Copyright © College of Nurses of Ontario, 2015

Accountability and Collaboration…Working With A Physician Assistant

Anthony Derro, RN Practice ConsultantLinda Levesque, RN Outreach Consultant, Acute CareKaren Riddell, Director, Professional Practice and Operations, Windsor Regional Hospital

Objectives

Identify College documents and resources that are relevant when you are working with physician assistants

Apply the relevant College documents to your practice when working with physician assistants

Understanding Accountabilities

Organizational Supports

CNO Expectations

Nurse’s Competence

Client

Legislation(such as PHA)

Authorizing Mechanisms

Initiation Orders Delegation

When Is An Order Needed?

Is the procedure a controlled act? Is an order required by organizational policy or

setting-specific legislation?

Orders

Direct orders: are client-specific can be written or verbal

Directives: apply to more than one client when certain

conditions exist are always written

Both are orders

“Co-Implementing” a Directive

Directive + Nurse = Nurse is implementing Directive + PA + Nurse = Nurse is co-implementing The nurse’s accountability does not change

Delegation

Delegation is when a health care professional transfers the authority to perform a controlled act to another person

The person delegating the controlled act is called the delegator. The person receiving the delegation is called the delegatee

When Working With PAs

Can a nurse accept an order from a PA? Can a nurse accept delegation from a PA? Can a nurse delegate to a PA?

Windsor Regional Hospital Accountability & Collaboration….Working With Physician Assistants

Objectives

• Review the process our hospital followed when implementing our policy on physician assistants

The Process

• We engaged a multidisciplinary team including senior leaders, physicians and nursing

• Our legal team assisted in ensuring all pertinent legislation reviewed and included

• Working with our ONA partners we developed an education and roll out plan for nursing

Hospital Specific PA Policy

At our hospital: • PA’s can either be employees of the hospital or office based• They work under the direction, supervision and delegated

authority of a physician• They are not authorized to perform Controlled Acts or operate

independently unless under approved medical directives • The supervising physician extends their privileges at WRH in

order have a PA• PA’s are physician extenders and are NOT independent

practitioners

Education

• We engaged the CNO• Event included:

– An overview of the CNO standards– A history and an explanation of the PA role– A comparison of the role to the NP role since we had NPs

in various departments that the PAs were or would be working

– An overview of the new policy

Questions From The Nurses…

• Can a PA give orders to others to follow?• What is a Co-implementer?• What if I have a question or concern?

Application of Knowledge

• We reviewed a number of scenarios to allow nurses to apply the information from College document to practice scenarios

Scenario 1• A 55 year old female presents to the ED with abdominal

discomfort. Following triage by the RN and admission to the department the PA assesses the patient and implements the Chest Pain Medical Directive. Which includes the following:• Perform a 15 lead ECG• Apply oxygen at 2L by NP and cardiac monitor• Start IV Therapy with 0.9% Sodium Chloride tkvo• Draw Cardiac Lab studies• Administer ASA 160 mg PO and instruct the patient to chew and swallow • Administer 1 dose of Nitroglycerin Spray (0.4mg/spray) sublingual and repeat as needed every 5 minutes to a maximum of 3 doses

• What steps should the Nurse follow to determine if they can implement the orders?

Scenario 1 Discussion

Assess patient. • The Nurse finds the patient c/o sternal chest pain, 8/10,

radiating to left arm, patient is diaphoretic, hypotensive, tachycardia and extremely anxious

• Nurse establishes agreement with decision of the PA to implement the chest pain medical directive. Reviews medical directive - patient meets indications/criteria, no contraindications identified - Nurse may implement order

Scenario 2• A 55 year old female presents to the ED with abdominal discomfort.

Following triage by the RN and admission to the department the PA assesses the patient and implements the Chest Pain Medical Directive which includes the following:

• Perform a 15 lead ECG• Apply oxygen at 2L by NP and cardiac monitor• Start IV Therapy with 0.9% Sodium Chloride tkvo• Draw Cardiac Lab studies• Administer ASA 160 mg PO and instruct the patient to

chew and swallow • Administer 1 dose of Nitroglycerin Spray (0.4mg/spray)

sublingual and repeat as needed every 5 minutes to a maximum of 3 doses

• What steps should the Nurse follow to determine if they can implement the orders?

Scenario 2 DiscussionAssess patient. • The Nurse finds the patient c/o nausea and epigastric

discomfort, on abdominal exam patient appears distended, on percussion the abdomen is tympanic and the patient states has had no bowel movement for 5 days, bowel sounds are hypoactive. Vital signs are stable, no SOB, no distress, skin warm and dry. Patient denies history of hypertension or other cardiac risk factors.

• Nurse disagrees with decision of the PA to implement the chest pain medical directive. Reviews medical directive-patient does not meet criteria. Nurse does not implementthe directive and communicates with the PA regarding findings.

Scenario 3

• PA assesses a 35 year old patient admitted with UTI. She writes an order for a urine culture that was received by telephone from the physician. There is no medical directive for urine culture.

• Can the nurse implement the order?

Scenario 3 Discussion

• The authority for the procedure is provided by the verbal order from the physician.

Scenario 4

• On the same patient the PA also orders IV insertion and administration of normal saline at 100 ml/hr and IV antibiotics. They did not obtain the order from the physician and there is no medical directive.

• Can the nurse implement the order?

Scenario 4 Discussion

• Controlled act requires authorizing mechanism• Public Hospitals Act requires an order for all treatments

Key Success Strategies

• Engage your staff• Use common clinical situations to generate

questions and discussion • Apply the CNO standards to your practice

areas

Resources

Practice documents www.cno.org/publications Authorizing Mechanisms Directives Professional Standards, Revised 2002 Conflict Prevention and Management Working with Unregulated Care Providers

Educational tools www.cno.org/learning Learning modules, webcasts, teleconferences Ask Practice

Resources continued

Practice Support: ppd@cnomail.org 416 928-0900, ext. 6397 1 800 387-5526, ext. 6397 (toll free in Canada)

Questions?