As Passed by the House
133rd General Assembly
Regular Session Sub. H. B. No. 224
2019-2020
Representatives Cross, Wilkin
Cosponsors: Representatives Becker, Lang, Riedel, Stein, Jordan, Kick, Carfagna, Brent, Edwards, Smith, T., Hoops, Manning, D., Lepore-Hagan, Liston, West, Baldridge, Blair, Boyd, Brown, Butler, Crawley, Crossman, Cupp, Dean, Denson, DeVitis, Fraizer, Galonski, Ghanbari, Ginter, Grendell, Hambley, Hicks-Hudson, Hillyer, Holmes, A., Howse, Ingram, Jones, Lanese, LaRe, Leland, Lightbody, Manning, G., McClain, Merrin, Miller, J., Miranda, O'Brien, Patterson, Patton, Perales, Reineke, Robinson, Roemer, Rogers, Romanchuk, Russo, Scherer, Sheehy, Sobecki, Strahorn, Sweeney, Sykes, Upchurch, Weinstein, Wiggam
A BILL
To amend sections 4723.43, 4729.01, and 4761.17 and to enact sections 4723.433, 4723.434, and 4723.435 of the Revised Code regarding the practice of certified registered nurse anesthetists.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 4723.43, 4729.01, and 4761.17 be amended and sections 4723.433, 4723.434, and 4723.435 of the Revised Code be enacted to read as follows:
Sec. 4723.43. A certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may provide to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education and clinical experience. In this capacity as an advanced practice registered nurse, a certified nurse-midwife is subject to division (A) of this section, a certified registered nurse anesthetist is subject to division (B) of this section, a certified nurse practitioner is subject to division (C) of this section, and a clinical nurse specialist is subject to division (D) of this section.
(A) A nurse authorized to practice as a certified nurse-midwife, in collaboration with one or more physicians, may provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically, consistent with the nurse's education and certification, and in accordance with rules adopted by the board of nursing.
No certified nurse-midwife may perform version, deliver breech or face presentation, use forceps, do any obstetric operation, or treat any other abnormal condition, except in emergencies. Division (A) of this section does not prohibit a certified nurse-midwife from performing episiotomies or normal vaginal deliveries, or repairing vaginal tears. A certified nurse-midwife may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices in accordance with section 4723.481 of the Revised Code.
(B)
A nurse authorized to practice as a certified registered nurse
anesthetist,
with the supervision and in the immediate presence of a physician,
podiatrist, or dentist, may administer anesthesia and perform
anesthesia induction, maintenance, and emergence, and may perform
with supervision preanesthetic preparation and evaluation,
postanesthesia care, and clinical support functions,
consistent with the nurse's education and certification,
and
in accordance with rules adopted by the board,
may do the following:
(1) With supervision and in the immediate presence of a physician, podiatrist, or dentist, administer anesthesia and perform anesthesia induction, maintenance, and emergence;
(2) With supervision, obtain informed consent for anesthesia care and perform preanesthetic preparation and evaluation, postanesthetic preparation and evaluation, postanesthesia care, and, subject to section 4723.433 of the Revised Code, clinical support functions;
(3) With supervision and in accordance with section 4723.434 of the Revised Code, engage in the activities described in division (A) of that section.
The physician, podiatrist, or dentist supervising a certified registered nurse anesthetist must be actively engaged in practice in this state. When a certified registered nurse anesthetist is supervised by a podiatrist, the nurse's scope of practice is limited to the anesthesia procedures that the podiatrist has the authority under section 4731.51 of the Revised Code to perform. A certified registered nurse anesthetist may not administer general anesthesia under the supervision of a podiatrist in a podiatrist's office. When a certified registered nurse anesthetist is supervised by a dentist, the nurse's scope of practice is limited to the anesthesia procedures that the dentist has the authority under Chapter 4715. of the Revised Code to perform.
(C) A nurse authorized to practice as a certified nurse practitioner, in collaboration with one or more physicians or podiatrists, may provide preventive and primary care services, provide services for acute illnesses, and evaluate and promote patient wellness within the nurse's nursing specialty, consistent with the nurse's education and certification, and in accordance with rules adopted by the board. A certified nurse practitioner may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices in accordance with section 4723.481 of the Revised Code.
When a certified nurse practitioner is collaborating with a podiatrist, the nurse's scope of practice is limited to the procedures that the podiatrist has the authority under section 4731.51 of the Revised Code to perform.
(D) A nurse authorized to practice as a clinical nurse specialist, in collaboration with one or more physicians or podiatrists, may provide and manage the care of individuals and groups with complex health problems and provide health care services that promote, improve, and manage health care within the nurse's nursing specialty, consistent with the nurse's education and in accordance with rules adopted by the board. A clinical nurse specialist may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices in accordance with section 4723.481 of the Revised Code.
When a clinical nurse specialist is collaborating with a podiatrist, the nurse's scope of practice is limited to the procedures that the podiatrist has the authority under section 4731.51 of the Revised Code to perform.
Sec. 4723.433. When performing clinical support functions as authorized by section 4723.43 of the Revised Code, a certified registered nurse anesthetist may direct a registered nurse, licensed practical nurse, or respiratory therapist to provide supportive care, including monitoring vital signs, conducting electrocardiograms, and administering intravenous fluids, if the nurse or therapist is authorized by law to provide such care.
In addition, the certified registered nurse anesthetist may direct the nurse or therapist to administer treatments, drugs, and intravenous fluids to treat conditions related to the administration of anesthesia if the nurse or therapist is authorized by law to administer treatments, drugs, and intravenous fluids and a physician, podiatrist, or dentist ordered the treatments, drugs, and intravenous fluids.
Sec. 4723.434. (A) During the time period that begins on a patient's admission for a surgery or procedure to a health care facility where the certified registered nurse anesthetist practices and ends with the patient's discharge from recovery, the nurse may engage in one or more of the following activities:
(1) Performing and documenting evaluations and assessments, which may include ordering and evaluating one or more diagnostic tests for conditions related to the administration of anesthesia;
(2) As necessary for patient management and care, selecting, ordering, and administering treatments, drugs, and intravenous fluids for conditions related to the administration of anesthesia;
(3) As necessary for patient management and care, directing registered nurses, licensed practical nurses, and respiratory therapists to perform either or both of the following activities if authorized by law to perform such activities:
(a) Providing supportive care, including monitoring vital signs, conducting electrocardiograms, and administering intravenous fluids;
(b) Administering treatments, drugs, and intravenous fluids to treat conditions related to the administration of anesthesia.
(B)(1) A certified registered nurse anesthetist may not engage in one or more of the activities described in division (A) of this section unless all of the following apply:
(a) The nurse is physically present at the health care facility when performing the activities.
(b) The nurse's supervising physician, podiatrist, or dentist is physically present at the health care facility where the nurse is performing the activities.
(c) The health care facility where the nurse practices has adopted a written policy developed by the facility's medical, nursing, and pharmacy directors that meets the requirements of section 4723.435 of the Revised Code.
(2) A certified registered nurse anesthetist shall not engage in one or more of the activities described in division (A) of this section if the supervising physician, podiatrist, or dentist or the health care facility where the nurse practices determines that it is not in a patient's best interest for the nurse to perform such an activity or activities. If a supervising physician, podiatrist, or dentist or facility makes such a determination, the patient's medical or electronic health record shall indicate that the nurse is prohibited from performing the activity or activities.
(3) If a certified registered nurse anesthetist performs one or more of the activities described in division (A) of this section, the nurse shall so indicate in the patient's medical or electronic health record.
(C)(1) This section does not authorize a certified registered nurse anesthetist to prescribe a drug for use outside of the health care facility where the nurse practices.
(2) This section does not prohibit a certified registered nurse from implementing a verbal order of a supervising physician, podiatrist, or dentist.
Sec. 4723.435. (A) A written policy adopted by a health care facility as described in section 4723.434 of the Revised Code shall establish standards and procedures to be followed by certified registered nurse anesthetists when performing one or more of the following activities in the health care facility:
(1) Selecting, ordering, and administering treatments, drugs, and intravenous fluids;
(2) Ordering diagnostic tests and evaluating those tests;
(3) Directing registered nurses, licensed practical nurses, and respiratory therapists to perform activities as described in division (A)(3) of section 4723.434 of the Revised Code.
(B) In adopting a policy, both of the following apply:
(1) The health care facility shall not authorize a certified registered nurse anesthetist to select, order, or administer any drug that a supervising physician, podiatrist, or dentist is not authorized to prescribe.
(2) The health care facility shall allow a supervising physician, podiatrist, or dentist to issue every order related to a patient's anesthesia care.
Sec. 4729.01. As used in this chapter:
(A) "Pharmacy," except when used in a context that refers to the practice of pharmacy, means any area, room, rooms, place of business, department, or portion of any of the foregoing where the practice of pharmacy is conducted.
(B) "Practice of pharmacy" means providing pharmacist care requiring specialized knowledge, judgment, and skill derived from the principles of biological, chemical, behavioral, social, pharmaceutical, and clinical sciences. As used in this division, "pharmacist care" includes the following:
(1) Interpreting prescriptions;
(2) Dispensing drugs and drug therapy related devices;
(3) Compounding drugs;
(4) Counseling individuals with regard to their drug therapy, recommending drug therapy related devices, and assisting in the selection of drugs and appliances for treatment of common diseases and injuries and providing instruction in the proper use of the drugs and appliances;
(5) Performing drug regimen reviews with individuals by discussing all of the drugs that the individual is taking and explaining the interactions of the drugs;
(6) Performing drug utilization reviews with licensed health professionals authorized to prescribe drugs when the pharmacist determines that an individual with a prescription has a drug regimen that warrants additional discussion with the prescriber;
(7) Advising an individual and the health care professionals treating an individual with regard to the individual's drug therapy;
(8) Acting pursuant to a consult agreement with one or more physicians authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery, if an agreement has been established;
(9) Engaging in the administration of immunizations to the extent authorized by section 4729.41 of the Revised Code;
(10) Engaging in the administration of drugs to the extent authorized by section 4729.45 of the Revised Code.
(C) "Compounding" means the preparation, mixing, assembling, packaging, and labeling of one or more drugs in any of the following circumstances:
(1) Pursuant to a prescription issued by a licensed health professional authorized to prescribe drugs;
(2) Pursuant to the modification of a prescription made in accordance with a consult agreement;
(3) As an incident to research, teaching activities, or chemical analysis;
(4) In anticipation of orders for drugs pursuant to prescriptions, based on routine, regularly observed dispensing patterns;
(5) Pursuant to a request made by a licensed health professional authorized to prescribe drugs for a drug that is to be used by the professional for the purpose of direct administration to patients in the course of the professional's practice, if all of the following apply:
(a) At the time the request is made, the drug is not commercially available regardless of the reason that the drug is not available, including the absence of a manufacturer for the drug or the lack of a readily available supply of the drug from a manufacturer.
(b) A limited quantity of the drug is compounded and provided to the professional.
(c) The drug is compounded and provided to the professional as an occasional exception to the normal practice of dispensing drugs pursuant to patient-specific prescriptions.
(D) "Consult agreement" means an agreement that has been entered into under section 4729.39 of the Revised Code.
(E) "Drug" means:
(1) Any article recognized in the United States pharmacopoeia and national formulary, or any supplement to them, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans or animals;
(2) Any other article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans or animals;
(3) Any article, other than food, intended to affect the structure or any function of the body of humans or animals;
(4) Any article intended for use as a component of any article specified in division (E)(1), (2), or (3) of this section; but does not include devices or their components, parts, or accessories.
"Drug" does not include "hemp" or a "hemp product" as those terms are defined in section 928.01 of the Revised Code.
(F) "Dangerous drug" means any of the following:
(1) Any drug to which either of the following applies:
(a) Under the "Federal Food, Drug, and Cosmetic Act," 52 Stat. 1040 (1938), 21 U.S.C.A. 301, as amended, the drug is required to bear a label containing the legend "Caution: Federal law prohibits dispensing without prescription" or "Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian" or any similar restrictive statement, or the drug may be dispensed only upon a prescription;
(b) Under Chapter 3715. or 3719. of the Revised Code, the drug may be dispensed only upon a prescription.
(2) Any drug that contains a schedule V controlled substance and that is exempt from Chapter 3719. of the Revised Code or to which that chapter does not apply;
(3) Any drug intended for administration by injection into the human body other than through a natural orifice of the human body;
(4) Any drug that is a biological product, as defined in section 3715.01 of the Revised Code.
(G) "Federal drug abuse control laws" has the same meaning as in section 3719.01 of the Revised Code.
(H) "Prescription" means all of the following:
(1) A written, electronic, or oral order for drugs or combinations or mixtures of drugs to be used by a particular individual or for treating a particular animal, issued by a licensed health professional authorized to prescribe drugs;
(2) For purposes of sections 2925.61, 4723.488, 4730.431, and 4731.94 of the Revised Code, a written, electronic, or oral order for naloxone issued to and in the name of a family member, friend, or other individual in a position to assist an individual who there is reason to believe is at risk of experiencing an opioid-related overdose.
(3) For purposes of section 4729.44 of the Revised Code, a written, electronic, or oral order for naloxone issued to and in the name of either of the following:
(a) An individual who there is reason to believe is at risk of experiencing an opioid-related overdose;
(b) A family member, friend, or other individual in a position to assist an individual who there is reason to believe is at risk of experiencing an opioid-related overdose.
(4) For purposes of sections 4723.4810, 4729.282, 4730.432, and 4731.93 of the Revised Code, a written, electronic, or oral order for a drug to treat chlamydia, gonorrhea, or trichomoniasis issued to and in the name of a patient who is not the intended user of the drug but is the sexual partner of the intended user;
(5) For purposes of sections 3313.7110, 3313.7111, 3314.143, 3326.28, 3328.29, 4723.483, 4729.88, 4730.433, 4731.96, and 5101.76 of the Revised Code, a written, electronic, or oral order for an epinephrine autoinjector issued to and in the name of a school, school district, or camp;
(6) For purposes of Chapter 3728. and sections 4723.483, 4729.88, 4730.433, and 4731.96 of the Revised Code, a written, electronic, or oral order for an epinephrine autoinjector issued to and in the name of a qualified entity, as defined in section 3728.01 of the Revised Code.
(I) "Licensed health professional authorized to prescribe drugs" or "prescriber" means an individual who is authorized by law to prescribe drugs or dangerous drugs or drug therapy related devices in the course of the individual's professional practice, including only the following:
(1) A dentist licensed under Chapter 4715. of the Revised Code;
(2)
A clinical nurse specialist, certified nurse-midwife, or certified
nurse practitioner who holds a current, valid license issued
under Chapter 4723. of the Revised Code to
practice nursing as an advanced practice registered nurse
issued
under Chapter 4723. of the Revised Code;
(3) A certified registered nurse anesthetist who holds a current, valid license issued under Chapter 4723. of the Revised Code to practice nursing as an advanced practice registered nurse, but only to the extent of the nurse's authority under sections 4723.43 and 4723.434 the Revised Code;
(4) An optometrist licensed under Chapter 4725. of the Revised Code to practice optometry under a therapeutic pharmaceutical agents certificate;
(4)
(5)
A
physician authorized under Chapter 4731. of the Revised Code to
practice medicine and surgery, osteopathic medicine and surgery, or
podiatric medicine and surgery;
(5)
(6)
A
physician assistant who holds a license to practice as a physician
assistant issued under Chapter 4730. of the Revised Code, holds a
valid prescriber number issued by the state medical board, and has
been granted physician-delegated prescriptive authority;
(6)
(7)
A
veterinarian licensed under Chapter 4741. of the Revised Code.
(J) "Sale" or "sell" includes any transaction made by any person, whether as principal proprietor, agent, or employee, to do or offer to do any of the following: deliver, distribute, broker, exchange, gift or otherwise give away, or transfer, whether the transfer is by passage of title, physical movement, or both.
(K) "Wholesale sale" and "sale at wholesale" mean any sale in which the purpose of the purchaser is to resell the article purchased or received by the purchaser.
(L) "Retail sale" and "sale at retail" mean any sale other than a wholesale sale or sale at wholesale.
(M) "Retail seller" means any person that sells any dangerous drug to consumers without assuming control over and responsibility for its administration. Mere advice or instructions regarding administration do not constitute control or establish responsibility.
(N) "Price information" means the price charged for a prescription for a particular drug product and, in an easily understandable manner, all of the following:
(1) The proprietary name of the drug product;
(2) The established (generic) name of the drug product;
(3) The strength of the drug product if the product contains a single active ingredient or if the drug product contains more than one active ingredient and a relevant strength can be associated with the product without indicating each active ingredient. The established name and quantity of each active ingredient are required if such a relevant strength cannot be so associated with a drug product containing more than one ingredient.
(4) The dosage form;
(5) The price charged for a specific quantity of the drug product. The stated price shall include all charges to the consumer, including, but not limited to, the cost of the drug product, professional fees, handling fees, if any, and a statement identifying professional services routinely furnished by the pharmacy. Any mailing fees and delivery fees may be stated separately without repetition. The information shall not be false or misleading.
(O) "Wholesale distributor of dangerous drugs" or "wholesale distributor" means a person engaged in the sale of dangerous drugs at wholesale and includes any agent or employee of such a person authorized by the person to engage in the sale of dangerous drugs at wholesale.
(P) "Manufacturer of dangerous drugs" or "manufacturer" means a person, other than a pharmacist or prescriber, who manufactures dangerous drugs and who is engaged in the sale of those dangerous drugs.
(Q) "Terminal distributor of dangerous drugs" or "terminal distributor" means a person who is engaged in the sale of dangerous drugs at retail, or any person, other than a manufacturer, repackager, outsourcing facility, third-party logistics provider, wholesale distributor, or pharmacist, who has possession, custody, or control of dangerous drugs for any purpose other than for that person's own use and consumption. "Terminal distributor" includes pharmacies, hospitals, nursing homes, and laboratories and all other persons who procure dangerous drugs for sale or other distribution by or under the supervision of a pharmacist, licensed health professional authorized to prescribe drugs, or other person authorized by the state board of pharmacy.
(R) "Promote to the public" means disseminating a representation to the public in any manner or by any means, other than by labeling, for the purpose of inducing, or that is likely to induce, directly or indirectly, the purchase of a dangerous drug at retail.
(S) "Person" includes any individual, partnership, association, limited liability company, or corporation, the state, any political subdivision of the state, and any district, department, or agency of the state or its political subdivisions.
(T) "Animal shelter" means a facility operated by a humane society or any society organized under Chapter 1717. of the Revised Code or a dog pound operated pursuant to Chapter 955. of the Revised Code.
(U) "Food" has the same meaning as in section 3715.01 of the Revised Code.
(V) "Pain management clinic" has the same meaning as in section 4731.054 of the Revised Code.
(W) "Investigational drug or product" means a drug or product that has successfully completed phase one of the United States food and drug administration clinical trials and remains under clinical trial, but has not been approved for general use by the United States food and drug administration. "Investigational drug or product" does not include controlled substances in schedule I, as defined in section 3719.01 of the Revised Code.
(X) "Product," when used in reference to an investigational drug or product, means a biological product, other than a drug, that is made from a natural human, animal, or microorganism source and is intended to treat a disease or medical condition.
(Y) "Third-party logistics provider" means a person that provides or coordinates warehousing or other logistics services pertaining to dangerous drugs including distribution, on behalf of a manufacturer, wholesale distributor, or terminal distributor of dangerous drugs, but does not take ownership of the drugs or have responsibility to direct the sale or disposition of the drugs.
(Z) "Repackager of dangerous drugs" or "repackager" means a person that repacks and relabels dangerous drugs for sale or distribution.
(AA) "Outsourcing facility" means a facility that is engaged in the compounding and sale of sterile drugs and is registered as an outsourcing facility with the United States food and drug administration.
(BB) "Laboratory" means a laboratory licensed under this chapter as a terminal distributor of dangerous drugs and entrusted to have custody of any of the following drugs and to use the drugs for scientific and clinical purposes and for purposes of instruction: dangerous drugs that are not controlled substances, as defined in section 3719.01 of the Revised Code; dangerous drugs that are controlled substances, as defined in that section; and controlled substances in schedule I, as defined in that section.
Sec. 4761.17. All of the following apply to the practice of respiratory care by a person who holds a license or limited permit issued under this chapter:
(A) The person shall practice only pursuant to a prescription or other order for respiratory care issued by any of the following:
(1) A physician;
(2) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner who holds a current, valid license issued under Chapter 4723. of the Revised Code to practice nursing as an advanced practice registered nurse and has entered into a standard care arrangement with a physician;
(3) A certified registered nurse anesthetist who holds a current, valid license issued under Chapter 4723. of the Revised Code to practice nursing as an advanced practice registered nurse and acts in compliance with sections 4723.43, 4723.433, and 4723.434 of the Revised Code;
(4) A physician assistant who holds a valid prescriber number issued by the state medical board, has been granted physician-delegated prescriptive authority, and has entered into a supervision agreement that allows the physician assistant to prescribe or order respiratory care services.
(B) The person shall practice only under the supervision of any of the following:
(1) A physician;
(2) A certified nurse practitioner, certified nurse-midwife, or clinical nurse specialist;
(3)
A physician assistant who is authorized to prescribe or order
respiratory care services as provided in division (A)(3)
(A)(4)
of
this section.
(C)(1) When practicing under the prescription or order of a certified nurse practitioner, certified nurse midwife, or clinical nurse specialist or under the supervision of such a nurse, the person's administration of medication that requires a prescription is limited to the drugs that the nurse is authorized to prescribe pursuant to section 4723.481 of the Revised Code.
(2) When practicing under the order of a certified registered nurse anesthetist, the person's administration of medication is limited to the drugs that the nurse is authorized to order or direct the person to administer, as provided in sections 4723.43, 4723.433, and 4723.434 of the Revised Code.
(3) When practicing under the prescription or order of a physician assistant or under the supervision of a physician assistant, the person's administration of medication that requires a prescription is limited to the drugs that the physician assistant is authorized to prescribe pursuant to the physician assistant's physician-delegated prescriptive authority.
Section 2. That existing sections 4723.43, 4729.01, and 4761.17 of the Revised Code are hereby repealed.