What APNs Need to Know to Prescribe in Ohio

What APNs Need to Know to Prescribe in Ohio Erin L. Keels RN MS CNP NNP-BC Deb Pratt RN MS

Ohio Law Ohio Revised Code (ORC) All laws in Ohio written by the legislature Nurse Practice Act section 4723 Ex: items required for CTPE application including 45 hours of pharm. http://codes.ohio.gov/orc/4723 Ohio Administrative Code (OAC) Rules, regulations that further define the laws Written by regulatory boards and must be consistent with the law Ex: lists specific requirements of the cont. pharm course http://codes.ohio.gov/oac/4723-8

Title Protection and Prescriptive Authority OAC 4723-8 Title protection: the state mandates that professional titles are restricted to those individuals who have achieved specific requirements. Ohio APNs gained Title protection in 2000. Gives legal recognition of the title Assures consumers Ties to reimbursement- federal and state Advanced Practice Nurse is the current state protected title Certified Nurse Practitioner Certified Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife - Will become APRN in 2013

Certified Nurse Practitioner (CNP) ORC 4723.43 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 and Evaluate and promote patient wellness added acute care language with HB 303 Within the nurse s nursing specialty, consistent with the nurse s education and certification, and in accordance with rules adopted by the board.

Clinical Nurse Specialist (CNS) ORC 4723.43 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.

Certified Registered Nurse Anesthetist (CRNA) ORC 4723.43 With the supervision and in the immediate presence of a physician, podiatrist, or dentist, may administer anesthesia and perform anesthesia functions Is not required to obtain a certificate to prescribe in order to provide the anesthesia care described in the ORC. When supervised by a podiatrist, the CRNA 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. May not administer general anesthesia under the supervision of a podiatrist in a podiatrist s office. When 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.

Certified Nurse Midwife (CNM) ORC 4723.43 A nurse authorized to practice as a certified nurse-midwife: in collaboration with one or more physicians 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. 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. May perform episiotomies or normal vaginal deliveries, or repair vaginal tears. A certified nurse-midwife who holds a certificate to prescribe issued under section 4723.48 of the Revised Code may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices in accordance with section 4723.481 of the Revised Code

Ohio Board of Nursing Primary function is to protect Ohio s health consumers Authority to issue, renew, revoke licenses to LPN, RN, APN Test (or accepts specific national certification tests) to assure competence Sets criteria for licensure (and revocation) per the Ohio Revised Code and Ohio Administrative Code

Ohio Board of Nursing and APN Prescribing Adopt rules as necessary to implement the provisions pertaining to the authority of clinical APNs to prescribe drugs and therapeutic devices and the issuance and renewal of certificates to prescribe. Consistent with the recommendations the board receives from the Committee on Prescriptive Governance (CPG). The Board shall not adopt any rule that does not conform to a recommendation made by the CPG.

Ohio Board of Nursing and APN Prescribing Established a formulary (based upon Drug Facts and Comparisons) listing the types of drugs and therapeutic devices that may be prescribed by a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner. The formulary may include controlled substances, as defined in section 3719.01 of the Revised Code. The formulary shall not permit the prescribing of any drug or device to perform or induce an abortion. Established safety standards to be followed by a nurse when personally furnishing to patients complete or partial supplies of certain drugs (listed in the OAC)

Ohio Board of Nursing and APN Prescribing Established standards and procedures for issuance and renewal of a certificate to prescribe, including specification of any additional information the board may require Established requirements for board approval of the instruction advanced pharmacology and related topics Established standards and procedures for the appropriate conduct of an externship required

In order to prescribe, you must possess: CTP or CTPE DEA for controlled substances COA Master Degree in Nursing National Certification SCA Reviewed and signed by all collaborating physicians Annual quality monitors

Prescriptive Authority in Ohio Certificate to Prescribe Externship (CTPE) Certificate to Prescribe (CTP)

CTPE OAC 4723-9 Externship means the practice relationship, consistent with the standard care arrangement, between a nurse who holds a current, valid externship certificate to prescribe and one or more licensed physicians. ORC4723.485 During the externship, the nurse s prescribing activities are reviewed and evaluated by a supervising professional for the purpose of ongoing improvement of the nurse s competence, knowledge, and skill in pharmacokinetic principles and the application of these principles to the nurse s area of practice. The standard care arrangement entered into between the collaborating physician and the nurse shall specify the frequency of the review needed for appropriate oversight

Requirements for CTPE ORC 4723.48, OAC 4723-9 Documentation of successful completion of at least 45 contact hours in advanced pharmacology A copy of a university/college transcript; AND/OR A copy of the certificate(s) from an approved continuing education course(s). The advanced pharmacology course must be completed within 3 years immediately preceding application for a CTP-E. Hope that this will change to 5 years Current, valid Ohio RN and COA Documentation of both a graduate degree and appropriate national certification in order to obtain a COA. Valid SCA with one or more collaborating physicians Application and Fees

CTPE 1500 hours total supervision (maximum 1800 hours) during which the nurse s prescribing practices are supervised as follows: Direct Supervision (Minimum of 500 Hours): The supervising professional is available on site. At the discretion of the collaborating physician, a prescribing nurse may provide up to 200 hours of direct supervision, provided the nurse is a current prescribing COA holder with a CTP (NOT a CTP-E). Indirect Supervision: The timely review by a physician of prescriptions written by and prescribing practices of a nurse holding an externship certificate to prescribe.

Certificate to Prescribe CTP- issued once externship is completed and appropriate application is submitted. Valid for 2 years Requires additional 12 hour of continuing pharmacology education to renew Q 2 years. Must include your CTP or CTPE number on all (outpatient) prescriptions OAC 4723-9

Educational Requirements OAC 4723-9 The content of the instruction must be specific to the applicant s nursing specialty and include all of the following: A minimum of 45 contact hours (36 from any one provider) of training in advanced pharmacology that includes pharmacokinetic principles and clinical application and the use of drugs and therapeutic devices in the prevention of illness and maintenance of health Training in the fiscal and ethical implications of prescribing drugs and therapeutic devices Training in the state and federal laws that apply to the authority to prescribe Effective June 2012, 6 hours of content must be related to schedule II content.

National Certification ORC 4723.46; OAC 4723-8 OBN-approved National Certification for 2013 American Academy of Nurse Practitioners Certification Program American Association of Critical-Care Nurses Certification Corporation American Midwifery Certification Board Formerly the American College of Nurse-Midwives. American Nurses Credentialing Center National Board for Certification of Hospice and Palliative Nurses National Board of Certification and Recertification for Nurse Anesthetists The Council on Certification of Nurse Anesthetists The Council on Recertification of Nurse Anesthetists Prior to September 2007, the Councils were under the American Association of Nurse Anesthetists. National Certification Corporation Oncology Nursing Certification Corporation Pediatric Nursing Certification Board Formerly the National Board of Pediatric Nurse Practitioners and Associates.

Certificate of Authority OAC 4723-8 of Authority License to practice as an APN in the State of Ohio Master of Science in Nursing from approved program National Certification (see previous slide) Application and Fees

Standard Care Arrangement ORC 4723.431; OAC 4723-8 Formal, written document of the collaborative relationship between the APN and physician/s CNP, CNM, CNS must have SCA Psych CNS only need SCA if they are prescribing CRNAs work under the supervision of the anesthesiologist and do not need a SCA

Standard Care Arrangement Collaboration= The Physician APN Relationship The APN can practice independently within his/her scope and consults or collaborates with the physician as needed The SCA can further limit this scope- must be stated Each physician or podiatrist must be actively engaged in direct clinical practice in this state and practicing in a specialty that is the same as or similar to the nurse s nursing specialty Must be reviewed and signed annually Must ALWAYS be current Must be kept at the site of employment

Standard Care Arrangement General scope of practice of the APN Criteria for referral of a patient by the APN to a collaborating physician or podiatrist (references) Process of introducing new technology, devices, treatments A process for the APN to obtain a consultation with a collaborating physician or podiatrist A plan for coverage in instances of emergency or planned absences of either the APN or a collaborating physician or podiatrist that provides the means whereby a physician or podiatrist is available for emergency care

Standard Care Arrangement The process for resolution of disagreements regarding matters of patient management between the APN and a collaborating physician or podiatrist Preceptorship arrangements- notify collaborating physician at NCH A procedure for a regular review of the referrals by the APN to other health care professionals and the care outcomes for a random sample of all patients seen by the nurse If the APN regularly provides services to infants, a policy for care of infants up to age one and recommendations for collaborating physician visits for children from birth to age three

Standard Care Arrangement Quality assurance standards Annual review of the SCA Chart reviews (2 per year) Prescribing practice reviews (10 prescriptions Q6 months) Documentation of participation in an ongoing, systematic quality assurance process at an institution Schedule II additions Acceptable travel time between the location at which the nurse is engaging in the prescribing components of the nurse s practice and the location of the nurse s collaborating physician or podiatrist

Standard Care Arrangement Prescribing privileges must be addressed in the SCA: Qualification of prescribing APN Timely evaluation by physician PI/PC drugs Use of off-label drugs Any additional parameters, limitations, and exclusions for prescribing

Out of State Prescribers OAC 4723-9 SB 89 (enacted in 2010) Decreases or eliminates externship hours for practicing APNs outside of Ohio: 1. Actively practicing in the last 3 years, actively prescribing in last 1 year AND prescribing controlled substances. Need: Documentation from collaborating physician, Complete 2 hour course on Ohio prescribing laws and rules 2. Actively practicing in the last 3 years, actively prescribing in last 1 year; NOT prescribing controlled substances. Need: Documentation from collaborating physician; Complete 2 hour course on Ohio prescribing laws and rules; Complete 500 hours of externship HB303- eliminated collaborating physician documentation for APNs coming to Ohio from an INDEPENDENT PRACTICE state.

Prescribing OAC 4723-9 Ordering situations that DO NOT require prescriptive authority - each must be within the individual COA holder's appropriate patient population /scope: 1) Lab tests 2) Diagnostic x-rays 3) Over-the-counter (OTC) medications (not listed on formulary) MSO bylaws may restrict to CTP holders 4) Diagnostic aids 5) Durable medical equipment: address in SCA 6) Blood products (other than plasma expanders)

Prescribing Prescriptive authority (holding a CTP/CTP-E) is required to order: 1) Medications approved by the FDA and governed by the State Board of Pharmacy law and rules Must be listed in OBN Formulary and NCH Formulary 2) Oxygen is considered a medication 3) Plasma expanders are considered medications

Prescribing -Must be consistent with your certification, scope of authority, SCA and area of practice -Except as provided, all drugs/therapeutic devices shall be prescribed in accordance with the manufacturer s package insert, the United States Pharmacopoeia (USP), and Standard Care Arrangement. If not, it is considered off- label -3:1 ratio of prescribing APN to Physician: for the purposes of prescribing, a physician may not collaborate with more than 3 prescribing APNs at the same time. Does not limit employment numbers or regular APN practice. Physician accountability.

Prescribing -As a prescriber, you are responsible for safety alerts and recalls that occur. -Appropriate follow-up with patients may include, among other actions, relaying information to your patients based on safety or recall information; discontinuing medication, and/or instituting new medication(s). -Timely information including recalls, warnings, safety alerts and patient information is available on the FDA website at: http://www.fda.gov/oc/oha/default.htm

Committee on Prescriptive Governance (CPG) ORC 4723.49 Created in 2000, after passage of title recognition and prescriptive authority The committee on prescriptive governance shall develop recommendations regarding the authority to prescribe drugs and therapeutic devices pursuant to a certificate to prescribe Committee Membership: A clinical nurse specialist A certified nurse-midwife A certified nurse practitioner A member of the board of nursing who at a minimum as a registered nurse Four physicians A pharmacist member of the state board of pharmacy A pharmacist actively engaged in practice in this state as a clinical pharmacist

CPG ORC 4723.49-4723.491-1 chairperson (Erin Keels for 2011-2013 ) -Five members constitute a quorum for the transaction of official business. -The clinical pharmacist member may participate in any meeting of the committee. Can only vote when the committee is considering one of the following: The composition of the formulary of drugs and therapeutic devices that may be prescribed by a CTP/E holder The manner in which a nurse may personally furnish to patients drugs and therapeutic devices packaged as samples and may personally furnish partial or complete supplies of other drugs and therapeutic devices;

Formulary OAC 4723-9 OBN chose Drug Facts and Comparisons as the template for the Formulary as a method to categorize drugs NUTRIENTS &NUTRITIONAL AGENTS ENDOCRINE & METABOLIC AGENTS RENAL &GENITOURINARY AGENTS CENTRAL NERVOUS SYSTEM AGENTS ANTI-INFECTIVES, SYSTEMIC DERMATOLOGIC AGENTS ANTINEOPLASTIC AGENTS HEMATOLOGICAL AGENTS CARDIOVASCULAR AGENTS RESPIRATORY AGENTS GASTROINTESTINAL AGENTS BIOLOGIC/IMMUNOLOGIC AGENTS OPHTHALMIC AGENTS DIAGNOSTIC AIDS OTHER

Facts and Comparisons http://online.factsandcomparisons.com Username: Nationwide Password: Hospital Must know how the drug is categorized according to Facts and Comparisons

BON Formulary Then you must know how what the prescribing parameters are for the drug per the Formulary at the OBN:

Formulary http://www.nursing.ohio.gov/pdfs/advpractice/formulary5-10-10.pdf Drugs within the categories are deemed: Physician Initiated (PI) Physician Consult (PC) CTP MAY prescribe (CTP may) CTP MAY NOT prescribe/nonformulary (CTP may not) OTC not specifically listed in Formulary (CTP may)

Physician Initiated OAC 4723-9 Physician Initiated (PI): collaborating physician is required to have personally examined and evaluated the patient before therapy is initiated. Following discussion with the collaborating physician, the initial order or prescription may be written by an APN holding a certificate to prescribe. Once therapy has been initiated, the APN may continue, modify, or discontinue the medication without further consultation.

Physician Consult OAC 4723-9 Physician Consultation (PC): a nurse holding a current, valid certificate to prescribe may initiate the medication after direct communication with the collaborating physician regarding a particular patient and documenting the consultation in the patient record. Once the medication is initially authorized by the collaborating physician, an APN holding a current valid certificate to prescribe may continue, modify, or discontinue the medication.

PI/PC Effective July, 2009, the drugs/categories listed as PI or PC in the Formulary were combined into PI- OR -PC (PI/PC) must be referenced in the SCA with the collaborating physician in order for a CTP holder to prescribe NCH combined all PI-PC drugs into the PC category- this is stated in the NCH SCA

Other Parameters OAC 4723-9 Non-Formulary and CTP Holder may NOT Prescribe: Medications in this category may not be prescribed by any CTP/CTP-E holder for any indication. Ex: Many of the Heme drugs, anabolic steroids, investigational drugs Over-the-counter medications need not appear on the formulary. A COA (Certificate of Authority) holder may recommend/order OTC medications without holding a Certificate to Prescribe (CTP/CTP-E). Ex: Desitin, Acetaminophen

Other Parameters Off-Label Use: A medication may be prescribed for purposes other than FDA indications when the purpose is supported by current peer review literature (to be produced by the CTP/CTP-E holder upon request, which emanates from a recognized body of knowledge and as provided in the standard care arrangement consistent with the formulary. Ex: 99% of the Neonatal drugs Combination Medication Preparations: In order to prescribe a combination drug, EACH of the component drugs must be "CTP holder may prescribe" in order for the APN prescriber to order the combination medication. Ex: Pentacel- each vaccine component is CTP may prescribe; many combination antibiotics For controlled medications, default to the DEA schedule

Drugs with Review Requirement: Removed in 2012 No longer have to review at 30, 60, 90 days

Formulary Cont. A CTP/CTP-E holder may prescribe a drug within their scope of practice in any form unless a drug, category of drugs, or route of administration is listed as an exclusion, or there are additional parameters specified. Footnote 1: The intravenous (IV) form of particular drugs and/or drug categories identified with an asterisk (*) in the "Additional Parameters" column may ONLY be initiated by a prescriber holding advanced specialty certification as an Acute Care Nurse Practitioner, Acute Care Clinical Nurse Specialist, or Neonatal Nurse Practitioner. OR Non-acute Care CTP holders in an institutional setting WITH PHYSICIAN CONSULT per institution protocol for monitored patient care units and as stated in the standard care arrangement. EX: IV electrolytes; IV inotropes and vasopressors- CTP may prescribe for the acute care APNs, with PC for non-acute care APNs with protocol and monitored patients.

Formulary Cont. Verification of a Prescriber: You can verify whether a particular APN holds current prescriptive authority by accessing the Board s website: http://www.nursing.ohio.gov and click on Verification. A new formulation or route of administration of a drug used for the same indication does not change the Formulary status of that drug. If a drug has a new indication, it must be reviewed by the CPG for Formulary status determination. You may not prescribe until it is reviewed.

New Drugs or Drug Formulations Any drug(s) approved by the FDA subsequent to the effective date of the current Formulary revision shall be considered NON- FORMULARY:CTP Holder may NOT prescribe until reviewed by the Committee on Prescriptive Governance (CPG). The most current version of the Formulary is available on the Board of Nursing website: www.nursing.ohio.gov in the Nursing Practice section.

Requests to CPG for Formulary Revision/Addition Use downloadable form Request for FormularReview/Revision available on the Board s website and MAIL them in http://www.nursing.ohio.gov/practice.htm#advancedpractice To be considered, a written recommendation must be received at the Board no later than close of business 30 days prior to the scheduled CPG meeting Requests should include the information requested on the Request for Formulary Review/Revision Form, including specific drug names (generic and trade names), and rationale for request

Sample and Stock Drugs OAC 4723-9 Sample Drugs: May provide samples of drugs that the APN may prescribe. Samples must be provided without charge, cannot exceed 72 hour supply, cannot be controlled substances Must document: The name of the prescribing nurse The name of the patient Directions for use of the drug or therapeutic device The nurse shall maintain a written record of all drugs and devices personally furnished by the nurse

Dispensing Stock Drugs OAC 4723-9 approved specific categories: antibiotics antifungals scabicides contraceptives prenatal vitamins antihypertensives drugs and devices used in the treatment of diabetes drugs and devices used in the treatment of asthma drugs used in the treatment of dyslipidemia

Ohio APN Schedule II Prescribing SB 83, introduced by Senator Scott Oelslager on February 16, 2011 signed by Governor Kasich on March 9, 2012 Became effective on June 8, 2012. Established sites where APNs can prescribe schedule IIIs Mandates 6 hours of schedule II advanced pharmacology Revisions to SCA Quality Monitors

Schedule II Prescribing Opioids for treatment of drug addiction: No CTP holder may prescribe an opioid for the treatment of drug addiction. Federal law requires that opioids for the treatment of drug addiction be prescribed by physicians only. NOTE restrictions in the law regarding ANY/ALL Schedule II drugs: Schedule II drugs may only be prescribed ONLY IF: 1) The particular drug appears on this formulary as Physician Initiated; AND 2) The patient to receive the drug is a patient with a terminal condition (as defined in ORC 2133.01); AND 3) The collaborating physician initially prescribes the drug; AND 4) The amount subsequently prescribed by the CTP holder is not greater than a 24 hr supply.

The restrictions on prescribing Schedule II drugs do not apply if a CTP holder issues the prescription to the patient from any of the following locations (ORC 4723.481): 1) A hospital registered under Section 3701.07 of the ORC 2) A entity owned or controlled, in whole or in part, by a hospital or by an entity that owns or controls, in whole or in part, one or more hospitals 3) A health care facility operated by the department of mental health or the department of developmental disabilities 4 ) A nursing home licensed under Section 3721.02 ORC or by a political subdivision certified under section 3721.09 of the ORC 5) A county home or district home operated under Chapter 5155. of the ORC that is certified under the Medicare or Medicaid program 6) A hospice care program, as defined in Section 3712.01of the ORC 7) A community mental health facility, as defined in Section 5122.01 of the ORC

8) An ambulatory surgical facility, as defined in Section 3702.30 of the ORC 9) A freestanding birthing center, as defined in Section 3702.51 of the ORC 10) A federally qualified health center, as defined in Section 3701.047 of the ORC 11) A federally qualified health center look-alike, as defined in Section 3701.047 ORC 12) A health care office or facility operated by the board of health of a city or general health district or the authority having the duties of a board of health under Section 3709.05 ORC 13) A site where a medical practice is operated, but only if the practice is comprised of one or more physicians who also are owners of the practice; the practice is organized to provide direct patient care; and the clinical nurse specialist; certified nurse-midwife; or certified nurse practitioner providing services at the site has a standard care arrangement and collaborates with at least one of the physicians owners who practices primarily at that site.

Convenience Care Clinics A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall not issue to a patient a prescription for a schedule II controlled substance from a convenience care clinic even if the clinic is owned or operated by an entity specified in Section 4723.481(C)(2) ORC.

6 hours of schedule II pharmacology http://www.nursing.ohio.gov/practice.htm#advancedpractice As directed by SB 83, the Board adopted rules pertaining to schedule II controlled substances, including prescribing and CE requirements for CTP holders. New Rule 4723-9-13, OAC, addresses the CE requirements and when you renew your CTP, you will be required to verify completion of the continuing education course. The amended rules in Chapters 4723-8 and 4723-9 became effective on November 5, 2012 to provide ample time for CTP holders to complete the required six hours of continuing education before the renewal cycle ends on August 31, 2013. To review the rules, go to the front page of the web site and click on Law and Rules. FAQs answering questions about the new prescribing law and CE requirements are located at the link below. If you have additional questions, please contact the Board at practice@nursing.ohio.gov.

Indications and contraindications Content must include: OAC 4723-9 Periodic assessment and documentation of the patient s functional status The most recent guidelines and recommendations for pain management therapies, as established by state and national organizations Fiscal and ethical implications of prescribing schedule II controlled substances REM State and federal laws that apply to the authority to prescribe schedule II controlled substances State medical board of Ohio rules governing controlled substances and the treatment of chronic pain Ohio state board of pharmacy rules governing the manner of issuance of a prescription Prevention of abuse and diversion, types of assistance available for prevention of abuse, addiction and diversion The use of the Ohio Automated Rx Reporting System (OARRS), and other methods of establishing safeguards against abuse and diversion

HB 303 Board of Nursing Bill that cleaned up language and made ensured that items are current. Major changes: a. Emergency rules take place immediately= online education b. 90 day effective dates: Included acute care in the scope of practice for CNPs APNs may prescribe IV dialysis additives (was restricted to physicians only) Out of state prescribers from independent practice states Change state title to APRN

For future renewal periods, will the six-hour course in schedule II controlled substances be required? No. However, you will need to obtain at least 12 hours in advanced pharmacology, of which includes at least some instruction in controlled substances. There is no minimum hour component to the controlled substances instruction. OAC 4723-9-07

Do I need to mail in a copy of my certificate documenting completion of the six hour course in schedule IIs with my CTP renewal application? No. You will be required to attest that you completed the sixhour course, and the Board will conduct a random audit to verify completion, so retain your certificate of completion as evidence in the event you are audited. You are required to keep this proof for a period of six years. OAC 4723-14-06

Preparing for Schedule II 1. Successfully complete NCH self study 2. Change DEA to include Schedule II and IIN 3. Update SCA (final end of Oct): Provisions for the use of schedule IIs Pain management ADD, ADHD Seizures Use and documentation of OARRS Include in quality monitors Quality assurance monitors Include representative sample of Schedule IIs in biannual med audit 4. Complete Ohio mandated schedule II pharmacology education by Aug 31, 2013

SCA Revisions SCA must address provisions for use of Schedule IIs OAC 4723-8 SCA must address use and documentation of OARRS OAC 4723-9

Quality Monitor Additions Bi-annual prescribing audits must include representative sample of schedule IIs prescribed OAC 4723-8 Audit for compliance with OARRS OAC 4723-9

OARRS OAC 4723-9 1. Register with OARRS: https://www.ohiopmp.gov/portal/registration/default.aspx 2. MUST Consult OARRS including: (1) If a patient is exhibiting signs of drug abuse or diversion (2) When you have a reason to believe the treatment of a patient with controlled substances or tramadol will continue for twelve weeks or more (3) At least once a year thereafter for patients receiving treatment with controlled substances or tramadol for twelve weeks or more http://www.med.ohio.gov/pdf/news

OARRS OAC 4723-9 3. Must document in the patient s record when OARRS is consulted and if any consultation with collaborating physician occurred 4. Must audit for compliance 5. Currently working with NCH IS to develop mechanism for ensuring compliance

DEA OAC 4723-9 Update your DEA to include Schedule II and IIN Must be done prior to prescribing schedule IIs

Schedule II Drugs See: http://www.justice.gov/dea/pubs/scheduling.html for entire list. Alfentanil Amphetamine Cocaine Codeine Fentanyl Hydrocodone Hydromorphone Meperidine

Prescribing Basics OAC 4723-9 Never prescribe with a lapsed CTP or CTPE Never practice on a lapsed national certification Never practice on a lapsed COA or RN license You are NOT considered to be current until the VERIFICATION site at the Ohio Board of Nursing has been updated to reflect the new expiration dates of your CTP, Certification, COA Always prescribe within your certification (acute vs. non acute), specialty, scope of practice and practice setting

Prescribing Basics A nurse who holds a current valid certificate to prescribe shall prescribe in a valid prescriber-patient relationship. This includes, but is not limited to: Obtaining a thorough history of the patient Conducting a physical examination of the patient Rendering a diagnosis Prescribing medication, ruling out the existence of any recognized contraindications Consulting with the collaborating physician when necessary; and Properly documenting these steps in the patient s medical records.

Prescribing Basics FAQs http://www.nursing.ohio.gov/practice.htm#advancedpractice Can a CTP holder prescribe for him/herself? No. A CTP holder may only prescribe in a valid prescriber-patient relationship. Can a Medical Assistant administer a medication as ordered by a CTP holder? A nurse may delegate the administration of ONLY the following medications to unlicensed personnel including medical assistants: Over-the counter medications topical medications to be applied to intact skin for the purpose of improving a skin condition or providing a barrier; and over-the-counter eye drop, ear drop, and suppository medications, foot soak treatments, and enemas CURRENTLY- NOT IMMUNIZATIONS

Prescribing Basics Prescribing for family members: OAC 4723-9 In 2010, CPG recommended that APNs MAY prescribe for family members, just as physicians may Recognized that there are some situations where a family member may be a patient Recommended serious caution

Medical Staff By Laws Approved by the Medical Staff Committee Directs the activities of the Medical and Allied Health Staff Addresses medication ordering Can further limit the scope of the APNs practice

NCH MSO By Laws Prescribing template: All medications orders shall include: patient name, age and medication, route of administration, dosage, frequency date and time when recorded.

NCH MSO By Laws Exception: vaccines, aerosols, and other medications where a standard dose and route of administration are implied by standard practice or by accepted protocol When appropriate, the duration of the course of therapy should be included Indication of the dosage calculation, when based upon either a weight, surface area, or age protocol is required (e.g., mg/kg)

NCH MSO By Laws Verbal Orders limited to situations in which recorded orders are impractical when the patient s condition requires urgent intervention and it is impractical for the ordering physician to come to the patient care area in time to address the patient s care need during the acute management of a life threatening emergency such that the benefits outweigh the risks of a verbally communicated order

NCH MSO By Laws Verbal orders for DEA Schedule II Narcotics can only be for a single stat dose. unless given to an Advance Practice Nurse by their collaborating attending practitioner or to a pharmacist. Advance Practice Nurses and pharmacists may take verbal orders for DEA Schedule II Narcotics either prn or scheduled for a time frame up to 72 hours. Narcotic drugs will not be given for more than seventy-two (72) hours and must be reordered.

Questions??