Q: Can LVNs in any practice setting be "on-call" to deal with after-hours issues called in by patients, families, or facility staff? Can a LVN perform "triage" duties (either telephone triage such as for home health or on-site such as an Emergency Room)? Finally, can a RN be on "back-up on-call" in case the LVN has questions? Can the RN be the one ultimately responsible [with the LVN relaying his/her assessment (telephonic or actual assessment)] to the RN?.
A: Triage is commonly defined as the sorting of patients and prioritizing of care based on the degree of urgency and complexity of patient conditions. Telephone triage is the practice of performing a verbal interview and making a telephonic assessment with regard to the health status of the caller. As the caller may not accurately describe symptoms, and/or may not accurately perceive or communicate the urgency of the situation or condition prompting the call, nurses who perform these functions must have specific educational preparation, as the consequences of inadequate triage can be devastating.¹
Though the BNE does not regulate employers, and the NPA and rules are not prescriptive to specific practice settings, the Board believes on-call duties, telephonic nursing, and/or being on-call to handle urgent/emergent issues telephonically are all beyond the scope of practice for LVNs. Exceptions could be made to this general stance in settings where the LVN utilizes an established, standardized and validated decision-tree process (most likely computerized) that guides the LVN through a specific pathway of questions leading to an end-point determination of recommended action for the caller. It is in settings where the LVN would be required to independently engage in assessment (either telephonically or face-to-face)for purposes of triaging a patient that are of concern to the Board.
The Board's concerns are based on the fact that LVNs are not educationally prepared, to perform triage assessments, either telephonically or in the role of the health care professional initially assessing a client to determine treatment priorities in any setting. A board document titled "Differentiated Entry Level Competencies of Graduates of Texas Nursing Programs"* states in part that "LVN nursing programs in Texas prepare entry-level bedside nurses to care for acutely and chronically ill patients with predictable health outcomes in structured healthcare delivery settings." This document further describes that LVNs are educated in basic head-to-toe assessment using the senses of sight, smell, touch, and hearing. In either telephonic or face-to-face triage, the LVN is likely to be dealing with a situation where the client's condition is not predictable.
In alignment with the educational preparation for vocational nursing, rule 217.11, Standards of Nursing Practice, establishes that LVNs "...collect data and perform focused nursing assessments of the health status of individuals"[217.11(2)(A)(I)]. NPA section 301.353 and rule 217.11(2) further establishe that LVNs have a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist.
Placing a LVN in a position to perform duties requiring comprehensive(versus "focused") assessments of patients potentially experiencing unpredictable changes in health status, as well as making independent nursing judgments (such as would be required for either telephonic or on-site initial triage) may place the LVN in a position that violates the BNE's Standards of Nursing Practice.
Both the Interpretive Guideline for LVN Scope of Practice Under Rule 217.11 and Position Statement 15.10 Continuing Education: Limitations for Expanding Scope of Practice, further clarify that while LVNs may expand their practice with post-licensure continuing education, this does not permit the LVN to expand his/her practice to a level that requires RN education, training, and licensure (such as comprehensive assessment). This relates to Rule 217.11(1)(B) which holds each nurse accountable to maintain client safety. This standard supersedes any doctor's order or facility policy, thus the nurse cannot avoid his/her "duty" to maintain client safety by placing responsibility for nursing actions on another party. Position Statement 15.14, Duty of a Nurse in Any Practice Setting, further clarifies the nurse's duty, regardless of the type of nursing license held.
It remains the opinion of the board (consistent with the opinion of the former Board of Vocational Nurse Examiners) that on-site triage and/or telephone triage (by an "on-call" LVN) that requires the LVN to perform a comprehensive assessment and make independent treatment decisions on the basis of information supplied by the client is beyond the scope of practice for a LVN. Triage is not taught in one-year vocational nurse education programs. The LVN has not received education in the complex and finite details of comprehensive assessment as provided in a professional registered nurse education program that would include the knowledge base necessary for on-site and telephone triage.
It is not acceptable to have either a RN or advanced practice nurse (APN) on "back-up call" to a LVN who is also responding only telephonically to clients in need. As the LVN's formal education does not prepare the LVN to perform telephonic assessments, the LVN may not be able to determine what information is essential to obtain and then relay to a RN or APN. In addition, if a client situation is emergent, even if the RN or APN subsequently call the client back, the delay in securing emergent treatment may result in serious harm or patient death.
LVNs On-Call/Telephone Triage in Independent Living Environments
LVNs and RNs have been disciplined in the past for not making prudent judgments with regard to taking appropriate and timely action to safeguard patients in an independent living environment. Regardless of job experience, a LVN does not have educational background equivalent to that of the RN, and is not educated or trained to analyze and synthesize symptoms or otherwise conduct a comprehensive assessment telephonically with a client. Additionally, if emergent action is needed and the LVN is unable to discern this need due to limited assessment abilities, assistance that may be necessary to save the client's life could be delayed.
The RN cannot under any circumstances assume "ultimate responsibility." RNs do not delegate to other licensed nurses (LVNs or RNs); RNs "make assignments" to other licensed nurses. Each nurse (LVN or RN) is responsible for making and/or accepting of assignments that are within the knowledge, skills, and abilities of the nurse performing the task [217.11(1)(S) and (T)].
"Medical Screening" in the ER:
The question of a LVN performing "triage" in an emergency room (ER) setting also raises another question----is the LVN being asked to perform a "medical screening" examination? This term refers to a requirement of the Emergency Medical Treatment and Active Labor Act (EMTALA) law. EMTALA requires that every patient who comes to the ER be assessed for the existence of an "emergency medical condition" before the patient can be transferred or discharged from the ER. For more information, you may wish to visit the following web site http://www.emtala.com.
The board believes that the performance of a medical screening exam is not within the scope of practice for a LVN, regardless of years of experience or post-licensure continuing education at the LVN level. The board believes a comprehensive RN nursing assessment would be the minimum level of assessment acceptable to conduct a medical screening exam. As defined in §217.11(2)(A) the scope of practice for a LVN is limited to performance of a hands-on focused assessment of an individual client. Even if a physician wishes to delegate assessment of medical conditions and/or treatments to a LVN, the LVN is accountable for only accepting those assignments within his/her scope of practice as outlined in the NPA and in Rule 217.11, Standards of Nursing Practice. Position Statement 15.11 Delegated Medical Acts contains additional information on physician delegation to nurses.
Other Practice-Setting Examples (Physician's Office, Call Center)
The Board is aware that LVNs may also practice in "call centers" (such as a poison control center), physician's offices, or other similar settings. In settings where a physician(s) is/are present, there may be a set of standardized guidelines approved by the physician(s) to establish treatment priorities within the office environment under the supervision of the physician(s). Such practice settings may be appropriate for a qualified LVN. In call centers, the LVN typically has access to computer systems that guide the LVN in asking specific symptom-driven decision-tree questions that then dictate what action the LVN recommends to the caller.
Evaluation of the system utilized is recommended to assure (1) it is appropriate for the practice setting, (2) that it has an established standardized and valid/reliable decision-making process (preferably determined outside of the institution/facility in which it is used), and (3) that the LVN has access to an appropriate supervisor for situations that might exceed the capabilities of any computer-based algorithm treatment model.
It is not the intent of the Board to preclude LVNs from practicing in settings where the LVN has sufficient guidance/support/supervision to promote both safe LVN practice as well as client safety. The LVN should not practice in settings where he/she is required to perform comprehensive assessments and make independent treatment decisions or establish treatment priorities as described in this statement.
The BON cannot provide legal advice or counsel to nurses; however, a nurse may wish to seek his/her own legal counsel for advice on the best course of action for the individual nurse.References:¹ Emergency Nurses Association Position Statement on Telephone Advice(1991; Revised 12/2001; www.ena.org; (847)460-4000; “Triage,” by Dr. Robert Derlet, 09/14/2004; http://www.ena.org/about/position/position/Telephone_Advice_-_ENA_PS.pdf.