Notice of Change/Withdrawal

Board of Nursing
64B9-8.005: Unprofessional Conduct
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 36 No. 33, August 20, 2010 issue of the Florida Administrative Weekly.

64B9-8.005 Unprofessional Conduct.

(1) through (12) No change.

(13) Practicing beyond the scope of the licensee’s license, educational preparation or nursing experience;

(13)(14) Using force against a patient, striking a patient, or throwing objects at a patient;

(14)(15) Using abusive, threatening or foul language in front of a patient or directing such language toward a patient;

(15) Practicing beyond the scope of the licensee’s license, educational preparation or nursing experience, including but not limited to: administration or monitoring the administration of any medication intended to create an altered level of consciousness that is a deeper level than moderate sedation for a surgical, diagnostic or therapeutic procedure by a registered nurse or licensed practical nurse; provided:

(a) A registered nurse may, pursuant to physician order, administer or monitor the administration of medications to achieve deep sedation to a patient who is continuously monitored and mechanically ventilated with a secured, artificial airway. Examples of medications used for deep sedation in this situation include, but are not limited to, propofol, pentothal and dexmedetomidine. Due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonist medications, even if moderate sedation is intended, patients receiving propofol should receive care consistent with that required for deep sedation. Therefore the administration of propofol should only be performed by a practitioner experienced in general anesthesia and not by a registered nurse, with the exception of a patient who is continuously monitored and mechanically ventilated with a secured, artificial airway. When a physician is actively managing a patient’s sedation, a registered nurse may monitor the patient under circumstances that may include both moderate and deep sedation.

(b) A registered nurse may administer prescribed pharmacologic agents to non-mechanically ventilated patients for the purpose of moderate sedation in anticipation of anxiety and or discomfort during a time-limited surgical, diagnostic or therapeutic procedure. The registered nurse must continuously monitor the patient throughout the procedure and have no other responsibilities that would require leaving the patient unattended or would compromise continuous monitoring during the procedure. The registered nurse must document the patient’s level of consciousness at least every five minutes during the procedure. In the event a deeper level of sedation (such as deep sedation or general anesthesia) results from the administration of prescribed pharmacologic agents, the procedure must be stopped and the level of sedation returned to moderate sedation with the assistance of the prescribing physician or credentialed anesthesia provider.

(c) A registered nurse or licensed practical nurse may, pursuant to physician order, administer or monitor the administration of medications for palliative sedation in a hospice program.

(d) In order to administer or monitor any pharmacologic agents in accordance with paragraph (a) or (b) above, a registered nurse must:

1. Prior to any administration or monitoring of any pharmacologic agents, successfully complete a program of study which reflects the extent of privileges requested and which will include a criteria-based competency evaluation. At a minimum, course content will include: pharmacology and physiology, physical assessment and monitoring techniques, airway anatomy, airway management techniques and an opportunity for skill development. The evaluative criteria will cover knowledge and psychomotor skills in assessment and monitoring, principles of pharmacodynamics and pharmacokinetics (onset, duration, distribution, metabolism, elimination, intended and adverse effects, interactions, dosages and contraindications), basic and difficult airway management, mechanical ventilation, and cardiopulmonary resuscitation. The registered nurse must also be certified in advanced cardiac life support;

2. Complete a patient assessment and ensure that the practice setting requires that the physician prescribing the pharmacologic agent has evaluated the patient based on established criteria;

3. Pharmacologic agents that may be administered by a registered or practical nurse pursuant to paragraph (b) shall not include medications that are intended to result in loss of consciousness such as propofol, penthothal, dexmedetomidine, or any medication which the manufacturer’s package insert states should be administered only by individuals trained in the administration of general anesthesia.

4. Ensure that the practice setting requires that the prescribing physician is immediately available throughout the procedure and recovery period;

5. Ensure that written policies and procedures for managing patients who receive moderate sedation are reviewed periodically and are readily available within the practice setting;

6. Ensure that the practice setting has in place a quality assurance and performance improvement process that measures patient, process and structural outcome indicators; and

7. Evaluate the patient for discharge readiness based on specific discharge criteria and ensure that the practice setting requires that the physician approves of the patient discharge.

(e) The following definitions apply for purposes of this rule:

1. Deep sedation means a medication-induced depression of consciousness that allows patients to respond purposefully only after repeated or painful stimulation. The patient cannot be aroused easily, and the ability to maintain a patent airway independently may be impaired with spontaneous ventilation possibly inadequate. Cardiovascular function usually is adequate and maintained.

2. General anesthesia means the patient cannot be aroused, even by painful stimulation, during this medication-induced loss of consciousness. Patients usually require assistance in airway maintenance and often require positive pressure ventilation due to depressed spontaneous ventilation or depression of neuromuscular function. Cardiovascular function may also be impaired.

3. Moderate sedation means a minimally depressed level of consciousness that allows a surgical patient to retain the ability to maintain a patent airway independently and continuously and respond appropriately to verbal commands and physical stimulation.

4. Immediately available means having a health care provider trained in advanced cardiac life support and resuscitation skills available to assist with patient care within five minutes.

5. Palliative sedation means the use of medications intended to provide relief of intractable or refractory symptoms by inducing varying degrees of unconsciousness in imminently dying patients.

6. Refractory symptoms means symptoms that cannot be adequately controlled in a tolerable time frame despite use of alternate therapies, and seem unlikely to be controlled by further invasive or noninvasive therapies without excessive or intolerable acute or chronic side effects or complications.

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Joe Baker, Jr., Executive Director, Board of Nursing, 4052 Bald Cypress Way, Bin #C02, Tallahassee, Florida 32399-3252