As Introduced

129th General Assembly Regular Session 2011-2012

H. B. No. 485

Representative Pelanda 

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A BILL

To amend sections 4723.43, 4723.44, 4729.01, and

1

4761.17 of the Revised Code to authorize certified

2

registered nurse anesthetists to issue medication

3

orders for the administration of drugs to patients

4

during certain phases of patient care and to

5

specify the circumstances in which such nurses may

6

perform clinical support functions.

7

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

Section 1. That sections 4723.43, 4723.44, 4729.01, and	8
4761.17 of the Revised Code be amended to read as follows:	9

Sec. 4723.43.  A certified registered nurse anesthetist,	10
clinical nurse specialist, certified nurse-midwife, or certified	11
nurse practitioner may provide to individuals and groups nursing	12
care that requires knowledge and skill obtained from advanced	13
formal education and clinical experience. In this capacity as an	14
advanced practice nurse, a certified nurse-midwife is subject to	15
division (A) of this section, a certified registered nurse	16
anesthetist is subject to division (B) of this section, a	17
certified nurse practitioner is subject to division (C) of this	18
section, and a clinical nurse specialist is subject to division	19
(D) of this section.	20

(A) A nurse authorized to practice as a certified	21
nurse-midwife, in collaboration with one or more physicians, may	22
provide the management of preventive services and those primary	23
care services necessary to provide health care to women	24
antepartally, intrapartally, postpartally, and gynecologically,	25
consistent with the nurse's education and certification, and in	26
accordance with rules adopted by the board of nursing.	27

No certified nurse-midwife may perform version, deliver	28
breech or face presentation, use forceps, do any obstetric	29
operation, or treat any other abnormal condition, except in	30
emergencies. Division (A) of this section does not prohibit a	31
certified nurse-midwife from performing episiotomies or normal	32
vaginal deliveries, or repairing vaginal tears. A certified	33
nurse-midwife who holds a certificate to prescribe issued under	34
section 4723.48 of the Revised Code may, in collaboration with one	35
or more physicians, prescribe drugs and therapeutic devices in	36
accordance with section 4723.481 of the Revised Code.	37

(B)(1) A nurse authorized to practice as a certified	38
registered nurse anesthetist, with the supervision and in the	39
immediate presence of a physician, podiatrist, or dentist who is	40
actively engaged in practice in this state, consistent with the	41
nurse's education and certification, and in accordance with rules	42
adopted by the board, may administerdo all of the following:	43

(a) While in the immediate presence of a physician,	44
podiatrist, or dentist, administer anesthesia and perform	45
anesthesia induction, maintenance, and emergence, and may perform	46
with supervision;	47

(b) Perform preanesthetic preparation and evaluation,and	48
postanesthesia care, and clinical support functions, consistent	49
with the nurse's education and certification, and in accordance	50
with rules adopted by the board.;	51

(c) Only in a facility in which the nurse engages in the	52
activities described in division (B)(1)(a) or (b) of this section,	53
perform clinical support functions using the same skills and	54
competencies the nurse uses to engage in the activities described	55
in division (B)(1)(a) or (b) of this section;	56

(d) Only during the phases of patient care directly related	57
to the activities described in divisions (B)(1)(a) to (c) of this	58
section and subject to divisions (B)(2), (4), and (5) of this	59
section, issue a written, oral, or electronic medication order	60
under which the certified registered nurse anesthetist directs any	61
of the following to administer a drug to a patient:	62

(i) An individual who is licensed under this chapter as a	63
registered nurse or a licensed practical nurse and is acting	64
within the scope of that individual's practice;	65

(ii) An individual who is licensed under Chapter 4761. of the	66
Revised Code as a respiratory therapist and is acting within the	67
scope of that individual's practice;	68

(iii) Any other individual who is licensed or otherwise	69
specifically authorized by the Revised Code to administer drugs	70
and is acting within the scope of that individual's practice.	71

(2) When, during the performance of a clinical support	72
function, a certified registered nurse anesthetist issues a	73
medication order directing an individual to administer a drug to a	74
patient receiving clinical support, the individual shall	75
administer the drug in the immediate presence of that certified	76
registered nurse anesthetist.	77

(3) A certified registered nurse anesthetist is not required	78
to obtain a certificate to prescribe in order to provide the	79
anesthesia care described in this divisionor issue a medication	80
order.	81

The physician, podiatrist, or dentist supervising a certified	82
registered nurse anesthetist must be actively engaged in practice	83
in this state.	84

(4) When a certified registered nurse anesthetist is	85
supervised by a podiatrist, theall of the following conditions	86
apply:	87

(a) The nurse's scope of practice is limited to the	88
anesthesia procedures that the podiatrist has the authority under	89
section 4731.51 of the Revised Code to perform. A certified	90
registered nurse anesthetist may	91

(b) The nurse shall not administer general anesthesia under	92
the podiatrist's supervision of a podiatrist in athe podiatrist's	93
office. When	94

(c) The nurse's authority to issue a medication order shall	95
not exceed the podiatrist's authority to issue such orders.	96

(5) When a certified registered nurse anesthetist is	97
supervised by a dentist, theall of the following conditions	98
apply:	99

(a) The nurse's scope of practice is limited to the	100
anesthesia procedures that the dentist has the authority under	101
Chapter 4715. of the Revised Code to perform.	102

(b) The nurse's authority to issue a medication order shall	103
not exceed the dentist's authority to issue such orders.	104

(c) The nurse shall not issue a medication order for	105
treatment of a patient in a dental office.	106

(C) A nurse authorized to practice as a certified nurse	107
practitioner, in collaboration with one or more physicians or	108
podiatrists, may provide preventive and primary care services and	109
evaluate and promote patient wellness within the nurse's nursing	110
specialty, consistent with the nurse's education and	111
certification, and in accordance with rules adopted by the board.	112
A certified nurse practitioner who holds a certificate to	113
prescribe issued under section 4723.48 of the Revised Code may, in	114
collaboration with one or more physicians or podiatrists,	115
prescribe drugs and therapeutic devices in accordance with section	116
4723.481 of the Revised Code.	117

When a certified nurse practitioner is collaborating with a	118
podiatrist, the nurse's scope of practice is limited to the	119
procedures that the podiatrist has the authority under section	120
4731.51 of the Revised Code to perform.	121

(D) A nurse authorized to practice as a clinical nurse	122
specialist, in collaboration with one or more physicians or	123
podiatrists, may provide and manage the care of individuals and	124
groups with complex health problems and provide health care	125
services that promote, improve, and manage health care within the	126
nurse's nursing specialty, consistent with the nurse's education	127
and in accordance with rules adopted by the board. A clinical	128
nurse specialist who holds a certificate to prescribe issued under	129
section 4723.48 of the Revised Code may, in collaboration with one	130
or more physicians or podiatrists, prescribe drugs and therapeutic	131
devices in accordance with section 4723.481 of the Revised Code.	132

When a clinical nurse specialist is collaborating with a	133
podiatrist, the nurse's scope of practice is limited to the	134
procedures that the podiatrist has the authority under section	135
4731.51 of the Revised Code to perform.	136

Sec. 4723.44.  (A) No person shall do any of the following	137
unless the person holds a current, valid certificate of authority	138
to practice nursing as a certified registered nurse anesthetist,	139
clinical nurse specialist, certified nurse-midwife, or certified	140
nurse practitioner issued by the board of nursing under this	141
chapter:	142

(1) Engage in the practice of nursing as a certified	143
registered nurse anesthetist, clinical nurse specialist, certified	144
nurse-midwife, or certified nurse practitioner for a fee, salary,	145
or other consideration, or as a volunteer;	146

(2) Represent the person as being a certified registered	147
nurse anesthetist, clinical nurse specialist, certified	148
nurse-midwife, or certified nurse practitioner;	149

(3) Use any title or initials implying that the person is a	150
certified registered nurse anesthetist, clinical nurse specialist,	151
certified nurse-midwife, or certified nurse practitioner;	152

(4) Represent the person as being an advanced practice nurse;

153

(5) Use any title or initials implying that the person is an	154
advanced practice nurse.	155

(B) No person who is not certified by the national council on	156
certification of nurse anesthetists of the American association of	157
nurse anesthetists, the national council on recertification of	158
nurse anesthetists of the American association of nurse	159
anesthetists, or another national certifying organization approved	160
by the board under section 4723.46 of the Revised Code shall use	161
the title "certified registered nurse anesthetist" or the initials	162
"C.R.N.A.," or any other title or initial implying that the person	163
has been certified by the council or organization.	164

(C) No certified registered nurse anesthetist, clinical nurse	165
specialist, certified nurse-midwife, or certified nurse	166
practitioner shall do any of the following:	167

(1) Engage, for a fee, salary, or other consideration, or as	168
a volunteer, in the practice of a nursing specialty other than the	169
specialty designated on the nurse's current, valid certificate of	170
authority issued by the board under this chapter;	171

(2) Represent the person as being authorized to practice any	172
nursing specialty other than the specialty designated on the	173
current, valid certificate of authority;	174

(3) Use the title "certified registered nurse anesthetist" or	175
the initials "N.A." or "C.R.N.A.," the title "clinical nurse	176
specialist" or the initials "C.N.S.," the title "certified	177
nurse-midwife" or the initials "C.N.M.," the title "certified	178
nurse practitioner" or the initials "C.N.P.," the title "advanced	179
practice nurse" or the initials "A.P.N.," or any other title or	180
initials implying that the nurse is authorized to practice any	181
nursing specialty other than the specialty designated on the	182
nurse's current, valid certificate of authority;	183

(4) Enter into a standard care arrangement with a physician	184
or podiatrist whose practice is not the same as or similar to the	185
nurse's nursing specialty;	186

(5) Prescribe(a) In the case of a clinical nurse specialist,	187
certified nurse-midwife, or certified nurse practitioner,	188
prescribe or issue orders for drugs or therapeutic devices unless	189
the nurse holds a current, valid certificate to prescribe issued	190
under section 4723.48 of the Revised Code;	191

(b) In the case of a certified registered nurse anesthetist,	192
issue medication orders in a manner that does not comply with	193
division (B) of section 4723.43 of the Revised Code.	194

(6) PrescribeIn the case of a clinical nurse specialist,	195
certified nurse-midwife, or certified nurse practitioner who holds	196
a certificate to prescribe issued under section 4723.48 of the	197
Revised Code, prescribe or issue orders for drugs or therapeutic	198
devices under a certificate to prescribe in a manner that does not	199
comply with section 4723.481 of the Revised Code;	200

(7) Prescribe any drug or device to perform or induce an	201
abortion, or otherwise Performperform or induce an abortion.	202

(D) No person shall knowingly employ a person to engage in	203
the practice of nursing as a certified registered nurse	204
anesthetist, clinical nurse specialist, certified nurse-midwife,	205
or certified nurse practitioner unless the person so employed	206
holds a current, valid certificate of authority to engage in that	207
nursing specialty issued by the board under this chapter.	208

(E) A certificate certified by the executive director of the	209
board, under the official seal of the board, to the effect that it	210
appears from the records that no certificate of authority to	211
practice nursing as a certified registered nurse anesthetist,	212
clinical nurse specialist, certified nurse-midwife, or certified	213
nurse practitioner has been issued to any person specified	214
therein, or that a certificate, if issued, has been revoked or	215
suspended, shall be received as prima-facie evidence of the record	216
in any court or before any officer of the state.	217

Sec. 4729.01. As used in this chapter:

218

(A) "Pharmacy," except when used in a context that refers to	219
the practice of pharmacy, means any area, room, rooms, place of	220
business, department, or portion of any of the foregoing where the	221
practice of pharmacy is conducted.	222

(B) "Practice of pharmacy" means providing pharmacist care	223
requiring specialized knowledge, judgment, and skill derived from	224
the principles of biological, chemical, behavioral, social,	225
pharmaceutical, and clinical sciences. As used in this division,	226
"pharmacist care" includes the following:	227

(1) Interpreting prescriptions;

228

(2) Dispensing drugs and drug therapy related devices;

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(3) Compounding drugs;

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(4) Counseling individuals with regard to their drug therapy,	231
recommending drug therapy related devices, and assisting in the	232
selection of drugs and appliances for treatment of common diseases	233
and injuries and providing instruction in the proper use of the	234
drugs and appliances;	235

(5) Performing drug regimen reviews with individuals by	236
discussing all of the drugs that the individual is taking and	237
explaining the interactions of the drugs;	238

(6) Performing drug utilization reviews with licensed health	239
professionals authorized to prescribe drugs when the pharmacist	240
determines that an individual with a prescription has a drug	241
regimen that warrants additional discussion with the prescriber;	242

(7) Advising an individual and the health care professionals	243
treating an individual with regard to the individual's drug	244
therapy;	245

(8) Acting pursuant to a consult agreement with a physician	246
authorized under Chapter 4731. of the Revised Code to practice	247
medicine and surgery or osteopathic medicine and surgery, if an	248
agreement has been established with the physician;	249

(9) Engaging in the administration of immunizations to the	250
extent authorized by section 4729.41 of the Revised Code.	251

(C) "Compounding" means the preparation, mixing, assembling,	252
packaging, and labeling of one or more drugs in any of the	253
following circumstances:	254

(1) Pursuant to a prescription issued by a licensed health	255
professional authorized to prescribe drugs;	256

(2) Pursuant to the modification of a prescription made in	257
accordance with a consult agreement;	258

(3) As an incident to research, teaching activities, or	259
chemical analysis;	260

(4) In anticipation of orders for drugs pursuant to	261
prescriptions, based on routine, regularly observed dispensing	262
patterns;	263

(5) Pursuant to a request made by a licensed health	264
professional authorized to prescribe drugs for a drug that is to	265
be used by the professional for the purpose of direct	266
administration to patients in the course of the professional's	267
practice, if all of the following apply:	268

(a) At the time the request is made, the drug is not	269
commercially available regardless of the reason that the drug is	270
not available, including the absence of a manufacturer for the	271
drug or the lack of a readily available supply of the drug from a	272
manufacturer.	273

(b) A limited quantity of the drug is compounded and provided	274
to the professional.	275

(c) The drug is compounded and provided to the professional	276
as an occasional exception to the normal practice of dispensing	277
drugs pursuant to patient-specific prescriptions.	278

(D) "Consult agreement" means an agreement to manage an	279
individual's drug therapy that has been entered into by a	280
pharmacist and a physician authorized under Chapter 4731. of the	281
Revised Code to practice medicine and surgery or osteopathic	282
medicine and surgery.	283

(E) "Drug" means:

284

(1) Any article recognized in the United States pharmacopoeia	285
and national formulary, or any supplement to them, intended for	286
use in the diagnosis, cure, mitigation, treatment, or prevention	287
of disease in humans or animals;	288

(2) Any other article intended for use in the diagnosis,	289
cure, mitigation, treatment, or prevention of disease in humans or	290
animals;	291

(3) Any article, other than food, intended to affect the	292
structure or any function of the body of humans or animals;	293

(4) Any article intended for use as a component of any	294
article specified in division (E)(1), (2), or (3) of this section;	295
but does not include devices or their components, parts, or	296
accessories.	297

(F) "Dangerous drug" means any of the following:

298

(1) Any drug to which either of the following applies:

299

(a) Under the "Federal Food, Drug, and Cosmetic Act," 52	300
Stat. 1040 (1938), 21 U.S.C.A. 301, as amended, the drug is	301
required to bear a label containing the legend "Caution: Federal	302
law prohibits dispensing without prescription" or "Caution:	303
Federal law restricts this drug to use by or on the order of a	304
licensed veterinarian" or any similar restrictive statement, or	305
the drug may be dispensed only upon a prescription;	306

(b) Under Chapter 3715. or 3719. of the Revised Code, the	307
drug may be dispensed only upon a prescription.	308

(2) Any drug that contains a schedule V controlled substance	309
and that is exempt from Chapter 3719. of the Revised Code or to	310
which that chapter does not apply;	311

(3) Any drug intended for administration by injection into	312
the human body other than through a natural orifice of the human	313
body.	314

(G) "Federal drug abuse control laws" has the same meaning as	315
in section 3719.01 of the Revised Code.	316

(H) "Prescription" means a written, electronic, or oral order	317
for drugs or combinations or mixtures of drugs to be used by a	318
particular individual or for treating a particular animal, issued	319
by a licensed health professional authorized to prescribe drugs.	320

(I) "Licensed health professional authorized to prescribe	321
drugs" or "prescriber" means an individual who is authorized by	322
law to prescribe drugs or dangerous drugs or drug therapy related	323
devices in the course of the individual's professional practice,	324
including only the following:	325

(1) A dentist licensed under Chapter 4715. of the Revised	326
Code;	327

(2) A clinical nurse specialist, certified nurse-midwife, or	328
certified nurse practitioner who holds a certificate to prescribe	329
issued under section 4723.48 of the Revised Code;	330

(3) A certified registered nurse anesthetist, to the extent	331
that the nurse is authorized by division (B) of section 4723.43 of	332
the Revised Code to order the administration of a drug to a	333
patient;	334

(4) An optometrist licensed under Chapter 4725. of the	335
Revised Code to practice optometry under a therapeutic	336
pharmaceutical agents certificate;	337

(4)(5) A physician authorized under Chapter 4731. of the	338
Revised Code to practice medicine and surgery, osteopathic	339
medicine and surgery, or podiatric medicine and surgery;	340

(5)(6) A physician assistant who holds a certificate to	341
prescribe issued under Chapter 4730. of the Revised Code;	342

(6)(7) A veterinarian licensed under Chapter 4741. of the	343
Revised Code.	344

(J) "Sale" and "sell" include delivery, transfer, barter,	345
exchange, or gift, or offer therefor, and each such transaction	346
made by any person, whether as principal proprietor, agent, or	347
employee.	348

(K) "Wholesale sale" and "sale at wholesale" mean any sale in	349
which the purpose of the purchaser is to resell the article	350
purchased or received by the purchaser.	351

(L) "Retail sale" and "sale at retail" mean any sale other	352
than a wholesale sale or sale at wholesale.	353

(M) "Retail seller" means any person that sells any dangerous	354
drug to consumers without assuming control over and responsibility	355
for its administration. Mere advice or instructions regarding	356
administration do not constitute control or establish	357
responsibility.	358

(N) "Price information" means the price charged for a	359
prescription for a particular drug product and, in an easily	360
understandable manner, all of the following:	361

(1) The proprietary name of the drug product;

362

(2) The established (generic) name of the drug product;

363

(3) The strength of the drug product if the product contains	364
a single active ingredient or if the drug product contains more	365
than one active ingredient and a relevant strength can be	366
associated with the product without indicating each active	367
ingredient. The established name and quantity of each active	368
ingredient are required if such a relevant strength cannot be so	369
associated with a drug product containing more than one	370
ingredient.	371

(4) The dosage form;

372

(5) The price charged for a specific quantity of the drug	373
product. The stated price shall include all charges to the	374
consumer, including, but not limited to, the cost of the drug	375
product, professional fees, handling fees, if any, and a statement	376
identifying professional services routinely furnished by the	377
pharmacy. Any mailing fees and delivery fees may be stated	378
separately without repetition. The information shall not be false	379
or misleading.	380

(O) "Wholesale distributor of dangerous drugs" means a person	381
engaged in the sale of dangerous drugs at wholesale and includes	382
any agent or employee of such a person authorized by the person to	383
engage in the sale of dangerous drugs at wholesale.	384

(P) "Manufacturer of dangerous drugs" means a person, other	385
than a pharmacist, who manufactures dangerous drugs and who is	386
engaged in the sale of those dangerous drugs within this state.	387

(Q) "Terminal distributor of dangerous drugs" means a person	388
who is engaged in the sale of dangerous drugs at retail, or any	389
person, other than a wholesale distributor or a pharmacist, who	390
has possession, custody, or control of dangerous drugs for any	391
purpose other than for that person's own use and consumption, and	392
includes pharmacies, hospitals, nursing homes, and laboratories	393
and all other persons who procure dangerous drugs for sale or	394
other distribution by or under the supervision of a pharmacist or	395
licensed health professional authorized to prescribe drugs.	396

(R) "Promote to the public" means disseminating a	397
representation to the public in any manner or by any means, other	398
than by labeling, for the purpose of inducing, or that is likely	399
to induce, directly or indirectly, the purchase of a dangerous	400
drug at retail.	401

(S) "Person" includes any individual, partnership,	402
association, limited liability company, or corporation, the state,	403
any political subdivision of the state, and any district,	404
department, or agency of the state or its political subdivisions.	405

(T) "Finished dosage form" has the same meaning as in section	406
3715.01 of the Revised Code.	407

(U) "Generically equivalent drug" has the same meaning as in	408
section 3715.01 of the Revised Code.	409

(V) "Animal shelter" means a facility operated by a humane	410
society or any society organized under Chapter 1717. of the	411
Revised Code or a dog pound operated pursuant to Chapter 955. of	412
the Revised Code.	413

(W) "Food" has the same meaning as in section 3715.01 of the	414
Revised Code.	415

(X) "Pain management clinic" has the same meaning as in	416
section 4731.054 of the Revised Code.	417

Sec. 4761.17.  All of the following apply to the practice of	418
respiratory care by a person who holds a license or limited permit	419
issued under this chapter:	420

(A) The person shall practice only pursuant to a	421
prescription, medication order, or other order for respiratory	422
care issued by a physician or by aone or more of the following:	423

(1) A physician;

424

(2) A registered nurse who holds a certificate of authority	425
issued under Chapter 4723. of the Revised Code to practice as a	426
certified nurse practitioner or clinical nurse specialist and has	427
entered into a standard care arrangement with a physician that	428
allows the nurse to prescribe or order respiratory care services;	429

(3) A certified registered nurse anesthetist when the order	430
for the administration of drugs is issued in accordance with	431
division (B) of section 4723.43 of the Revised Code.	432

(B) The person shall practice only under one of the following	433
conditions:	434

(1) Pursuant to the supervision of a physician or under;

435

(2) Pursuant to the supervision of a certified nurse	436
practitioner or clinical nurse specialist who is authorized to	437
prescribe or order respiratory care services as provided in	438
division (A)(2) of this section;	439

(3) Pursuant to the authority of a certified registered nurse	440
anesthetist who is supervised by a physician in accordance with	441
division (B) of section 4723.43 of the Revised Code.	442

(C)(1) When practicing under the prescription or order of a	443
certified nurse practitioner or clinical nurse specialist or under	444
pursuant to the supervision of such a nurse, the person's	445
administration of medication that requires a prescription is	446
limited to the drugs that the nurse is authorized to prescribe	447
pursuant to the nurse's certificate to prescribe issued under	448
section 4723.48 of the Revised Code.	449

(2) When practicing under a medication order issued by a	450
certified registered nurse anesthetist or pursuant to the	451
authority of such a nurse, the person's administration of	452
medication shall occur only during the phases of patient care	453
directly related to the nurse's activities described in divisions	454
(B)(1)(a) to (c) of section 4723.43 of the Revised Code and in	455
accordance with the nurse's authority to order the administration	456
of a drug to a patient during those phases.	457

Section 2. That existing sections 4723.43, 4723.44, 4729.01,	458
and 4761.17 of the Revised Code are hereby repealed.	459