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Comment Letter to Pennsylvania State Board of Nursing
Quality and Patient Safety (State Board of Nursing)
Last Updated: 3/20/2007
March 20, 2007
Ann Steffanic, Board Administrator
Pennsylvania State Board of Nursing
Bureau of Professional and Occupational Affairs
P.O. Box 2649
Harrisburg, PA 17105-2649
RE: LPN IV Therapy Draft Regulations
Dear Members of the Pennsylvania State Board of Nursing,
The Hospital & Healthsystem Association of Pennsylvania (HAP), on behalf of its members, more than 225 acute and specialty hospitals and health systems, appreciates the opportunity to comment on the State Board of Nursing’s draft regulations concerning the role of licensed practical nurses with respect to intravenous therapy.
The regulations are of particular interest because of the increased utilization of peripherally inserted central catheters and other centrally inserted intravenous access devices in the patient population cared for in Pennsylvania hospitals and health systems. HAP encouraged the State Board of Nursing to address the role of the licensed practical nurse with central catheters and not just peripherally inserted central catheters as was done in the initial draft in 2003. HAP appreciates the efforts that the State Board has taken to incorporate many of HAP’s original recommendations into the revised draft, along with the thorough process the State Board has used to engage appropriate stakeholders even prior to releasing these draft regulations for further comment. This includes involvement of the regulated practical nurse community wherein the State Board held meetings in Erie and Harrisburg to understand practice in various organizational settings, and to obtain input from professionals as to the draft regulations. Additionally, HAP recognizes the work that the Pennsylvania State Board of Nursing has done with the directors of the state’s practical nurse education programs in developing a standard IV therapy curriculum.
HAP supports the overall direction taken by the Pennsylvania State Board of Nursing in the revisions it is recommending around the role of the licensed practical nurse in intravenous therapy. Specifically, HAP would like to offer the following comments and/or recommendations on how to improve or clarify the draft regulations.
§21.141. Definitions
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Add Definition of IV Access Devices
- HAP appreciates the inclusion of the definitions of the various types of catheters in the definition section; however, it might be helpful to include a definition of IV access devices which is used in §21.145(g)(3). In particular, HAP would recommend that unless otherwise specified in the regulations, all IV access devices include peripheral short catheters, peripheral midline catheters, peripherally inserted central catheters, and central catheters. Readers may not be clear about whether the provisions in this section relate to only peripheral intravenous catheters or all catheters, primarily because the next provision, §21.145(g)(4), allows only for the insertion or removal of a peripheral short catheter. HAP recommends the following definition for venous access device:
Venous Access Device — Any centrally or peripherally inserted catheter used for the purpose of intravenous infusion therapy.
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Modify Definition of Maintenance
– HAP recommends that the State Board revise its definition such that the definition would read,
Maintenance – occurs once IV therapy is initiated and includes observing, monitoring, and evaluating the patient, IV site, and related equipment.
It appears that the State Board of Nursing wants to differentiate that a higher skill level more appropriate for the professional registered nurse is required when IV therapy is initiated. On the other hand, IV therapy maintenance could fall under the purview of either the licensed practical nurse or professional registered nurse, particularly given the manner in which the State Board has developed the provisions contained in these draft regulations. Since assessment has traditionally been reserved for use in describing the role of the professional registered nurse and the State Board wants to convey that maintenance is something that could be done by licensed practical nurses as well as professional registered nurses, HAP recommends avoiding the use of the term assessment in this definition until such time as the State Board revisits the licensed practical nurse scope of practice and what it means when using the term assessment for licensed practical nurses. For this reason, HAP recommends using more neutral language such as observing, monitoring and evaluating in the definition for maintenance.
§21.145. Functions of the LPN
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Modify Language in Existing Regulation
– HAP recommends that the State Board of Nursing modify §21.145(a) to read,
The LPN is prepared to function as a member of the health care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing, and competency.
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Consider Inclusion of the Physician Assistant
– HAP recommends that the State Board of Nursing consider including physician assistant in §21.145(a)(1) and §21.145(f)(1), along with registered nurse, certified registered nurse practitioner, physician, or dentist. The most recently adopted State Board of Medicine regulations governing physician assistant practice state, “The physician assistant shall be considered the agent of the supervising physician in the performance of all activities, including the ordering of diagnostic, therapeutic, or other medical services.”
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Clarification in §21.145(g)
– HAP recommends that the State Board of Nursing revisit the provisions in this section to enhance clarity. HAP would recommend that those tasks that relate to all IV access devices be included under that heading. Otherwise, it is not clear whether the licensed practical nurse can perform some of the functions identified in this section with only selected IV access devices or all IV access devices. For instance, it is not clear whether the State Board envisions that the licensed practical nurse could observe and report subjective and objective signs of adverse reactions to IV administration and initiate appropriate interventions for all IV access devices; whether the licensed practical nurse could maintain, monitor, and discontinue blood, blood components, and plasma volume expanders through all IV access devices; and administer solutions to maintain patency through any type of IV access device through direct push or bolus routine since these functions are not listed under §21.145(g)(3).
HAP also questions whether the State Board intended in §21.145(g)(7) to include only patient controlled analgesia pumps in this provision, rather than any infusion device used to administer medications and other solutions. Additionally, HAP believes that the State Board would not want to limit the practice to only maintaining and discontinuing IV medications and fluids administered through some sort of pump or infusion device, since IV fluids and medications can also be administered without the use of such devices as is often the case in physician office practices.
§21.145a. Prohibited Acts
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Clarification
– As suggested above, HAP believes that it would be beneficial to consider grouping those functions that apply to all IV access devices and those that might be limited to selected IV access devices, such as central venous catheters to improve the clarity of the provisions contained in this section.
HAP is also unclear about what provision §21.145a.(e) means since it refers back to §21.145(g)(7) and §21.145(g)(8) which do not speak to direct IV push or IV bolus. HAP believes that the State Board intended to refer back to §21.145(g)(6), which indicates that the licensed practical nurse can only push those solutions to maintain IV patency, and cannot push or bolus medications. HAP recommends that the State Board develop language to make this clearer for the regulated community.
HAP has also included its previous recommendations related to the role of licensed practical nurse and IV therapy. In particular, HAP still believes that the two questions raised previously have not been adequately addressed in these regulations. HAP requests that the Board consider these outstanding issues as it makes revisions to this draft.
§21.145b. IV Therapy Curriculum Requirements
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Recommended Number of Hours
– HAP supports the adoption of a standardized course curriculum such that the course could be provided as part of a licensed practical nurse education program or outside of such a program. In discussion with HAP member hospitals and health systems, hospitals asked whether the State Board contemplated the need for some minimum number of hours that would be required to deliver the course content. HAP is not suggesting that the State Board consider regulating the number of course hours or how the course be implemented. However, it would be beneficial if the State Board worked with Pennsylvania’s licensed practical nursing programs to develop some guidance related to appropriate methods to teach the course and guidance on the number of hours needed to deliver the course content that could in turn be used in developing such a program, or could be used by employers to judge the adequacy of an IV therapy course attended by licensed practical nurses.
Licensed Practical Nurses in Other States
– The State Board specifically asked for comments related to licensed practical nurses seeking licensure by endorsement in Pennsylvania. The State Board is seeking feedback as to whether these licensed practical nurses should be required to complete a Pennsylvania IV therapy course, or whether course work completed outside of Pennsylvania could be used to satisfy the curriculum requirements.
In discussion with Pennsylvania hospitals and health systems about this subject, several comments emerged, including:
- To the extent possible, there should be recognition for the course work that a licensed practical nurse completed in another state. However, Pennsylvania hospitals and health systems recommend that the regulations include a provision that makes the licensed practical nurse responsible for providing evidence that he/she completed an IV therapy course and provide the course curriculum to his/her employer.
- Pennsylvania hospitals and health systems believed that it should fall primarily to the employer to assess the adequacy and equivalency of the IV therapy course completed by a licensed practical nurse outside of Pennsylvania. This is another reason why hospitals are requesting some guidance as to the appropriate range of hours that might be needed to deliver the content outlined in the course curriculum proposed by the Pennsylvania State Board of Nursing.
- Finally, Pennsylvania hospitals and health systems asked that they have the ability to consult with Pennsylvania State Board of Nursing staff to assist them in assessing equivalency and adequacy of IV therapy courses delivered outside of Pennsylvania should they have questions or concerns.
HAP appreciates the opportunity to provide comments to the State Board of Nursing on its draft licensed practical nurse and intravenous therapy regulations. HAP hopes that the State Board will consider HAP’s suggestions in improving the draft regulations.
If you have any questions about HAP’s comments, please feel free to contact me at 717-561-5308 or by e-mail at lgleighton@haponline.org.
Sincerely, Lynn G. Leighton
Vice President
Professional & Clinical Services
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