Problem with Amarillo area hospital

[NeoTrion]

I was wondering if I could get some opinions from the forum, and maybe some advice.  I work with three other PA's at an Amarillo hospital that is requiring physician co-signatures on all of our H&P's and orders including all medication orders, scheduled drugs and dangerous drugs (for those outside of Texas, 'legend' drugs are referred to as 'dangerous' drugs here in the Lone Star State).  After doing some investigation the hospital does not require the same for NP's.  Orders from NP's do not require a physician co-signature.  

 

As PA's we inquired with the medical staff office at our hospital asking for clarity as to why PA's and NP's have different requirements regarding co-signatures.  Their responses have all had a central theme:  The hospital's medical staff office is convinced that PA's have more restrictions and less privileges when compared to NP's.

 

I work in a group with 3 other P.A.'s and although we are not the first to be employed by our group, we are the first that seem to be seeing these issues come up.  We submitted the Texas Medical Boards laws and regulations, but after calling them they do state that every hospital has to interpret the words for themselves.  TMB treats NP's and PA's the same.  When confronted with this they then claim that the Texas Nursing Board has a rule saying that nurses cannot take orders from PA's.  Obviously I found this questionable but did do some digging.  All I could find was a "Position Statement" saying the following:

 

I work in a group with 3 other P.A.'s and although we are not the first to be employed by our group, we are the first that seem to be seeing these issues come up.  We submitted the Texas Medical Boards laws and regulations, but after calling them they do state that every hospital has to interpret the words for themselves.  TMB treats NP's and PA's the same.  When confronted with this they then claim that the Texas Nursing Board has a rule saying that nurses cannot take orders from PA's.  Obviously I found this questionable but did do some digging.  All I could find was a "Position Statement" saying the following:

 

15.1 Nurses Carrying out Orders from Physician's Assistants

 

The Nursing Practice Act includes the "administration of medications or treatments ordered by a physician, podiatrist or dentist" as part of the practice of nursing. There are no other health care professionals listed. The Board recognizes that in some practice settings nurses work in collegial relationships with physician assistants (PAs) who may relay a physician's order for a client being cared for by a nurse.

 

A nurse may carry out a physician's order for the administration of treatments or medications relayed by a physician assistant (PA) when that order originates with the PA's supervising physician. Supervision must be continuous but does not require the physical presence of a supervising physician at the place where the PA services are performed provided a supervising physician is readily available by telecommunications. The supervising physician should have given notice to the facility that he/she is registered with the Texas Medical Board (TMB) as the supervising physician for the PA and that he/she has authorized the PA to relay orders. The PA must be licensed or registered by the TMB. A list of physician assistants credentialed by the medical staff and policies directing their practice should be available to the nursing staff.

 

The order relayed by the PA may originate from a protocol; if the order originates from a protocol, the PA may select specific tasks or functions required to implement the protocol, provided they are within the scope of the protocol. The protocol must be signed by the supervising physician and should be made available as necessary to verify authority to provide medical aspects of care. If the tasks or functions ordered fall outside the scope of the protocol, the PA must consult with the physician to obtain a verbal order before the nurse may carry out the order.

As with any order, the nurse must seek clarification if he/she believes the order or treatment is inaccurate, non-efficacious or contraindicated by consulting with the PA and physician as appropriate. The nurse may request to review the PA’s protocol as one mechanism for clarification of orders and treatments.

 

(Board Action: 01/1994; Revised: 01/2005; 01/2006; 01/2010; 01/2012)

(Reviewed: 01/2007; 01/2008; 01/2009; 01/2011; 01/2013; 01/2014; 01/2015 )

 

I could not find a rule saying this other than this position statement.  We have contacted some other colleagues at MD Anderson that were kind enough to send us their hospital guidelines for PA practice.  Obviously they have none of the above mentioned restrictions.  The colleagues at MD Anderson also put us in touch with the council for TAPA.  The main issue now is actually getting the hospital to talk to the council for TAPA and the administration at MD Anderson.  We were originally encouraged by medical staffing to reach out to other facilities and get this information for them.  Now we are in the position now of convincing administration to even call these people for the information they requested.  Does anyone have any further advice on what we can do to get these guys off their can and look at the information?  Maybe ask AAPA to write a letter?

[NeoTrion]

So I just wanted to give anyone in Texas an update on this issue.  More digging  on this issue showed a pattern that some hospitals were using this to lock out P.A.'s and higher N.P's preferentially.  It was more an issue with the RN's that held administrative positions.  We were lucky enough to network with some people at M.D. Anderson that had some good friends including a lawyer that worked for T.A.P.A.  This caused a massive chain email that was sent to all of us that were concerned about this and kept running into this issue at hospitals Texas wide.  A formal letter of protest was written by T.A.P.A to the Board of Medicine, The P.A. Board, and the Board of Nursing.  We were lucky enough to get enough peoples ear's that caused a meeting to take place between the Board of Medicine and the Board of Nursing.  Long story short this position statement is being changed due to an order made by the board of medicine.  There were some legal issues thrown around like "restriction of trade" and other issues presented to the executives attached to the Board of Nursing.  Of course the Board of Medicine took issue that they were trying to decide whom could practice medicine when they made a statement like this.  We are taking our specialty group and rescheduling a meeting with the CMO of the hospital in question along with the various RN administrators, that were using this as a reason that we needed co-signatures on every order we wrote, to reconsider their position before we take this further.  If you are not a member of T.A.P.A I would strongly suggest you become one.  While they can't help with everything we were extremely fortunate that we got this taken care of and it should help everyone that has hit administrators using this think twice.  Here is the edited version of the new position statement.  While it is not perfect it is a heck of a lot better than what they were trying to get away with.  Everything in red has been deleted.

 

15.1 Nurses Carrying out Orders from Physician's Assistants
The purpose of this position statement is to provide guidance to nurses with regard to carrying out orders from Physician Assistants (PAs).

The Nursing Practice Act (NPA) includes the "administration of medications or treatments ordered by a physician, podiatrist or dentist" as part of the practice of nursing.1 There are no other health care professionals listed thus leading to questions regarding nurses carrying out orders from other licensed healthcare providers. Although PAs are not included in the NPA, the Board recognizes that nurses work collaboratively with PAs to provide patient care in various practice settings. The Board recognizes that in some practice settings nurses work in collegial relationships with physician assistants (PAs) who may relay a physician's order for a client being cared for by a nurse.

A nurse may carry out a physician's order for the administration of treatments or medications relayed by a physician assistant (PA) when that order originates with the PA's supervising physician. Supervision must be continuous but does not require the physical presence of a supervising physician at the place where the PA services are performed provided a supervising physician is readily available by telecommunications. The supervising physician should have given notice to the facility that he/she is registered with the Texas Medical Board (TMB) as the supervising physician for the PA and that he/she has authorized the PA to relay orders. The PA must be licensed or registered by the TMB. A list of physician assistants credentialed by the medical staff and policies directing their practice should be available to the nursing staff.

The PA is licensed and regulated by the Physician Assistant Board.2 PAs may order medical aspects of care as delegated by a physician consistent with laws, rules and regulations applicable to the PA practice including those of the Texas Medical Board (TMB) Chapter 193.3 The order relayed by the PA may originate from a protocol. If the order originates from a protocol, the PA may select specific tasks or functions required to implement the protocol, provided they are within the scope of the protocol. The protocol must be signed by the supervising physician and should be made available as necessary to verify authority to provide medical aspects of care. If the tasks or functions ordered fall outside the scope of the protocol, the PA must consult with the physician to obtain a verbal order before the nurse may carry out the order. As with any order, the nurse must seek clarification if he/she believes the order or treatment is inaccurate, non-efficacious or contraindicated by consulting with the PA and physician as appropriate.4 The nurse may request to review the PA’s protocol as one mechanism for clarification of orders and treatments.A list of physician assistants credentialed by the medical staff and policies directing their practice should be available to the nursing staff. 

[MediMike]

Well done.  Can't believe that crap was on the books to begin with.

[sas5814]

I am glad that worked out. The medical board in Texas has been successfully sued several times for exceeding their mandate and writing rules that restrict trade. They generally do that to protect money and power for physicians and have no other basis other than vague "patient safety" and "people will die" comments that they can't support with any measurable evidence.

Some of the most fun I ever had back in the day when I was in health care politics in Texas was presenting information to legislators or committees with a lot of data, telling them exactly what the physicians were going to say, and encouraging them to ask for measurable data to support their positions. They did and the physicians never could.

Another problem we had with the legislature is the number of physicians that serve. They are all Texas Medical Association members. TMA's #1 item on their political agenda for many years has been to stop the expansion of any non-physician services or scope of practice.  

[davidccs]

nicely done. It is incredible what good representation can do for the profession in a few months, imagine what could be accomplished if PAs were well represented for longer periods and on a national level!