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hospitals and hospice care. But it does not introduce controlled substances into settings where they are not prescribed today, Senator Nelson emphasizes. And physicians still must supervise, says Dr. Fiesinger, TAFP


president. The provision’s intent, he says, is to strike a balance be- tween the need for adequate safety controls of these high-risk narcotics and for certain patients to get access to the drugs in critical situations, for example, those facing chronic pain or end-of-life situations, or children with attention deficit/hyper- activity disorder in rural areas.


“The thought was to do this in facilities that are already highly regulated,” and where teams tend to work closely to- gether, said Dr. Fiesinger. “And we wanted to make sure we weren’t impairing good care for patients with those needs.” In addition to physician supervision, hospitals and hospices have additional oversight by The Joint Commission, and APRNs and PAs practicing there are sub- ject to those facilities’ credentialing poli- cies, he says. Such delegation must com- ply with hospital medical staff bylaws, providing another avenue for physician oversight. Facilities may have additional controls,


Mr. Pickard added. At MD Anderson, for example, PAs involved in ordering any medication sets, which could include Schedule II drugs, must complete a 12- hour internal education program that includes a comprehensive review of pain management and drug side effects. Referring back to the prescriptive au- thority agreement, however, Dr. Fiesinger reiterated: “If physicians don’t want to delegate prescribing of Schedule II drugs, they don’t have to.” The bill also increases monitoring of this new activity by the various licensing boards involved, which must gather and share information relating to those enter- ing into prescriptive authority agreements. The medical, nursing, and physician as- sistant boards also must develop ways to notify one another when their respective licensees become the subject of an investi- gation involving such agreements. The boards would have to adopt the


necessary rules to implement those pro- cesses by Dec. 31.


Patient safety paramount Sen. Charles Schwertner, MD (R-George- town), however, raised some doubts at the Senate committee hearing in February about whether the bill could be construed


to allow APRNs and PAs to prescribe Schedule II drugs in out- patient hospital clinics that may not have the same safeguards as those within hospital walls.


He also questioned whether BON is equipped to oversee those expanded activities by APRNs and whether nurse prac- titioners are adequately trained to handle the new role. TMB and PAB jointly handle prescription delegation for PAs. “This is a dangerous, potent, and addictive class of drugs,” said Senator Schwertner, an orthopedic surgeon. “My concern is regarding the oversight of individuals with the authority to prescribe these dangerous drugs when the [nursing] board doesn’t have the expertise. … And what will the board do dif- ferently to ensure those nurses have the appropriate training, education, credentials, and discipline?”


Senator Nelson said at the hearing that the bill is not in-


PRESCRIPTION FOR COLLABORATION


Instead of following a web of inconsistent rules, Senate Bill 406 allows physicians to use a single prescriptive authority agree- ment to delegate their prescribing authority to qualified advanced practice registered nurses (APRNs) and physician assistants (PAs) under their supervision. At minimum, the agreement must:


• Be in writing and signed and dated by the parties to the agree- ment;


• State the name, address, and all professional license numbers of the parties to the agreement;


• State the nature of the practice, practice locations, or practice settings;


• Identify the types or categories of drugs or devices that may be prescribed or the types of categories of drugs or devices that may not be prescribed;


• Describe a prescriptive authority quality assurance plan, and specify methods for documenting the implementation of the plan that includes chart review and periodic face-to-face meet- ings that occur monthly or quarterly;


• Provide a general plan for addressing consultation and referral; • Provide a plan for addressing patient emergencies; • State the general process for communication and information sharing between the physician and APRN or PA to whom the physician has delegated prescriptive authority related to the care and treatment of patients; and


• Designate one or more alternate physician who may provide ap- propriate supervision temporarily if alternate physician supervi- sion is to be used.


May 2013 TEXAS MEDICINE 19


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