June 10, 2008

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:03 a.m., at the Board of Nursing offices via videoconference between 5011 Meadowood Mall Way, Ste. 300, Reno, Nevada 89502, and 2500 W. Sahara, Ste. 207, Las Vegas, Nevada 89102.

                          MEMBERS PRESENT

                                                                                                                                              Debra Scott, MSN, RN, APN, NSBN Executive Director, Chair

                                                                                                                                                                  Betty McKay, LPN, Board Liaison

                                                                                                                                                Diane Allen, RN               Linda Morton, RN

                                                                                                                                               Kelly Benway, RN            Joseph Rosich, RN

                                                                                                                                        Caroline Copeland, RN           Diane Smith, RN

                                                                                                                                               Lisa Mantkus, RN            Karen Winter, RN

MEMBERS ABSENT

Cheryl McKinney, RN

Susan Moore, RN

OTHERS PRESENT

Linda Aure, RN, NSBN, Sr. Nurse Investigator

Lark Muncy, RN, Nurse Investigator

Fred Olmstead, General Counsel

Kathie Lloyd, Renown, Prenatal CNS, Renown Regional Medical Center

Rick Sowadsky, Nevada State Health Division

Jeanette Belz, NV Society of Anesthesiologists/NV Opthamological Society

Tandy Wilson, RN, Renown Regional Medical Center

Deborah Pontius, RN, Pershing County School District Nurse

Yvette Wintermute, Clark County School District

Irma Pumphrey, Clark County School District

Jose R. Gonzalez, RN, Spring Valley Hospital

call to order: The meeting was called to order by D. Scott at 9:03 a.m.

PUBLIC COMMENTS:  Kathie Lloyd, Prenatal Clinical Nurse Specialist, Renown Regional Medical Center, requested clarification for several issues during open forum.  Those issues included RNs administering spinal anesthetics through and epidural catheter and administering prostaglandins or other cervical ripening agents in term pregnancy prior to labor induction if certain guidelines have been met.

A.   APPROVAL OF MINUTES—February 5, 2008: The minutes of the February 5, 2008, meeting were approved as written.

B.     OLD BUSINESS

1.    Board meeting follow up:  D. Scott gave the highlights of the March and May, 2008 Board meetings, including new regulations that have been codified, another group of regulations which are still pending codification, and a proposed bill draft request that may go before the 2009 legislative session.

2.    Review, discussion and action regarding the practice question “Is it legal in   Nevada for APNs or RNs to provide Expedited Partner Therapy?”:  R. Sowatzky presented guidance for use of expedited partner therapy and the executive summary of the CDC’s STD Treatment Guidelines reviewing the evidence concerning EPT efficacy and recommendations for implementation.  He stated that this practice was already happening in doctor’s offices statewide. According to the CDC’s studies, EPT was found to be “as effective” as what clinics are currently doing by taking a history from the patient as to sexual partners for follow up treatment.  Nevada law allows practitioners in NV to follow the CDC guidelines for STD treatment that may be interpreted that EPT is “permissible” in Nevada. The committee discussed concerns related to patient safety of dispensing medication to treat STDs even though the practitioner had not seen the patient nor had a patient/practitioner relationship before prescribing the treatment. There were also concerns about whether the nurse would be “diagnosing” and “prescribing” in the scenarios that were presented related to EPT.  Questions about what was the accepted nursing practice across the nation and how had other nursing boards addressed the practice of EPT.  The committee members related the practice of EPT to administering immunizations and other well-documented practices by public health nurses.  One committee member asked whether the state health officer supported this practice.  R. Sowatzky will return to the NPAC with clarifying information related to other nursing boards’ stance on EPT and whether the state Health officer supports EPT.  F. Olmstead will review existing law to ensure the appropriateness of the interpretation that EPT as “permissible” in Nevada.  This agenda item will be added to the August meeting’s agenda.

3.    Review, discussion and action regarding the role of the school nurse in treating school employees:  D. Pontius presented the Pershing County School District Employee Health and School Nurse Policy and Procedure to define and describe the scope of school nursing practice in PDSD as it relates to faculty and staff.   The 17 District Chief School Nurses in the state have “signed off” on the policy and its intent.  The committee suggested some minimal wording changes, but overall the policy was well supported by the committee who moved to support the policy as amended.  The Chief Nurses stated they are planning on utilizing the policy to revise the job descriptions related to healthcare employees in the school setting.  The policy will be submitted to the State Department of Education for approval.

4.    Review and discussion and action regarding utilization of “standing orders” or  “protocols” for certain procedures at the time of patient admission:  This agenda item was continued until the next NPAC meeting.

C.     NEW BUSINESS

1.    Review, discussion and action regarding the practice question” Is it within the scope of practice for an RN, in particular those who practice in the critical care settings such as ER or ICU, to insert an external jugular line for IV access?”:  J. Gonzales, ER Clinical Supervisor, Spring Valley Hospital,  presented this agenda item.  He stated that allowing an RN in a critical care setting to lace an external jugular access would reduce the time the patient has to wait to receive medication, fluids, or procedures. Some committee members stated that the “EJ” should only be used as a last resort when no other venous access is available.  J. Gonzales submitted the Arizona State Board of Nursing’s Advisory Opinion for peripherally inserted external jugular catheters. The committee agreed with the components of the Arizona Advisory Opinion.  They were of the opinion that rather than this procedure being done only in “critical care” that the practice decision should focus on the practice being available for the critical care patient.  D. Scott will draft the wording for a possible practice decision in conjunction with J. Gonzales and put the draft on the agenda for the next NPAC meeting in August, 2008, and plan to take the proposed practice decision to the September Board Meeting.

2.       Scheduling of NPAC meetings for 2009:  The committee unanimously approved the NPAC meeting dates of February 10, April 7, June 9, August 4, October 13, and December 8, 2009.

3.      Discussion and action regarding the committee consideration of the Practice Decision Request: "Is it within the scope of practice for a Registered Nurse to insert an arterial canula?":  This agenda item was continued until the next NPAC meeting for further research.

4.       Review of the school nurse practice decision:  The Chief School Nurses requested that the Board review the current School Nurse Practice Decision to clarify the roles of the “school nurse” who is certified by the Nevada Department of Education and the “classified nurse” who may work in the school setting.  D. Scott will draft possible language for inclusion in the School Nurse Practice Decision, specifically the practice grid, for clarifying the nursing roles as well as the “qualified person” role.  This agenda item will be added to the October, 2008, NPAC meeting agenda.

5.    Suggestions for agenda items for next meeting:  The following are suggested items for the next NPAC meeting—Standing orders and protocols, the nurses scope of practice related to arterial canulas, and the administration of prostaglandin or other cervical ripening agents in term pregnancy, including the definition of “term pregnancy”.  Review of the School Nurse Practice Decision will be brought to the October 2008 NPAC meeting. 

ADJOURNMENT: The meeting was adjourned at 11:17 a.m.

February 5, 2008

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:07 a.m., at the Board of Nursing offices via videoconference between 5011 Meadowood Mall Way, Ste. 300, Reno, Nevada 89502, and 2500 W. Sahara, Ste. 207, Las Vegas, Nevada 89102.

                          MEMBERS PRESENT

                       Debra Scott, MSN, RN, APN, NSBN Executive Director, Chair

                                    Betty McKay, LPN, Board Liaison

Kelly Benway, RN               Diane Allen, RN

Caroline Copeland, RN               Joseph Rosich, RN

Lisa Mantkus, RN               Diane Smith, RN

Mary Wherry, RN              Susan Moore

MEMBERS ABSENT

Cheryl McKinney, RN

Linda Morton, RN

Karen Winter, RN

OTHERS PRESENT

Chris Sansom, BSN, RN, NSBN Director of Operations

Linda Aure, BSN, RN-BC, NSBN Sr. Nurse Investigator

Lark Muncy, RN, NSBN Nurse Investigator

Jeanette Belz, NV Society of Anesthesiologists/NV Opthamological Society

Deborah Pontius, RN, Pershing County School District Nurse

Adrina Cohen, RN, Lyon County School District Chief Nurse

Tina Cotter, RN, Washoe County School District Nurse Manager

Dana Balchunas, RN, Washoe County School District, Chief Nurse

Stefanie Utz, RN, Churchill County School District, School Nurse

Brenda McNaughton, RN, Sunrise Children's Hospital, Peds/Neo Transport Team

Jeanine Brignone, RN

call to order: The meeting was called to order by D. Scott at 9:11 a.m.

PUBLIC COMMENTS:  There was no public comment.

A.   APPROVAL OF MINUTES—December 4, 2007: The minutes of the December 4, 2007, meeting were approved as written.

B.     OLD BUSINESS

1.    Board meeting follow up: D. Scott deferred this agenda item to the next NPAC meeting.

2.    Discussion and action regarding the committee consideration of the Practice Decision Request: “Is it within the scope of practice for a Registered Nurse to insert an arterial canula?”: B. McNaughton presented this agenda item by submitting the information requested by the committee at the last NPAC meeting—the job description for the RN Transport Nurse, a copy of the practice decisions from the five states who have adopted this practice into their RN scope of practice, information on whether this has been incorporated into any certification curriculum, a copy of the policy and procedure for Transport Nurse defining expanded scope, and written support from the intensivist physicians at her practice site.  All documents were reviewed and the committee agreed that the RN Transport Nurse should have advanced certification to support an expanded scope of practice as defined in the job description and that these nurses should also be EMS certified with the NSBN. Suggestions were made that possibly a CFRN or an Air and Surface Transport Nurses Association (ASNTA) certification would cover the nurse for the proposed expanded scope of practice. ASTNA publishes a Flight and Ground Transport Nursing Core Curriculum that prepares an RN for an expanded scope of practice. One committee member cited NAC 632.225, which requires accepted national standards as a foundation for an RN’s expanded scope of practice.  The committee suggested that B. McNaughton contact ASTNA for further information and return to the NPAC for further consideration at either the April or June meeting.

3.    Review, discussion and action regarding the role of the school nurse in treating school employees:  J. Brignone presented the history of this agenda item.  She cited NAC 632.890 (13) and the National Association of School Nurses (NASN) 1999 Issue Brief to define the role of the school nurse. D. Scott stated that the Issue Brief could be interpreted in different ways in regards to nursing interventions in the school setting with individuals other than students.  It became apparent to the committee and attendees that there is a need for a standardized job description across the state of Nevada for the School Nurse and for other nurses working within the school setting.  It would need to include the duties of the School Nurse in regards to other school employees and the expectation for nursing interventions for individuals other than students.   One School Nurse attendee requested that Board staff review the School Nurse Advisory opinion to clarify the delegation grid when it refers to “RN only”. There was also discussion regarding the definition of “patient”.  The School Nurses who were present stated they are planning to create clear job descriptions and policies for nurses in the school setting, taking into consideration the ASNA Issue Brief and the discussion by the NPAC committee.  They will bring back the new documents to the NPAC at a later date.

C.     NEW BUSINESS

1.    Discussion regarding review of medical assistant curriculum syllabus: Since the committee had presented information at a previous meeting regarding the regulation of medical assistants by the medical board, the medical assistant curriculum was distributed so that the members could become familiar with a sample of a program that the MAs may be completing to train for their role.  D. Scott stated that Board staff had surveyed the other nursing boards in the U.S. and had found that only one nursing board regulates medical assistants.

2.       Review, discussion and action regarding the school nurse utilizing a qualified person as a “second pair of hands” in caring for a student on a ventilator in the school setting:  D. Balchunas presented this issue to the committee members and described the guidelines that she has formulated entitled, “10 Considerations in Determining the Scope of Practice for WCSD RNs Providing 1:1 Care of Students Who Are 100% Ventilator Dependent”.  All School Nurses present and all committee members agreed that it is within the scope of the school nurse to utilize a qualified person to be the “second pair of hands” in caring for these students.  D. Scott will write a letter to D. Balchunas to summarize the committee’s stance.

3.      Review and discussion regarding utilization of “standing orders” or  “protocols” for certain procedures at the time of patient admission:  This agenda item was brought forward to clarify definitions for these two terms.  The committee is interested in Board staff writing an advisory opinion to be forwarded to the Board and eventually to explore the possibility of new concept and wording to incorporate these definitions into regulation.  The definitions that were suggested are:  (1) Standing orders – medical treatment orders generated by an authorized prescriber which identifies an action or medication which must be implemented or administered regardless of the circumstances, and without exception, to each patient.  (2) Protocols  - a series of actions (which may include a number of medications) which may be implemented in order to manage a patient’s clinical status.  A protocol includes alternative actions or “exceptions” to the prescriptive orders, which allows for individual patient circumstance.  A protocol may include several algorithms. (3) Algorithms – a step-by- step procedure for solving a problem or accomplishing an intervention.  Algorithms are developed and agreed upon by the multidisciplinary health care team, based upon generally accepted standards of care.

4.       Review, discussion and action regarding the practice question, “Is it legal in Nevada for APNs or RNs to provide Expedited Partner Therapy?”:  After much discussion, the committee requested that D. Scott contact Pam Graham for follow-up and further information related to other laws impacting the provision of EPT.

5.    Suggestions for agenda items for next meeting: The items suggested were the arterial canula issue, school nurse job description, review of the School Nurse Practice Decision, Expedited Partner Therapy, and follow up from the January and March Board meetings. 

6.    Review, discussion and action regarding the Board’s Practice Decision related to Procedural Sedation:  D. Smith submitted information about a discussion which came about at her facility regarding the draft, Procedural Sedation and Rapid Sequence Intubation (RSI) Consensus Statement which was developed during a Procedural Sedation Stakeholders Meeting in Washington, DC. The Emergency Nurses Association (ENA) has requested feedback on this statement.  She stated that the discussion group supported the NSBN’s current advisory opinion on Procedural Sedation, but that the group has some discomfort with the consensus statement.  D. Scott will forward D. Smith’s comments to the ENA for their review

ADJOURNMENT: The meeting was adjourned at 11:55 a.m.

December 4, 2007

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:07 a.m., at the Board of Nursing offices via videoconference between 5011 Meadowood Mall Way, Ste. 300, Reno, Nevada 89502, and 2500 W. Sahara, Ste. 207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Board Executive Director, Chair

Betty McKay, LPN, Board Liaison

Kelly Benway, RN

Caroline Copeland, RN

Lisa Mantkus, RN

Cheryl McKinney, RN

Diane Smith, RN

Mary Wherry, RN

Karen Winter, RN

MEMBERS ABSENT

Diane Allen, RN

Susan Moore, RN

Linda Morton, RN

Joseph Rosich, RN

OTHERS PRESENT

Fred Olmstead, Board Counsel

Chris Sansom, RN, Board Director of Operations

Linda Aure, RN, Board Investigator

Lark Muncy, RN, Board Investigator

Dana Balchunas, RN, WCSD

Lynette Harper, RN, Student

Brenda McNaughton, RN

call to order: The meeting was called to order by D. Scott at 9:07 a.m.

PUBLIC COMMENTS:  D. Scott discussed a court challenge against the Louisiana State Board of Nursing in relationship to nurses providing interventional pain management practice. The committee commented on this issue and another scope of practice issue which has surfaced in Colorado regarding tightening physician oversight at clinics that perform Botox injections, laser hair removal, and other medical spa treatments. The proposed Colorado regulation matches what is written in Practice Decision in Nevada. The committee discussed the ongoing examination of scope of practice issues across the nation.

A.   APPROVAL OF MINUTES—October 2, 2007: The minutes of the October 2, 2007, meeting were approved as written.

B.     OLD BUSINESS

1.    Board meeting follow up:  D. Scott gave the highlights of the November 2007 Board meeting, including the Boards utilization of paperless technology in its meeting processes. She announced three new Board members were recently appointed by the governor: Belen Gabato, RN member; Carrie McMurray, CNA member; and Sandy Peltyn, Consumer member.

C.     NEW BUSINESS

1.    Discussion and action regarding the committee consideration of the Practice Decision Request: “Is it within the scope of practice for a Registered Nurse to insert an arterial canula?”: Brenda McNaughton, RN, introduced the question to the committee members, highlighting the information that had been distributed to the members prior to the meeting. She stated that respiratory therapists who are certified by their hospitals to insert arterial lines may do so within their scope of practice. She is requesting that this practice be within the scope of a Registered Transport Nurse, a title which does not require national certification. The committee suggested that if this would be within the scope for pediatric patients, that it also should be considered for adults. Cannulation would be used monitor blood pressure readings’ response so that medications may be more precisely titrated. The committee requested that further research be done by B. McNaughton to include submission of:  the job description for the Registered Transport Nurse, a copy of the practice decisions from the five states who already have formulated and approved decisions regarding this practice, information about whether or not the states which have included this practice in the scope of RNs have a standardized curriculum, and a copy of the policy and procedure which is used in defining the scope of practice for Registered Transport Nurses in her facility. There was also a request for written support from intensivist physicians. This item will be included in the next NPAC meeting agenda in February 2008.

2.       Discussion regarding the American Nurses Association and its state affiliate ANA/California filing a lawsuit in the Superior Court of the State of California against the Superintendent of Public Instruction and the California Department of Education to remedy violations of law arising from its directive that calls on unlicensed volunteer school employees to administer insulin to students with diabetes:  D. Scott opened the discussion of this agenda item by clarifying that the basis of this lawsuit is that the Department of Education in California did not give public notice for the adoption of this legal advisory opinion. The suggestions made by the ANA regarding the ratio of school nurses to students at 1 to 750 was supported by the committee members. A further discussion of the role of the school nurse ensued.

3.      Review, discussion and action regarding the role of the school nurse in treating school employees: This agenda item was submitted by Jeanine M. Brignone, RN. She was not present to provide further explanation, but Dana Balchunas, WCSD Chief School Nurse, explained the actions of the nurse and how this situation may have arisen. The committee was clear in their feedback that they believed the role of the school nurse included only treating students, not employees of the school district. They believe that any nurse would give first aid when necessary, but should not be involved in giving health education and consultation to the school employees. D. Balchunas stated that she plans on creating a policy and procedure to provide guidance to the nurses in her district, and would consult with Diana Taylor, the chief nurse for the Clark County School District.

4.       Suggestions for agenda items for next meeting:  The members suggested that the following items be included on the next meeting agenda in February 2008:  The regulation of medical assistants, utilization of “standing orders” or “protocols” for certain procedures at the time of patient admission, consideration of insertion of an arterial canula being within the scope of practice of an RN. 

ADJOURNMENT: The meeting was adjourned at 10:45 a.m.

October 2, 2007

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:05 a.m., at the Board of Nursing offices via videoconference between 5011 Meadowood Mall Way, Ste. 300, Reno, Nevada 89502, and 2500 W. Sahara, Ste. 207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

                            Debra Scott, RN, Board Executive Director, Chair

                                        Betty McKay, LPN, Board Liaison

                           Kelly Benway, RN                    Linda Morton, RN

   Caroline Copeland, RN             Joseph Rosich, RN

   Lisa Mantkus, RN                     Diane Smith, RN

   Cheryl McKinney, RN              Mary Wherry, RN

   Susan Moore, RN                   

                                                                                        MEMBERS ABSENT

                Diane Allen, RN

           Karen Winter, RN

OTHERS PRESENT

     Fred Olmstead, Board Counsel

Chris Sansom, RN, Board Director of Operations

Lynette Harper, RN, Student-University of Pacific

  Jeanette Belz, Nevada State Society of Anesthesiologists

call to order: The meeting was called to order by D. Scott at 9:05 a.m.

PUBLIC COMMENTS: D. Scott distributed three documents related to procedural sedation. One was the current NSBN practice decision regarding the administration of medications for the purpose of induction of sedation for short-term therapeutic, diagnostic, or surgical procedures; the second was the Vermont position statement regarding administration of propofol (diprivan); and the third was a draft document of a consensus statement which was developed at a meeting of approximately 14 organizations which was convened at the request of the Emergency Room Nurses to try to develop guidelines for procedural sedation. These documents were used as the basis of a discussion of trends across the nation regarding procedural sedation, or what is more commonly known as conscious sedation. The committee requested that this item be added to the next committee meeting agenda for further discussion.

A.   APPROVAL OF MINUTES—June 5, 2007: The minutes of the June 5, 2007 meeting were approved as written.

B.     OLD BUSINESS

1.  Board meeting follow up: 

a.      Practice decision—CNA and surgical drains:  C. Sansom discussed the origination of this practice decision, stating that the Board had approved this decision at the last Board meeting and that it is available on the website.

b.      Practice decision—RN using ultrasound guidance to place a peripheral intravenous catheter in the upper extremity when normal insertion techniques are inadequate:  D. Scott discussed the development of this practice decision which was approved by the Board at the last Board meeting and is available on the website.

c.      Practice decision—RN initiating administration of Vitamin K, Erythromycin eye ointment, and Hepatitis B vaccine for newborns based on standing protocols:  D. Scott reviewed this practice decision, stating that the Board had approved this decision at the last Board meeting and it is available on the website.

d.      Other information from July and September, 2007, Board meetings: D. Scott discussed other decisions made by the Board at its last two Board meetings, including the new affidavit policies for newly educated nursing applicants, and other developments in the legislative and educational areas acted on by the Board.

C.    NEW BUSINESS

   1. Discussion regarding NSBN considering oversight of medical assistants—submitted by Diane Smith: D. Smith discussed her agency’s concerns about the role of the medical assistant (MA) in ambulatory settings. She described the process that Southwest Medical/Sierra Health Services utilizes in ensuring the competence of the MAs used in their agency. Discussion arose regarding the process that has been outlined in the Board of Medical Examiners’ (BOME) Board meeting minutes regarding MAs. The latest action was the decision to be less specific about the scope of practice for this level of care provider since they are being used in such diverse practice settings. The NSBN has no authority over MAs who are regulated by the BOME and work under the license of the physician. The committee requested that this item be added to the next committee meeting agenda. D. Smith submitted the curriculum that her agency uses in providing training for MAs in their setting.

 2. Review of proposed regulations:  F. Olmstead described the regulatory process required for promulgation of new regulations.

a.    NAC 632.190 Fees: New fees are being requested for capturing fingerprints for electronic transmission on equipment which is housed in both of the NSBN’s office sites. The NSBN wishes to charge any non-nursing consumers of this service a $15 fee for capturing their prints. In addition, the NSBN is requesting that testing sites for CNA examination be able to charge for both the knowledge and the skills portions of the CNA examination.  At this time, the manpower cost to administer the examinations is greater than the sites are able to charge based on existing regulation.

b.   NAC 632.890           Unprofessional Conduct: The NSBN is requesting to add sexual orientation discrimination as a basis for unprofessional conduct.  In addition, the NSBN is requesting that an additional definition of unprofessional conduct be added to include a pattern of misconduct.

c.    NAC 632.040           “Contact hour” defined: The NSBN is requesting that a contact hour be defined as a 60-minute hour rather than the existing 50- minute hour to coincide with the national definition accepted by the American Nurses Credentialing Center.

d.   NAC 632.___ Titles and Abbreviations:  The NSBN is requesting that the titles “Nurse,” “Registered Nurse,” “Licensed Practical Nurse,” and “Advanced Practice Nurse” be protected titles.

  3.  Discussion regarding utilization of “standing orders” or “protocols” for certain procedures at the time of patient admission:  D. Scott asked that this item be continued to the next committee meeting to allow further research into the issue as it is related to the Joint Commission on Accreditation of Hospitals Organization’s requirements for accreditation of hospitals.

 4.  Discussion and action regarding scheduling of committee meetings for 2008:  The committee scheduled these meeting dates for 2008: February 5, April 8, June 10, August 12, October 14, and December 9.

ADJOURNMENT: The meeting was adjourned at 10:30 a.m.

June 5, 2007

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:05 a.m., at the Board of Nursing offices via videoconference between 5011 Meadowood Mall Way, Ste. 300, Reno, Nevada, 89502, and 2500 W. Sahara, Ste. 207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Board Executive Director, Chair

Betty McKay, LPN, Board Liaison

Diane Allen, RN 

Caroline Copeland, RN

Linda Morton, RN

Susan Moore, RN

Diane Smith, RN

MEMBERS ABSENT

Kelly Benway, RN

Terry Edmonson, RN

Cheryl McKinney, RN

Joseph Rosich, RN

Mary Wherry, RN

Karen Winter, RN

Vickie Wright, RN

OTHERS PRESENT

Fred Olmstead, Board Counsel            

call to order: The meeting was called to order by D. Scott at 9:05 a.m.

PUBLIC COMMENTS: There were no public comments.

A.     APPROVAL OF MINUTES—April 10, 2007: The minutes of the April 10, 2007 meeting were accepted as written, although not formally approved due to the absence of a quorum.

B. OLD BUSINESS:

1. Board meeting follow-up:  D. Scott reviewed the outcomes of the May, 2007, Board meeting, highlighting the proposed regulations and the appointments to the Nursing Practice Advisory Committee. 

C. NEW BUSINESS:

1. Review, discussion, and action regarding whether it is within the scope of practice for an RN to initiate administration of Vitamin K, Erythromycin eye ointment, and Hepatitis B vaccine for newborns based on standing protocols:  D. Scott reviewed the handout which asked the scope of practice related to the initiation of Vitamin K, Erythromycin eye ointment, and Hepatitis B Vaccine to newborns at the time of birth based on standard protocols. One committee member differentiated between “standing orders,” which are protocol driven and “preprinted orders,” which need to be initiated by a physician. The committee’s opinion was that administration of the listed medications was routine newborn care at the time of birth in a facility. Although the committee did not have a quorum to make a final recommendation, the consensus of the members present was that this practice is within the scope of practice for an RN and that the question should go forward to the Board for final approval at its July Board meeting.

2. Legislative update:  D. Scott and F. Olmstead updated the committee on the Board related bills that had been passed and those which died during the legislative session. They fielded questions from the members on other legislative issues, and clarified questions about other legislative initiatives, including certified medication aides, the Nurse Licensure Compact, education requirements for nursing program faculty, cosmetic procedures, and student clinical privileging.

3. Suggestions for agenda items for next meeting:  The committee requested that another legislative update be given at the next committee meeting.

ADJOURNMENT: The meeting was adjourned at 10:30 a.m.

April 10, 2007

B.     OLD BUSINESS:

1. Board meeting follow-up: D. Scott reviewed the agenda items from the January 2007 Board meeting highlighting the Board’s approval of the change to the School Nurse Advisory Opinion related to reinsertion of a Mic-Key.

C. NEW BUSINESS:

1. Review, discussion, and action regarding the practice question, “Is it within the scope of practice for an RN to use ultrasound guidance to place a peripheral intravenous catheter in the upper extremity when normal insertion techniques are inadequate?” Mary Mang from Renown Regional Medical Center presented this agenda item. She gave the background on this procedure, stating that nurses have been doing this procedure in the United States for years. She quoted research showing 86% of the attempts by nurses were successful in placing the devices and 98% were successful after repositioning. She indicated that the results have been increased patient satisfaction, decreased injury to the patient, and decreased delays in IV treatment, resulting in shorter hospital stays. The committee discussed the proposed practice decision and voted to recommend it be brought to the Board for approval.

2. Presentation by Dan Burke regarding Mosby's Online Nursing Tools: D. Burke, Western Regional Account Manager, Institutional Electronic Sales from Elsevier, presented Mosby’s Nursing Skills, Nursing Index, and Nursing Consult as an alternative for CINAHL, which is utilized in Nevada to identify procedures within a nurse’s scope of practice. The committee members were impressed with the information available through these programs. He stated that all of the articles included in Mosby’s Index were from peer-reviewed journals. D. Scott remarked that there would be no contraindication for nurses in Nevada to utilize Mosby’s Nursing Index since the information would be comparable to CINAHL. In fact, Mosby’s Nursing Index includes 1,300 titles unique to its database.

3. Legislative update: D. Scott gave an update on the progress of legislative bills that may affect the Board.

4. Suggestions for agenda items for next meeting: The members requested that there be a legislative update at the next meeting.

ADJOURNMENT: The meeting was adjourned at 10:30 a.m.

February 6, 2007

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:05 a.m., at the Board of Nursing offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Board Executive Director, Chair

Betty McKay, LPN, Board Liaison

Diane Allen, RN                        Susan Moore, RN

Caroline Copeland, RN             Linda Morton, RN                

Sadie Tate-Crowder, RN          Mary Wherry, RN

Terry Edmonson, RN                Karen Winter, RN

Cheryl McKinney, RN

MEMBERS ABSENT

Ryan Murphy, RN

Joseph Rosich, RN

Vickie Wright, RN

OTHERS PRESENT

Chris Sansom, RN, Board Director of Operations

Linda Aure, RN, Board Sr. Investigator

Lark Muncy, RN, Board Investigator

Dana Balchunas, RN, Chief Nurse, Washoe County School District

Cathy Dinauer, Chief Nurse, Carson Tahoe Medical Center

Diana Taylor, RN, Clark County School District (CCSD)

Joan Lapham, RN, Sierra Surgery Hospital

call to order: The meeting was called to order by D. Scott at 9:05 a.m.

PUBLIC COMMENTS:  There were no public comments

A.     APPROVAL OF MINUTES—December 5, 2006: The minutes of the December 5, 2006, meeting of the Nursing Practice Advisory Committee were approved by a unanimous vote of the committee members with the following corrections:  Ryan Murphy was moved from Members Present to Members Absent, the spelling of Carolyn Copeland was changed to Caroline, the spelling of Lorraine Heinz was changed to Loraine Hines. 

B.     OLD BUSINESS:

1. Review, discussion, and action regarding the School Nurse Advisory Opinion and the “phrenic nerve” stimulator procedure: This item was presented by Dana Balchunas, Chief Nurse, Washoe County School District, who described the research and the consensus of the chief school nurse group related to the practice in the school setting of managing phrenic nerve stimulators. All of the chief school nurses agreed that when a student has a mechanical ventilator backup, the student needs to be managed by an RN. When there is no mechanical ventilator involved, an LPN may care for a student with a phrenic nerve stimulator or a diaphragmatic pacing system. They all agreed that “trach care” as listed in the School Nurse Advisory Opinion includes bagging a patient when necessary—which is within the scope of practice for a licensed practical nurse. The group suggested that the following changes be made on the practice grid for the advisory opinion: “Phrenic nerve stimulator” should be changed to “Phrenic nerve stimulator/diaphragmatic pacing system without mechanical ventilator” which may be managed by a “Qualified Licensed Nurse.” The committee members voted unanimously to recommend this change to the Board at its March 2007, meeting in Reno.

2. Review, discussion and action regarding the question by the Clark County School District Health Services Department about the School Nurse Advisory Opinion requirement for an RN to insert a Foley or reinsert a Mic-Key: Diana Taylor, Director of Health Services for Clark County School District, presented this agenda item. Again, during the Chief School Nurses meeting, the group agreed that it was within the scope of practice for an LPN to reinsert a gastrostomy device in an emergency situation with the goal of maintaining the opening. D. Taylor described her research in looking at other states which allow LPNs to perform this procedure. She cited results from Kentucky, Iowa, Maine, and South Carolina where LPNs are allowed to perform this procedure. The committee members agreed to revise the School Nurse Advisory Opinion grid by changing the procedure entitled “Gastrostomy feeding” to read, “Gastrostomy Care,” and adding two subheadings, “Feedings” and “Emergency maintenance of patency of the tract.” Both subheadings would be within the scope of practice by a Qualified Licensed Nurse.  The committee members voted unanimously to recommend the Board approve this proposed revision of the advisory opinion grid at its March, 2007 meeting. As in every procedure in the list, competency of the nurse or qualified person must be maintained.

3. Review, discussion and action regarding the proposed revision of the Procedural Sedation Practice Decision: D. Scott presented this agenda item, reporting to the NPAC members that the Board had adopted the proposed revision to the previous practice decision with the addition of “on-site” under Safety Considerations when referring to the availability of back-up personnel for airway management, resuscitative and emergency intubation and of emergency equipment. D. Scott gave a synopsis of the discussion at the January 2007 Board meeting, including testimony of Dr. Jonathan Zucker, president of the Nevada State Society of Anesthesiologists (NSSA). D. Allen reported that she had been contacted by Jeanette Belz, lobbyist for NSSA, for information about facility law regarding this issue. D. Allen will bring any further information, including an opinion by the Bureau of Licensure and Certfication's (BLC) Deputy Attorney General, whether or not there are external restraints to nurses having the scope of practice outlined in this practice decision. The committee maintained that the practice decision provides guidelines under which nurses may safely administer procedural sedation when all safety precautions are in place. The nurse always has the option of refusing an unsafe assignment if precautions or competencies are not in place. The Board has approved the practice decision as written at this time. Further information may be brought back to the committee and the full Board as it becomes available.

C. NEW BUSINESS:

1. Review, discussion and action regarding the question by the Bureau of Licensing and Certification of whether a chief nurse can supervise at two facilities: D. Allen of the Bureau of Licensure and Certification presented this agenda item. The BLC’s Deputy Attorney General requested that this question be asked of the Board to clarify if there is a legal requirement in Chapter 632 for having a chief nurse at every licensed medical facility. D. Scott replied that she was unaware of any nursing statute or regulation that requires one chief nurse for every facility. She gave the results of a survey of Boards of Nursing regarding this question. Out of the eight states that require a chief administrative nurse, only one requires a chief administrative nurse for every hospital. Out of the 17 states responding to the survey, five states did not require a chief nurse to oversee nursing services, and four reported that it depended on the type of facility. The underlying important issue was the accountability of the chief nurse to meet the responsibilities outlined in NAC chapter 632. The committee members underscored that no matter how many facilities a chief nurse was responsible for that person would be held to the requirements of the law should there be a problem. The committee agreed that facilities which shared similar services, policies, and procedures, may lend themselves to being overseen by one administrative nurse.

2. Legislative update: D. Scott, D. Allen, M. Wherry, and C. Sansom gave information about issues coming out of the legislative session which started this week.

3. Suggestions for agenda items for next meeting: The members suggested that a legislative update be given at the next committee meeting.

ADJOURNMENT: The meeting was adjourned at 10:30 a.m.

December 5, 2006

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:05 a.m., at the Board of Nursing Offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Board Executive Director, Chair

Betty McKay, LPN, Board Liaison

Cheryl McKinney, RN            Joseph Rosich, RN

Linda Morton, RN                  Mary Wherry, RN

Ryan Murphy, RN                  Karen Winter, RN

MEMBERS ABSENT

Caroline Copeland, RN           Vickie Wright, RN           

Susan Moore, RN                   Terry Edmonson, RN                       

Diane Allen, RN                      Sadie Tate-Crowder, RN

OTHERS PRESENT

Fred Olmstead, Board General Counsel

Jeanette Belz, Nevada Anesthesiology Society

Diana Taylor, Clark County School District (CCSD)

Loraine Hines, Feeding Team Nurse, CCSD

call to order: The meeting was called to order by D. Scott at 9:05 a.m.

PUBLIC COMMENTS: There were no public comments.

A.     APPROVAL OF MINUTES—October 10, 2006: It was moved and seconded to approve the minutes as revised, adding this replacement sentence for clarification, “Occupational boards are holding individuals accountable for reckless behavior but yet are encouraging a culture of safety in healthcare facilities by reinforcing that individuals are not always the source of medical errors.” to agenda item B.1.

B.     OLD BUSINESS:

1. Review, discussion and action regarding the Procedural Sedation Practice Decision to include a discussion about IV push propofol: D. Scott and K. Winter presented the revisions to the current Procedural Sedation Practice Decision. The introductory paragraph will be added to the revised decision and brought to the January 2007 Board meeting for consideration by the Board. The committee members were in support of the revisions, which included some minor word changes to emphasize the RN's role in being accountable for competencies, safety considerations, and the management of nursing care, during administration of procedural sedation. The committee did not delineate specific drugs that can be given by RNs in the practice decision. The role of the RN as a patient advocate was underscored in the decision.

C. NEW BUSINESS:

1. Review, discussion and action regarding the question by the Clark County School District Health Services Department about the School Nurse Advisory Opinion requirement for an RN to insert a Foley or reinsert a Mic-Key: D. Taylor, director of Health Services, Clark County School District, presented this agenda item, which asks if it is within the scope of practice within the school setting, for an LPN to insert a Foley catheter at the gastrostomy site when the primary tube has been dislodged (the primary tube is usually a Mic-Key). Timely insertion is important because the site may begin closing within 30 minutes, which would then require surgical reinsertion of the primary tube by a physician. Lorraine Heinz, Feeding Team Nurse, demonstrated the procedure for the committee using an actual Mic-Key and a Foley catheter. The committee voiced concerns about the level of education which LPNs have in comparison with RNs and whether parents are given information about whom might perform the procedure when they sign consent forms. R. Colosimo asked about the level of follow up that is done by the LPNs after the procedure is completed and the involvement of the school site RN (school nurse). L. Heinz assured the committee that the school policy requires that the LPN report the procedure to the RN for follow up. D. Taylor offered to call D. Balchunas, director of Student Health Services for Washoe County School District, to ascertain the support of school nurses in northern Nevada for the addition of this procedure for LPNs to the School Nurse Delegation Grid in the Advisory Opinion. The committee supported the revision to the Advisory Opinion, although one member was not in support of the revision. The proposed revision of the decision will be considered by the Board at its January 2007 Board meeting in Las Vegas.

2. Suggestions for agenda items for next meeting: D. Scott informed the committee that two agenda items from the last meeting will be continued until the next meeting in February 2007. These items are regarding phrenic nerve stimulators and the role of the chief nurse in supervising nursing staff in more than one licensed facility. The committee suggested that a legislative update be given at the next meeting.

ADJOURNMENT: The meeting was adjourned at 9:52 a.m.

October 10, 2006

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:02 a.m., at the Board of Nursing Offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

                        MEMBERS PRESENT

Debra Scott, RN, Committee Chair    Vickie Wright, RN

Susan Moore, RN                              Diane Allen, RN

Linda Morton, RN                              Carolyn Copeland, RN

Ryan Murphy, RN

MEMBERS ABSENT

Betty McKay, LPN, Board Liaison

Terry Edmonson, RN              Joseph Rosich, RN

Cheryl McKinney, RN            Sadie Tate-Crowder, RN

Linda Charlebois, RN             Nancy Harland, RN

Karen Winter, RN                  Mary Wherry, RN

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Dianna Baldemor, Orvis Nursing Student

Jeanette Belz, NV State Society of Anesthesiologists

Tina Cotter, RN, School Nurse, Washoe County School District

call to order: The meeting was called to order by D. Scott, chair, at 9:10 a.m.

PUBLIC COMMENTS: There were no public comments.

A.     APPROVAL OF MINUTES—August 8, 2006: It was moved and seconded to approve the minutes of the August 8, 2006 Nursing Practice Advisory Committee.

B.     OLD BUSINESS:

1. Discussion of National Safety Goals (Joint Commission on Accreditation of Healthcare Organization): D. Allen discussed the Patient Safety Improvement Corps and her attendance at a recent conference related to the National Safety Goals. She stated occupational boards are holding individuals accountable for reckless behavior but yet are encouraging a culture of safety in healthcare facilities by reinforcing that individuals are not always the source of medical errors There has been increased interest in identifying “near misses” to prevent future harm to patients. D. Allen offered to give a presentation to the Board sometime during 2007 to educate them regarding the issues being discussed nationwide.

2. Review, discussion and action regarding RN scope in performing phoropter refraction—follow up from BOME minutes: D. Scott presented the excerpt from the Board of Medical Examiners’ minutes for their meeting, June 9-10, 2006, where this agenda item was presented by K. Testolin, the individual who requested a decision by the NPAC regarding delegation of phoropter refraction to a licensed professional nurse. The decision of the BOME was that delegation of this procedure to a medical assistant, or unlicensed person, was inappropriate, but that physician assistants already have the authority to perform the procedure. In asking whether this procedure is within the scope of practice for an RN, K. Testolin asked specifically if an RN could perform the procedure without a physician being present. The NPAC members agreed that if an RN is performing this procedure, he/she would be acting in the capacity of an unlicensed individual, which would require the physician to be immediately present and directly supervising the task. The RN would not be able to perform the procedure in his/her RN role, and definitely not without a physician directly supervising. Should the RN decide to work as an unlicensed person, he/she would not be able to identify herself/himself as an RN. The NPAC members recommended that an RN not take the risk of working as an unlicensed individual when he/she has an active RN license. D. Scott will write a letter to K. Testolin describing the committee’s discussion.

3. Review, discussion and action regarding the Procedural Sedation Practice Decision to include a discussion about IV push propofol—additional information from the Nevada State Society of Anesthesiologists and Karen Winter, committee member: The committee discussed the additional information and generally decided that there may be some changes needed to the current practice decision, but that they still did not want to list specific medications in the decision. The members suggested that this agenda item be continued until the next NPAC meeting and in the meantime, D. Scott make some of the suggested revisions to the decision and bring it back to the committee in December, 2006.

C. NEW BUSINESS:

1. Review, discussion, and action regarding the School Nurse Advisory Opinion and the “phrenic nerve” stimulator procedure”: T. Cotter presented this agenda item and provided the article, Phrenic Nerve Stimulator System Overview by Kenneth Aron. She described a student who will be attending school in the Washoe School District very soon who is maintained on a “phrenic pacer.” It is a device which is implanted internally to assist the patient who would normally be ventilator dependent. She stated that the ventilator will come to school with the student as a “back-up” in the event of pacer malfunction. The current School Nurse Advisory Opinion requires an RN give the care when there is a student who is on a ventilator. Until the committee can have a more extensive review of the literature, the members suggested that the school nurses rely on the current requirement for RN care for a ventilator-dependent student. T. Cotter will further research the issue, and obtain further information from the student’s attending physician and from others who have worked with this device in the school setting. She will obtain information so that a differentiation can be made between a “phrenic pacer” and a “phrenic nerve stimulator.” D. Scott will research the history of the addition of the latter in the current School Nurse Advisory Opinion. This item will be brought back to the NPAC when the research is complete.

2. Board actions from the September 2006 Board meeting: D. Scott discussed the decisions of the Board at the last meeting, including the dates of the 2007 and 2008 Board meetings. The committee set its meeting schedule for 2007 to include meetings on Tuesdays, February 6, April 10, June 5, August 14, October 2, and December 4, 2007.

3. Suggestions for agenda items for next meeting: The committee requested that the Procedural Sedation Practice Decision and the School Nurse Advisory Opinion (as it relates to the “phrenic nerve pacer”) be placed on the next agenda. One committee member suggested that the committee consider the question of how many licensed healthcare or medical facilities may be supervised by one chief nurse.

ADJOURNMENT: The meeting was adjourned at 10:46 a.m.

August 8, 2006

CALL TO ORDER

The meeting of the Nevada State Board of Nursing Practice Advisory Committee was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:01 a.m., at the Board of Nursing Offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Committee Chair             Betty McKay, LPN, Board Liaison            

Carolyn Copeland, RN                               Joe Rosich, RN

Cheryl McKinney, RN                               Karen Winter, RN

Susan Moore, RN                                     Vickie Wright, RN

Linda Morton, RN                

MEMBERS ABSENT

            Diane Allen, RN                                        Sadie Tate-Crowder, RN

Terry Edmonson, RN                                Mary Wherry, RN    

Ryan Murphy, RN

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Chris Sansom, RN, Director of Operations, NSBN

Linda Aure, RN, Sr. Investigator, NSBN

Lark Muncy, RN, Investigator, NSBN

Bob Hartman, Nevada Department of Corrections

Mary Eaton, Nevada Department of Corrections

Pamela Johnson, Department of Corrections

Jeanette Belz, Nevada Ophthalmological Society

Crisandra Eastmond, Nevada State College, nursing student

CALL TO ORDER: The meeting was called to order at 9:01 a.m.

PUBLIC COMMENTS: No one was present for public comment, although D. Scott discussed two issues—a letter from the Nevada Vascular Access Network regarding the Board’s revision to the PICC placement practice decision allowing nurses to determine the position of the distal tip by viewing x-rays and the LCB File No. R078-06 from the Health Division regarding changes to Chapter 449 of NAC. The committee directed D. Scott to contract the network for follow-up and possible placement of the issue on a future agenda. D. Scott stated the second issue provided an example of the regulation of patient care attendants.

APPROVAL OF MINUTES— June 6, 2006: The June 6, 2006 minutes were approved as written.

A.      OLD BUSINESS:

1. Review, discussion and action regarding RN scope in performing phoropter refraction: D. Scott presented this agenda item. The question that has been posed to the committee by Kelly Testolin of Hale Lane, Attorneys at Law, is whether is it within the scope of practice of a licensed RN to perform phoropter refraction under the supervision of a physician, provided that the RN has the skill and education necessary to competently refract? Jeanette Belz, representing the Nevada Ophthalmological Society, stated that this issue was discussed at the last Board of Medical Examiners’ meeting, during which the BOME expressed concerns about the lack of physician oversight as described in the proposal. It was discussed that the RN could practice this skill under the physician’s license if the nurse acted as a medical assistant, but that RNs do not practice under a physician’s license. Rather, nurses practice at the direction of the physician and under physician orders. Working as a medical assistant requires the physician to be at the site of the care being given. The proposal suggests that the physician would not necessarily be at the site where the RN would be practicing this skill. L. Muncy, RN, volunteered that the research she had done suggests that this test may be utilized to diagnose certain disease states, which is beyond the scope of practice for an RN. The committee members stated their concerns were not centered around this practice being a danger to the public, but that it would lead to a blurring of roles for the nurse. A representative from the Optometry Board stated that, as a consumer, she would prefer that the doctor perform the refraction.

B.      NEW BUSINESS:

1. Review, discussion and action regarding the scope of practice for an RN or LPN employed by the Nevada Department of Corrections to withdraw, package and label antibiotics from floor stock, under supervision: Mary Eaton, Chief of Nursing Services—North, Department of Corrections, submitted a practice decision request on July 6, 2006. D. Scott responded with existing laws and regulations, which spoke to the request. The question submitted was: Is it within the scope of practice for an RN or LPN employed by the Nevada Department of Corrections to withdraw, package and label a 10-day supply of antibiotics from the institution’s floor stock for the treatment of an inmate under the order of a licensed physician, Physician Assistant or APN employed by the Nevada Department of Corrections? Based on the existing laws, it is within the scope for an RN to have this practice. If an LPN is incorporating this into her practice, the RN will need to delegate (NAC 632.222) the task to the LPN.

2. Board actions from Annual Business Meeting in July 2006: D. Scott reviewed the actions taken at the Board’s annual business meeting in July 2006.

3. Discussion of the Procedural Sedation Practice Decision to include a discussion about IV push propofol: K. Winter presented this agenda item to the committee. The committee reviewed the existing Procedural Sedation Practice Decision. Members of the committee commented that some of the medications being used for procedural sedation are extremely fast-acting drugs with a lack of antagonists to be used when complications arise. Discussion arose around limiting certain types of medications to certain settings and have certain qualified individuals present when the medications are being administered. The committee settled on strengthening some of the language in the decision to include: Changing the words “will” and “would” to “shall” in statements that the RN shall ensure that emergency equipment and back-up personnel are immediately available for airway management, resuscitative and emergency intubation. The members suggested that the two sentences be reversed in order to better address the safety issues and to provide an introductory paragraph for the decision to underscore the relative risk of this practice. K. Winter volunteered to create an introductory statement for the decision and forward it to D. Scott, who will then forward to the committee members for review. The proposed revision will then be forwarded to the Board for possible approval—tentatively at the September 2006 Board meeting.

4. Discussion of National Safety Goals (Joint Commission on Accreditation of Healthcare Organizations): This agenda item was discussed and the committee directed the chair to include this item on the committee’s next agenda for further review.

5. Suggestions for agenda items for next meeting: As described in the public comment and agenda items B.1. and C. 4.

 ADJOURNMENT: The meeting was adjourned at 11:05 a.m.

June 7, 2006

CALL TO ORDER

The meeting of the Nevada State Board of Nursing Practice Advisory Committee was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:08 a.m., at the Board of Nursing Offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Committee Chair    Diane Allen, RN

Betty McKay, LPN, Board Liaison    Mary Wherry, RN

Susan Moore, RN                              Linda Morton, RN

Karen Winter, RN                              Vickie Wright, RN 

MEMBERS ABSENT

Terry Edmonson, RN                            Sadie Tate-Crowder, RN
Cheryl McKinney, RN                          Ryan Murphy, RN

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Linda Aure, Sr. Investigator, NSBN

Lark Muncy, Investigator, NSBN

Tina Cotter, Washoe County School District Nurse

Noel Kerr, Clinical Specialist, Washoe Medical Center

Stacy Bosch, Clark County School District Nurse

CALL TO ORDER:  The meeting was called to order at 9:08 a.m.

PUBLIC COMMENTS: There were no public comments.

A.     APPROVAL OF MINUTES— February 2, 2006: The minutes were approved as

revised.

B.      OLD BUSINESS:

1. Review, discussion and action regarding continued competence:  K. Winter led a discussion highlighting Washoe Medical Center’s Competency Data Sheet and the process that her facility goes through to document continued competency in their staff. The process is extremely thorough and the members of the committee showed interest in hearing more about the subject. D. Scott gave information about the work that National Council State Boards of Nursing (NCSBN) is doing around continued competency, describing the direction that the council is headed at this time.  All involved agreed that this issue is very important and also very complex.

C.      NEW BUSINESS:

1. Review, discussion and action regarding the advisory opinion regarding the role of the school nurse in delegation or assignment to a parent designee:  D. Scott introduced the agenda item, and Tina Cotter, Washoe County School District (WCSD) Nurse, presented the specific request for revision submitted by Dana Balchunas, Director, WCSD Student Health Services. Her comments included that the School Nurse Regulation and Advisory Opinion states that a school nurse may delegate certain care to a “qualified” person.  Section 8 of the opinion defines a qualified person to whom the school nurse may delegate care. This list includes (under section C) the parent or parent designee. The implication is that the school nurse must ensure that the parent is a willing, competent provider; provide supervision; and then provide training of the parent or designee.  D. Balchunas suggested that references to parents or their designees from item C be removed since the Board does not require that the nurse delegate care to parents and their designees. She recommended that the opinion be changed to add a section 4 which would read, “A family member/friend, designated or identified by the student’s parent or legal guardian, is exempt from the regulations of the Nurse Practice Act and, without delegation, training or supervision by the school nurse, may perform required care for the student unless employed by the school district.” The committee agreed that this suggestion would provide clarity to the opinion without changing its intent.  The committee voted unanimously to recommend the revision to the Board.

2. May Board meeting follow-up:  D. Scott and F. Olmstead reviewed some of the salient actions which occurred during the Board’s May 2006 meeting in Las Vegas, including the appointment of Linda Morton to the NPAC and the approval of several new regulations by the Board at the public hearing.

3. Suggestions for agenda items for next meeting:  The committee requested that those items, which were continued during this meeting, be put on the next NPAC agenda.  They also requested that the following be included: discussion of the Procedural Sedation Practice Decision to include a discussion about IV push propofol and the National Safety Goals which have been being developed by the Joint Comission on Accreditation of Healthcare Organizations (JCAHO).

4. Discussion regarding nurse-administered propofol as conscious sedation survey results:  D. Scott presented the memo, which describes a survey done by the Massachusetts Board of Registration in Nursing. The results showed that 67% of nursing boards have issued an advisory ruling, opinion, warning, alert or otherwise declarative statement regarding nursing administered propofol as conscious sedation: 29% allow the activity to be performed by a non-CRNA as conscious sedation and 38% do not allow this. The members suggested that the NPAC revisit this issue at its next meeting.

5. Review, discussion and action regarding practice decision Epidural Catheter Removal:  D. Scott presented this item which was submitted by Kevin Lasko, MD, and was addressed by Noel Kerr, MN, RN, CMSRN, a clinical nurse specialist at Washoe Medical Center. N. Kerr agreed that K. Lasko’s request for nurses to be allowed to remove any percutaneously placed epidural catheter regardless of time in place was appropriate. The committee suggested that the Practice Decision Regarding Removal of an Epidural Catheter be revised by deleting the second description of epidural catheters which may not be removed by an RN—to delete “Permanent epidural catheter, or those in situ for greater than 72 hours.” And replace it with, “Any tunneled epidural catheter.” They also suggested changing the third paragraph under “Consumer Safety” to read, “For consumer safety, the qualified RN may remove epidural percutaneously inserted catheters.” The last section of the Practice Decision gives “Definitions of Terms.” The committee suggested that the term, “Tunneled Epidural Catheter” be added and requested that N. Kerr research an appropriate definition for the decision. All members agreed to this revision and are recommending that the Board approve the revision at its next meeting. (Immediately after the NPAC meeting, N. Kerr submitted the following definition for Tunneled Epidural Catheter:  A catheter placed in the epidural space and tunneled subcutaneously resulting in an exit site some distance away from the insertion site, usually the patient’s abdomen. Reference citations were included.)

6. Review, discussion and action regarding:  RN scope in performing phoropter refraction: This item was submitted by Kelly Testolin of Hale Lane, Attorneys at Law. This agenda item was continued due to the need for more information before the committee may consider the request.  D. Scott will contact K. Testolin to request further information.

ADJOURNMENT:  The meeting was adjourned at 11:20 a.m.

February 7, 2006

CALL TO ORDER

The meeting of the Nevada State Board of Nursing Practice Advisory Committee was called to order by Debra Scott, MSN, RN, APN, Executive Director, at   a.m., at the Board of Nursing Offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Committee Chair    Nancy Harland, RN

Terry Edmonson, RN                         Linda Charlebois, RN

Susan Moore, RN                             Ryan Murphy, RN    

Sadie Tate-Crowder, RN                  Karen Winter, RN

Cheryl McKinney, RN                      Diane Allen, RN        

MEMBERS ABSENT

Betty McKay, RN, Board Liaison

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Chris Sansom, Director of Operations, NSBN

Donna Cowling, Education Consultant, NSBN

Linda Aure, Sr. Investigator, NSBN

Patti Chambers, Bureau of Licensure and Certification

Roxanne Horner, Silver Hills Healthcare Center

Kerry Laviolette, Silver Hills Healthcare Center

Wayne Jacobs, M.D., Sunrise/Columbia Radiology Services

Judy Mahoney, North Vista Hospital

Thomas Davis, North Vista Hospital

Claire Bradley, Mountainview Hospital

CALL TO ORDER:  The meeting was called to order at 9:20 a.m.

PUBLIC COMMENTS: There were no public comments.

A.  APPROVAL OF MINUTES— December 7, 2005: The minutes were approved as written.

B.  OLD BUSINESS:

1. Review, discussion and action regarding proposed policy draft regarding online searchable journal databases:  D. Scott presented a proposed policy regarding an alternative to the CINAHL process for the committee’s review.  The committee suggested that the name of the proposed policy be changed to Validation of Reference Materials, and recommended the Board accept the proposed policy as written.

2. Review, discussion and action regarding continued competence:  The committee discussed the difficult issues around documentation and measurement of continued competence for nurses.  It was suggested that when appropriate, the Nevada State Board of Nursing might want to appoint a task force in the state to address how the Board might proceed in addressing this issue.

3. Review, discussion and action regarding, NAC 632.450 scope of practice of an LPN,  submitted by Silver Hills Healthcare Center, Changing G-tubes: Results from Board staff poll of other states to inquire about this practice in their state:  This task is not taught in the LPN’s basis curriculum in Nevada.  The committee discussed that many tasks are learned while nurses are on the job.  Some discussion occurred around some individual problems with nurses replacing gastrostomy tubes, but the committee agreed that anecdotal information should not necessarily preclude LPNs having the replacement of G-tubes within their scope of practice.  Further research will be done regarding this issue by Board staff in conjunction with Silver Hills Healthcare Center.

C.  NEW BUSINESS:

1.   Review, discussion and action regarding RNs scope of practice to interpret the placement   of a PICC line using a chest x-ray:  T. Edmonson, committee member, presented research related to this agenda item.  He stated that 15 states allowed RNs to check placement of PICC lines using a chest x-ray which was described as a “preliminary reading”.  Wayne Jacobs, MD, Sunrise Radiology Department, supported the proposal that a practitioner who places a PICC line should be allowed to verify placement.  He stated that nursing would not be expected to do diagnostic interpretation of the x-ray, but should be allowed to very placement of the PICC line.  Some committee members asked if the Imaging Nurses Association or the IV Nurses Association had a position statement on this skill.  Some discussion arose that it most likely would be the nurse at the bedside that would be expected to verify the placement of the PICC through an x-ray and not necessarily radiology or IV team nurses so that it should be allowed for any competent nurse to do this skill.  T. Edmonson will research the presence of a position statement for further review at the next meeting, as well as formulate a draft practice decision for committee review.

2.   Review, discussion and action regarding scope of practice of LPNs regarding providing inhalation therapy treatments in a hospital setting: Medications involved would be albuterol, xopenex, and atrovent:  J. Mahoney and Thomas Davis presented information that this practice is taught in CCSN’s basic LPN program and that Arizona, Utah, and Louisiana Boards of Nursing allow this practice for LPNs.  The committee agreed that based on the data provided by Ms. Mahoney and Mr. Davis, it is within the LPN’s scope of practice to provide respiratory treatments via SVN (small volume nebulizer) and MDIs (meter dose inhaler) with aerosolized meds.

ADJOURNMENT:  The meeting was adjourned at 10:33 a.m.

December 7, 2005

CALL TO ORDER

The committee meeting was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:02 a.m., at the Board of Nursing Offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Committee Chair  Nancy Harland, RN

Terry Edmonson, RN                       Linda Charlebois, RN

Susan Moore, RN                            Diane Allen, RN

Sadie Tate-Crowder, RN                 Karen Winter, RN

MEMBERS ABSENT

Helen Vos, RN, Board Liaison         Martha McNabb, RN

Ryan Murphy, RN                            Cheryl McKinney, RN

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Linda Aure, RN Investigator, NSBN

Lark Muncy, RN Investigator, NSBN

Donna Cowling, RN, Education Consultant, NSBN

Kerry Laviolette, Silver Hills Healthcare

Roxanne Horner, Silver Hills Healthcare

Deb Milliner, REMSA, Care Flight

CALL TO ORDER:  The meeting was called to order at 9:02 a.m.

PUBLIC COMMENTS: There were no public comments.

A.     APPROVAL OF MINUTES—October 19, 2005: It was moved and seconded to approve the minutes of the October 19, 2005 Nursing Practice Advisory Committee.

B.     OLD BUSINESS:

1. Review, discussion and action regarding online searchable journal databases: D. Scott presented an interpretation of NAC 632.242 and 225, subsection 3 of both regulations.  The NPAC has been entertaining the issue of recommending the Board approve additional databases from which nurses could choose publications, practice guidelines, or national standards for nursing practice to provide a basis for determining if a task or procedure is within a nurse’s scope.  Upon further review of these regulations, it appears that they do not refer to databases, which are individually approved by the Board; they do refer to publications, practice guidelines, or national standards for nursing practice, which are individually approved by the Board.  The committee supported this interpretation.  The process by which a nurse could ascertain if a task or procedure as within her scope of practice was discussed. Adhering to the regulation would require the Board to approve a policy to delegate the authority of the Board to the NPAC to review publications, practice guidelines, or national standards for nursing practice and rate them within the hierarchy of evidence-based practice.  K. Winter submitted Washoe Medical Center’s Clinical Interdisciplinary Policies and Procedures for Document Development and Implementation, which outlines a rating system for hierarchy of evidence-based practice.  The committee suggested that Board staff draft a policy for the committee to review to facilitate the transfer of authority to the NPAC to be able to review and rate publications, practice guidelines, or national standards for nursing practice when they are submitted for Board approval.  D. Scott will draft the proposed policy for further review by the committee at the next meeting.

C.  NEW BUSINESS:

1. Review, discussion and action regarding continued competence: The committee discussed the Board’s responsibility to the public to assure that nurses possess continued competency to practice.

2. Discussion and action regarding, NAC 632.450 scope of practice of an LPN, submitted by Silver Hills Healthcare Center.

1. Flushing of PICC lines with saline and hang/administer antibiotics (premixed with saline by the pharmacy) without using the piggyback system: K. Laviolette submitted a practice question regarding the issue of PICC lines. The committee agreed that the intent of NAC 632.450 was that LPNs can do IVPBs and can also administer fluid from a container, which is properly labeled and contains antibiotics, steroids, or histamine H2 receptor antagonists that were added by a pharmacist or a registered nurse designated by the pharmacist. The remainder of the regulation clearly gives guidance to LPNs in IV therapy. Please see attached regulation. D. Scott will write a letter to K. Laviolette formalizing the committee’s clarification.

2. Changing G-tubes: K. Laviolette also presented his question regarding LPNs changing G-tubes. The committee reached no consensus and the agenda item was continued until the next NPAC meeting in February after further research may be done. T. Edmonson requested that Board staff poll other states to inquire about this practice in other states.

3. Review, discussion and action regarding scope of practice of RN supervision of paramedic student’s start of IVs and inserting nasogastric tubes and indwelling urinary catheters, submitted by Alaska State Board of Nursing: D. Scott presented this issue for clarification by the NPAC. Several of the committee members discussed the practice in the agencies where they are employed. Most agencies allow RNs to train paramedic students to do clinical tasks, but not all allow the paramedic students to do hands-on clinical tasks within the hospital.  Some only allow the students to observe. Questions arose about who is ultimately responsible for the actions the paramedic students take within the hospital and who is ultimately responsible for the actions of the paramedic students related to their having been taught to do the clinical tasks by the RNs. The committee agreed that the contract between the hospital and the emergency agency must be very specific regarding the level of didactic training the students must have prior to their being trained by the RN. It must also outline the specific clinical tasks which will be taught by the RN. These tasks would only be tasks which are within the paramedics’ scope of practice in the prehospital setting. The question posed by the Alaska State Board of Nursing included indwelling catheters which is not done by paramedics in Nevada. D. Allen clarified that the committee was only considering the role of the RN in teaching clinical tasks to paramedic students for future use in the prehospital setting upon their completion of their training and subsequent certification—that the committee was not considering the role of the RN in supervising or delegating clinical nursing tasks to paramedics in the hospital setting. The committee agreed with her clarification. The committee requested that Board staff draft an advisory opinion to be reviewed at the next NPAC meeting in February 2006, which outlines the role of the RN in teaching clinical tasks to paramedic students in the hospital setting.

4. Suggestions for agenda items for next meeting: The committee requested that the agenda continue to include an opportunity to discuss continued competence in nursing practice. K. Winter volunteered to send Board staff information about universal competencies in nursing, which have been developed at her agency.

ADJOURNMENT:  The meeting was adjourned at 10:33 a.m.

Addendum to agenda item C.2.a

NAC 632.450  Procedures delegable to licensed practical nurses. (NRS 632.120)

     1.  A licensed practical nurse who has completed a course in intravenous therapy approved by the Board pursuant to NAC 632.242 and who acts pursuant to a written order of a physician and under the immediate supervision of a physician, physician assistant or registered nurse may:

     (a) Start peripheral intravenous therapy using devices which act like needles and are not longer than 3 inches;

     (b) Introduce one or more solutions of electrolytes, nutrients or vitamins;

     (c) Piggyback solutions of electrolytes, nutrients and vitamins;

     (d) Administer any of the following medications by adding a solution by piggyback:

          (1) Antibiotics;

          (2) Steroids; and

          (3) Histamine H2 receptor antagonists;

     (e) Administer fluid from a container which is properly labeled and contains antibiotics, steroids or histamine H2 receptor antagonists that were added by a pharmacist or a registered nurse designated by the pharmacist;

     (f) Flush locks;

     (g) Except as otherwise provided in paragraph (h), administer fluid by continuous or intermittent infusion through a peripheral device which uses a mechanism to control the flow;

     (h) Administer fluid to a patient with a temporary central venous catheter by continuous or intermittent infusion through a peripheral device which uses an electronic mechanism to control the flow;

     (i) Discontinue peripheral intravenous catheters which are not longer than 3 inches; and

     (j) Change a central venous catheter dressing.

     2.  In addition to the procedures set forth in subsection 1, a licensed practical nurse who has completed a course in intravenous therapy approved by the Board pursuant to NAC 632.242 and who acts pursuant to a written order of a physician and under the direct supervision of a registered nurse may assist the registered nurse in the intravenous administration of blood and blood products by collecting data and performing simple nursing tasks related to that administration of blood or blood products.

     [Bd. of Nursing, § V subsec. B, eff. 8‑21‑81]—(NAC A 3‑26‑90; 1‑24‑92; R122‑01, 12‑17‑2001; R102‑03, 10‑30‑2003; R091‑04, 8‑13‑2004)

October 19, 2005

CALL TO ORDER

The meeting of the Nevada State Board of Nursing Practice Advisory Committee was called to order by Debra Scott, MSN, RN, APN, Executive Director, at   9:00 a.m., at the Board of Nursing Offices via videoconference between 5011 Meadowood Mall Way, Ste. 201, Reno, Nevada, 89502, and 2500 W. Sahara, #207, Las Vegas, Nevada 89102.

MEMBERS PRESENT

Debra Scott, RN, Committee Chair  Terry Edmonson, RN                       

Helen Vos, RN, Board liaison          Linda Charlebois, RN           

Nancy Harland, RN                         Sue Moore, RN

Kay Panelli, RN                               Karen Winter, RN

Cheryl McKinney, RN                     Ryan Murphy, RN

MEMBERS ABSENT   

                        Diane Allen, RN                              Sadie Tate-Crowder, RN

                        Martha McNabb, RN                          

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Linda Aure, RN Investigator, NSBN

Lark Muncy, RN Investigator, NSBN

Donna Cowling, RN, Education Consultant, NSBN

Diana Taylor, Clark County School District, DON

Judy Dalo, RN, Clark County School District

Stacy Busul, RN, Clark County School District

Todd Issell, UNLV Nursing Student

Diana Mendez, RN, Clark County School District

Maureen Field, RN, The Weiland Group

Melissa Fry, RN, Washoe County School District

Tina Cotter, RN, Washoe County School District

Carol Shephard, RN, PACU, St. Mary’s Medical Center

CALL TO ORDER:  The meeting was called to order at 9:00 a.m.

PUBLIC COMMENTS: There were no public comments.

A.  APPROVAL OF MINUTES— August 24, 2005: It was moved and seconded to approve the minutes with the addition under "Others present" of Donna Cowling, RN, Education Consultant, NSBN.

B.  OLD BUSINESS:

1.   Review, discussion and action regarding possible revisions to the school nurse delegation opinion of emergency administration of glucagon injection:  D. Scott introduced this agenda item, inviting those interested persons attending to give public testimony regarding this issue. F. Olmstead stated that he had attempted contact several times with counsel for the schools but had not had the opportunity to discuss the requirements of IDEA in relation to providing students access to nursing procedures allowed by NSBN practice decisions and regulations.  All non-committee members present for this agenda item spoke in opposition to the Board's addition of the emergency administration of glucagon injection to the delegable tasks in the school setting to a Qualified Person. The issues were:  the liability of the aides and nurses in delegating this procedure, the lack of teaching materials, limited resources, and the lack of opportunity to witness a return demonstration.  F. Olmstead will bring back the information regarding the IDEA to the December NPAC meeting; D. Scott stated that with that information and the ongoing testimony of the school nurses, the NPAC would consider how to best protect the public with the School Nurse Practice Decision and possibly make a recommendation to the Board at its January, 2006 meeting in Las Vegas.

C.  NEW BUSINESS:

1.   Review, discussion and action regarding these questions:  a. Can the nurse give local anesthetics? and b. Can the nurse give epidural anesthetics via the PCA route?  This agenda item was presented by Carol Shephard, RN, PACU, St. Mary's Medical Center, who submitted the questions. The committee agreed that nurses may give local anesthetics for the purpose of analgesia and that nurses may give epidural anesthetics via the PCA route for the purpose of analgesia. In addition, RNs may set up PCEA for patients to bolus themselves for the purpose of analgesia. If the purpose of any of the above is anesthesia, it is beyond the scope of practice for an RN. D.Scott will send a letter to C. Shephard stating the above.

2.   Scheduling of 2006 Nursing Practice Advisory Committee meeting dates: The dates approved for the 2006 NPAC meetings are as follows:  February 7, April 4, June 6, August 8, October 3, and December 5, 2006.

3.   Suggestions for agenda items for next meeting:  Suggested agenda items were continued competency, mutual recognition, and proposed regulation changes.

4.   Review, discussion and action regarding injection of FDA-approved filler material for cosmetic purposes and sclerotherapy injection for spider veins:  This agenda item was presented by Maureen Field, RN, of The Weiland Group.  She complimented NSBN's practice decision regarding cosmetic procedures; specifically that it lists the procedures which are within the RN's scope of practice.  She discussed agendized items as procedures which have historically been done by RNs across the country for many years. She requested that these two procedures be added to the list of approved procedures within the current practice decision.  The committee suggested that, rather than "laundry listing" the approved procedures, the Board add an "e" to the current a-d list which would provide guidance to nurses to address which procedures are within their scope by their utilizing the practice decision tree provided in the Nurse Practice Act and on the Board’s website. D. Scott will add the proposed language to the current practice decision, circulate the proposed changes, and take the committee's proposal to the Board for consideration.

ADJOURNMENT:  The meeting was adjourned at 10:30 a.m.

August 24, 2005

CALL TO ORDER

MEMBERS PRESENT

Debra Scott, RN, Committee Chair     Terry Edmonson, RN

Susan Moore, RN                               Kay Panelli, RN

Sadie Tate-Crowder, RN                    Karen Winter, RN

MEMBERS ABSENT  

Linda Charlebois, RN                        Helen Vos, RN, Board liaison

Ryan Murphy, RN                             Nancy Harland, RN

Diane Allen, RN                                Martha McNabb, RN

Cheryl McKinney, RN

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Linda Aure, RN, NSBN

Lark Muncy, RN, NSBN

Donna Cowling, RN, NSBN

Scott Moller, RN, Nevada Emergency Nurses Association

Melissa Fry, Washoe County School District, School Nurse

Diana Taylor, Clark County School District, DON

Stacy Bosch, Clark County School District, School Nurse

Renee Ball, Clark County School District, School Nurse

Ken Richardson, ED, Nevada Donor Network

John Dickerson, Nevada Donor Network

Cynthia Sanders, Nevada Donor Network

CALL TO ORDER:  The meeting was called to order at 9:05 a.m.

PUBLIC COMMENTS: There were no public comments.

A.  APPROVAL OF MINUTES— June 8, 2005:  The minutes were approved as written.

B.  OLD BUSINESS:

1.      Review, discussion and action regarding online searchable journal databases:  F. Olmstead presented this agenda item clarifying how the regulation currently reads.  The committee decided to maintain the current regulation and utilize a Board policy, which would be reviewed by the NPAC on an annual basis and then go to the Board for annual approval.  Since this policy does not exist at this time, Board staff will formulate a list of possible approved databases which have been suggested by National Council of State Boards of Nursing, and incorporate any suggestions that the committee members have before the next NPAC meeting. The committee will review the list and forward it to the Board for approval at its next regularly scheduled meeting.

2.      Review, discussion and action regarding NAC 632.059 “Immediate supervision” defined:  F. Olmstead presented this agenda item.  The committee recommended deleting the words, “or both” from NAC 632.059 and changing the word “immediate” to “direct” in NAC 632.450.  These recommended changes to regulation will be forwarded to the Board at its November 2005 meeting in Reno for approval of concept and wording.

C.  NEW BUSINESS:

1. Review, discussion and action regarding possible revisions to the school nurse delegation opinion of emergency administration of glucagon injections:  D. Scott gave a brief history of this issue, describing the public NPAC meeting discussions and the Board’s approval of the change to the School Nurse Practice Decision Delegation Grid.  School Nurses from Clark County School District and Washoe County School District (Diana Taylor, Stacy Bosch, Renee Ball, and Melissa Frye) spoke of their concerns related to the Board’s decision to add the emergency administration of glucagon to the list of delegable tasks to a qualified person in the school setting.  Their concerns included:  a lack of resources to teach qualified persons this task, which compromises safety for students; frequent qualified person turnover; fears expressed by qualified persons regarding needle stick injuries; difficulty finding qualified persons willing to do this task; the inordinate amount of time the school nurses are spending training people to do this task, which takes the nurses away from being able to spend time with other students; and the need for a nursing assessment of the student prior to giving emergency glucagon. They mentioned the mandate of the Individuals with Disabilities Education Improvement Act (IDEA), which requires the school to provide any treatment requested by a parent which is within the scope of nursing as defined by any state Board of nursing.  The committee members reminded the school nurses about the law related to delegation of nursing tasks and reiterated the Board’s role in protecting the public. F. Olmstead clarified for the school nurses the process that the NSBN went through in approving this addition to the School Nurses Delegation Grid.  The emergency administration of glucagon remains delegable to a qualified person at this time, as the Board has approved this change. F. Olmstead will follow up on the IDEA issue with counsel for the school district and this agenda item will be put on the next NPAC meeting agenda for further review, discussion, and possible action by the committee.

2. Review, discussion and action regarding the role of an RN in performing organ recovery procedures:  This agenda item was presented by Ken Richardson, Executive Director of the Nevada Donor Network, Inc. He gave a brief history of changes in educational and experience requirements for organ recovery coordinators. The committee agreed that a professional nursing license is not required to assume the position of organ recovery coordinator. D. Scott will write a formal letter to Mr. Richardson stating the above position of the NPAC.

3. Review, discussion and action regarding the apprentice nurse skills list:  D. Scott presented this agenda item stating that the content of the current RN/PN nurse apprentice lists had been maintained but the format had been changed to make the content more easily understandable and accessible. The committee discussed several of the tasks on the lists and made suggestions for revisions. The suggested changes will be disseminated to all committee members for review and then be taken to the Board’s November 2005 meeting in Reno, for final approval by the Board. There was further discussion about what initials should be used for RN nurse apprentices and PN nurse apprentices.  Board staff will do further research and decide if this issue needs to be referred to the Board.

4. Review, discussion regarding emergency personnel being utilized in hospital emergency rooms:  This agenda item was presented by S. Moore, committee member, who had talked extensively with Fergus Laughridge, Nevada State Health Division, Emergency Medical services.  She stated that NRS 450B at this time states that the scope of practice for EMTs ends at the door of the emergency room.  She understood from her discussion with F. Laughridge that there has been no undue pressure for this concept to be changed in statute. Scott Moller, Nevada Emergency Nurses Association, stated that nurses have mixed opinions on this issue, but he believed they are not immediately interested in having EMTs in the emergency room.  D. Scott described previous meetings from a few years ago where there was discussion of the role of EMTs in the emergency room, but did not believe there was pressure from the regulatory side to change statute related to this issue at this time.  All parties involved made it clear that, should it become necessary to address this issue in the future, that all would be willing to collaborate on any possible solution.

5. Suggestions for next meeting agenda: As above.

ADJOURNMENT:  The meeting was adjourned at 11:20 a.m.

June 8, 2005

CALL TO ORDER

MEMBERS PRESENT

Debra Scott, RN, Committee Chair      Linda Charlebois, RN                          

Susan Moore, RN                                Diane Allen, RN

Nancy Harland, RN                              Helen Vos, RN, Board liaison

Ryan Murphy, RN                                Cheryl McKinney, RN

Terry Edmonson, RN  

MEMBERS ABSENT         

            Kay Panelli, RN                                   Karen Winter, RN

Sadie Tate-Crowder, RN                     Martha McNabb, RN  

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Linda Aure, RN, NSBN

Lark Muncy, RN, NSBN

Tina Cotter, Washoe County School District

Melissa Fry, RN, Washoe County School District

Irene Smith, American Diabetes Association

Darla Carpenello, American Diabetes Association

Lisa Murdock, American Diabetes Association

Alex Barrera, American Diabetes Association

Joyce Malaskovitz, Desert Springs Hospital

Khanh Pham, Nevada Pharmacist Association

Sherri Lindsay, Vegas Valley Rehabilitation

Diana Taylor, Clark County School District

CALL TO ORDER:  The meeting was called to order at 9:00 a.m.

PUBLIC COMMENTS:  Public comment included the following issues: 

L. Aure, Board Investigator, reported to the committee that the Board office has received numerous calls in the past month related to the Practice Decision passed in 2000 regarding peripherally inserted central catheters.  N. Harland, one of the committee members who was part of the committee in 2000, clarified for Ms. Aure that the decision relates only to peripherally inserted central catheters, not any other central catheters.  Documents relating to this practice decision will be revised to reflect this clarification.

N. Harland, committee member, suggested that the committee research the issue of emergency personnel being utilized in hospital emergency rooms.  This issue will be agendized for further research and discussion. 

S. Lindsay from Vegas Valley Rehabilitation Hospital had further questions regarding central lines.  D. Scott described the various methods of determining the scope of practice for RNs in Nevada.  Ms. Lindsay’s issue may be submitted to the committee for further discussion and/or action if needed.  

A.  APPROVAL OF MINUTES— February 9, 2005: 

B.  OLD BUSINESS:

1. Discussion and possible action regarding recent revision of school nurse practice decision, which allows an RN to delegate the emergency administration of glucagon injection to a “qualified person.” : D. Scott presented this agenda item, describing her telephone conversation with Carol Bangheart, Director of Nursing, Elko School District. Ms. Bangheart voiced her concerns regarding the current School Nurse Practice Decision.  Diana Taylor, Director of Nursing, Clark County School District, outlined the concerns that she and the school nurses from her district had identified, as did other school nurse representatives from the Washoe County School District.  The concerns included:  training and documenting the competence of emergency administration of glucagon, monitoring of the student after administration of glucagon, the large of number of individuals who would need to be trained, the fact that the glucagon set is not a prefilled, predosed injection, the necessity of calculating dose based on body weight, and the delegation of the task to qualified personnel.  The representatives from the American Diabetes Association and parent representatives spoke to the concerns, concluding with the bottom line being that allowing a qualified person to administer glucagon in an emergency situation “will save a life.”  Khanh Pham, President of the Nevada Pharmacist’s Association, stated that Eli Lilly will provide training material for glucagon administration. In addition, she volunteered to provide training upon request. The committee suggested those in attendance exchange contact information to address their needs.

2.      Discussion and possible action regarding online searchable journal databases:  D. Scott presented this agenda item.  D. Allen suggested that the Legislative Counsel Bureau be contacted to inquire about wording for a possible regulation change to NAC 632.225 and 242 where Chapter 632 regulations refer to the Cumulative Index to Nursing and Allied Health Literature as the sole database used to establish practice guidelines or national standards for nursing practice in Nevada.  F. Olmstead will make that contact and report back to the committee.

3.      Report on recent actions by the Nevada State Board of Nursing:  D. Scott and H. Vos updated the committee on recent actions from the March and May, 2005 Board meetings.

C.  NEW BUSINESS

1. Discussion and possible action regarding NAC 632.059 “Immediate supervision" defined: D. Scott presented this agenda item.  A letter was submitted by Sheila Weeks, RN, questioning the intent and/or interpretation of NAC 632.450 and 632.059 related to LPNs administering IV therapy under the immediate supervision of a physician, physician assistant or registered nurse.  NAC 632.059 defines “immediate supervision” as direction given by a supervisor of nurses who is physically present at the site where care is provided to a patient and directly observing or assisting in that care, “or both.”  The committee members agreed that NAC 632.059 was not clearly understandable.  F. Olmstead will review the regulations regarding “direct supervision” and “immediate supervision” and report back to the committee.

2. Discussion and possible action regarding the administration of Diastat by an LPN in the school setting:  D. Scott presented this agenda item.  Stefanie Utz, Chief Nurse for the Churchill County School District, submitted a question regarding the rectal administration of Diastat by LPNs in the school setting. The current School Nurse Practice Decision delegation grid indicates that “only RNs” may administer bladder/rectal medications.  The committee members agreed that, as part of their nursing program education, LPNs are taught to administer rectal medications.  It was recommended that the practice decision grid be changed to allow LPNs to administer rectal medications.  The recommended revision will be forwarded to the Board for consideration at their September 2005 Board meeting in Las Vegas.

3. Legislative update:  D. Scott and F. Olmstead gave a brief update related to legislative action taken during the session.

4. Suggestions for next meeting agenda:  Committee members suggested emergency personnel being utilized in hospital emergency rooms be put on a future agenda.

ADJOURNMENT:  The meeting was adjourned at 11:00 a.m.

February 9, 2005

CALL TO ORDER

MEMBERS PRESENT

Debra Scott, RN, Committee Chair             Kay Panelli, RN                       

Diane Allen, RN                                          Susan Moore, RN

Nancy Harland, RN                                     Cheryl McKinney, RN

Terry Edmonson, RN                                   Karen Winter, RN   

Sadie Tate-Crowder, RN                             Linda Charlebois, RN

Ryan Murphy, RN

MEMBERS ABSENT

           Martha McNabb, RN  

OTHERS PRESENT

           Fred Olmstead, General Counsel, NSBN

           Carolyn Leontos, American Diabetes Association (ADA)

           Irene Smith, ADA

           Steve Bieringor, ADA

           Marty Katz, Sunrise Hospital

           Catherine Sparkman, Association of PeriOperative Registered Nurses (AORN)

           Alex Barrera, ADA

           Patricia Seifert, RN, AORN

           La Rhonda Morris, RN, CNOR, RNFA

           Olga Lumsden, Nevada Alliance Against Diabetes

           Khanh Pham, Nevada Pharmacist Association

CALL TO ORDER:  The meeting was called to order at 9:00 a.m.

PUBLIC COMMENTS: There were no public comments. 

A.  APPROVAL OF MINUTES: December 8, 2004:  The minutes were approved as written.

B.  OLD BUSINESS:

1. Discussion and possible action regarding the practice decision related to the CRNFA’s  scope of practice in preparing/harvesting a saphenous vein for coronary artery bypass grafting:  D. Scott presented the additional information submitted by the representatives of the Association of PeriOperative Registered Nurses: Catherine Sparkman, Patricia Seifert, and LaRhonda Morris, RN, CNOR, RNFA.  The suggestions from AORN were as follows:  1. To change the existing language in the stem of the decision by identifying the CRNFA or RNFA as “the nurse” to be able to utilize this term throughout the decision. 2. To change the existing language in item #1 by accepting the language proposed by AORN to read, “The nurse must have successfully completed an RN First Assistant program that meets the AORN Recommended Education Standards for RN First Assistant Programs and a clinical preceptorship devoted to the application of knowledge and clinical skills associated with the process of harvesting a coronary conduit/saphenous vein.  The nurse must maintain documentation of competency and maintain current CNOR certification.”  3. To keep the existing language in items 2, 3, 4, 5, and 6.  Item #7 would be changed to refer to “the nurse” as identified in the stem of the practice decision.  The committee thanked the AORN representatives for their input and voted to recommend the Board accept the changes to the existing practice decision as discussed.

2. Subcommittee report on the current practice decision regarding RN administration of anesthetic agents for the purposes of pain management or moderate sedation meeting results: The subcommittee, made up of Nancy Harland, Cheryl McKinney, and Sue Moore, presented a proposed practice decision for procedural sedation to replace the existing practice decision regarding RN administration of anesthetic agents for the purposes of pain management or moderate sedation. The committee voted to recommend the Board accept the proposed decision as submitted. 

C.  NEW BUSINESS

1. Discussion and possible action regarding school nurse delegation of emergency administration of glucagon injections:  Presentations were made by Carolyn Leontas, Irene Smith, and Steve Bieringor of the American Diabetes Association; Olga Lumsden of the Nevada Alliance Against Diabetes; and Khanh Pham of the Nevada Pharmacist Association, submitting the possibility of school nurse delegation of emergency administration of glucagon injections to qualified persons in the school setting.  Information given highlighted the extreme emergency which occurs when a diabetic child is hypoglycemic.  The pros and cons of administration were discussed by the diabetic educators and the pharmacist.  After several questions, clarifications, and viewing of the injection kit, the committee voted to recommend the Board add the administration of glucagon to those delegable tasks in the School Nurse Delegation Grid which is part of the Board’s School Nurse Practice Decision.

2. Legislative update: D. Scott gave an update on pending legislation related to the functions of the NSBN and the profession of nursing.  Assembly Bill 1 was discussed as was other legislation related to personal care assistants and employment protection for nurses who refuse to take on an unsafe assignment. 

3. Suggestions for next meeting agenda:  No suggestions were given for future agenda items.

ADJOURNMENT:  The meeting was adjourned at 11:15 a.m.

December 8, 2004

CALL TO ORDER

MEMBERS PRESENT

Debra Scott, RN, Committee Chair                            Kay Panelli, RN

Helen Vos, RN                                                          Susan Moore, RN

Nancy Harland, RN                                                   Cheryl McKinney, RN

Terry Edmonson, RN                                                 Karen Winter, RN

Sadie Tate-Crowder, RN                                                                       

MEMBERS ABSENT       

                                                Martha McNabb, RN  

                                                Diane Allen, RN        

Ryan Murphy, RN

Linda Charlebois, RN

OTHERS PRESENT

Fred Olmstead, General Counsel, NSBN

Don Rennie, RN, Associate Executive Director

CALL TO ORDER:  The meeting was called to order at 9:10 am.

PUBLIC COMMENTS:  There were no public comments.

A.  APPROVAL OF MINUTES— October 13, 2004:  The minutes were approved as written.

B.  OLD BUSINESS:

1. Annual NSBN Committee Evaluation—discussion and recommendations:  The members discussed the outcome of the annual committee evaluation.  Seven members of the committee returned the evaluation.  All scores were either very satisfied or satisfied.  The members remarked that they were overall pleased with the performance of the NPAC for FY03/04.

2. Discussion and possible action regarding the practice decision related to the CRNFA’s scope of practice in preparing/harvesting a saphenous vein for coronary artery bypass grafting:  This item was continued on request from AORN

3. Update on Nevada State Board of Nursing meeting activities since the last NPAC meeting:  D. Scott and D. Rennie gave an update about the Board’s activities since the last NPAC meeting which included the addition of several tasks to the CNA curriculum and scope of practice.  It was announced that T. Edmonson was reappointed to the NPAC for another three-year term.

4. Discussion of current practice decision regarding RN administration of anesthetic agents for the purposes of pain management or moderate sedation  (see agenda item C.1.):  Discussion ensued regarding the possible need to revise the current practice decision to speak to emergency situations when the physician is in attendance, so that the RN is acting as an extra pair of hands.  It was mentioned that JCAHO has requirements for administering deep sedation.  S. Moore, S. Tate-Crowder, N. Harland, and C. McKinney volunteered to be part of a task force to look at this issue in more depth.  This subcommittee plans to meet the last week in January 2005.

5. School nurse update:  D. Scott gave an update on the addition of certain delegable procedures related to treatment of the diabetic child in the school setting.  She presented a letter from the National Council of State Boards of Nursing to the National Association of School Nurses outlining proposed bills in various states related to in-school diabetes care. 

C.  NEW BUSINESS

1. Discussion and possible action regarding RN administration of an epidural combination of narcotic and Bupicaine/Marcaine by way of a pump for pain control:  C. McKinney described the practice in her facility which allows RNs to give opiate infusion as long as the anesthesiologist gives all the orders.  The other committee members agreed that this is a common practice. This situation is already covered under the Nurse Practice Act.  D. Scott will write a letter to E. Young, UMC, who submitted the question to the NPAC.

2. Discussion and possible action regarding intubation practice decision:  The committee voted to maintain the intubation practice decision as written.  They commented that this information is important to have in the Nurse Practice Act for guidance in writing policies in the practice setting.

3. Discussion and possible action regarding administration of tube feeding practice decision: The committee voted to delete this practice decision because the administration of tube feedings has become a standard of practice for LPNs and is taught as part of the LPN education curriculum.

4. Scheduling of Nurse Practice Advisory Committee meeting dates for 2005:  The following dates were approved for the 2005 tentative meetings:  Wednesdays on February 9, April 13, June 8, August 10, October 12, and December 7, 2005.

ADJOURNMENT:  The meeting was adjourned at 11 a.m.

October 13, 2004

CALL TO ORDER

MEMBERS PRESENT

Debra Scott, RN, Committee Chair                            Kay Panelli, RN

Nancy Harland, RN                                                   Cheryl McKinney, RN

Terry Edmonson, RN                                                 Karen Winter, RN     

            Diane Allen, RN                                                         Linda Charlebois, RN

            Terry Edmondson, RN                                               Ryan Murphy, RN

            Sadie Tate-Crowder, RN                                           Susan Moore, RN

MEMBERS ABSENT

Martha McNabb, RN              

OTHERS PRESENT

Marlene Craden, RN, BSN, CNOR, CRNFA

LaRhonda Morris, CNOR, RNFA

Fred Olmstead, General Counsel, NSBN

Chris Sansom, RN, Associate Director for Practice

Linda Aure, RN, NSBN Investigator

Nancy Bridges

Patsy Ruchala

Jen Richards

Dana Balchunas

Tina Cotter

Neena Laxalt

CALL TO ORDER:  The meeting was called to order 9:30 a.m.

PUBLIC COMMENTS: No public comments were given.

A.  APPROVAL OF MINUTES— August 11, 2004:  It was moved and seconded the committee approve the August 11, 2004, committee meeting minutes as written.  MOTION CARRIED.

B.  OLD BUSINESS:

*1.  The LPN scope related to the Functional Independent Measurement (FIM) in the rehabilitation hospital setting:  Continued due to videoconferencing equipment failure.

*2.  Annual NSBN Committee Evaluation-discussion and recommendations:  Continued due to videoconferencing equipment failure.

*3.  Discussion and possible action regarding the practice decision related to the CRNFA scope of practice in preparing/harvesting a saphenous vein for coronary bypass grafting:  Presentation by Marlene Craden, RN and LaRhonda Morris, RN.  There was lengthy discussion regarding the Board’s practice decision.  Further discussion will continue at the next NPAC meeting on December 8, 2004.

 

 4.     Update on NSBN meeting activities since the last NPAC meeting:  Continued due to videoconferencing equipment failure.

C.  NEW BUSINESS            

*1.  Discussion and action regarding the scope of practice for provision of nursing care by licensed nurses and qualified personnel in schools specific to the safe delegation of the  monitoring of insulin injections, insulin pens and insulin pumps by non-licensed personnel, submitted by Washoe County School District Student Health Services:  

Presentation by Dana Balchunas, RN, and Tina Cotter, RN.  The Practice Decision Request information was distributed to the committee members (attached).  D. Balchunas and T. Cotter described the increased incidence of children with diabetes in the school setting and the change in technology.  The committee agreed to recommend the Board make the following changes to the School Nurse Advisory Opinion, Nursing Procedure Grid: 

1)  Under “Injections” keep the “Qualified licensed nurse” designation for injections, but add another nursing procedure which would be worded, “Calculation of insulin dosage via pump, pen, or syringe for student self-administration” and “Verification of insulin dosage via pump, pen, or syringe for student self-administration” which could be delegated to a “Qualified person”.

2) Change “Automatic devices for injection of medication—Epi-pen allergy kit” to “Automatic devices for fixed dosage injection”.  This designation has been previously approved for both the “Qualified licensed nurse” and “Qualified person” to complete the nursing procedure.

The committee’s recommendation will be forwarded to the November, 2004 Board meeting in Reno for approval, revision, or referral back to the committee.

*2.  Discussion and possible action regarding intubation practice decision: Continued due to videoconferencing failure.

*3.  Discussion and possible action regarding administration of tube feedings practice decision:  Continued due to videoconferencing failure.

*4.  Scheduling of Nurse Practice Advisory Committee meeting dates for 2005:  Continued due to videoconferencing failure.

ADJOURNMENT:  The meeting was adjourned at 11 a.m. prior to the completion of the agenda due to videoconferencing failure.  The remaining agenda items will be continued to the next regularly scheduled Nursing Practice Advisory Committee meeting on December 8, 2004.

August 11, 2004

CALL TO ORDER

MEMBERS PRESENT

Debra Scott, RN, Committee Chair                            Kay Panelli, RN

Nancy Harland, RN                                                     Cheryl McKinney, RN

Terry Edmonson, RN                                                 Karen Winter, RN     

            Diane Allen, RN         

MEMBERS ABSENT       

Ryan Murphy, RN

Linda Charlebois, RN

Martha McNabb, RN

Sadie Tate-Crowder, RN

OTHERS PRESENT

Don Rennie, MSN, RN, AED, Licensure and Certification           

                                                Fred Olmstead, General Counsel, NSBN

Helen Vos, MS, RN, Board Liaison

Lark Muncy, RN, NSBN Investigator

Sue Moore, RN, REMSA/CareFlight

Jeri Bennet, RN, Medicaid

CALL TO ORDER:  The meeting was called to order at 9:10 a.m.

PUBLIC COMMENTS:  Public comments included discussion led by D. Allen regarding the dilemma of evaluating psychiatric patients for referral or hospitalization who are presenting in acute hospital emergency rooms in our state. 

A.  APPROVAL OF MINUTES—April 4, 2004:  The minutes of the previous

meeting were approved as written.

B.  OLD BUSINESS:

1.      Discussion of committee evaluation data:  D. Scott informed the members that the incorrect evaluation form was distributed and thanked those members who had already returned the forms. She announced that her assistant would be distributing the correct form via email and encouraged the members to complete the form and return for discussion of the data at the next committee meeting.

2.      Discussion and possible action regarding the practice decision related to the CRNFA’s

scope of practice in preparing/harvesting a saphenous vein for coronary artery bypass

grafting:   The individuals who submitted this agenda item to the committee requested that the discussion be continued until the next committee meeting in October and noticed for the regularly scheduled Board meeting in November, 2004, in Reno.  The item was continued.

3.      Update on Nevada State Board of Nursing meeting activities since the last NPAC meeting: D. Scott reviewed actions taken by the NSBN during its annual business  meeting in Las Vegas.

4.      Discussion and action regarding how to handle future requests for additions to the practice decision regarding cosmetic procedures:  D. Scott introduced a request by Sherrie Koppelman, Reno Vein Clinic, regarding sclerotherapy.  The committee recommended that sclerotherapy be deemed within the scope of practice for RNs who have received formal education in the technique based on a Cumulative Index to Nursing and Allied Health Literature review which was submitted by Ms. Koppelman for committee review.  The committee requested that any further cosmetic procedure practice decision requests be submitted and reviewed by the committee who will then recommend what further approval is needed.  If the request meets the CINAHL criteria and needs no further approval by the Board, a letter will be forwarded by the executive director to the individual or group who has made the request.  The committee underscored the need for any cosmetic procedure to be administered under all other guidelines set forth in the Board’s Practice Decision Regarding Cosmetic Procedures (attached).

C.  NEW BUSINESS:

1.      Discussion of AANA-ASA Joint Statement Regarding Propofol Administration:  D.  Scott reviewed a letter and an American Association of Nurse Anesthetists (AANA)/

            American Society of Anesthesiologists (ASA) Joint Statement Regarding Propofol

            Administration dated April 14, 2004, for congruency with the Board’s current practice

            decision regarding the administration of anesthetic agents for pain management and/or

            moderate sedation.  It appeared that the joint statement was not congruent with the

Board’s current practice decision and discussion ensued.  The current standard of  

            practice in acute hospitals in Nevada was discussed which varied from one hospital to  

            the next.  The committee expressed interest in adding a clarifying line to the current

            practice decision to give guidance to chief nurses in developing policy regarding this

            issue.  The members suggested that the revision include the concepts of emergent 

            situations and the administration of anesthetic agents during intubation procedures.

   Board staff will bring the current practice decision back to the committee at the

October meeting for further review.

2.      Discussion of Personal Care Assistant services pursuant to NRS 632.340 (8) and NRS 629.091-Presented by Jeri Bennett, RN, CCM, Nevada Medicaid:  J. Bennett presented information on the current utilization of personal care assistants for disabled individuals.  She described that PCAs are not regulated, but oversight falls to the person or agency who is paying for the services.  Medicaid pays for PCA services through a waiver and refers to this service as “skilled care by the unskilled”.  She described  the process of providing services to the disabled with this program which included the “rampant fraud and abuse” in some instances.  She stated that she is aware of at least two bill drafts related to UAPs going to the next legislative session.  D. Scott suggested that committee members review ANA’s latest Principles of Delegation paper.  She offered to email this document to all committee members in follow-up.   

  3.  Discussion regarding “Physicians Orders for Scope of Treatment”(POST)-Presented by  Trish White, Nevada Center For Ethics and Health Policy:  Sally Hardwick of the Nevada Center for Ethics and Health Policy presented the Physicians Orders for Scope of Treatment (POST) form for the committee’s information.  The form is still in the planning stage, but she hopes that agencies will begin using the form very soon.  The form is “owned” by the patient and includes information on whether or not to resuscitate if a person is not breathing, a section on medical interventions with choices involving full treatment, comfort measures, or limited interventions, and whether a person wishes life-sustaining antibiotics or artificially administered fluids and nutrition. The form “travels” with the patient to communicate the patient’s end of life wishes in clear specific terms.  It’s bright pink color makes it quickly recognizable by practitioners in the field and in various agencies.  The committee asked pertinent questions and applauded Ms. Hardwick for the concept of the POST form.

 4.  Discussion and action regarding the following practice decisions:

a.       RNs may

1.   perform intubation 6/86

2.   perform postmortem enucleation (surgical removal of the eye) 6/87

3.   remove mediastinal draining tubes 11/86

4.   remove respirator 9/87

5.   replace gastrostomy tube/suprapubic catheter 9/86

6.   insert intraosseus lines 9/88

7.   place PICC 9/00

8.   instill reversible opioid agonists 12/88

9.   perform amniotome, place spiral (fetal scalp) electrodes 9/87

The committee recommended that the Board keep the practice decisions above because the procedures addressed are not a standard of practice for every nurse and require specific training in order for them to be within the scope of practice for RNs.

b.      LPNs may

1.   insert oral gastric tubes 11/86

2.   administer tube feedings 9/86

3.   perform postmorten enucleation 6/87

The committee recommended that practice decision described as agenda item 4.b.2. be revised to identify the type of tube, but as it stands, administration of tube feeding via naso/oral gastric tubes is currently a standard of practice for LPNs.  The practice decision will be brought back to the committee at it’s October meeting.  Decisions 1 and 3 will be kept.

c.       RNs and LPNs may not

1.   accept employment as CNA unless certified 8/90

2.   perform apnea testing for brain death 6/90

The committee recommended that the practice decision described as 4.c.1 be rescinded due to its being superseded by statute and it’s being confusing.  An RN/LPN may work as a CNA as long as he is licensed in this state as an RN/LPN but can’t identify herself as a CNA unless actually certified as a nursing assistant.  All CNA tasks are within the scope of practice of an RN/LPN.  D. Rennie explained the history of this practice decision which appears to be related to preventing someone who may have graduated from a nursing program, has not been licensed, but attempts to work as a CNA. This category of individual may not work and represent herself as a CNA unless actually certified as a nursing assistant.

d.       LPNs may not

1.   insert PICC lines 11/89, reconfirmed 12/92

   The committee recommended that the practice decision described as 4.d.1 be kept.

ADJOURNMENT:  The meeting was adjourned at 11:30 a.m.

April 14, 2004

CALL TO ORDER

The meeting of the Nevada State Board of Nursing Practice Advisory Committee was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:05 a.m., at the Washoe County District Health Dept., 1001 E. Ninth Street, Reno, Nevada, with other committee members at the Nevada Early Intervention Services Conference Room, 3811 W. Charleston, Suite 209, Las Vegas, Nevada, via videoconference.

MEMBERS PRESENT

Debra Scott, RN, Committee Chair                            Kay Panelli, RN

Ryan Murphy, RN                                                     Terry Edmonson, RN

            Karen Winter, RN                                                      Cheryl McKinney, RN

            Diane Allen, RN                                                         Linda Charlebois, RN           

Sadie Tate-Crowder, RN                                           Nancy Harland, RN 

MEMBERS PRESENT

Martha McNabb, RN

OTHERS PRESENT

                                                Fred Olmstead, General Counsel, NSBN

Helen Vos, MS, RN, Board Liaison

Neena Laxalt, Nevada Nurses Association

Sherrie Koppelman, Reno Vein Clinic

Jeanie Jenkins, Management Assistant, NSBN

Jennie Shipp, RN, Div. of Mental Health and Developmental Services

Linda Suzanne, RN, Div. of Mental Health and Developmental Services

Michael Malay, RN, Washoe Health System

Terry De Vault, RN

Linda Mantkus, RN

Christine Siwicki, RN

Shane Jenson, RN, Prison Health Services

CALL TO ORDER:  The meeting was called to order at 9:05 a.m.

PUBLIC COMMENTS:  Fred Olmstead, General Counsel for the Board, reviewed an Attorney General’s memorandum, written in 1990 by Donald G. Haight, deputy attorney general, regarding the legal effect of advisory opinions. In summary, practice decisions are the Board’s opinion about how it interprets its statutes and regulations. Debra Scott distributed the new practice decisions adopted by the Board regarding Sexual Assault Nurse Examiners and the Nevada nursing licensure requirements for individuals who come to Nevada in nontraditional roles such as consultants, surveyors, or to give continuing education seminars for nurses.

A.  APPROVAL OF MINUTES—February 11, 2004 meeting: It was moved and seconded to approve the minutes of the February 11, 2004, meeting with one correction: Nancy Harland, RN, was not present at the meeting.

B.  OLD BUSINESS:

  1. The LPN scope related to the Functional Independent Measurement (FIM) in the Rehabilitation hospital setting:  This item was continued until the individual who submitted could attend the meeting to present the issue.

2. Discussion of the role of unlicensed assistive personnel supervision and interfacing with RN in a supportive living arrangement submitted by the Division of Mental Health and Developmental Services:  Jennie Shipp, RN, and Linda Suzanne, RN, Division of Mental Health and Developmental Services, presented proposed language for a bill draft for the next legislative session. The proposed language includes the addition of an exemption from required licensure or certification under NRS 632.340. The proposed addition reads, “9) the trained staff of supported living arrangements as defined in NRS 435.xxx, approved by the Division of Mental Health and Developmental Services, from performing services for individuals with mental retardation or related conditions.” Ms. Shipp and Ms. Suzanne discussed the setting, which includes quarterly review by an assessment team. A case manager does quarterly reviews and an RN does annual assessments. The Division would be providing training to the supported living arrangement (SLA) staff and would be certified through the Division.The clients involved would be those whose condition has a stable and predictable course. Quality assurance activities occur every 3-4 months, which is a review by a service coordinator. The committee suggested that Ms. Shipp and Ms. Suzanne write a rough draft of proposed regulations that would support guidelines under which the SLA staff could provide care to this population. They stated that potential care by SLA staff might include administering oral medications, providing G-tube feedings, and providing care for indwelling urinary catheters. The committee suggested that this issue be on the committee’s June, 2004, agenda and that a recommendation and information be presented to the Board at its July annual business meeting.

C.  NEW BUSINESS:

1.   Discussion and action regarding scope of practice for an RN and APN to perform nonablative laser treatments for spider veins and telangiectases, hair removal/reduction and facial skin rejuvenations. Discussion and action of the Nursing Practice :  Sherrie Koppelman, Nursing Supervisor of the Reno Vein Clinic, presented information to request that the current cosmetic procedures practice decision be revised to include using laser treatment for skin rejuvenation, and to revise subsection #3 which states, “The procedure is not performed independently. It is authorized pursuant to NAC 632.071 and is performed under the direct supervision of a physician who is present at the site where the procedure is performed and has the knowledge, skill, and ability to perform the procedure.”  She is recommending that this statement read, “The procedure is not performed independently.  It is authorized pursuant to NAC 632.071 and is performed under the direct supervision of a physician who is licensed in the state of Nevada and readily available by telephone within a 30-minute physical response time present at the site where the procedure is performed and has the knowledge, skill, and ability to perform the procedure.” The committee agreed to recommend these revisions to the Board at its regular May Board meeting in Las Vegas. 

Lisa Mantkus, RN, and Terry De Vault, RN, presented information to amend the current cosmetic procedures practice decision to include some of the same revisions as suggested by Sherrie Koppelman, but were interested in providing these procedures through their own company, which would include a medical director as the physician who “indirectly” would supervise their practice. The committee was hesitant to recommend the changes as described by Ms. Mantkus and Ms. De Vault, but requested that they rethink and restructure their request for further review by the committee at its next meeting in June, 2004.

2.   Laws and regulations

a. Discussion and action regarding NAC 632.450 (4) & (5), procedures delegable to LPNs:  This agenda item was listed to provide background for agenda item 2.b.

b. Discussion and action regarding NAC 632.455, procedures not delegable to LPNs: Debra Scott informed the committee that in NAC 632.455 (1)  the phrase “Any drug other than an antibiotic or histamine H2 receptor antagonist;” should read “Any drug other than an antibiotic, steroid, or histamine H2 receptor antagonist;” so that this subsection is consistent with NAC 632.450. The committee recommended this issue be considered with the other regulations going to public workshop and hearing during May and June. This is not a change in the concept and wording, but only to make the regulations consistent throughout. 

3. Discussion and action regarding scope of practice of an LPN/LVN performing non-stress tests and amniotic fluid indexes on high risk OB patients, submitted by Meadows Women’s Center: This item was continued until the individual who submitted could attend the meeting to present the issue.

4. Discussion and action regarding scope of practice of an RN performing insertion of external jugular intravenous lines, submitted by Washoe Health System: This item was presented by Mike Malay, RN.  After his presentation and committee discussion, the committee recommended the chair issue Mr. Malay a letter stating that it is within the scope of practice of an RN to perform insertion of an external jugular intravenous line based on the rationale that an EJ line is considered a peripheral line. 

5. Discussion and action regarding the role of the LPN in performing venipuncture/phlebotomy for the purpose of withdrawing blood samples, submitted by Shane Jensen, RN,Prison Health services: This item was presented by Shane Jensen, RN.  After his presentation and committee discussion, the committee recommended the chair issue Mr. Jensen a letter stating that it is within the scope of practice of an LPN to perform venipuncture/phlebotomy for the purpose of withdrawing blood samples based on existing regulations in the Nurse Practice Act.

ADJOURNMENT:  The meeting was adjourned at 12:00 p.m.

February 11, 2004

CALL TO ORDER

The meeting of the Nevada State Board of Nursing Practice Advisory Committee was called to order by Debra Scott, MSN, RN, APN, Executive Director, at 9:05 a.m., at the Nevada Early Intervention Services Conference Room, 3811 W. Charleston, Suite 209, Las Vegas, Nevada and via videoconference with other committee members at the Washoe County District Health Dept., 1001 E. Ninth Street, Reno, Nevada.

MEMBERS PRESENT

Debra Scott, RN, Committee Chair                            Kay Panelli, RN

Marty McNabb, RN                                                   Terry Edmonson, RN

            Karen Winter, RN                                                      Cheryl McKinney, RN

            Diane Allen, RN                                                         Linda Charlebois, RN           

Sadie Tate-Crowder, RN                                           Nancy Harland, RN    

MEMBERS ABSENT

None

OTHERS PRESENT

                                                Fred Olmstead, General Counsel, NSBN

Helen Vos, MS, RN, Board Liaison

Neena Laxalt, Nevada Nurses Association

Sherrie Koppelman, Reno Vein Clinic

Dottie Jones, Nathan Adelson Hospice

Mona Raynor, Nathan Adelson Hospice

Chris Salm, SEIU

Patti Ann Rauser, Attorney for TransHealth

Teri Troke, Executive Assistant, NSBN

Jennie Shipp, RN, Div. of Mental Health and Developmental Services

Linda Suzanne, RN, Div. of Mental Health and Developmental Services

Lora Olvera, Developmental Specialist IV, Div. of Mental Health and Developmental Services

CALL TO ORDER:  The meeting was called to order at 9:05 a.m.

PUBLIC COMMENTS:  Sherrie Koppelman, RN, Reno Vein Clinic, submitted a practice question for the upcoming April meeting, but gave a short presentation to prepare the committee for future consideration. Her question was, “Is it within the scope of practice for an RN and an APN to perform nonablative laser treatments for spider veins and telangiectases, hair removal/reduction, and facial and skin rejuvenations?”

A.  APPROVAL OF MINUTES—December 17, 2003 meeting:  The minutes of the previous

meeting were approved as written.

B.  OLD BUSINESS:

1.      Review and discussion of infusion pump settings and subcutaneous sites-LPNs in the                   home setting, submitted by Nathan Adelson Hospice (NAH):  Dottie Jones presented a revised policy related to this issue to be utilized at NAH. The committee voted to endorse the revised policy with the following further revision: remove “palliative care patients” from the policy so that the policy would include only hospice patients. D. Scott will forward a letter to NAH outlining the outcome of the committee review. MOTION CARRIED.

2.      Discussion regarding Nevada licensure requirement for out-of-state corporate nurse                      consultants:  F. Olmstead presented a draft practice decision regarding parameters for licensure requirements for nurse consultants, surveyors, or nurse educators who give national seminars in Nevada. The committee suggested: 1. “chief nurse” be added to item #3 under “The following conduct includes, but is not limited to, conduct that is considered to be delivering patient care in the role of the licensed nurse: . . .”  2. under “The following conduct includes, but is not limited to, conduct that is NOT considered to be delivering patient care in the role of the licensed nurse:” item #6, “charts” be changed to “records” and “and no recommendations regarding patient care are made as a result of the audit.” be deleted, and 3. add “#8. Making recommendations regarding global patient care.”  The committee recommended the proposed practice decision be presented to the Board at the March, 2004 Board meeting.  MOTION CARRIED.

C.  NEW BUSINESS:

1.      The LPN scope related to the Functional Independent Measurement (FIM) in the    rehabilitation hospital setting: This item was continued to the next NPAC meeting for review upon presentation.

2.      Discussion of the role of unlicensed assistive personnel in a supportive living

arrangement (SLA) submitted by the Division of Mental Health and Developmental Services:  Linda Suzanne, Jennie Shipp, and Lora Olvera presented information about patient care services in the Division’s supportive living arrangement settings. Registered nurses are involved peripherally in this setting in that an RN is required to do an annual nursing assessment on individuals in the SLA setting. Nurses provide education to the unlicensed assistive personnel and/or caregivers. Other oversight includes the state’s responsibility in providing quality improvement in the SLA setting. Quarterly evaluations are done by social workers in the SLA setting. Needs of the individuals in the SLA setting may include assistance or actual administration of prescription medications and feeding through a G-tube. Nurses are involved in some instances, but the question being submitted to the committee is for guidance related to how nurses should be involved in the care given to individuals in the SLA setting. The committee recognized the need for this type of setting, but requested that further discussion and further information be presented at the next NPAC meeting. K. Panelli will invite Jeri Bennet from Medicaid to speak to the issue of UAPs.

3.      General discussion regarding unlicensed assistive personnel: D. Scott introduced this agenda item in conjunction with agenda item, C.2. The theme of the discussion was that the NSBN must be proactive in addressing the RN’s role in the utilization of the UAPs.  Current regulation outlines the RN’s role in supervision of “other personnel” in the delivery of patient care.

4.      Discussion of LPN access of ports with Huber needle submitted by IHS Education:  Discussion resulted in the committee’s recommending that it is not within the scope of practice of an LPN to access ports with a Huber needle. The committee members agreed that central access with a Huber needle would require ongoing RN assessment and is challenging to the RN’s skills. D. Scott will write a letter in response to K. Davis’ request for committee review. 

5.      Review and discussion of NAC 632.455: Dee Hicks, Chief Nursing Officer of Sunrise Hospital, submitted a request for clarification of the new regulation NAC 632.455. It appears that there is an inconsistency between NAC 632. 450 and 455. Board staff will explore the requirements to add “steroids” to NAC 632.455.  Ken Steinberg, LPN, submitted a request for the committee to review the definition of “piggyback” in NAC 632.450. The committee believes the intent of the regulation is that a “piggyback” may be administered peripherally through either an existing line or a lock. They discussed that “piggyback” may be an outdated term and may need to be rephrased in regulation in the future. Board staff will follow up related to addressing this issue for a possible change in regulation at a later date. 

ADJOURNMENT:  The meeting was adjourned at 11:30 a.m.