to the hospital.

May an APRN discharge a patients from CCHMC?

YES

See CCHMC policy MCP-C-100

An APRN can prescribe medications in accordance with Ohio Board of Nursing that include:

-Morphine - Amphetamines

-Blood Products - Heparin

- TPN/IL - Rocuronium

- Inotropes - Epi Spritzer

-Maintenance and replacement fluids

- Calcium Bolus

- Diuretics

Examples of medications that an APRN may NOT prescribe include Cardioplegic agents or General Anesthetics (ie Propofol)

Questions/Comments

We appreciate all of your participation with this CICU Role Clarity Project and would appreciate your participation in a follow-up survey.

A link to the final survey will arrive in your email.

We learned a great deal from all of the free text comments, please include any further questions or comments within the final survey.