|CPAP and BiPAP Procedures||Medications or Procedures in an Emergency Situation|
|Delegation and the Advanced Practice Registered Nurse||Paramedics/EMTs in the Emergency Department (ED)|
|Health Maintenance Activities(HMAs)|
In January of 2012, the Texas Board of Nursing (BON) approved noninvasive ventilation (NIV), such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) therapy as additional tasks that RNs may determine are safe and appropriate to delegate in...
accordance with Chapter 225, RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions. The tasks RNs may decide to delegate are listed in Rule 225.10; and specifically, Rule 225.10 (13) now permits RNs to delegate NIV procedures to unlicensed personnel.
The BON is aware that in independent living environments the use of NIV has increased for the treatment of numerous chronic respiratory disorders, such as chronic obstructive pulmonary disease, asthma, sleep apnea and cystic fibrosis. In order for clients to achieve optimal health benefits in the least restrictive environments as possible, RNs may use the delegation process in collaboration with the client or the client's responsible adult (CRA) to decide if NIV procedures are safe to delegate in home settings.
RNs are responsible for adequately and accurately assessing the needs of clients in order to ensure their safety in these settings. The delegation process can assist RNs to make decisions as to how unlicensed personnel will be utilized to accomplish safe and effective supportive services and care.
In January 2013, the Board approved a list of life-sustaining medications and treatments that an RN may delegate in emergency situations for clients in independent living environments, provided the RN has an order to administer or perform the following and the client has received a diagnosis...
that required a prescription for:
- Glucagon injections for treatment of severe hypoglycemia in unconscious clients or clients who are unable to swallow oral glucose
- Epinephrine injections from a single-dose pre-filled automatic injection device for severe allergic anaphylactic reactions
- Diazepam rectal gel in a pre-filled syringe for episodes of increased seizure activity
- Nitroglycerin tablet(s) administered sublingually for the acute relief of an attack of angina pectoris
- Use of a hand held magnet to activate a vagus nerve stimulator to prevent or control seizure activity
- Metered dose inhalers or nebulizer treatments for the relief of acute respiratory symptoms
- Oxygen administration for the relief of acute respiratory symptoms
Planning for emergencies in independent living environments requires the RN to utilize both Chapter 224, Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments and Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions. RNs must use their nursing judgment to decide when it is safe and appropriate to delegate life-sustaining medications and treatments to unlicensed personnel in independent living environments such as community-based settings, client homes or schools.
While all the delegation criteria are important in Board Rule 224.6, the RN must take into consideration how the supervisory standards will be met as delegation decisions are made. The RN is required to provide adequate supervision while an unlicensed person is performing a task, particularly in emergency situations. The RN must consider his or her geographical distance and the time it takes to reach a client that is experiencing an emergency in order to direct unlicensed personnel when to notify the Emergency Medical System (EMS). RNs are also responsible for timely follow-up, which may include a face-to-face assessment depending on the emergency situation and the RN's location to the individual. Delegation decisions and instructions to unlicensed personnel should be documented in the client's record.
Yes, the Board approved expanding this list during the January 2013 Board Meeting, according to their authority under Board Rule 225.4(8) (E). RNs in independent living environments such as, home and community-based settings or school health must utilize the rules in Chapter 225,...
RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions when making decisions that pertain to delegation. The RN depending on the assessment of the client and the delegation criteria may decide to: designate a task a HMA that does not require delegation; delegate a task to an unlicensed person; or have a nurse perform the task.
HMAs are defined as "tasks that enable the client to remain in an independent living environment and that go beyond activities of daily living (ADLs) because of the higher skill level required to perform," [See Board Rule 225.4(8)]. The Board believes that expanding the list of HMAs will foster a client's independence and further supports a client or the client's responsible adult (CRA) who is able to train and supervise unlicensed personnel in the performance of a HMA, thus enabling the client to remain in the least restrictive environment as possible. For a complete list of tasks that can be designated as HMAs please refer to Board Rule 225.4(8) (A-E). The additional tasks that may be designated as HMAs are:
- Noninvasive ventilation (NIV) such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) therapy
- Routine administration of a prescribed dose of oxygen
- Unit dose medication administration by way of inhalation (MDIs) including medications administered as nebulizer treatments for prophylaxis and/or maintenance
- Topically applied medications
- Insulin administration subcutaneously, nasally, or via an insulin pump
Because all nurses are required to promote a safe environment for their clients and others [See Board Rule 217.11(1)(B)], the RN must always consider what is safest for the client when making decisions to designate a task a HMA that does not require delegation. Nurses are reminded to document their decisions concerning delegation in the client's record. For additional information on delegation, see the Texas Board of Nursing Delegation Resource Packet.
No. Advanced practice registered nurses are regulated solely by the Texas Board of Nursing. As RNs, advanced practice registered nurses may only delegate tasks to unlicensed staff or assistive personnel utilizing the applicable RN Delegation Rules 224 or 225 as appropriate and in compliance...
With regard to other nurses, it is important to note that an advanced practice registered nurse may make an assignment to another nurse that takes into account his/her scope of practice and level of licensure [Rule 217.11(1)(S)]. An advanced practice registered nurse may not assign tasks to RNs or LVNs that exceed the RN or LVN scope of practice, even if the advanced practice registered nurse agrees to co-sign the RN's or LVN's documentation. An advanced practice registered nurse’s co-signature for something that is beyond the RN's or LVN's scope of practice does not legitimize the RN's or LVN's actions. A nurse never functions "under the license" of another nurse nor does a nurse "delegate" to another licensed nurse. Board rules are accessible in their entirety on the BON web page under Laws and Rules.
Can an RN delegate starting a peripheral IV saline lock to an EMT/Paramedic in the Emergency Department (ED)? Some of the "techs" in our ED are "licensed paramedics" who also work for EMS. What other kinds of tasks can be delegated to Emergency Medical Technicians (EMTs)/Paramedics in the ED setting?
The rules governing EMTs and Paramedics are located in Title 25, Texas Administrative Code, Section 157.2. This rule limits the scope of practice of EMTs/Paramedics to performing duties in the "pre-hospital and inter-facility transport" settings. Therefore, whether certified or licensed,...
the BON delegation rules view EMTs, Paramedics, or other similarly trained staff as "unlicensed assistive personnel" (UAPs) when working in acute care settings, such as the ED.
Each RN decides on a case-by-case basis what nursing tasks may be delegated to unlicensed personnel in accordance with Rule 224 (relating to RN delegation in acute care settings or for patients with acute conditions). It should be noted that position descriptions developed by employing institutions can neither mandate RN delegation, nor force RN delegation by facility policy or physician order.
The BON's delegation Rule 224 is not prescriptive to specific procedures or tasks that may or may not be delegated. Rule 224 permits an RN to delegate starting a peripheral IV saline lock to an unlicensed person providing all of the delegation criteria are met. The applicable section of Rule 224 in delegating this task is §224.8(b), Discretionary Delegation Tasks, under (2)(A), Sterile Procedures. Section 224.8(c)(5) does prohibit delegation of administration of IV fluids, so an unlicensed tech in the ED could not connect and administer a bag of IV fluid under RN delegation.
Other laws outside of the BON's jurisdiction may prohibit performance of certain tasks by unlicensed personnel, even if a physician is willing to delegate a task. Under physician delegation, the physician must willingly make the decision and delegate the task(s) and such delegation must be permitted by hospital/facility policy. BON staff cannot speak as experts on the Texas Medical Board's (TMB) rules; however, Rule 193 of the TMB Rules addresses "physician delegation." You may wish to contact the TMB at (512) 305-7010, or check their web site at http://www.tmb.state.tx.us for more information on this law.
The delegation rules also address the RN who may be supervising an unlicensed person to whom the physician has delegated tasks. The RN always has a responsibility to protect client safety [§217.11(1)(B)], so the RN has a duty to intervene if he/she sees something being done incorrectly by the unlicensed person, and to notify the delegating practitioner of the incident. For additional information on EMTs and Paramedics in the pre-hospital and interfacility transport setting, check the Texas Department of State Health Services web site at http://www.dshs.state.tx.us/emstraumasystems/default.shtm, or, to access applicable laws, see Texas Legislature Online at http://www.capitol.state.tx.us.
For more information on these and other topics, use the search field at the top right corner of the page. Should you have further questions or are in need of clarification, please feel free to contact the Board.