11

LICENSURELICENSURECRNA PRACTICE IN WASHINGTON STATECRNA PRACTICE IN WASHINGTON STATE

22

WAC 246-840-302WAC 246-840-302

• (2) An ARNP must maintain current (2) An ARNP must maintain current certification by an accredited certifying body certification by an accredited certifying body as identified in subsection (3) of this section. as identified in subsection (3) of this section. An ARNP license becomes invalid when the An ARNP license becomes invalid when the certification expires.certification expires.

• (c) For CRNA designation, the CRNA (c) For CRNA designation, the CRNA exam from Council on Certification of Nurse exam from Council on Certification of Nurse Anesthetists.Anesthetists.

33

AANA CertificationAANA Certification

• 40 hours of approved continuing education every 40 hours of approved continuing education every two years, document substantial anesthesia two years, document substantial anesthesia practice, maintain current state licensure, and practice, maintain current state licensure, and certify that they have not developed any conditions certify that they have not developed any conditions that could adversely affect their ability to practice that could adversely affect their ability to practice anesthesia.anesthesia.

• Annual Dues Annual Dues $645 $645

• Biannual Recertification $100Biannual Recertification $100

• There is a $300 fee to submit documentation of the There is a $300 fee to submit documentation of the required 40 CE credits to NBCRNA that is waived for required 40 CE credits to NBCRNA that is waived for active AANA members or those who have active AANA members or those who have purchased this service from AANA. purchased this service from AANA.

44

ARNP SCOPE OF PRACTICEARNP SCOPE OF PRACTICE

• The Washington ARNP scope of practice was broadened to include “perform procedures or provide care services that are within the scope of practice according to the Commission approved certification program;”

• The identification of Commission approved certification examinations are those accepted by the National Commission on Certifying Agencies or the American Boards of Nursing Specialties {Refer to WAC 246-840-302(3) for programs and approved examinations}.

http://www.doh.wa.gov/Portals/1/Documents/6000/ARNPFAQs.pdfMarch 2009

55

AANA SCOPE OF PRACTICEAANA SCOPE OF PRACTICE

• Performing and documenting a preanesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering preanesthetic medications and fluids; and obtaining informed consent for anesthesia. Developing and implementing an anesthetic plan.

• Initiating the anesthetic technique which may include: general, regional, local, and sedation. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient’s physical status.Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic. http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

66

AANA SCOPE OF PRACTICEAANA SCOPE OF PRACTICE

• Managing a patient’s airway and pulmonary status using current practice modalities. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support.

• Discharging the patient from a postanesthesia care area and providing postanesthesia follow-up evaluation and care.

• Implementing acute and chronic pain management modalities.Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques.

http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

77

AANA ADDITIONAL DUTIESAANA ADDITIONAL DUTIES

• Administration/management: scheduling, material and supply management, development of policies and procedures, fiscal management, performance evaluations, preventative maintenance, billing, data management, and supervision of staff, students or ancillary personnel.

• Quality assessment: data collection, reporting mechanism, trending, compliance, committee meetings, departmental review, problem-focused studies, problem solving, interventions, documents and process oversight.

• Education: clinical and didactic teaching, BCLS/ACLS instruction, in-service commitment, EMT training, supervision of residents, and facility continuing education.

• Research: conducting and participating in departmental, hospital-wide, and university-sponsored research projects. http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

88

AANA ADDITIONAL DUTIESAANA ADDITIONAL DUTIES

• Committee appointments: assignment to committees, committee responsibilities, and coordination of committee activities.

• Interdepartmental liaison: interface with other departments such as nursing, surgery, obstetrics, postanesthesia care units (PACU), outpatient surgery, admissions, administration, laboratory, pharmacy, etc.

• Clinical/administrative oversight of other departments: respiratory therapy, PACU, operating room, surgical intensive care unit, pain clinic, etc.

http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

99

Licensure RequirementsLicensure Requirements

99

CE $

Washington State RN

NA $101 yearly

Washington State ARNP

30 credits every 2 years*

$97 every 2 years

Washington State RxA

30 credits initially, 15 credits every two years

No additional fee

NBCRNA Certification

40 credits every 2 years

$100 every 2 years

AANA Membership $650 per year

DEA Licensure$791 every three years

Total yearly:45 credits every 2 years

$850 / $1114 per year

*Personal communication, Janice Pulvino, DOH

1010

RCW 18.79.240RCW 18.79.240http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.240

In the context of the definition of registered nursing practice and advanced registered nursing practice, this chapter shall not be construed as:

(r) Prohibiting advanced registered nurse practitioners, approved by the commission as certified registered nurse anesthetists from selecting, ordering or administering controlled substances as defined in Schedules II through IV of the Uniform Controlled Substances Act, chapter 69.50 RCW, consistent with their commission recognized scope of practice subject to facility specific protocols, and subject to a request for certified registered nurse anesthetist anesthesia services issued by a physician licensed under chapter 18.71 RCW, an osteopathic physician and surgeon licensed under chapter 18.57 RCW, a dentist licensed under chapter 18.32 RCW, or a podiatric physician and surgeon licensed under chapter 18.22 RCS, the authority to select order and administer Schedule II through IV controlled substances being limited to those drugs that are to be directly administered to patients who require anesthesia for diagnostic, operative, obstetrical or therapeutic procedures in a hospital, clinic, ambulatory surgical facility , or the office of a practitioner licensed under chapter 18.71, 18.22, 18.36, 18.36A, 18.57, 18.57A or 18.32 RCW.

1111

RCW 18.79.240RCW 18.79.240

“select meaning the decision making process of choosing a drug, dosage, route and time of administration: and “order” meaning the process of directing licensed individuals pursuant to their statutory authority to directly administer a drug or to dispense, deliver or distribute a drug for the purpose of direct administration to a patient, under instruction of the certified registered nurse anesthetist. “Protocol” means a statement regarding practice and documentation concerning such items as categories of patients, categories of medications, or categories of procedures rather than detailed case-specific formulas for the practice of nurse anesthesia.

http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.240http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.240

1212

RCW DefinitionsRCW Definitions

• Select: Select: the decision-making process of choosing a drug, the decision-making process of choosing a drug, dosage, route, and time of administration. dosage, route, and time of administration. • Example: Example: The CRNA, based upon the surgical procedure and The CRNA, based upon the surgical procedure and

the patientthe patient’’s health status, selects sevoflurane as the s health status, selects sevoflurane as the inhalational agent for the anestheticinhalational agent for the anesthetic. .

• Order: Order: the process of directing licensed individuals to the process of directing licensed individuals to directly administer a drug to a patient, under instructions of directly administer a drug to a patient, under instructions of the CRNA. the CRNA. • Example: Example: The CRNA in PACU writes an order on the patientThe CRNA in PACU writes an order on the patient ’’s s

chart for the patient to receive 25 mcg of fentanyl q 20 minutes chart for the patient to receive 25 mcg of fentanyl q 20 minutes PRN painPRN pain. .

• Administer: Administer: Directly apply or inject the medication to the Directly apply or inject the medication to the body of a patient. body of a patient. • Example: Example: The CRNA administers 100 mg of propofol to the The CRNA administers 100 mg of propofol to the

patient by IV injectionpatient by IV injection. .

1313

LimitationsLimitations• An employer or health care institution, public or private,

can choose to limit prescribing privileges of any credentialed health care provider with prescriptive authority.

• The Nursing Commission, Medical Board and Pharmacy Board have no jurisdiction or ability to overrule these institutional policies.

• State and Federal regulations both define our practice. State and Federal regulations both define our practice. Whichever is more restrictive must be applied.Whichever is more restrictive must be applied.

• Washington Law : Washington Law : https://apps.legwagov/RCW/default.aspx?cite=69.50.101. https://apps.legwagov/RCW/default.aspx?cite=69.50.101.

• DEA Regulations : DEA Regulations : http://www.deadiversion.usdoj.gov/pubs/manuals/pract/inhttp://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.htmldex.html

1414

DEA APPLICATIONDEA APPLICATION

• To obtain a DEA registration, a practitioner must apply using a DEA Form 224. Applicants may submit the form by hard copy or on-line. Complete instructions accompany the form. To obtain the application, DEA may be contacted at www.DEAdiversion.usdoj.gov

• DEA registration grants practitioners federal authority to handle controlled substances.

• Registration Requirements:• Every person or entity that handles controlled substances must be

registered with DEA or be exempt by regulation from registration.

• Fee: $791 every 3 years.

1414

DEA Practitioner Manual, 2006 Edition p 7.

1515

DEA DefinitionsDEA Definitions

• Legend Drugs: Legend Drugs: All drugs requiring a All drugs requiring a prescription from a licensed individual before prescription from a licensed individual before they can be sold to an individual. Controlled they can be sold to an individual. Controlled substances are a subset of legend drugs. substances are a subset of legend drugs.

• Controlled Substances: Controlled Substances: means a drug, means a drug, substance, or immediate precursor included in substance, or immediate precursor included in Schedules I through V as set forth in federal or Schedules I through V as set forth in federal or state laws, or federal or board rules. state laws, or federal or board rules.

1616

DEA DefinitionsDEA DefinitionsThe problem:The problem:

• Prescription: Prescription: An order for medication which is to An order for medication which is to be dispensed to the ultimate user. This does not be dispensed to the ultimate user. This does not include an order for medication which is dispensed include an order for medication which is dispensed for immediate administration to the ultimate user for immediate administration to the ultimate user (e.g., an order to dispense a drug to a bed patient (e.g., an order to dispense a drug to a bed patient for immediate administration in a hospital is not a for immediate administration in a hospital is not a prescription – see the definition for prescription – see the definition for ““orderorder”” above). above).

• Prescribe: Prescribe: Based upon the definition above, to Based upon the definition above, to prescribe is to write an order for a medication that prescribe is to write an order for a medication that will be dispensed to the patient. will be dispensed to the patient.

1717

DEA Appendix A DefinitionsDEA Appendix A Definitions

• Dispense To deliver a controlled substance to an ultimate user or research subject by, or pursuant to the lawful order of, a practitioner, including the prescribing and administering of a controlled substance and the packaging, labeling, or compounding necessary to prepare the substance for such delivery.

Example: Example: A pharmacist dispenses 20 A pharmacist dispenses 20 oxycodone tablets to a patient based upon a oxycodone tablets to a patient based upon a prescription written by a physician or a CRNA prescription written by a physician or a CRNA with prescriptive authority and DEA registrationwith prescriptive authority and DEA registration. .

DEA Practitioner Manual, 2006 Edition

1818

DEA Appendix A DefinitionsDEA Appendix A Definitions

• Administer Administer The direct application of a controlled The direct application of a controlled substance to the body of a patient or research substance to the body of a patient or research subject by 1) a practitioner or (in his presence) by his subject by 1) a practitioner or (in his presence) by his authorized agent, or 2) the patient or research authorized agent, or 2) the patient or research subject at the direction and in the presence of the subject at the direction and in the presence of the practitioner, whether such application is by injection, practitioner, whether such application is by injection, inhalation, ingestion, or any other means.inhalation, ingestion, or any other means.

DEA Practitioner Manual, 2006 Edition

1919

Appendix A DefinitionsAppendix A Definitions

• Mid-level Practitioner Mid-level Practitioner An individual practitioner, An individual practitioner, other than a physician, dentist, veterinarian, or other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered or otherwise podiatrist, who is licensed, registered or otherwise permitted by the United States or the jurisdiction in permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled which he/she practices, to dispense a controlled substance in the course of professional practice. substance in the course of professional practice. Examples of mid-level practitioners include, but are Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists, and physician assistants clinical nurse specialists, and physician assistants who are authorized to dispense controlled who are authorized to dispense controlled substances by the state in which they practice. substances by the state in which they practice.

DEA Practitioner Manual, 2006 Edition

2020

Prescribing Schedule II-IVPrescribing Schedule II-IV

• ARNPS may prescribe Schedule II-IV medications only after obtaining prescriptive authority

• {Refer to WAC 246-840-410 and www.doh.wa.gov/nursing}.

• Drug Enforcement Authority’s website: www.deadiversion.usdoj.gov

http://www.doh.wa.gov/Portals/1/Documents/6000/ARNPFAQs.pdfMarch 2009

2121

Practitioner’s Use of Hospital DEA Number

• Practitioners (e.g., intern, resident, staff physician, mid-level practitioner) who are agents or employees of a hospital or other institution may, when acting in the usual course of business or employment, administer, dispense, or prescribe controlled substances under the registration of the hospital or other institution in which they are employed, provided that:

• The dispensing, administering, or prescribing is in the usual The dispensing, administering, or prescribing is in the usual course of professional practice course of professional practice

• Practitioners are authorized to do so by the state in which they Practitioners are authorized to do so by the state in which they practice practice

• The hospital or institution has verified that the practitioner is The hospital or institution has verified that the practitioner is permitted to dispense, administer or prescribe controlled permitted to dispense, administer or prescribe controlled substances within the state substances within the state

• The practitioner acts only within the scope of employment in the The practitioner acts only within the scope of employment in the hospital or institution hospital or institution

• The hospital or institution authorizes the practitioner to dispense The hospital or institution authorizes the practitioner to dispense or prescribe under its registration and assigns a specific internal or prescribe under its registration and assigns a specific internal code number for each practitioner so authorized code number for each practitioner so authorized

2121

2222

HB 1486 HB 1486 June 7 2012June 7 2012

Allows Washington pharmacists to fill prescriptions for controlled substances written by advanced registered nurse practitioners (ARNPs) licensed outside of Washington working up to their scope of practice. This law amended the Controlled Substance Act y adding ARNPs to the list of practitioners with prescriptive authority for controlled substances in any state. ARNPs with prescriptive authority for controlled substances from Idaho and Oregon write prescriptions for their patient who may reside in Washington or may wish to have their prescriptions filled in Washington. The new law allows Washington pharmacies to fill these prescriptions for controlled substances.

ARNPs UNITED, AUSA: http://auws.org/

2323

The Opt outThe Opt out

• January 2001 Medicare removed the federal January 2001 Medicare removed the federal requirement for physician supervision of nurse requirement for physician supervision of nurse anesthesia practice. November 2001, Bush anesthesia practice. November 2001, Bush administration implemented a compromise in response administration implemented a compromise in response to protest by anesthesiologists, allowing state governors to protest by anesthesiologists, allowing state governors to opt out of the supervision requirement. to opt out of the supervision requirement.

Iowa December 2001 Washington October 2003

Nebraska Feb 2002 Alaska October 2003

Idaho March 2002 Oregon December 2003

Minnesota April 2002 Montana January 2004

New Hampshire June 2002 South Dakota March 2005

New Mexico Nov 2002 Wisconsin June 2005

Kansas April 2003 California June 2009

North Dakota October 2003 Colorado Sept 2010