LICENSURE
CRNA PRACTICE IN WASHINGTON STATE
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Licensure Requirements
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 ARNP
30 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
*Personal communication, Janice Pulvino, DOH
** Personal communication Thomas Bolender,
NQAC
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$850 / $1114 per year
RN LICENSURE
• The Nursing Care Quality Assurance Commission adopted rules for
independent Continuing Competency effective January 2011.
• 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
http://www.doh.wa.gov/LicensesPermitsandCertificates/NursingCommission/ContinuingCompetency.aspx
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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.
•
(c) For CRNA designation, the CRNA exam from
Council on Certification of Nurse Anesthetists.
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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.
• Annual Dues
$645
• Biannual 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.
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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
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March 2009
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
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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
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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, inservice 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
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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
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RCW 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.
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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 casespecific formulas for the practice of nurse anesthesia.
http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79.240
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RCW Definitions
• 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.
• 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.
• 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.
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Limitations
• 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.
• Washington Law :
https://apps.legwagov/RCW/default.aspx?cite=69.50.101.
• DEA Regulations :
http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html
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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.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.
DEA Practitioner Manual, 2006 Edition p 7.
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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.
• 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.
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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).
• Prescribe: Based upon the definition above, to prescribe is to
write an order for a medication that will be dispensed to the
patient.
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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
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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.
DEA Practitioner Manual, 2006 Edition
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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.
DEA Practitioner Manual, 2006 Edition
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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}.
• Drug Enforcement Authority’s website:
www.deadiversion.usdoj.gov
http://www.doh.wa.gov/Portals/1/Documents/6000/ARNPFAQs.pdf
March 2009
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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
• 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 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
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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/
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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.
Iowa December 2001
Washington October 2003
Nebraska Feb 2002
Alaska October 2003
Idaho March 2002
Oregon December 2003
Minnesota April 2002
Montana January 2004
New Hampshire June 2002
South Dakota March 2005
New Mexico Nov 2002
Wisconsin June 2005
Kansas April 2003
California June 2009
North Dakota October 2003
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Colorado Sept 2010