session 3: state law and standing orders
TRANSCRIPT
THIS INITIATIVE IS BEING SUPPORTED BY A SPONSORSHIP FROM PFIZER
Session 3
Disclosure The Immunization Action Coalition has been responsible for all aspects of content development for the enclosed presentation and all other assets supporting the Take a Stand™ program. Any questions should be directed to the Immunization Action Coalition.
Pfizer is supporting this initiative because it provides focus on the importance of adult immunization. Pfizer has had no role in the creation of content for this presentation or other assets supporting the Take a Stand™ program workshops and therefore accepts no responsibility for the content.
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.
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
Certified Nurse Midwife Advanced Practice Nurse Nurse Practitioner Clinical Nurse Specialist
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,
occupational health, community health settings
Permissible Practice Settings
Registered Nurse • Public/private clinical settings, patient’s home, schools,
occupational health, community health settings
Vocational Nurse • Public/private clinical settings, patient’s home, schools,
occupational health, community health settings
Pharmacist • Hospitals, pharmacies, other health care facilities, jails
Physician Assistant • Clinical and community locations
Permissible Practice Settings (cont.)
Practice Settings: NEW JERSEY Professional Setting
Certified Nurse Midwife Advanced Practice Nurse Nurse Practitioner Clinical Nurse Specialist
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
Certified Nurse Midwife Advanced Practice Nurse Nurse Practitioner Clinical Nurse Specialist
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]
Comments????