Direct Entry Midwife
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The RN delegating nurse is the primary decision maker and is the only person who can determine whether insulin administration can be delegated to the CMT, including the drawing up of insulin. The DDA MTTP Training Program permits the RN to exercise judgment to permit delegating insulin administration (including drawing up of insulin) to a CMT. There was an error in the original DDA - MTTP manual, however, corrected information and replacement pages for the MTTP have been provided to each DDA RN who completed the RN, CM/DN Training Program. These replacement pages permit the RN, CM/DN to delegate drawing up and administration of insulin to the CMT
The monitoring of insulin pumps cannot be delegated because nursing judgmentand interpretation of the readings is required.
In the event of a hypoglycemic emergency, a glucagon injection may be delegated to the CMT to administer, if essential requirements have been met. These requirements include, but are not limited to the following:
Current HCP order;
The glucagon injection must be prepared utilizing a single dose, self
contained, pharmacy dispensed kit with a subcutaneous needle;
The preparation procedure may not include the calculating or wasting of the dose (the kit must have the exact amount of medication and dilutant to be used);
Training on use of the glucagon kit;
Procedure for checking the expiration date of the glucagon kit;
Documentation of staff competency in medication preparation and injection technique (e.g., practice demonstration and ongoing competency checks);
Protocol/directions to include when to give the injection, and a check list of yes or no questions detailing the presence or absence of the signs/ symptoms of hypoglycemic reaction;
Emergency notification protocols; and,
Documentation of occurrence and administration.
Yes, the assessment and evaluation process should include blood pressure, pulse, respiration checks, and temperature.
If an agency has an AED available for use in the event of a cardiac arrest, the agency needs to have a policy addressing the use of the AED. Documentation of staff training in the use of the AED must be accessible and retrievable.
The use and reuse of Single Use Devices (SUDs) was discussed with Dr. Brenda Roup, PhD, RN, CIC, and DHMH Nurse Epidemiologist. The following DDA guidelines were developed by the DDA regional nurses with Dr. Rupp’s guidance.
There are many products that are available OTC that the RN may select and recommend for use. In addition, the Board has an educational document addressing the conditions that permit an RN to select and recommend the use of an OTC. In order for the RN to make recommendations on the use of the OTC the conditions referenced in the Board’s document must be complied with. The following examples are intended as a guide for the RN but are not all inclusive. The use of the OTC would be incorporated in the Client’s care plan and in the training for staff. Selection of the OTC’s and recommendations for use must be permitted by the agency’s written policies. Training must include all staff.
Very often renewal orders in DD are signed by a HCP who did not write the original order. The implication for any HCP who signs renewal orders is that the HCP is responsible for the orders for which the HCP signs. It continues to be a “Best Practice” recommendation that a HCP within a designated sub-specialty sign for the medications specific to that sub-specialty. For example, the ordering and management of psychotropic medications is best handled by psychiatrists.
There is no law requiring 911 to be called for a seizure. The DDA MTTP Training Program does however require that 911 be called for a seizure lasting 5 minutes or longer. One need not call 911 as stipulated in the DD-MTTP training program if a healthcare protocol for that DD-client is developed in conjunction with and signed by the HCP. The protocol would need to be specific and well documented.
The following guidelines were developed by the DDA regional nurses with Dr. Brenda Roup, PhD, RN, CIC, DHMH Nurse Epidemiologist; and, following review of COMAR 10.06.06 which defines medical waste. The following items may be placed in regular trash:
The HRST is not a required tool. However, it is highly recommended as a reliable tool that has been very effective in helping to identify individuals who may require an RN initial nursing assessment; or a nursing care plan; or nursing delegation of a nursing function.
An Epipen is an emergency intervention and anyone can be trained to administer it. The person does not have to be a CMT. Training documentation should be accessible and retrievable.
Clients attending a day or vocational program should be screened by the provider agency to identify the need for nursing intervention. It is recommended that a formal screening tool, such as the HRST, or another professionally accepted health screening tool, be completed by a licensed nurse or other appropriate provider representative to make a preliminary determination of the need for:
When utilizing the HRST, the results, (along with the individual’s medical history), should be reviewed by the RN for a final decision as to whether or not a nursing assessment is indicated. Individuals with chronic health conditions, while not requiring on-site nursing delegation, may still require individual education. Therefore, the nurse may determine that there is a need to provide health teaching or counseling to the unlicensed care provider, employer, or client. Subsequently, the educational health instructions by the nurse may be supplemented by providing standardized information (see COMAR 10.27.11.06) via pamphlets, video, handouts, etc. It is recommended that educational instructions/directions be accessible to the unlicensed care provider and reviewed on a routine basis. This may be completed in collaboration with other interdisciplinary members (nutritionist, OT/PT, speech, etc). Training must be documented, accessible and retrievable.
the Client (IP), the personal well-being of the individual client must be considered including “Receiving health care services that respond to the client’s needs...” and COMAR 10.22.02 A (5) “having one’s basic needs met.” The client’s healthcare needs must be assessed and if medications or other nursing interventions are needed, those services must be provided.
The LPN may not triage. The LPN may serve as “On Call” IF protocols are in place which specify disposition of common routine calls. The designated decision maker for all triage calls must be either an RN or MD.
Consistent with the Standards of Practice for the Registered Nurse COMAR 10.27.09 the RN assuming care of the individual MUST perform an “initial” assessment on each individual in their caseload. In addition, the new RN,CM/DN assuming the caseload must review the individual’s care plan to assure the care plan is complete and accurate and to assure staff are aware of how to care for the individual.
At the time of discharge from the hospital, all orders for medications/treatments must be re-ordered by the HCP. If medication and treatment orders for the client are to be continued as they were at the time of the admission to the hospital, an order authorizing the continuation of all pre-hospital orders must be written. For example, “resume previous medication and treatment orders”.
There is no regulation that specifies that a RN must see an individual client upon discharge from a hospital. However, under COMAR 10.27.11.03 D, when delegating a nursing task, the nurse shall “make an assessment of the patient’s nursing care needs before delegating the task”. In addition, the RN Standards of Practice COMAR 10.27.09 (I)(1) states the RN may delegate nursing tasks to individuals who are competent to perform the nursing tasks. The RN is accountable for practicing nursing in compliance with all Board statutes and regulations and exercising reasonable prudent judgment. The clinical status of the client, the reason for the hospital admission, and the discharge orders and instructions for the client’s care -will dictate the timeliness with which the RN needs to see the client. An example may be – a client returns to the agency at 7PM after having a bowel resection and hospital stay of 10 days with orders for tube feedings. A prudent nurse would assess the client for bowel sounds before delegating tube feedings or delegating medication administration through the G-Tube.
Yes, the MBON permits a 30 day grace period for the renewal of the CMT certificate beyond the expiration date of the CMT’s certificate. For example, the certificate expires February 28, 2007, then the CMT has until March 28, 2007 to complete the renewal process (including submission of the online clinical update and the renewal form).
The “expired” CMT contacts the Maryland Board of Nursing (MBON) at 410-585-1918 and requests a renewal application. The CMT gives the renewal application to the RN, CM/DN approved to teach the 20 Hour CMT training program. After completing the training program and the renewal application, the renewal application is sent to the MBON with the required renewal fee and a Class List. It is recommended that a copy be retained for the agency’s record. It will take approximately 30 days for the updated information to appear on the MBON website. This information should be verified by the RN/agency’s designee by checking the MBON website. The “expired” CMT does not complete a second initial application form.
When a CMT trained in another Board approved CMT program, is hired by a DD agency, it is up to the agency RN’s discretion to determine what training will be necessary for the new CMT employee to safely function as a CMT in the DD agency. While it is not required that the CMT repeat the entire DDA-MTTP, the delegating RN must ensure that the CMT has received training that is specific to the DD population and the employer’s policy/procedures (e.g. high risk drugs, common disease process, regulations applicable to DDA etc). Training documentation must be accessible and retrievable.
The medication technician may work up to 60 days following the medication technician course completion. If the MT does not receive notification of certification within 30 days of submission of the application, the MBON should be contacted at 410-585-1918 or 410-585-2051.
If the person is repeating the training at the request of the delegating nurse or the employer, (for example, errors in medication administration and it is not time to renew the CMT certificate), no information is sent to the MBON. The information is simply placed in the individual’s personnel folder, etc. If the individual can not be remediate and their performance as a CMT does not meet safety standards then a complaint may need to be filed with the Board. The complaint form is available on the Board’s web page at www.mbon.org.
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