Transcript Dies and Crosby_Medical Directives CAPA 2016 - CAPA

Breakfast With Your
Medical Directives
Ken Crosby, BSc., B.Sc. PA
Natalie Dies, MSc., B.HSc. PA
CAPA 2016
Winnipeg, MB
Blake Wheeler
Red, Assiniboine
The Forks
Origin of “Winnipeg”
1) Extreme cold
2) Muddy water
3) Mosquito
Cree
Outline
• What are controlled acts and medical directives?
• How to create and use medical directives
• Nurses and medical directives
• Examples of medical directives for shared use
• Similarities and differences between documents
•Advice on implementation
•Discussion (time permitting), experiences with medical directives
Regulated Health Professions Act (1991)
• Under the RHPA in Ontario, physicians may delegate tasks to
physician assistants (PAs)
• “Controlled Acts”
• Procedures that may be potentially harmful if performed by an unqualified person
• “... acts which may only be performed by authorized regulated
health professionals… Physicians [can] in appropriate
circumstances, delegate the performance of those acts to other
individuals who may or may not be members of a regulated health
profession” -CPSO
Controlled Acts
• Controlled acts may be delegated through direct order or medical
directives
• PAs may not perform these tasks in the absence of an order or
medical directive given they are unregulated/unauthorized to do so
independently
• Exception: rendering first aid, temporary assistance in an emergency
Controlled Acts - Conditions to delegate
• The controlled act must be within the scope of the delegating
physician practice
• The individual performing controlled act must be capable of
performing it safely and competently
• Patient consent must be obtained prior to performing delegated act
1.Communicating diagnosis
2.Procedure below the dermis
3.Setting/casting a fracture
4.Moving joints of the spine beyond usual ROM
5.Administering substance via inhalation or injection
6.Putting hand/instrument into opening of body eg. ear canal,
urethra
7.Applying/ordering form of energy eg. imaging
8.Prescribing, dispensing, selling or compounding medications
9.Prescribing or dispensing contact lenses or glasses
10.Prescribing hearing aids
11.Fitting or dispensing dental prosthesis
MD unable to perform
12.Delivering a baby
13.Allergy challenge testing
14.Treating by means of psychotherapy
MD unable to delegate
Controlled Acts - Conditions to delegate
• The individual performing controlled act must be capable of
performing it safely and competently
• No official process for determining individual’s competence
• Physician/PA relationship emphasized
• Patient consent must be obtained prior to performing delegated act
• ?Realistic
Medical Directives - Defined
• “...written orders by physicians to other health care providers that
pertain to any patient who meets the criteria set out in the medical
directive. When the directive calls for acts that will require
delegation, it provides the authority to carry out the treatments,
procedures, or other interventions that are specified in the
directive, provided that certain conditions and circumstances exist” CPSO
Medical Directives - In Practice
• A medical directive pertains to multiple patients in appropriate
predetermined clinical circumstances
• Allows PAs to perform acts that would otherwise require delegation
prior to the physician establishing a relationship with the patient
• “Prospective”
Direct orders
• A direct order pertains to one patient in a specific circumstance
• May be verbal (eg. telephone, in-person, video conference) or
written
• Takes place after the physician-patient relationship has been
established or physician has knowledge of patient’s current clinical
status
• “Retrospective”
Are controlled acts and medical directives
the same thing?
• Medical directive is the “authorizing mechanism” to perform the
controlled act -CNO
• Controlled acts -- sentences / Medical directives -- story, structure
• Medical directives help define the PA role
• Medical directives reflect our level of education and furthering
education
What needs to be included
• Name and description of order, intervention
• “Sufficient information so it may be implemented… authorized individual
can safely carry out the order, intervention”
• Itemized list of specific clinical criteria that involved patient must
meet
• Itemized list of specific clinical criteria that circumstance must meet
• List of contraindicated patients/circumstances (criteria not met)
• List of individuals authorized to implement direct
• Names and signatures of authorizing physicians
• Date the directive becomes effective
• List of authorizing administration
• *Must be updated if a change of staffing
What needs to be documented when used
• Name and number of medical directive
• Name and signature of delegate
• Name(s) of authorizing physician
Working with nurses
• RN must receive delegation from a regulated professional (eg.
physician). Through a medical directive, the PA acts as the “vehicle”
of the delegation; it is the physician order
• Implementing a medical directive from a PA ≠ performing a direct
order
• “Co-implementing” medical directive with the PA
• RN cannot take verbal orders from the PA, though may accept a
physician's verbal order transcribed by the PA into patient chart (if
physician is unable to transcribe own order and institution allows)
• “Nurses should be involved in the development and approval of the
directives” - CNO
CAPA Medical Directives working group
• Goals of this project:
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Define current problems/issues with medical directive implementation
Provide possible solutions to these problems/issues, and
Create future directions for medical directive implementation in Ontario.
Post directives for reference
Develop a standard directive universal to all PAs
“Dos and don’ts” of medical directives
• More than a dozen CAPA members contributed
Results
• Compiled 17 Medical Directives from 14 different clinics and hospitals
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4 from outpatient Family Medicine
4 General Surgery
4 Internal Medicine and IM subspecialties
3 ER
2 Surgical specialties
Abilities granted through medical directive
Ability granted through directive
Proportion of Directives which contain
History and Physical
Putting an instrument, hand or finger, beyond the …
17/17
9/17
Documentation
16/17
Ordering laboratory investigations
15/17
X-rays
14/17
ECG
14/17
Ultrasounds
11/17
Echocardiogram
7/17
CT
5/17
MRI
3/17
…continued
Ability granted through directive
Proportion of Directives which contain
Medications
11/17
IV fluids
4/12 (only 12 were inpatient)
Procedures
Suturing
Casting/splinting
PAP smear
Surgical Assist
15/17
10/17
5/17
4/17
3/6 (applicable to 6)
Referral to allied health professionals
Referral to other MD
May sign CCAC referral
6/17
2/17
3/17
Verbal order
5/17
Format of directives
Format
Proportion
Indications and contraindications
9/17
Indications only
2/17
Neither, (ie. PA is authorised to…)
5/17
*One required review with MD for all investigations and treatments
• Indications ranged from very specific (ie. Pt presenting with GI bleed),
or very vague (ie. Patient admitted in certain location).
• Some referred to external resources ie Guidelines or RxFiles for
indications and contraindications.
Education/Certification Requirements
Requirement
Proportion
Passed the PACCC, or be PA-C
7/17
Additional Competency Assessment
5/17
Liability insurance
1/17
• Many have no specific requirement
• Without title protection education requirement listed in directive
helps define “Physician Assistant”
Key points
1. History, physical, documentation, laboratory investigations, ECG,
and xrays are most common
•Starting point for entry to practice
•Inherent ability of all PAs
2. Some elements of physical exam are controlled acts
3. Minimal consistency between institutions
•Range in length from 2-100 pages, various formats/styles, variance in scope
of practice
•Many hospitals have medical directives, for other roles that can guide
development
Example Medical Directive #1
Example Medical Directive #1 continued
Example Medical Directive #2
Example Medical Directive #3
“DO”
• Start working on them as early as possible into practice
• Educate your SPs
• Offer to attend meetings with office/hospital administration when
medical directives are to be discussed - proactivity!
• Provide examples of other medical directives implemented in
similar areas of practice
• Contact CAPA when difficulties arise
• Respect that SPs/administration may be hesitant in implementing
them
• Baby-steps
• Involve administration/nursing staff during implementation
Key points
1.As an unregulated health professional, medical directives are
required for PAs to legally perform delegated controlled
acts/provide patient care
2.Although medical directives can be cumbersome and challenging to
created, they improve efficiency of PA practice and allow for some
practice autonomy as they avoid need for constant verbal orders
from supervising physician(s)
Key points
1.Medical directives should be implemented ASAP and frequently
updated (consider every 4-6 months) to reflect changes in
staff/supervising physicians and expansion of PA knowledge and
skills
2.It is easy to become “sloppy” in documenting the use of medical
directives. Proper documentation is essential for liability
3.Recognize it could take weeks-months to implement
Ken - [email protected]
Natalie - [email protected]
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Other RHPs
• PAs are able to perform 12 of the 14 controlled acts with delegation
-CPSO
• RNs are able to perform 4 of the 14 controlled acts
• Able to “initiate” some controlled acts without an order or directive (wound
care, venipuncture, finger beyond nasal passage/larynx/anal verge/labia)
• Able to delegate some controlled acts to other unregulated individuals eg. a
family member/PSW to provide wound care -RNAO
• RTs are able to perform 5 of the 14 controlled acts
• Able to initiate 3 without an order or directive (suctioning, administering
inhalants)