As Reported by the Senate Medicaid, Health and Human Services Committee

130th General Assembly Regular Session 2013-2014

Am. H. B. No. 139

Representative Gonzales 

Cosponsors: Representatives Hackett, Letson, Antonio, Wachtmann, Bishoff, Brown, Hill, Lynch, Ramos, Sears, Smith, Anielski, Barborak, Barnes, Beck, Blessing, Boose, Boyd, Brenner, Celebrezze, Curtin, Damschroder, DeVitis, Driehaus, Fedor, Green, Hagan, C., Hall, Hayes, Hood, Milkovich, O'Brien, Patmon, Patterson, Pelanda, Reece, Retherford, Roegner, Rogers, Rosenberger, Scherer, Sheehy, Stinziano, Strahorn, Winburn Speaker Batchelder 

Senator Tavares 

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A BILL

To amend sections 3727.06, 4723.431, and 4730.09 of

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the Revised Code to permit certain advanced

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practice registered nurses and physician

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assistants to admit patients to hospitals.

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BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1.  That sections 3727.06, 4723.431, and 4730.09 of	5
the Revised Code be amended to read as follows:	6

Sec. 3727.06. (A) As used in this section:

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(1) "Doctor" means an individual authorized to practice	8
medicine and surgery or osteopathic medicine and surgery.	9

(2) "Podiatrist" means an individual authorized to practice	10
podiatric medicine and surgery.	11

(B)(1) Only athe following may admit a patient to a	12
hospital:	13

(a) A doctor who is a member of the hospital's medical	14
staff,;	15

(b) A dentist who is a member of the hospital's medical	16
staff, or;	17

(c) A podiatrist who is a member of the hospital's medical	18
staff may admit a patient to a hospital;	19

(d) A clinical nurse specialist, certified nurse-midwife, or	20
certified nurse practitioner if all of the following conditions	21
are met:	22

(i) The clinical nurse specialist, certified nurse-midwife,	23
or certified nurse practitioner has a standard care arrangement	24
entered into pursuant to section 4723.431 of the Revised Code with	25
a collaborating doctor or podiatrist who is a member of the	26
medical staff;	27

(ii) The patient will be under the medical supervision of the	28
collaborating doctor or podiatrist;	29

(iii) The hospital has granted the clinical nurse specialist,	30
certified nurse-midwife, or certified nurse practitioner admitting	31
privileges and appropriate credentials.	32

(e) A physician assistant if all of the following conditions	33
are met:	34

(i) The physician assistant is listed on a supervision	35
agreement approved under section 4730.19 of the Revised Code for a	36
doctor or podiatrist who is a member of the hospital's medical	37
staff.	38

(ii) The patient will be under the medical supervision of the	39
supervising doctor or podiatrist.	40

(iii) The hospital has granted the physician assistant	41
admitting privileges and appropriate credentials.	42

(2) Prior to admitting a patient, a clinical nurse	43
specialist, certified nurse-midwife, certified nurse practitioner,	44
or physician assistant shall notify the collaborating or	45
supervising doctor or podiatrist of the planned admission.	46

(C) All hospital patients shall be under the medical	47
supervision of a doctor, except that services that may be rendered	48
by a licensed dentist pursuant to Chapter 4715. of the Revised	49
Code provided to patients admitted solely for the purpose of	50
receiving such services shall be under the supervision of the	51
admitting dentist and that services that may be rendered by a	52
podiatrist pursuant to section 4731.51 of the Revised Code	53
provided to patients admitted solely for the purpose of receiving	54
such services shall be under the supervision of the admitting	55
podiatrist. If treatment not within the scope of Chapter 4715. or	56
section 4731.51 of the Revised Code is required at the time of	57
admission by a dentist or podiatrist, or becomes necessary during	58
the course of hospital treatment by a dentist or podiatrist, such	59
treatment shall be under the supervision of a doctor who is a	60
member of the medical staff. It shall be the responsibility of the	61
admitting dentist or podiatrist to make arrangements with a doctor	62
who is a member of the medical staff to be responsible for the	63
patient's treatment outside the scope of Chapter 4715. or section	64
4731.51 of the Revised Code when necessary during the patient's	65
stay in the hospital.	66

Sec. 4723.431.  (A) Except as provided in division (D)(1) of	67
this section, a clinical nurse specialist, certified	68
nurse-midwife, or certified nurse practitioner may practice only	69
in accordance with a standard care arrangement entered into with	70
each physician or podiatrist with whom the nurse collaborates. A	71
copy of the standard care arrangement shall be retained on file at	72
each site where the nurse practices. Prior approval of the	73
standard care arrangement by the board of nursing is not required,	74
but the board may periodically review it for compliance with this	75
section.	76

A clinical nurse specialist, certified nurse-midwife, or	77
certified nurse practitioner may enter into a standard care	78
arrangement with one or more collaborating physicians or	79
podiatrists. Not later than thirty days after first engaging in	80
the practice of nursing as a clinical nurse specialist, certified	81
nurse-midwife, or certified nurse practitioner, the nurse shall	82
submit to the board the name and business address of each	83
collaborating physician or podiatrist. Thereafter, the nurse shall	84
give to the board written notice of any additions or deletions to	85
the nurse's collaborating physicians or podiatrists not later than	86
thirty days after the change takes effect.	87

Each collaborating physician or podiatrist must be actively	88
engaged in direct clinical practice in this state and practicing	89
in a specialty that is the same as or similar to the nurse's	90
nursing specialty. If a collaborating physician or podiatrist	91
enters into standard care arrangements with more than three nurses	92
who hold certificates to prescribe issued under section 4723.48 of	93
the Revised Code, the physician or podiatrist shall not	94
collaborate at the same time with more than three of the nurses in	95
the prescribing component of their practices.	96

(B) A standard care arrangement shall be in writing and,	97
except as provided in division (D)(2) of this section, shall	98
contain all of the following:	99

(1) Criteria for referral of a patient by the clinical nurse	100
specialist, certified nurse-midwife, or certified nurse	101
practitioner to a collaborating physician or podiatrist;	102

(2) A process for the clinical nurse specialist, certified	103
nurse-midwife, or certified nurse practitioner to obtain a	104
consultation with a collaborating physician or podiatrist;	105

(3) A plan for coverage in instances of emergency or planned	106
absences of either the clinical nurse specialist, certified	107
nurse-midwife, or certified nurse practitioner or a collaborating	108
physician or podiatrist that provides the means whereby a	109
physician or podiatrist is available for emergency care;	110

(4) The process for resolution of disagreements regarding	111
matters of patient management between the clinical nurse	112
specialist, certified nurse-midwife, or certified nurse	113
practitioner and a collaborating physician or podiatrist;	114

(5) A procedure for a regular review of the referrals by the	115
clinical nurse specialist, certified nurse-midwife, or certified	116
nurse practitioner to other health care professionals and the care	117
outcomes for a random sample of all patients seen by the nurse;	118

(6) If the clinical nurse specialist or certified nurse	119
practitioner regularly provides services to infants, a policy for	120
care of infants up to age one and recommendations for	121
collaborating physician visits for children from birth to age	122
three;	123

(7) Any other criteria required by rule of the board adopted	124
pursuant to section 4723.07 or 4723.50 of the Revised Code.	125

(C)(1) A standard care arrangement entered into pursuant to	126
this section may permit a clinical nurse specialist, certified	127
nurse-midwife, or certified nurse practitioner to supervise	128
services provided by a home health agency as defined in section	129
3701.881 of the Revised Code.	130

(2) A standard care arrangement entered into pursuant to this	131
section may permit a clinical nurse specialist, certified	132
nurse-midwife, or certified nurse practitioner to admit a patient	133
to a hospital in accordance with section 3727.06 of the Revised	134
Code.	135

(D)(1) A clinical nurse specialist who does not hold a	136
certificate to prescribe and whose nursing specialty is mental	137
health or psychiatric mental health, as determined by the board,	138
is not required to enter into a standard care arrangement, but	139
shall practice in collaboration with one or more physicians.	140

(2) If a clinical nurse specialist practicing in either of	141
the specialties specified in division (D)(1) of this section holds	142
a certificate to prescribe, the nurse shall enter into a standard	143
care arrangement with one or more physicians. The standard care	144
arrangement must meet the requirements of division (B) of this	145
section, but only to the extent necessary to address the	146
prescribing component of the nurse's practice.	147

(E) Nothing in this section prohibits a hospital from hiring	148
a clinical nurse specialist, certified nurse-midwife, or certified	149
nurse practitioner as an employee and negotiating standard care	150
arrangements on behalf of the employee as necessary to meet the	151
requirements of this section. A standard care arrangement between	152
the hospital's employee and the employee's collaborating physician	153
is subject to approval by the medical staff and governing body of	154
the hospital prior to implementation of the arrangement at the	155
hospital.	156

Sec. 4730.09. (A) Under a physician supervisory plan approved	157
under section 4730.17 of the Revised Code, a physician assistant	158
may provide any or all of the following services without approval	159
by the state medical board as special services:	160

(1) Obtaining comprehensive patient histories;

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(2) Performing physical examinations, including audiometry	162
screening, routine visual screening, and pelvic, rectal, and	163
genital-urinary examinations, when indicated;	164

(3) Ordering, performing, or ordering and performing routine	165
diagnostic procedures, as indicated;	166

(4) Identifying normal and abnormal findings on histories,	167
physical examinations, and commonly performed diagnostic studies;	168

(5) Assessing patients and developing and implementing	169
treatment plans for patients;	170

(6) Monitoring the effectiveness of therapeutic	171
interventions;	172

(7) Exercising physician-delegated prescriptive authority	173
pursuant to a certificate to prescribe issued under this chapter;	174

(8) Carrying out or relaying the supervising physician's	175
orders for the administration of medication, to the extent	176
permitted by law;	177

(9) Providing patient education;

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(10) Instituting and changing orders on patient charts;

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(11) Performing developmental screening examinations on	180
children with regard to neurological, motor, and mental functions;	181

(12) Performing wound care management, suturing minor	182
lacerations and removing the sutures, and incision and drainage of	183
uncomplicated superficial abscesses;	184

(13) Removing superficial foreign bodies;

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(14) Administering intravenous fluids;

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(15) Inserting a foley or cudae catheter into the urinary	187
bladder and removing the catheter;	188

(16) Performing biopsies of superficial lesions;

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(17) Making appropriate referrals as directed by the	190
supervising physician;	191

(18) Performing penile duplex ultrasound;

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(19) Changing of a tracheostomy;

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(20) Performing bone marrow aspirations from the posterior	194
iliac crest;	195

(21) Performing bone marrow biopsies from the posterior iliac	196
crest;	197

(22) Performing cystograms;

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(23) Performing nephrostograms after physician placement of	199
nephrostomy tubes;	200

(24) Fitting, inserting, or removing birth control devices;

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(25) Removing cervical polyps;

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(26) Performing nerve conduction testing;

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(27) Performing endometrial biopsies;

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(28) Inserting filiform and follower catheters;

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(29) Performing arthrocentesis of the knee;

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(30) Performing knee joint injections;

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(31) Performing endotracheal intubation with successful	208
completion of an advanced cardiac life support course;	209

(32) Performing lumbar punctures;

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(33) In accordance with rules adopted by the board, using	211
light-based medical devices for the purpose of hair removal;	212

(34) Administering, monitoring, or maintaining local	213
anesthesia, as defined in section 4730.091 of the Revised Code;	214

(35) Applying or removing a cast or splint;

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(36) Inserting or removing chest tubes;

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(37) Prescribing physical therapy or referring a patient to a	217
physical therapist for the purpose of receiving physical therapy;	218

(38) Ordering occupational therapy or referring a patient to	219
an occupational therapist for the purpose of receiving	220
occupational therapy;	221

(39) Taking any action that may be taken by an attending	222
physician under sections 2133.21 to 2133.26 of the Revised Code,	223
as specified in section 2133.211 of the Revised Code;	224

(40) Determining and pronouncing death in accordance with	225
section 4730.092 of the Revised Code;	226

(41) Admitting patients to hospitals in accordance with	227
section 3727.06 of the Revised Code;	228

(42) Performing other services that are within the	229
supervising physician's normal course of practice and expertise,	230
if the services are included in any model physician supervisory	231
plan approved under section 4730.06 of the Revised Code or the	232
services are designated by the board by rule or other means as	233
services that are not subject to approval as special services.	234

(B) Under the policies of a health care facility, the	235
services a physician assistant may provide are limited to the	236
services the facility has authorized the physician assistant to	237
provide for the facility. The services a health care facility may	238
authorize a physician assistant to provide for the facility	239
include the following:	240

(1) Any or all of the services specified in division (A) of	241
this section;	242

(2) Assisting in surgery in the health care facility;

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(3) Any other services permitted by the policies of the	244
health care facility, except that the facility may not authorize a	245
physician assistant to perform a service that is prohibited by	246
this chapter.	247

Section 2.  That existing sections 3727.06, 4723.431, and	248
4730.09 of the Revised Code are hereby repealed.	249