Session 3: State Law and Standing Orders

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Session 3

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Session 3 State Law & Standing Orders: NEW JERSEY

Alexandra Stewart, JD Associate Professor Milken Institute School of Public Health George Washington University

Overview • Professions Practice Acts

• Identified: – Terms equivalent to Standing Orders – Terms equivalent to Vaccination – Elements of Immunization Practice

• Immunization Practice in NEW JERSEY

• Supervision Requirements

• Practice Settings

• Summary

Purpose Ensure supervising physicians understand: • Immunization practice = medical practice • All states have laws governing how physicians

delegate medical tasks to health professionals • Laws may address:

• The medical practice eligible for delegation • Which professionals may participate • Level of required supervision • Where the practice may occur

• Broad variability among states – No state authorizes all NPHPs to assess, prescribe and administer vaccines

State Law Review Reviewed all laws, regulations, case law, attorney’s general advisory opinions governing: • Medical Assistants • Midwives • Nurses

– Advanced Practice Nurse – Nurse Practitioner – Practical Nurse – Registered Nurse – Vocational Nurse

• Pharmacists • Physician Assistants

Terms Equivalent to “Standing Orders” 1. Standardized Procedures

2. Written Guidelines

3. Collaboration: – With collaboration – Collaborative practice – Collaborative practice agreement – Collaborative authority – Collaborating provider

4. Delegation – Delegated authority – Delegation order, agreement

5. Protocol – Prescriber-approved protocol

“Standing Orders” in NEW JERSEY Law Professional Equivalent Terms

Certified Nurse Midwife Advanced Practice Nurse • Nurse Practitioner • Clinical Nurse Specialist

As developed with a collaborating physician: • Standing Orders • Practice protocols • Written protocols

Certified Medical Assistant May administer injections as directed by a physician

Practical Nurse May administer medications as delegated by a registered nurse

Registered Nurse SILENT

Vocational Nurse SILENT

Pharmacist Physician’s standing order

Physician Assistant Protocols

Terms Equivalent to “Vaccination” • Immunization • Diagnostic or therapeutic regimens/measures • Drug or device by injection • Nonscheduled legend drug/substance* • Medication** • Pharmacological agents • Prescription drugs or devices

* LEGEND DRUGS are approved by the FDA and must be dispensed to the public only when a licenses physician or other licensed provider prescribes them. Legend drugs may be a controlled substance or a non-narcotic.

SOURCE “Legend Drug Law and Legal Definition.” USLegal.com. Available at: http://definitions.uslegal.com/I/legend-drug/.

** MEDICATION includes drugs and pharmaceuticals and may be administered by injection or other methods.

http://definitions.uslegal.com/I/legend-drug/

Defining “Vaccination” in NEW JERSEY Law Professional Terms

Certified Nurse Midwife Advanced Practice Nurse Nurse Practitioner Clinical Nurse Specialist

• Drugs • Medications • Preventive care services

Certified Medical Assistant Intradermal, intramuscular and subcutaneous injections Practical Nurse Medication Registered Nurse • Treatment for actual or potential health problems

• Vaccines (Related to distribution and administration of vaccines during shortage or an emergency)

Vocational Nurse SILENT Pharmacist FLU VACCINE:

• May be administered to ages 7+ • Under 18, only with parental consent • Under 12, only pursuant to prescribers prescription • 12+ prescription not required OTHER VACCINES: • Ages 18+ under non patient-specific standing orders

Physician Assistant Injections, Medications

State Law Review

Immunization Practice includes: Assessment: Screening, examining, diagnosing, treating

• EXCLUDES: merely collecting or reporting data, interviewing or taking patient history

Prescription: Oral, written or electronic • EXCLUDES: simply transmitting a prescription

issued by another provider

Administration: Injection, oral, nasal • EXCLUDES: Dispensing medication

Immunization Practice: NEW JERSEY Professional Assessment Prescription Administration


OWN AUTHORITY

DELEGATED

OWN AUTHORITY

Certified Medical Assistant PROHIBITED PROHIBITED DELEGATED

Practical Nurse SILENT SILENT DELEGATED

Registered Nurse OWN AUTHORITY SILENT OWN

AUTHORITY

Vocational Nurse SILENT SILENT SILENT

Pharmacist DELEGATED SILENT DELEGATED

Physician Assistant DELEGATED DELEGATED DELEGATED

Supervision Requirements Include

Medical Assistant Direct, within close proximity of supervisor, undefined supervision, at physician’s discretion

Midwife Collaborative agreements with supervising physicians if midwife is an Advanced Practice Nurse

Nurses in Advanced Practice Collaborative agreement with supervising physician/system governs entire practice

Supervision Requirements (cont.) Practical Nurse Direct, on-site supervision from physician, dentist, podiatrist, nurse in advanced practice, registered nurse, physician assistant

Registered Nurse In collaboration with physician, dentist, podiatrist

Vocational Nurse None listed

Pharmacist Under own license or under delegated authority, protocol

Physician Assistant With adequate physician supervision

Supervision Requirements: NEW JERSEY Professional Provision

Certified Nurse Midwife Nurse Practitioner Clinical Nurse Specialist

Practice must comply with written protocols developed with a collaborating physician who must be present or readily available through electronic communications

Registered Nurse SUPERVISION OF PRACTICAL NURSES, ANCILLARY NURSING PERSONNEL (AIDES, ASSISTANTS, ATTENDANTS, TECHNICIANS) • RN may delegate selected nursing tasks and must

provide on-site supervision as determined by delegating RN

• Delegation of Medication Administration requires extensive documentation

Supervision Requirements: NEW JERSEY Professional Provision

Certified Medical Assistant

Supervising physician must remain: • On premises, in reasonable proximity to treatment

room • Available to observe, assess and take necessary

actions if an adverse reaction or emergency occurs • Determine/document the MA is qualified and

graduated from an accredited program

ONLY PHYSICIANS ARE AUTHORIZED TO: • Assess patients and Prescribe injections MEDICAL ASSISTANT: • Must wear a clearly visible identification badge

indicating name and credentials

Supervision Requirements: NEW JERSEY Professional Provision Pharmacist Supervising physician must remain:

Easily accessible to the practice site, available by telephone, receive annual status reports on the immunization program

Physician Assistant

Direct physician supervision at all times: ALL SETTINGS: • Physical presence of physician, regular practice review, personal

review of all charts within 24 hours of an entry

INPATIENT SETTINGS: • Continuing or intermittent presence with constant availability

through electronic communications; regularly scheduled practice review; personal review of all charts and patient records and countersignature of all medical orders within 24 hours

OUTPATIENT SETTINGS: • Constant availability through electronic communications; regularly

scheduled practice review; review of charts within 48 hours of an entry.

Medical Assistant • Public, private ambulatory care setting, delegating

physician’s office, licensed clinics

Midwife • Public/private clinical settings, physician’s offices

Nurses in Advanced Practice (APN; CNS; NP) • Public/private clinical settings, patient’s home, schools,

occupational health, community health settings

Practical Nurse • Public/private clinical settings, patient’s home, schools,


Permissible Practice Settings

Registered Nurse • Public/private clinical settings, patient’s home, schools,


Vocational Nurse • Public/private clinical settings, patient’s home, schools,


Pharmacist • Hospitals, pharmacies, other health care facilities, jails

Physician Assistant • Clinical and community locations

Permissible Practice Settings (cont.)

Practice Settings: NEW JERSEY Professional Setting


Inpatient setting; other medically appropriate settings; licensed acute care facility; long-term care facility

Certified Medical Assistant Where the supervising physician practices medicine

Practical Nurse SILENT Registered Nurse SILENT Vocational Nurse SILENT Pharmacist SILENT Physician Assistant All medical care settings, including, but not

limited to a physician’s office, health care facility; institution; veterans’ home; private home; inpatient or outpatient setting

Summary: NEW JERSEY Professional Summary


May assess patients, prescribe and administer drugs, medications and preventive care services under own authority, standing orders and protocols developed with a collaborating physician

Certified Medical Assistant

May administer injections under direct physician supervision

Practical Nurse May administer medications as delegated by and under supervision of a registered nurse

Registered Nurse May assess patients and administer treatments under own authority

Pharmacist May assess patients and administer vaccines under standing orders and with physician supervision

Physician Assistant May assess patients, prescribe and administer injections and medications under protocols and direct supervision of a physician

Citations 1. N.J. Admin. Code 13:35-6.4 (2016) Delegation of administration of

subcutaneous and intramuscular injections to certified medical assistants

2. N.J. Admin. Code 13:37-6.2 (2016) Delegation of selected nursing tasks

3. N.J. Admin. Code 13:37-7.9 (2016) Prescriptive practice

4. N.J. Admin. Code 13:37-8.1 (2016) Standards for joint protocols between advanced practice nurses and collaborating physicians

5. N.J. Stat. 45:11-46 (2016) Certification Required

6. N.J. Stat. 45:11-49 (2016) Permitted duties of advanced practice nurse

7. N.J. Stat. 45:10-18 (2016) Certified nurse-midwife may prescribe drugs

8. N.J. Stat. 45:11-23 (2016) Definitions

9. N.J. Admin. Code 13:37-6.2 (2016) Delegation of selected nursing tasks

10. N.J. Admin. Code 13:37-6.4 (2016) Registered nurse obligations relating to delegations to a licensed practical nurse, CHHA, or assistive person

Citations

11. N.J. Stat. 26:13-23 (2016) New Jersey Vaccine Education and Prioritization Plan

12. N.J. Stat. 45:14-63 (2016) Administration of prescription medication directly to patient, immunizations

13. N.J. Admin. Code 13:35-6.26 (2016) Procedures for physician ordered immunizations performed by licensed pharmacists

14. N.J. Admin. Code 13:39-4.21 (2016) Procedures for physician ordered or government sponsored immunizations performed by pharmacists

15. N.J. Stat. 45:9-27.16 (2016) Allowable procedures

16. N.J. Stat. 45:9-27.18 (2016) Direct supervision required [Effective until August 1, 2016]

17. N.J. Stat. 45:9-27.18 (2016) Supervision [Effective August 1, 2016]

18. N.J. Stat. 45:9-27.15 (2016) Practice of physician assistant [Effective until August 1, 2016]

19. N.J. Stat. 45:9-27.15 (2016) Practice of physician assistant [Effective August 1, 2016]

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Session 3: State Law and Standing Orders