1. 1 LICENSURE CRNA PRACTICE IN WASHINGTON STATE

2. 2 Licensure Requirements 2 CE$ Washington RN Continuing competency requires 531 hours of active nursing practice and 45 hours of continuing nursing education over 3-years. $101 yearly Washington ARNP30 credits every 2 years*$97 every 2 years Washington RxA 30 credits initially, 15 credits every two years Initial $92 application** then $0. NBCRNA Certification 40 credits every 2 years$100 every 2 years AANA Membership$650 per year DEA Licensure$791 every three years Total yearly:45 credits every 2 years$850 / $1114 per year *Personal communication, Janice Pulvino, DOH ** Personal communication Thomas Bolender, NQAC

3. 3 RN LICENSURE The Nursing Care Quality Assurance Commission adopted rules for independent Continuing Competency effective January 2011.rules Using on-line forms RNs must keep documentation acknowledging several practice requirements, setting practice goals, and reflecting on their professionalism. Document at least 531 hours of active practice and 45 clock hours of continuing education every 3 years, beginning on your 2011 renewal date. You will have until your renewal date in 2014 to meet these requirements. DOH will begin random audits in 2014. You will not need to send in documentation unless selected for an audit. License renewals will continue to be annual; however, nurses must attest every three years that they have met the requirements for both practice and continuing education h ttp://www.doh.wa.gov/LicensesPermitsandCertificates/NursingCommission/ContinuingCompetency.aspx

4. 4 WAC 246-840-302 (2) An ARNP must maintain current certification by an accredited certifying body as identified in subsection (3) of this section. An ARNP license becomes invalid when the certification expires. (2) An ARNP must maintain current certification by an accredited certifying body as identified in subsection (3) of this section. An ARNP license becomes invalid when the certification expires. (c) For CRNA designation, the CRNA exam from Council on Certification of Nurse Anesthetists.(c) For CRNA designation, the CRNA exam from Council on Certification of Nurse Anesthetists.

5. 5 AANA Certification 40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any conditions that could adversely affect their ability to practice anesthesia.40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any conditions that could adversely affect their ability to practice anesthesia. Annual Dues $645Annual Dues $645 Biannual Recertification $100Biannual Recertification $100 There is a $300 fee to submit documentation of the required 40 CE credits to NBCRNA that is waived for active AANA members or those who have purchased this service from AANA.There is a $300 fee to submit documentation of the required 40 CE credits to NBCRNA that is waived for active AANA members or those who have purchased this service from AANA.

6. 6 ARNP SCOPE OF PRACTICE The Washington ARNP scope of practice was broadened to include “ perform procedures or provide care services that are within the scope of practice according to the Commission approved certification program; ” The identification of Commission approved certification examinations are those accepted by the National Commission on Certifying Agencies or the American Boards of Nursing Specialties {Refer to WAC 246-840-302(3) for programs and approved examinations}. http://www.doh.wa.gov/Portals/1/Documents/6000/ARNPFAQs.pdf March 2009

7. 7 AANA SCOPE OF PRACTICE Performing and documenting a preanesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering preanesthetic medications and fluids; and obtaining informed consent for anesthesia. Developing and implementing an anesthetic plan. Initiating the anesthetic technique which may include: general, regional, local, and sedation. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient ’ s physical status. Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic. http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

8. 8 AANA SCOPE OF PRACTICE Managing a patient ’ s airway and pulmonary status using current practice modalities. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support. Discharging the patient from a postanesthesia care area and providing postanesthesia follow-up evaluation and care. Implementing acute and chronic pain management modalities. Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques. http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

9. 9 AANA ADDITIONAL DUTIES Administration/management: scheduling, material and supply management, development of policies and procedures, fiscal management, performance evaluations, preventative maintenance, billing, data management, and supervision of staff, students or ancillary personnel. Quality assessment: data collection, reporting mechanism, trending, compliance, committee meetings, departmental review, problem-focused studies, problem solving, interventions, documents and process oversight. Education: clinical and didactic teaching, BCLS/ACLS instruction, in- service commitment, EMT training, supervision of residents, and facility continuing education. Research: conducting and participating in departmental, hospital-wide, and university-sponsored research projects. http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

10. 10 AANA ADDITIONAL DUTIES Committee appointments: assignment to committees, committee responsibilities, and coordination of committee activities. Interdepartmental liaison: interface with other departments such as nursing, surgery, obstetrics, postanesthesia care units (PACU), outpatient surgery, admissions, administration, laboratory, pharmacy, etc. Clinical/administrative oversight of other departments: respiratory therapy, PACU, operating room, surgical intensive care unit, pain clinic, etc. http://www.aana.com/aboutus/Documents/scopeofpractice.pdf

11. 11 RCW 18.79.240 RCW 18.79.240 http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.240 http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.240 In the context of the definition of registered nursing practice and advanced registered nursing practice, this chapter shall not be construed as: (r) Prohibiting advanced registered nurse practitioners, approved by the commission as certified registered nurse anesthetists from selecting, ordering or administering controlled substances as defined in Schedules II through IV of the Uniform Controlled Substances Act, chapter 69.50 RCW, consistent with their commission recognized scope of practice subject to facility specific protocols, and subject to a request for certified registered nurse anesthetist anesthesia services issued by a physician licensed under chapter 18.71 RCW, an osteopathic physician and surgeon licensed under chapter 18.57 RCW, a dentist licensed under chapter 18.32 RCW, or a podiatric physician and surgeon licensed under chapter 18.22 RCS, the authority to select order and administer Schedule II through IV controlled substances being limited to those drugs that are to be directly administered to patients who require anesthesia for diagnostic, operative, obstetrical or therapeutic procedures in a hospital, clinic, ambulatory surgical facility, or the office of a practitioner licensed under chapter 18.71, 18.22, 18.36, 18.36A, 18.57, 18.57A or 18.32 RCW.

12. 12 RCW 18.79.240 “select meaning the decision making process of choosing a drug, dosage, route and time of administration: and “order” meaning the process of directing licensed individuals pursuant to their statutory authority to directly administer a drug or to dispense, deliver or distribute a drug for the purpose of direct administration to a patient, under instruction of the certified registered nurse anesthetist. “Protocol” means a statement regarding practice and documentation concerning such items as categories of patients, categories of medications, or categories of procedures rather than detailed case- specific formulas for the practice of nurse anesthesia.http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.240

13. 13 RCW Definitions Select: the decision-making process of choosing a drug, dosage, route, and time of administration. Select: the decision-making process of choosing a drug, dosage, route, and time of administration. Example: The CRNA, based upon the surgical procedure and the patient ’ s health status, selects sevoflurane as the inhalational agent for the anesthetic.Example: The CRNA, based upon the surgical procedure and the patient ’ s health status, selects sevoflurane as the inhalational agent for the anesthetic. Order: the process of directing licensed individuals to directly administer a drug to a patient, under instructions of the CRNA. Order: the process of directing licensed individuals to directly administer a drug to a patient, under instructions of the CRNA. Example: The CRNA in PACU writes an order on the patient ’ s chart for the patient to receive 25 mcg of fentanyl q 20 minutes PRN pain.Example: The CRNA in PACU writes an order on the patient ’ s chart for the patient to receive 25 mcg of fentanyl q 20 minutes PRN pain. Administer: Directly apply or inject the medication to the body of a patient. Administer: Directly apply or inject the medication to the body of a patient. Example: The CRNA administers 100 mg of propofol to the patient by IV injection.Example: The CRNA administers 100 mg of propofol to the patient by IV injection.

14. 14Limitations An employer or health care institution, public or private, can choose to limit prescribing privileges of any credentialed health care provider with prescriptive authority. The Nursing Commission, Medical Board and Pharmacy Board have no jurisdiction or ability to overrule these institutional policies. State and Federal regulations both define our practice. Whichever is more restrictive must be applied. State and Federal regulations both define our practice. Whichever is more restrictive must be applied. Washington Law : https://apps.legwagov/RCW/default.aspx?cite=69.50.101. Washington Law : https://apps.legwagov/RCW/default.aspx?cite=69.50.101. https://apps.legwagov/RCW/default.aspx?cite=69.50.101 DEA Regulations : http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html DEA Regulations : http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html

15. 15 DEA APPLICATION To obtain a DEA registration, a practitioner must apply using a DEA Form 224. Applicants may submit the form by hard copy or on-line. Complete instructions accompany the form. To obtain the application, DEA may be contacted at www.DEAdiversion.usdoj.govwww.DEAdiversion.usdoj.gov DEA registration grants practitioners federal authority to handle controlled substances. Registration Requirements: Every person or entity that handles controlled substances must be registered with DEA or be exempt by regulation from registration. Fee: $791 every 3 years. 15 DEA Practitioner Manual, 2006 Edition p 7.

16. 16 DEA Definitions Legend Drugs: All drugs requiring a prescription from a licensed individual before they can be sold to an individual. Controlled substances are a subset of legend drugs. Legend Drugs: All drugs requiring a prescription from a licensed individual before they can be sold to an individual. Controlled substances are a subset of legend drugs. Controlled Substances: means a drug, substance, or immediate precursor included in Schedules I through V as set forth in federal or state laws, or federal or board rules. Controlled Substances: means a drug, substance, or immediate precursor included in Schedules I through V as set forth in federal or state laws, or federal or board rules.

17. 17 DEA Definitions The problem: Prescription: An order for medication which is to be dispensed to the ultimate user. This does not include an order for medication which is dispensed for immediate administration to the ultimate user (e.g., an order to dispense a drug to a bed patient for immediate administration in a hospital is not a prescription – see the definition for “ order ” above). Prescription: An order for medication which is to be dispensed to the ultimate user. This does not include an order for medication which is dispensed for immediate administration to the ultimate user (e.g., an order to dispense a drug to a bed patient for immediate administration in a hospital is not a prescription – see the definition for “ order ” above). Prescribe: Based upon the definition above, to prescribe is to write an order for a medication that will be dispensed to the patient. Prescribe: Based upon the definition above, to prescribe is to write an order for a medication that will be dispensed to the patient.

18. 18 DEA Appendix A Definitions Dispense To deliver a controlled substance to an ultimate user or research subject by, or pursuant to the lawful order of, a practitioner, including the prescribing and administering of a controlled substance and the packaging, labeling, or compounding necessary to prepare the substance for such delivery. Example: A pharmacist dispenses 20 oxycodone tablets to a patient based upon a prescription written by a physician or a CRNA with prescriptive authority and DEA registration. DEA Practitioner Manual, 2006 Edition

19. 19 DEA Appendix A Definitions Administer The direct application of a controlled substance to the body of a patient or research subject by 1) a practitioner or (in his presence) by his authorized agent, or 2) the patient or research subject at the direction and in the presence of the practitioner, whether such application is by injection, inhalation, ingestion, or any other means. Administer The direct application of a controlled substance to the body of a patient or research subject by 1) a practitioner or (in his presence) by his authorized agent, or 2) the patient or research subject at the direction and in the presence of the practitioner, whether such application is by injection, inhalation, ingestion, or any other means. DEA Practitioner Manual, 2006 Edition

20. 20 Appendix A Definitions Mid-level Practitioner An individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists, and physician assistants who are authorized to dispense controlled substances by the state in which they practice. Mid-level Practitioner An individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists, and physician assistants who are authorized to dispense controlled substances by the state in which they practice. DEA Practitioner Manual, 2006 Edition

21. 21 Prescribing Schedule II-IV ARNPS may prescribe Schedule II-IV medications only after obtaining prescriptive authority {Refer to WAC 246-840-410 and www.doh.wa.gov/nursing}. www.doh.wa.gov/nursing Drug Enforcement Authority ’ s website: www.deadiversion.usdoj.gov http://www.doh.wa.gov/Portals/1/Documents/6000/http://www.doh.wa.gov/Portals/1/Documents/6000/ARNPFAQs.pdf March 2009

22. 22 Practitioner ’ s Use of Hospital DEA Number Practitioners (e.g., intern, resident, staff physician, mid-level practitioner) who are agents or employees of a hospital or other institution may, when acting in the usual course of business or employment, administer, dispense, or prescribe controlled substances under the registration of the hospital or other institution in which they are employed, provided that: The dispensing, administering, or prescribing is in the usual course of professional practice The dispensing, administering, or prescribing is in the usual course of professional practice Practitioners are authorized to do so by the state in which they practice Practitioners are authorized to do so by the state in which they practice The hospital or institution has verified that the practitioner is permitted to dispense, administer or prescribe controlled substances within the state The hospital or institution has verified that the practitioner is permitted to dispense, administer or prescribe controlled substances within the state The practitioner acts only within the scope of employment in the hospital or institution The practitioner acts only within the scope of employment in the hospital or institution The hospital or institution authorizes the practitioner to dispense or prescribe under its registration and assigns a specific internal code number for each practitioner so authorized The hospital or institution authorizes the practitioner to dispense or prescribe under its registration and assigns a specific internal code number for each practitioner so authorized 22

23. 23 HB 1486 June 7 2012 Allows Washington pharmacists to fill prescriptions for controlled substances written by advanced registered nurse practitioners (ARNPs) licensed outside of Washington working up to their scope of practice. This law amended the Controlled Substance Act y adding ARNPs to the list of practitioners with prescriptive authority for controlled substances in any state. ARNPs with prescriptive authority for controlled substances from Idaho and Oregon write prescriptions for their patient who may reside in Washington or may wish to have their prescriptions filled in Washington. The new law allows Washington pharmacies to fill these prescriptions for controlled substances. ARNPs UNITED, AUSA: http://auws.org/

24. 24 The Opt out January 2001 Medicare removed the federal requirement for physician supervision of nurse anesthesia practice. November 2001, Bush administration implemented a compromise in response to protest by anesthesiologists, allowing state governors to opt out of the supervision requirement.January 2001 Medicare removed the federal requirement for physician supervision of nurse anesthesia practice. November 2001, Bush administration implemented a compromise in response to protest by anesthesiologists, allowing state governors to opt out of the supervision requirement. Iowa December 2001Washington October 2003 Nebraska Feb 2002Alaska October 2003 Idaho March 2002Oregon December 2003 Minnesota April 2002Montana January 2004 New Hampshire June 2002South Dakota March 2005 New Mexico Nov 2002Wisconsin June 2005 Kansas April 2003California June 2009 North Dakota October 2003Colorado Sept 2010