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    Advanced practice registered nurses in Ohio – Major changes coming in April!

    If you have any advanced practice registered nurses (APRNs) working in your office or hospital, H.B. 216, which will go into effect in early April, includes some major changes in the current laws governing APRNs. We recommend that you review the changes and prepare revised standard care arrangements (SCAs) and amendments to the applicable medical staff documents (e.g., advanced practice provider policies, etc.) so that you are ready to go forward on that date. 

    Key changes

    • The current Certificate of Authority will be replaced by an APRN license issued by the Ohio Board of Nursing which will authorize the APRN to practice as a Certified Nurse-Midwife (CNM), Certified Nurse Practitioner (CNP), Clinical Nurse Specialist (CNS) or Certified Registered Nurse Anesthetist (CRNA) (i.e., APRNs will now have two licenses: an RN license and an APRN license). 
    • A CNS (see next bullet), CNM and CNP must continue to practice in collaboration with a physician/podiatrist in accordance with a current, valid SCA (as modified by the bill). Collaboration requires that a collaborating physician/podiatrist be continuously available to communicate with the CNS, CNM or CNP. The term “communicate” is now defined as either in person or by electronic communication. This provision does not apply to CRNAs (i.e., they are not required to have a SCA or a collaborating physician/podiatrist). See additional information regarding CRNAs below.
    • Under current law, a CNS who does not have prescriptive authority and whose specialty is mental health or psychiatric mental health may practice without a SCA as long as the CNS practices in collaboration with one or more physicians. However, if such a CNS has prescriptive authority, the CNS must enter into a SCA with one or more physicians who practice in the same or similar specialty. In such event, the SCA only needs to address the prescribing components of the CNS’ practice. By contrast, the new law, as written, requires all CNSs to enter into a SCA. In addition, and with respect to a CNS whose nursing specialty is mental health or psychiatric mental health, the law has expanded who can be a collaborating physician to include not only a specialty that is the same as or similar to the nurse’s nursing specialty but also pediatrics, primary care or family practice.
      • A question has been raised as to whether the legislation intended to include the requirement that a CNS (whose specialty is mental health or psychiatric mental health) without prescriptive authority must have a SCA with a collaborating physician, as this was not required in the current law.
    • A SCA will no longer be required to include:
      • A procedure for regular review of referrals by the CNS, CNM or CNP to other health care professionals and the care outcomes for a random sample of all patients seen by the nurse.
      • If the CNS or CNP regularly provides services to infants, a policy for care of infants up to age one and recommendations for collaborating physician visits for children from birth to age three.
    • A SCA will now only need to be retained on file by the APRN’s employer rather than retained on file at each site where the APRN practices.
      • We continue to recommend that a hospital require and retain a copy of an APRN’s current SCA in the APRN’s credentials file.
    • A CNP, CNS or CNM may continue to practice without a collaborating physician/podiatrist for a period of up to 120 days provided certain conditions are met.
      • We do not believe this limits the ability of a hospital to continue to require that an APRN have a SCA with a collaborating physician/podiatrist with current appointment/clinical privileges at the hospital for purposes of maintaining clinical privileges.
    • Note that a CRNA must continue to practice with a supervising physician, dentist or podiatrist. Supervision continues to be defined, in part, as requiring that a CRNA practice in the immediate presence of a physician/dentist/podiatrist when administering anesthesia and performing anesthesia induction, maintenance and emergence.
    • Continuing education/pharmacology education requirements have been modified and should be reviewed.

    Prescriptive authority

    In relation to prescriptive authority, HB 216:

    • Eliminates the current Certificate to Prescribe and Externship Certificate to Prescribe. Prescriptive authority will be addressed within the APRN license for CNPs, CNSs and CNMs.  No changes have been made with respect to the ability of CRNAs to order prescriptive drugs as it relates to their scope of practice. 
    • A physician/podiatrist may now collaborate with up to five APRNs (with prescriptive authority) at the same time in the prescribing component of their practices.
    • Retains the drug formulary but requires that it be exclusionary (i.e. specify only those drugs/devices that an APRN with prescriptive authority is not authorized to prescribe or furnish).
      • This is a welcomed change.
    • Makes changes to the current law/limitations with respect to prescribing a schedule II controlled substance.
    • Eliminates the existing conditions with respect to a CNS, CNM or CNP (with prescriptive authority) furnishing a sample or a complete or partial supply of a drug; provided, however, that the current requirement prohibiting distribution of samples of controlled substances remains.
    • Establishes both of the following as additional grounds for professional discipline:
      • The revocation, suspension, restriction, reduction or termination of clinical privileges by the U.S. Department of Defense or Department of Veterans Affairs or the termination or suspension of a certificate of registration to prescribe drugs by the Drug Enforcement Administration of the U.S. Department of Justice.
    • Expands current law authorizing a coroner to notify the State Medical Board of Ohio in the event of a drug overdose death to include notice to the Ohio Board of Nursing and Ohio Dental Board. 

    Other items

    • There are a number of other provisions in the bill including:
      • Insurance and maternity benefits with respect to coverage of follow up care directed by either a physician or APRN
      • Applications for hospital medical staff membership or clinical privileges
      • Extension of physician-patient testimonial privilege to APRNs
      • Report of death to treating physician or APRN
      • Do-not-resuscitate orders (existing law allows CNPs and CNSs to take any action that an attending physician may take with respect to a DNR order; the bill extends this authority to CNMs and CRNAs)
      • Diabetes care in schools (bill authorizes a physician assistant or a CNS or CNP to issue an order related to diabetes care provided to a student in school)
    • There are also administrative/operational changes such as creation of an Advisory Committee on Advanced Practice Registered Nursing to advise the Ohio Board of Nursing on APRN related practice issues and amendments with respect to the Committee on Prescriptive Governance.
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