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TRANSMITTAL NOTICE -JNDIAN HEALTH MANUAL TN 2006-15

BACKGROUND

The purpose of this section is to establish the Indian Health Service (illS) policy for nationalscopes of practice for advanced practice nurses (APN). The APN national scopes of practice isbased on Federal supremacy and preempts State law. The requirements standardize scopes ofpractice, simplify the credentialing and privileging process, and reduce the complexity ofmonitoring multiple State licenses at a single site.

C~ W. ~.bDSCharles W. Grim, D.D:SJ,M.H.S.'A.Assistant Surgeon GeneralDirector, illS

MATERIAL TRANSMITTED

Part 4, Chapter 3, Section 11, "Advanced Practice Nurses," Indian Health Manual (illM).

MATERIAL SUPERSEDED

None.

MANUAL MAINTENANCE

Insert the attached copy of the Part 3, Chapter 4, Section 11, "Advanced Practice Nurses," lliM,in its appropriate place.

Log and file this Transmittal Notice in its sequential order.

Distribution: illS-wideDate: July 5, 2006

MANAGEMENT SERVICESCHAPTER 4NURSING

Part 3

Table of Contents

Chapter 4 -NursingSection Page

Advanced Practice Nurses. 3-4.11 43

Purpose 3-4.11A 43Background 3-4.11B 43Authorities 3-4.11C 43Policy ... 3-4.11D 43Responsibilities 3-4.11E 43Scope of Practice 3-4.11F 44

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PROFESSIONAL SERVICES Pae:e43CHAPTER 4NURSING

3-4.11 ADVANCED PRACTICE NURSES

A. PUlJ>ose.The purpose of this section is to establish the Indian Health Service(IHS) policy for national scopes of practice for advanced practice nurses (APN).The APN national scopes of practice is based on Federal supremacy and preemptsState law. The requirements standardize scopes of practice, simplify thecredentialing and privileging process, and reduce the complexity of monitoringmultiple State licenses at a single site.

B. Background. Advanced practice nurses are nurses who hold advanced degrees,have completed an accredited APN program, have received a national certificatein a specialty by the American Nurses Credentialing Center, or other nationallyrecognized credentialing body, have completed advanced pharmacology educationallowing prescribing and dispensing privileges, and are licensed as a registerednurse or APN in at least one United States jurisdiction.

C. Authorities.

(1) Snyder Act, 25 United States Code (U.S.C.) 13

(2) Transfer Act, 42 U.S.c. 2001

(3) Persons Entitled to Issue Prescriptions, 21 Code of Federal Regulations(CFR), Section 1306.03

D. Policy. It is the policy ofthe IHS that except for controlled substances, theAgency will exercise its authority and the power of Federal preemption to defineinpatient and outpatient scopes of practice for APN working for the IHS. Inaccordance with 21 CFR Section 1306.03, "Persons Entitled to IssuePrescriptions," the health care practitioner's State of licensure/registration mustauthorize prescription of controlled substance. Each IHS facility that pennitsAPN to prescribe controlled substances is responsible for ensuring that suchpractitioners are authorized to do so by their State oflicensure or registration andfor complying with the limitations and restrictions on that authority.

E. Responsibilities. Some registered nurses choose to become advanced practicenurses, who often are considered primary health care practitioners and workindependently or in collaboration with physicians. For example, in most States,an APN can prescribe medications. Advanced practice nurses function as

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Pal!e 44 STAFF SERVICES/SPECIAL PROGRAMS

Chapter 4ADVANCED PRACTICE NURSES

(3-4.1 IE - continued)

independent primary care practitioners who practice in ambulatory, inpatient,long-term care, and community health settings within the privileges granted by thelocal governing body. The four types of APN employed by the rns are:

(1) Nurse Practitioners. Nurse practitioners provide basic preventive healthcare to patients, and increasingly serve as primary and specialty careproviders in mainly medically under-served areas. The most commonareas of specialty for nurse practitioners are family practice, adult practice,women's health, pediatrics, acute care, and gerontology; however, there aremany other specialties.

(2) Certified Nurse Midwives. Certified nurse midwives provide primary careto women, including gynecological exams, family planning advice,prenatal care, assistance in labor and delivery, and neonatal care.

(3) Certified Rel!istered Nurse Anesthetists. Certified registered nurseanesthetists (CRNA) administer anesthesia, monitor patient's vital signsduring surgery, and provide post-anesthesia care. A CRNA administersanesthesia and anesthesia-related care in four general categories:

a. pre-anesthetic preparation and evaluation;

b. anesthesia induction, maintenance, and emergence;

c. post-anesthesia care; and

d. perianesthetic and clinical support functions.

(4) Clinical Nurse Specialists. Clinical nurse specialists provide direct patientcare and expert consultations in one of many of the nursing specialties.

F. Scope of Practice. The APN scope of practice includes, but is not limited to, thefollowing:

(I) Nurse Practitioners. Nurse practitioners scope of practice includes, but isnot limited to, the following:

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(3-4.llF(1) - continued)

a. Works as a licensed, independent practitioner.

b. Examines patients and establishes medical diagnoses by clienthistory, physical examination, and other criteria.

c. Orders, conducts, and interprets screening studies, tests, anddiagnostic procedures to assess and diagnose problems andestablish management/treatment plans.

d. Initiates consultation, collaboration, and referral requests tospecialists and other health professionals.

e. Teaches, counsels, and advises patients, families, and communitiesabout current health status and illnesses, and provides healthpromotion and disease prevention services, taking into account age,developmental status, disability, culture, ethnicity, sexualorientation, spiritual/religious affiliation, and lifestyle issues.

f. Provides appropriate periodic mental health assessments andscreening, and counseling for mental illness, family violence, anddiseases of addiction.

g. Prescribes and dispenses medications and durable medical devicesand supplies.

h. Prescribes and dispenses controlled substances within anindividual's Advanced Practice Nurse State license.

1. Admits, cares for, and discharges patients, when privileged to doso by the employing facility.

J. Provides culturally competent care with respect to cultural, Tribal,and spiritual beliefs and incorporates ceremonies and practices ofthe patient belief system into the plan of care.

k. Practices within specialty area of training and certification only.

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(3-4.11F(l) - continued)

I. Incorporates new procedures and treatment protocols into practiceafter appropriate training, evaluation of competence, identificationof consultation and referral system related to the new procedure,and periodic outcome and competency review.

m. Practices in accordance with the standards of practice as defined bythe American Academy of Nurse Practitioners and/or as outlinedby an American professional organization for a specific specialtysuch as pediatrics, geriatrics, emergency care, etc.

(2) Certified Nurse-Midwives. A certified nurse midwife scope of practiceincludes:

a. Works as a licensed independent practitioner.

b. Provides health care of women focused primarily on, but notlimited to, reproductive health.

c. Admits and discharges women to health care facilities whenprivileged to do so by the employing facility.

d. Orders diagnostic exams, laboratory tests, x-rays, and sonograms.

e. Analyzes and interprets data, formulates diagnoses, and establishesmanagement/treatment plans.

f. Provides prenatal, intrapartum, and postpartum care of the low anddesignated at-risk obstetrical patient.

g. Manages complicated pregnancies by consultation or collaborationwith a physician. A physician is not always present in rural areasand patient conditions are sometimes managed via phone"consultation."

h. Utilizes written practice guidelines that describe the parameters ofservice for independent and collaborative midwifery managementand transfer of care when needed.

1.

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(3-4.11F(2) - continued)

J. Evaluates fetal well-being in labor.

k. Evaluates and cares for the newborn, including airwaymanagement, resuscitation, and initial examination and well-babycare.

1. Manages acute, episodic, and chronic conditions occurring inwomen, referring patients when disease process exceeds providereducation, training, and experience.

m. Prescribes and dispenses medications and durable medical devicesand supplies.

n. Prescribes and dispenses controlled substances within anindividual's certified nurse-midwife State licensure.

o. Develops health promotion and maintenance plans, includingdisease prevention and health education counseling.

p. Provides age-appropriate, periodic physical health screening.

q. Screens, assesses, treats, and provides health education to patientswith gynecological conditions and treats sexually transmitteddiseases in women and their contacts.

r. Provides initial infertility evaluation and referral as appropriate.

s. Screens and treats for behavioral health problems, includingaddiction, domestic violence, and depression.

t. Incorporates new procedures and treatment protocols into practiceafter appropriate training, evaluation of competence, identificationof consultation and referral system related to the new procedure,and periodic outcome and competency review.

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(3-4.llF(2) - continued)

u. Practices in accordance with the standards for the practice ofnurse-midwifery, as defined by the American College ofNurse-Midwives.

(3) Certified Registered Nurse Anesthetists. The Certified Registered NurseAnesthetists scope of practice includes, but is not limited to, the following:

a. Works as a licensed independent practitioner.

b. Performs and documents pre-anesthetic assessment and evaluationof the patient, including requesting consultations and diagnosticstudies; selects, obtains, orders, and/or administers pre-anestheticmedications and fluids; and obtains informed consent foranesthesia.

c. Develops and implements an anesthetic plan.

d. Selects and initiates the planned anesthetic technique, which mayinclude general, regional, and local anesthesia and intravenoussedation.

e. Selects, obtains, and administers the anesthetics, adjuvant drugs,accessory drugs, and fluids necessary to manage the anesthetic, tomaintain the patient's physiologic homeostasis, and to correctabnormal responses to the anesthesia or surgery.

f. Selects, applies, and inserts appropriate non-invasive and invasivemonitoring modalities for collecting and interpreting patientphysiological data. .

g. Manages a patient's airway and pulmonary status usingendotracheal intubation, airway adjuncts, mechanical ventilation,pharmacological support, respiratory therapy, or extubation.

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(3-4.IIF(3) - continued)

h. Manages emergence and recovery from anesthesia by selecting,obtaining, ordering, and/or administering medications, fluids, orventilatory support in order to maintain homeostasis, to providerelief :trompain and anesthesia side effects, or to prevent ormanage complications.

1. Releases or discharges patients :troma post-anesthesia care areaand provides post-anesthesia follow-up evaluation and care relatedto anesthesia side effects or complications.

J. Orders, initiates and modifies pain relief therapy, through theutilization of drugs, regional anesthetic techniques, or otheraccepted pain relief modalities, including labor epidural analgesia.

k. Prescribes and dispenses controlled substances as authorized by anindividual's Certified Registered Nurse Anesthetists Statelicensure.

l. Responds to emergency situations by providing airwaymanagement, administering of emergency fluids or drugs, andusing basic or advanced cardiac life support techniques.

m. Initiates consultation, collaboration, and referral requests tospecialists and other health professional when disease processexceeds provider education, training, and experience.

n. Performs additional nurse anesthesia responsibilities, which arewithin the education, training, and expertise of the individualCertified Registered Nurse Anesthetists.

o. Practices in accordance with the American Association of NurseAnesthetists Scope and Standards for Nurse Anesthesia Practice.

(4) Clinical Nurse Specialists. Clinical nurse specialists may be coveredunder these scopes of practice only if they are also licensed as nursepractitioners.

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