| Position Statement (DRAFT) |
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| Regulatory Clarification |
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OHLA, RTLB Support Specialized Practice if Respiratory Therapist Qualified, under Medical Direction
The Oregon Health Licensing Agency (OHLA) and Respiratory Therapist Licensing Board (RTLB) support specialized practice in the patient transport setting and in other specialized practice settings.
Oregon Revised Statutes (ORS) 688.805(6) specifies that “The practice of respiratory care may be performed in any clinic, hospital, skilled nursing facility, private dwelling or other place considered appropriate or necessary by the Respiratory Therapist Licensing Board....”
As with any setting in which a respiratory therapist may practice, licensees must practice “…in accordance with the prescription of a licensed physician and under a qualified medical director” under ORS 688.800(3).
Also, under Oregon Administrative Rule (OAR) 331-715-0000(6), "Licensees shall not render respiratory care without written authorization or standing orders from a supervising physician...."
Therapists are in violation of ORS 688.800(3) and OAR 331-715-0000(6) if they practice outside of the parameters set by a physician / medical director.
The majority of Oregon’s approximately 1,500 licensed respiratory therapists do not actively practice in specialized settings. For example, approximately 50 practitioners are part of patient transport teams statewide.
In addition to being statutorily required under ORS 688.800(3), OHLA and the RTLB believe that medical direction is critical to patient safety and care in specialized practice settings, which may involve advanced procedures1 and administration of an expanded range of pharmacological agents2.
Such specialized practice settings require knowledge and skills beyond that of a practitioner’s initial education and training.
To ensure a high standard of patient care and safety, therapists should obtain appropriate and verifiable training and education to perform procedures and administer agents in a safe and responsible manner to ensure patient health and safety.
These procedures and the administration of agents must be for “…the treatment, management, diagnostic testing, control and care of patients with deficiencies and abnormalities associated with the cardiopulmonary system….” under ORS 688.800(3).
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| Purpose of Statement |
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The purpose of this position statement is to clarify the type of settings in which respiratory therapists may practice, at the request of a licensed respiratory care practitioner who works as a transport team member for critical care patients.
The Oregon Health Licensing Agency (OHLA) and Respiratory Therapist Licensing Board (RTLB) initially addressed the request for clarification at the February 13, 2009, RTLB meeting.
OHLA and the RTLB Legislation / Rules / Practice Standards Sub-Committee met on March 13, 2009, to further review the issue and draft the position statement.
Rather than limit the scope of the statement to the transport speciality practice setting only, OHLA and the RTLB chose to provide guidelines for therapists working in any specialized setting.
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| Qualifications |
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Respiratory therapists who work in specialized settings 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 agency and board will provide guidance for individual situations on request, with sufficient advance notice.
Therapist working in specialized settings must also have completed a baccalaureate degree in respiratory care or have a minimum of two years documented experience in critical and emergency care or other specialized area after graduation from an associate degree respiratory care program.
Licensees should also be guided by Oregon Administrative Rules (OAR) 331-720-0010, Continuing Education Requirements, for obtaining specialty practice training and certification.
For example, the Commission on Accreditation of Medical Transport Systems provides accreditation for transport care providers.
Specifically for the transport environment, therapists 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.
Licensees may also obtain advanced certification from The National Board for Respiratory Care.
Surface and air transport is one of multiple specialized practice settings identified by the American Association of Respiratory Care (AARC) at http://www.aarc.org/sections/. OHLA / RTLB acknowledge that specialized practice settings are not limited to those identified by the AARC.
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| Practice Setting / Protocols |
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Respiratory therapists must follow written policies and protocols that are readily available and approved by a qualified medical director.
These policies and protocols should be consistent with current respiratory care practice and should include but not be limited to patient selection, patient monitoring, availability and responsiblity of a physician or other licensed independent healthchare provider (LIP), drug administration and directions for addressing potential complications or emergency situations.
Respiratory therapists may not perform any procedures independently that go beyond current and accepted respiratory care practice. For example, therapists may assist a physician or LIP in performing a bronchoscopy, a procedure used to look inside the lungs' airways, but not perform the procedure independently.
As technology and scope of practice evolve, procedures respiratory therapists may or may not perform independently (while under medical direction) evolve as well. Again, respiratory therapists should be guided by prevailing standards in the profession articulated by national professional organizations such as the AARC.
For example, the AARC Clinical Practice Guidline for Bronchoscopy Assisting provides information on both respiratory care practice roles and limitations.
Procedures listed such as surgical airways must only be performed when other, less-invasive procedures have failed and patient health and safety is in imminent jeopardy.
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| Advanced Procedures |
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1Advanced Procedures: OHLA/RTLB have previously adopted position statements regarding conscious sedation and extracorporeal membrane oxygenation (ECMO), two advanced procedures that require additional education beyond a therapist’s initial qualifying education:
Conscious Sedation Position Statement
Extracorporeal_Membrane_Oxygenation Position Statement
Therapists do not perform all advanced procedures independently.Advanced procedures include, but are not limited to:
Acute Care / Diagnostics
- Bronchoscopy (assisting)
- C-PAP and BI-PAP titration
- Extracorporeal membrane oxygenation
- Hyperbaric oxygenation
- Pulmonary function and physiological pulmonary and cardiac stress testing
- Diagnostic polysomnography
- IV insertion
Transport
- Rapid sequence intubation
- Needle cricothyrotomies
- Needle chest decompression
- Chest tube placement
- External counter pulsation
- External pacing and other emergent airways
- Intraosseous placement
- Invasive line placement including but not limited to internal jugular, femoral, subclavian, peripheral arterial and umbilical lines
- Surgical airways (only in instances where other less invasive procedures fail; only in very rare circumstances)
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| Pharmacological Agents |
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2Pharmacological Agents: OHLA/RTLB previously adopted a position statement on the administration of pharmacological, diagnostic and therapeutic agents at:
Pharmacological Agents Position Statement
In the patient transport setting, for example, therapists administer paralytics, sedatives, anti-arrythmics, blood and cardiac stimulants.
Any therapist 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.
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| Competency Evaluation |
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Therapists working in a specialized practice setting must have a documented competency evaluation signed off by their medical director every two years. The comptency evaluation must include an assessment of all advanced procedures and pharmacologic agents that the therapist administers.
A copy of the competency evaluation must be available and provided upon request to OHLA.
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| Medical Director Definition |
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“Medical Director” Statutory Definition: ORS 688.800(2) “Qualified medical director” means the medical director of any inpatient or outpatient respiratory care service, department or home care agency who is a physician licensed by the State of Oregon and who has special interest and knowledge in the diagnosis and treatment of respiratory problems.
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| Questions? |
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While the intent of position statements is to clarify regulatory requirements, licensees and other stakeholders may have additional questions. For further clarification, please contact OHLA at 503-378-8667 or ohla.info@state.or.us.
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