Nitric Oxide Transports for CCT-RN's

[BobBarker]

Good Afternoon,
Currently work on a CCT ambulance in LA county. Our company is requiring CCT-RN's to complete an online and hands-on course of 2hrs to be able to work with and transport patients that have inhaled nitric oxide blended through our ventilator. Problem is, we as nurses do not think it is in our scope to do this and only RT's in hospitals deal with this, so pawning off to CCT-RN's after a 2hr class seems not only dangerous but unethical especially since these patients are very complex and super high-acuity/unstable. We placed a call to our County EMS office for guidance on the legality as our company said "it's legal and within your scope as long as you have a doctor's order, protocols on it and are trained on it" and are waiting to hear back.

Does anyone here work as a ground CCT-RN and have familiarity with transporting patients using nitric oxide? If so, how long/in-depth was your training? Does anyone know if it is legal/within scope for a CCT-RN to be the one handling nitric oxide without an RT? We have done one transport with a patient on nitric oxide however we asked for the facility RT to come with us and they allowed that, so we did not touch that piece of equipment.

 

[DesertMedic66]

County EMS agencies really leave CCT up to the individual company and their medical director on what they want to do and setting their scope. There are some flight companies who fly Medic/RN that do nitric oxide.

Your best option might be to have all the nurses come together and tell your company that you all do not feel comfortable with it. Then take the 2 hour class. Then once again say you do not feel comfortable with it.

 

[Carlos Danger]

Assuming legal and scope-of-practice issues are ironed out, why would the RN's uncomfortable with it? Is it just unfamiliarity with the equipment or the NO itself, or the severity of illness?

I presume the are adult transports and not neonatal? Are you using dedicated transport equipment or bringing the hospitals stuff?

 

[BobBarker]

Assuming legal and scope-of-practice issues are ironed out, why would the RN's uncomfortable with it? Is it just unfamiliarity with the equipment or the NO itself, or the severity of illness?

I presume the are adult transports and not neonatal? Are you using dedicated transport equipment or bringing the hospitals stuff?

Assuming those issues are absent, Unfamiliarity and the fact that the class is 2hrs long with only half being hands on. In the Hospital, RN’s don’t touch vents/nitric oxide other than maybe upping the 02, thats RT’s job and their schooling is dedicated to respiratory. When you become a CCT-RN, you get “vent certified” by getting 40hrs of training here, far less than RT’s in the Hospital also. Here we run CCT-RN’s with one RN and 2 EMT-Basics. Now you go from 1 RN watching drips and a vent to drips, vent and Nitric Oxide with only a basic in the back for extra help. We haven’t been told if we are borrowing the Hospitals NO or if the company is buying the NO machine and supplying it on these specialized calls.

We got a call back from an investigator with county EMS who so far said that he believes this is not OK but says he has to dig a little deeper.

I equate this to Balloon Pump calls where a transport perfusionist comes with us with their machine. The specialized perfusionist is in charge of the balloon pump and we are in charge of the drips/vent.

 

[VentMonkey]

Assuming those issues are absent, Unfamiliarity and the fact that the class is 2hrs long with only half being hands on. In the Hospital, RN’s don’t touch vents/nitric oxide other than maybe upping the 02, thats RT’s job and their schooling is dedicated to respiratory. When you become a CCT-RN, you get “vent certified” by getting 40hrs of training here, far less than RT’s in the Hospital also. Here we run CCT-RN’s with one RN and 2 EMT-Basics. Now you go from 1 RN watching drips and a vent to drips, vent and Nitric Oxide with only a basic in the back for extra help. We haven’t been told if we are borrowing the Hospitals NO or if the company is buying the NO machine and supplying it on these specialized calls.

We got a call back from an investigator with county EMS who so far said that he believes this is not OK but says he has to dig a little deeper.

I equate this to Balloon Pump calls where a transport perfusionist comes with us with their machine. The specialized perfusionist is in charge of the balloon pump and we are in charge of the drips/vent.

While I am familiar with SoCal ground CCT, and this crew configuration. I know there are too many companies to count (or were), some seemingly more legitimate than others, so I hear your concerns, 100%. But, this is one fiefdom in a world choc full of different types of CCT configurations provided, not only in the state, but also the country.

Prehospital medicine historically has a shoddy track record with quality training for their folks regardless of their role. There are outliers, but they’re just that.

Having said all that, in my pocket of this line of work many of our bases who are IABP qualified have their own company provided balloon pumps, and (@DesertMedic66 correct me if I am wrong) are given extra annual training at their IABP bases aside from standard IABP training the entire company gets. Perfusionists are, let’s say, discouraged.

A great example for my base is the uptick in Impella requests. While area dependent, these seem to be replacing IABP’s more commonly. Again, while our company does not employ perfusionists we are given orientation and guidance on such calls so that one is not necessary when transportation is requested.

Again, I do realize YMMV depending on the service you work for, but there are parts of the country where medics are doing these call completely solo. It is in part the “austere” nature of the EMS industry…

I too am curious as to why NO with ventilators. Are y’all doing NICU PPHN kiddos or something? The suggestion about raising concern, doing the in service then doubling down on concerns assuming everyone still feels that way is valid.

We do and have guidance on Flolan through our vents, which can also be not so common depending on the bases mission profile, but it is a rather simple setup.

Lastly, and please don’t take this as a knock or an “us vs. them” argument, but educate me:

What exactly is it that a nurse expects when entering an out-of-hospital setting?

I ask for a couple of reasons, but mainly because my (and most others in EMS) training has/ have been very much trained to think on the fly whatever that may look like with…[enter scenario here].

Again, it’s a genuine question and by no means a dig, but I would like to understand this better because it does seem to be a fundamental gap in understanding in nurse/ medic realms with the exception of the dual roles out there.

 

[BobBarker]

While I am familiar with SoCal ground CCT, and this crew configuration. I know there are too many companies to count (or were), some seemingly more legitimate than others, so I hear your concerns, 100%. But, this is one fiefdom in a world choc full of different types of CCT configurations provided, not only in the state, but also the country.

Prehospital medicine historically has a shoddy track record with quality training for their folks regardless of their role. There are outliers, but they’re just that.

Having said all that, in my pocket of this line of work many of our bases who are IABP qualified have their own company provided balloon pumps, and (@DesertMedic66 correct me if I am wrong) are given extra annual training at their IABP bases aside from standard IABP training the entire company gets. Perfusionists are, let’s say, discouraged.

A great example for my base is the uptick in Impella requests. While area dependent, these seem to be replacing IABP’s more commonly. Again, while our company does not employ perfusionists we are given orientation and guidance on such calls so that one is not necessary when transportation is requested.

Again, I do realize YMMV depending on the service you work for, but there are parts of the country where medics are doing these call completely solo. It is in part the “austere” nature of the EMS industry…

I too am curious as to why NO with ventilators. Are y’all doing NICU PPHN kiddos or something? The suggestion about raising concern, doing the in service then doubling down on concerns assuming everyone still feels that way is valid.

We do and have guidance on Flolan through our vents, which can also be not so common depending on the bases mission profile, but it is a rather simple setup.

Lastly, and please don’t take this as a knock or an “us vs. them” argument, but educate me:

What exactly is it that a nurse expects when entering an out-of-hospital setting?

I ask for a couple of reasons, but mainly because my (and most others in EMS) training has/ have been very much trained to think on the fly whatever that may look like with…[enter scenario here].

Again, it’s a genuine question and by no means a dig, but I would like to understand this better because it does seem to be a fundamental gap in understanding in nurse/ medic realms with the exception of the dual roles out there.

100% understand where you are coming from. Def not a fly by knight company like a lot are here in SoCal.
These are adult patients who are extremely ill and go to tietary facilities (usually for heart transplants), no peds. Actually, this company has PICU/NICU rigs dedicated (EMTs and ambulance staffed by the company, specialized PICU/NICU nurses staffed by the Hospital)

This isn't an optional training and was not discussed with any of the front-line staff prior to them sending an email saying the training is required within a month or else you are suspended.

In regards to out of hospital, CCT is cool because you definitely do get to be autonomous up to a certain extent and you don't have to deal with a lot of the drama that takes place in Hospitals. The hospital nursing background forces you to take care of very critical patients in the hospital with a ton of help, including doctors, at your disposal within seconds if a patient codes, whereas in the back of the ambulance, you obviously don't have that, so yes, you have to think quickly and a lot of times plan ahead with medications. I think that is the biggest difference between EMS vs RN initially. I also think this is why RN/Medic is better because it blends medics who are more EMS and have a lot of similar protocols with RN's who are more hospital but operate on standing orders and allows them to do more than just a basic can in the back and work together pretty well. When you are monitoring 3-8 IV pumps, a ventilator and Nitric Oxide and your EMT-Basic isn't allowed to technically touch any of that or push any medication, it can get challenging.

At some point in your career, you might begin to question things that might affect your licensure and also wonder why no other ambulance company in the county (maybe state) does it. It seems as though specialized equipment is being added (they already added AirVo during Covid), and you are expected to learn it with very little training, while RT's in the hospital who are in charge of it undergo more intense and specialized training in it and deal with it every single day.


The primary concern was the legality of it, esp in LA County where protocols suck to begin with, and it seems like the EMS investigators are def looking into this. The secondary concern was the training aspect and how short it is, so I wanted to see if anyone here also had any training on it and how long/in depth it was.

 

[Carlos Danger]

Assuming those issues are absent, Unfamiliarity and the fact that the class is 2hrs long with only half being hands on. In the Hospital, RN’s don’t touch vents/nitric oxide other than maybe upping the 02, thats RT’s job and their schooling is dedicated to respiratory. When you become a CCT-RN, you get “vent certified” by getting 40hrs of training here, far less than RT’s in the Hospital also. Here we run CCT-RN’s with one RN and 2 EMT-Basics. Now you go from 1 RN watching drips and a vent to drips, vent and Nitric Oxide with only a basic in the back for extra help. We haven’t been told if we are borrowing the Hospitals NO or if the company is buying the NO machine and supplying it on these specialized calls.

We got a call back from an investigator with county EMS who so far said that he believes this is not OK but says he has to dig a little deeper.

I equate this to Balloon Pump calls where a transport perfusionist comes with us with their machine. The specialized perfusionist is in charge of the balloon pump and we are in charge of the drips/vent.

Presumably, your CCT RNs are competent and comfortable managing sick, vented patients in the transport setting. For someone who already has a solid degree of competence in general critical care and ventilator management, a couple hour inservice on NO and the related equipment should suffice in terms of training. It isn't really a big deal. It's probably less so than transporting IABP.

Now when it comes to doing this kind of CCT with just one RN, that is another discussion altogether. I can see the issue with transporting increasingly complex patients requiring more and more equipment with no trained help (no offense to the EMT assistants), but that's much more of a staffing issue than it is an issue of using nitric oxide.

 

[BobBarker]

Presumably, your CCT RNs are competent and comfortable managing sick, vented patients in the transport setting. For someone who already has a solid degree of competence in general critical care and ventilator management, a couple hour inservice on NO and the related equipment should suffice in terms of training. It isn't really a big deal. It's probably less so than transporting IABP.

Now when it comes to doing this kind of CCT with just one RN, that is another discussion altogether. I can see the issue with transporting increasingly complex patients requiring more and more equipment with no trained help (no offense to the EMT assistants), but that's much more of a staffing issue than it is an issue of using nitric oxide.

Thanks for the reply and agree with managing critical patients, that's what the ER and ICU teaches us. The CCT staffing in LA County is RN+EMT+EMT, so you won't ever have a medic with you. You can request Hospital staff ride along with you, and we have had RN's and MD's come with us on specific transports but for the most part they can't/don't.

The problem we saw was that every one of these patients on NO was extremely critical/unstable. We took 1 but had the RT from the Hospital luckily. Had 7 drips plus 70% Fi02 on the vent plus NO. Every other RN in our company who has ran these calls also had an RT come with them and it was similar, multiple drips and close to maxing the vent out. We take critical patients all the time but there comes a point where you have to ask how much more can they add for you to still feel "somewhat" safe with the staffing provided and when there should be a specialized transport, like PICU/NICU

 

[Carlos Danger]

Thanks for the reply and agree with managing critical patients, that's what the ER and ICU teaches us. The CCT staffing in LA County is RN+EMT+EMT, so you won't ever have a medic with you. You can request Hospital staff ride along with you, and we have had RN's and MD's come with us on specific transports but for the most part they can't/don't.

The problem we saw was that every one of these patients on NO was extremely critical/unstable. We took 1 but had the RT from the Hospital luckily. Had 7 drips plus 70% Fi02 on the vent plus NO. Every other RN in our company who has ran these calls also had an RT come with them and it was similar, multiple drips and close to maxing the vent out. We take critical patients all the time but there comes a point where you have to ask how much more can they add for you to still feel "somewhat" safe with the staffing provided and when there should be a specialized transport, like PICU/NICU

Yes. These transports should definitely be done with two CCT clinicians. Transport RRT's are great for these (I worked in a HEMS program that used a RN / RRT staffing model and I quickly learned to really appreciate them for these types of transports), but RNs and EMTPs can learn to do these very competently., which is why that's the model you find in most HEMS and CCT agencies. One RN and an EMT helper does not suffice when the patient is sick and dependent on multiple pieces of technology.

Grabbing a spare body from the sending facility might be better than nothing in some cases, but it isn't ideal.

 

[BobBarker]

Yes. These transports should definitely be done with two CCT clinicians. Transport RRT's are great for these (I worked in a HEMS program that used a RN / RRT staffing model and I quickly learned to really appreciate them for these types of transports), but RNs and EMTPs can learn to do these very competently., which is why that's the model you find in most HEMS and CCT agencies. One RN and an EMT helper does not suffice when the patient is sick and dependent on multiple pieces of technology.

Grabbing a spare body from the sending facility might be better than nothing in some cases, but it isn't ideal.

Exactly our thoughts. We’ve had an additional RN from thr facility able to come with us 2 times in 5yrs, so yea not banking on that even though that would be awesome

 

[Akulahawk]

Given how sick a patient on NO would need to be to require NO, I'd be more concerned about transporting that patient than I would be about the NO/O2 blend itself. With appropriate training, is it in the RN scope? IMO, yes. Is an RT going to be more of an expert in managing the vent while the patient is on NO? Yes. All that being said, if I were transporting a patient on NO, I would want to have another ALS or CCT level provider in the back with me because I would expect the workload (not necessarily because of the NO itself) to be much higher. In-hospital I would suspect that patient could easily be a 2:1 or a 1:1 with a LOT of support... all because the acuity of that patient would be extremely high, not just because they're on NO.

 

[Akulahawk]

On that note, at least we're not having to deal with a heliox blend during transport...