Youre Officially an APN Now What

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Youre Officially an APN Now What?

• Alma L. Saravia, Esquire

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Youre Officially an APN - Now What?

• The Legislature amended the law governing the
  practice of advanced practice nurses (APNs) in
  2004 to permit an APN to diagnose and treat
  patients.
• This amendment was adopted because granting APNs
  increased medical responsibilities will improve
  the landscape of medical care throughout the
  State, said Senator Madden . . . Many times, APNs
  . . . cannot perform certain duties . . .
  despite being fully qualified to do so.
• Advanced practice nurses are trained in a
  wide-range of health care protocols, however,
  state law currently limits their ability to use
  this education to further assist doctors and
  other medical professionals in treating
  patients, stated Senator Loretta Weinberg.

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Youre Officially an APN - Now What?

• The APN law does not mandate physician
  supervision, they are independent professionals
  . . . according to the bills sponsor, Senator
  Joseph Vitale.
• Under the APN law, an APN may prescribe or order
  drugs and devices pursuant to a written joint
  protocol with a collaborating physician.
  N.J.S.A. 4511-49.
• The APN law requires the Division of Consumer
  Affairs to adopt regulations governing the joint
  protocol in consultation with the Board of
  Medical Examiners and the Board of Nursing.

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Youre Officially an APN - Now What?

• The regulations adopted by the Board of Medical
  Examiners and the Board of Nursing require that
  the APN and the physician address thirteen issues
  when they negotiate the terms of the joint
  protocol. The definitions of Collaboration,
  Joint Protocol, and Medication are as follows
• Collaboration is defined as the ongoing process
  by which an advanced practice nurse and a
  physician engage in practice, consistent with
  agreed-upon parameters of their respective
  practices.
• Joint Protocol is defined as an agreement or
  contract between an advanced practice nurse and a
  collaborating physician which conforms to the
  standards established by the Director of the
  Division of Consumer Affairs pursuant to this
  rule.
• Medication is defined as any substance for which
  a prescription is required which is intended for
  use in the diagnosis, cure, mitigation, treatment
  or prevention of disease, injury, pain or
  deformity or physical or emotional condition or
  health problem in humans or intended to affect
  the structure or function of the human body.

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Youre Officially an APN - Now What?

• The thirteen issues that must be addressed in the
  Joint Protocol are
• Nature of practice/patient population/setting
• Any particular circumstance for which, prior to
  ordering, dispensing or prescribing a medication
  or anesthetic agent a specific examination is to
  be performed
• These duties are based upon the individual needs
  of patients in accordance with rights and
  privileges granted through RN licensure and APN
  certification by the New Jersey Board of Nursing.
  The nature and extent of assessments performed
  and resultant diagnoses made by APNs follow
  accepted standards of Advanced Nursing Practice.

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Youre Officially an APN - Now What?

• Recordkeeping methodology At (this practice
  site) every patient encounter requires a dated
  entry in the patients record or on the
  anesthesia record of every drug, medication or
  anesthetic agent ordered, dispensed or
  prescribed.
• A list of categories of drugs, medications or
  anesthetic agents appropriate to the practice
  APNs may order, dispense or prescribe drugs,
  medications and anesthetic agents as appropriate
  for the patient within the scope of practice for
  APNs.
• Specific requirements with respect to the
  recordation in the patient record or anesthesia
  record of drugs, medications or anesthetic agents
  ordered, dispensed or prescribed. Drugs,
  medications and anesthetic agents ordered,
  dispensed or prescribed by APNs will be recorded
  in the patients record or anesthesia record
  noting the date, name of the drug, medication or
  anesthetic agent.

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Youre Officially an APN - Now What?

• Any medical conditions or findings within the
  nature of the practice which should require
  direct consultation prior to the ordering,
  dispensing or prescribing of drugs, medications
  or anesthetic agents APNs will communicate with
  a collaborating physician prior to ordering,
  dispensing or prescribing drugs, medications or
  anesthetic agents when, in the APNs professional
  opinion, the patients condition requires
  physician consultation or intervention.
• The frequency and methodology to be employed to
  ensure periodic review of patient records Joint
  review of __ number of patient records shall
  occur on at least an annual basis (include a
  brief statement of the procedures utilized at
  this site).
• Identification of the means by which the APN and
  the collaborating physician can be in direct
  communication as well as arrangements which will
  assure that peer coverage is accessible and
  available A collaborating physician is
  physically available to consult with the APN. A
  collaborating physician will arrange for peer
  coverage in his or her absence from the practice.

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Youre Officially an APN - Now What?

• Procedures for the ordering, dispensing or
  prescribing of drugs, medications or anesthetic
  agents in emergency situations Procedures for
  the use of drugs, medications or anesthetic
  agents in emergency situations will be based upon
  accepted standards of nurse anesthesia practice
  in accordance with rights and privileges granted
  through RN licensure and APN certification.
• Identification of reference materials containing
  practice guidelines or accepted standards of
  practice Clinical references used by the APN
  and the collaborating physician as guidelines to
  ordering or prescriptive practice include but are
  not limited to the following (list references).

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Youre Officially an APN - Now What?

• Under the current law, the collaborating
  physician does not have to be physically present
  when the APN treats the patient.
• The prescribing or ordering of devices and
  medications is the final stage in the treatment
  of a patient. The APN and the collaborating
  physician negotiate the terms of the joint
  protocol and many joint protocols do not contain
  any restrictions on the drugs that an APN may
  prescribe.
• APNs must obtain a Drug Enforcement Agency
  Registration and a State Controlled Dangerous
  Substance permit in order to prescribe
  medications, the same as other practitioners.

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Youre Officially an APN - Now What?

• Determining what kind of relationship is needed
  with other professionals, when it is needed, and
  what form it should take are questions of
  professional judgment and norms.
• APNs are not agents of the physicians - i.e. can
  be sued in their own name for medical
  malpractice. Malpractice claims are dramatically
  lower for APNs.
• A new study to determine the effects of the APN
  prescribing versus physician prescribing found
  that the prescribing practices of APNs and
  physicians were more similar than different, and
  that the clinical parameters were found to be the
  same or better when the treatment was given by
  APNs.

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Youre Officially an APN Now What?

• Points to Consider in Your New Role as APN
• What type of employment arrangement will you
  have?
• Independent contractor with a hospital or an
  anesthesiology group?
• Employee of the hospital of anesthesiology group?
  
• (Either way, you should have a written agreement
• specifying the terms of your arrangement.)

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Youre Officially an APN Now What?

• A recent Texas study to determine why so few APNs
  choose independent practice found that almost all
  APNS do not have entrepreneurial traits.
• The only exception was for CRNAs, who were
  slightly more likely to be entrepreneurial.
• ASK YOURSELF
• What is my personality?
• Am I ready to negotiate new terms of employment?

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Youre Officially an APN Now What?

• Pitfalls You May Encounter When Negotiating New
  Terms With a Collaborating Physician
• Physicians do not understand the meaning of the
  term collaboration
• They may think that the term means supervision
• Collaborating physicians may not understand that
  the only collaboration required is for the
  ordering or prescribing of drugs or devices

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Youre Officially an APN Now What?

• Points to Keep In Mind When Negotiating New Terms
  With a Collaborating Physician
• Collaboration should be a process where you and
  the physician work interdependently within the
  boundaries of your respective scope of practices
• You have power when negotiating if you know the
  financial and billing status of where you are
  administering anesthesia

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Youre Officially an APN Now What?

• Points to Keep In Mind When
• Applying for Hospital Privileges
• APNs maybe privileged to practice in hospitals
  and subject to peer reviews similar to
  physicians.
• A hospital is permitted by law to restrict or
  deny an APNs privileges if the decision is
  supported by reasonably credible evidence, even
  if it is of a hearsay nature.
• However, a hospitals denial or restriction on
  privileges must be linked to quality of patient
  care.
• A court will uphold a hospitals decision unless
  there is no medical rationale.

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Update Heather Howard Meeting 2/18/2009

• The National Council of State Boards of Nursing
  recognizes Certified Registered Nurse
  Anesthetists (CRNAs) as APNs in their APN
  compact as well as in their model APN practice
  act.
• The Consensus Model for APRN Regulation
  Licensure, Accreditation, Certification
  Education was completed through the work of the
  APRN Consensus Work Group the National Council
  of State Boards of Nursing APRN Advisory
  Committee it provides that CRNAs are one of the
  four Advanced Practice Registered Nurses (APRN)
  and that APRNs will be licensed as independent
  practitioners.
• Thirty eight states recognize CRNAs as Advanced
  Practice Nurses.
• Effective June 16, 2009 all CRNAs must apply to
  the Board of Nursing for certification to
  practice as an APN/anesthesia.

On the Web at www.flastergreenberg.com
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Update Heather Howard Meeting 2/18/2009

• The Legislature enacted a law mandating that the
  New Jersey Department of Health and Senior
  Services (DHSS) is responsible for providing
  health care services that are efficiently
  provided and properly provided at a reasonable
  cost . . . N.J.S.A. 262H-12.
• The current DHSS regulations referencing the
  practice of APNs do not mandate physician
  supervision.
• NJANA met with Heather Howard, the Commissioner
  of the Department of Health and Senior Services
  to request the repeal of the anesthesiologist
  subversion regulations.

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Thank You!