Microsoft word - final-declaratory ruling rcp advanced practice-revised 7-12-07.doc
NORTH CAROLINA RESPIRATORY CARE BOARD RALEIGH, NORTH CAROLINA IN RE: REQUEST FOR DECLARATORY DECLARATORY RULING MEDCENTER ) REVISED 7/12/2007
I, Joseph Coyle, as Chair of the North Carolina Respiratory Care Board (the “Board”),
and based on a resolution by the Board of this date, duly adopted pursuant to N.C. Gen. Stat. § 150B-4, do hereby issue this declaratory ruling. This declaratory ruling will interpret the applicability of N.C. Gen. Stat. § 90-648 (10)(b) in regard to licensed Respiratory Care Practitioners (RCP’s) providing advanced practice procedures to patients who are being transported by an Ambulance Provider licensed under G.S. 131E.
Mr. Scott Prater, RRT, NREMT-P, an RCP who is employed at Medcenter Air, an
affiliate of Carolinas Medical Center, has requested this ruling and has provided the facts on which it is based. For the reasons set out below, the Board does conclude that RCP’s may provide certain advanced practice procedures and administer pharmacologic agents related to these procedures based on the information provided and within the limitations described in this Declaratory Ruling.
The basis for the Board’s conclusion is set forth below in the Analysis section of this
declaratory ruling. This ruling is binding upon the Board so long as the facts that the Board deems to be material are accurately stated, but the ruling only pertains to this request. The Board also reserves the right, prospectively, to change the conclusion that is contained in this ruling.
FACTUAL BASIS FOR THE RULING
Based on information submitted by Mr. Prater, Medcenter Air is an Ambulance Provider
licensed under Chapter 131E of the North Carolina General Statutes. RCP’s at Medcenter Air are currently providing certain advanced practice procedures to patients who are being transported by their medical transport team. Mr. Prater has provided the Board the facility’s policy and procedure for training and competency assessments for advanced practice procedures and the administration of pharmacologic agents related to these procedures.
Mr. Prater has asked the Board to determine if the provision of the following advance
practice procedures, including the administration of the related pharmacologic agents that are identified below, is within the scope of practice by Respiratory Care Practitioners pursuant to the Respiratory Care Practice Act and Board Rules:
Advanced Practice Skills- Rapid Sequence Intubation, needle and surgical cricothyrotomies, femoral and external jugular IV insertion, needle chest decompression, external/internal pacing, intraosseous placement, and intra aortic balloon counterpulsation. Pharmacologic Agents related to the advanced respiratory care procedures- adenosine, amiodarone, anectine, ativan, atropine, benadryl, calium chloride, clonidine, demerol,
dextrose, dilantin, dobutamine, epinephrine, esmolol, etomidate, furosemide, haldol, ibuprofen, labetalol, lidocaine, magnesium sulfate, morphine, narcan, nitroglycerine, nitroprusside, norcuron, phenergan, procainamide, procardia, sodium bicarbonate, succinylcholine, tylenol, valium, verapamil, and versed.
The scope of practice of Respiratory Care Practitioners as defined in the North Carolina
Respiratory Care Practice Act § 90-648 (10)(f) recognizes that RCP’s may perform new and innovative respiratory care procedures, but only in appropriately identified environments and under the training and practice guidelines established by the American Association for Respiratory Care.
It is the American Association for Respiratory Care’s (AARC) position that Respiratory
Therapist education, which expands the scope or depth of respiratory care practice, should build upon a solid foundation of didactic and clinical respiratory care. Education leading to expanded practice should therefore take place following general respiratory therapist education. Expanded practice education may take place within college programs; in baccalaureate and/or graduate degree programs; in internships, residencies, or fellowships; or as experience-based learning. Credentialing, or recognition, for expanded practice expertise is in addition to the respiratory therapist credential and may be at either a state or national level.
The scope of practice of Respiratory Care Practitioners as defined in the North Carolina
90-648 (10)(b) states that RCP’s may administer
pharmacological agents related to respiratory care procedures.
The United States Drug Enforcement Association (DEA) has added Respiratory Care
Practitioners to its list of licensed medical professionals who are authorized to administer controlled substances, provided the administration of the controlled substance has been ordered by a physician and such administration is related to a respiratory care procedure.
The Office of Emergency Medical Services in the Division of Facility Services of the
North Carolina Department of Health and Human Services has approved the utilization of Respiratory Therapists for Specialty Transport under 10A NCAC 13P.0303 (a). The rules further define the requirements for operational protocols for the management of equipment, supplies and medications under 10A NCA 13P .0303(c) and patient care skills and procedures capabilities under 10A NCA 13P .0301(a).
The North Carolina Respiratory Care Board agrees that RCP’s may perform the
following respiratory care procedures, and may also administer the related pharmacologic agents that are identified below, in appropriately identified environments, and following the criteria that are outlined in this Declaratory Ruling. So long as the criteria set forth in this Declaratory Ruling are followed, the performance of these procedures and the administration of the related pharmacologic agents is within the scope of practice defined by the North Carolina Respiratory Care Practice Act under § 90-648:
• Needle and surgical cricothyrotomies • Femoral and external jugular IV insertion
• External pacing and monitoring of Internal pacing • Intraosseous placement, and
• Monitoring of Intra Aortic Balloon Counterpulsation.
Pharmacologic Agents related to the Advanced Respiratory Care Procedures:
The Board’s fundamental mission and foremost concern is the health, safety and welfare
of the public. Therefore the Board concludes that the following guidelines must be followed by RCP’s providing advanced practice respiratory care procedures and administering pharmacological agents as described in this Declaratory Ruling:
• The only practice setting in which the Board is addressing this issue is that of an EMS
System. Therefore, the procedures approved by this Declaratory Ruling may only occur in established Emergency Medical Systems in North Carolina and may only be conducted by persons employed by an Ambulance Provider licensed pursuant to Chapter131E of the North Carolina General Statutes.
• While providing any advanced care procedure, or administering a pharmacologic agent,
the RCP must remain in constant communications contact within the EMS System and consult with medical staff concerning the procedures and medications administered
• The Ambulance Provider must have written policies and procedures for the provision of
each advanced care procedure, including procedures that specifically address the administration of pharmacologic agents by RCP’s.
• Any RCP who engages in these activities must have an active unencumbered license
• Any RCP who engages in these activities must have an advanced practice credential, such
as being registered by the National Board for Respiratory Care as a Registered Respiratory Therapist (RRT). Should any question arise about the appropriateness of any other advanced practice credential, the Board will provide guidance for individual situations on request, with sufficient advance notice.
• Any RCP who engages in these activities must also have completed a Baccalaureate
Degree in Respiratory Care or have a minimum of 2 years experience in critical and emergency care after graduation from an associate degree Respiratory Care Program.
• Any RCP who engages in these activities must be certified in accordance with the
Ambulance Provider’s policy as competent to provide advanced care procedures and to administer pharmacologic agents under medical supervision and the direct orders of a physician and/or protocols established by the Ambulance Provider and approved by the Ambulance Provider’s Medical Director.
• Any RCP who engages in these activities must be certified and maintain Advanced
Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and Neonatal Resuscitation Protocol (NRP) certification by the American Heart Association.
• Any RCP who engages in these activities must understand the pharmacology of the
agents that are administered, and the role of any pharmacological antagonist that can be administered as well as techniques, medications, side effects, monitoring devices, response or untoward effects of medications, and documentation for any specific procedure.
• Any RCP who engages in these activities must closely monitor patients receiving any of
these therapeutic interventions or pharmacologic agents and must be able to recognize the associated complications, consult with a physician within the EMS System and take appropriate actions under Medical Direction.
• Any RCP who engages in these activities may only administer the pharmacologic agents
approved by the Ambulance Provider’s Medical Director. The Ambulance Provider must maintain a formulary of the pharmacologic agents approved by the provider’s Medical Director for RCP’s to administer.
• The RCP must comply with the continuing education requirements of 21 NCAC 61 .0401
of which a minimum of 5 hours of continuing education must be directly related to the advanced care procedures provided. The RCP is required to notify the Board annually that he or she provides advanced care procedures. All continuing education performed must be approved as outlined in 21 NCAC 61 .0401.
• If requested, the RCP must provide the Board a copy of all certifications required by this
• Any RCP who engages in these activities must have an annual documented competency
evaluation by the Ambulance Provider’s Medical Director, which includes an assessment of all advanced care procedures and pharmacologic agents that the RCP administers.
• The RCP must complete and maintain the documentation required by this ruling for a
period of 3 years after the relevant date of service.
• Any licensed RCP who is actively and continuously engaged in workplace training that
can lead to eligibility to provide the advanced practice procedures enumerated in this ruling, and who is working at all times under the direct supervision of a Respiratory Care Practitioner who has already been approved by the Board to provide advance care procedures may, so long as the workplace training continues, participate in providing the advanced practice procedures enumerated in this ruling, including the administration of pharmacologic agents; but only for a maximum period of ONE YEAR from the date of this ruling, or the first date that the trainee began the workplace training, whichever is later.
For the foregoing reasons, and based upon the information provided and within the
limitations expressed above, the North Carolina Respiratory Care Board concludes that Respiratory Care Practitioners may provide advanced care procedures and administer pharmacologic agents related to these procedures under the direct orders of a physician and protocols established by an Ambulance Provider licensed pursuant to Chapter131E of the North Carolina General Statutes.
This the 12th day of July, 2007. ___________________________________ Joseph Coyle, MD Chair North Carolina Respiratory Care Board
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