Scope of Practice

Hi all, need some input. Does anyone know or know where I can find info on Scrub-First Assist? We have a scrub who recently finished the program and is being allowed to inject local. I thought you needed a license to inject, but it's been a long time since I was in school and things change in our field often.

He has not become certified yet, but has plans to sit for the test.

Any input is welcome.

Thanks in advance

RNFA or CFA?

It depends on whether they are licensed and what the state license allows. If they are not licensed depending on the local law for delegated tasks its probably allowed. You have to remember that MAs who are not licenses give injections all the time.

It also depends on your institutions practice prerogatives. I don't have separate privileges for local injection but I have only applied for privileges as a PA. I have seen RNFA privileges but I don't remember if they covered local injections (which I am assuming what you are talking about).

David Carpenter, PA-C

No, I'm talking about a scrub tech who has attended a first assist. program. He has no license. I can't find any state practice info for a scrub tech.

First of all I am assuming you are from Wisconsin (from your profile). I cannot find any licensing informations for CFAs in Wisconsin so I will assume that they are not licensed there (I will admit I don't have a lot of expertise here). In states that CFAs are not licensed they are treated as unlicensed assistive personnel. I am assuming that this works the same way that Colorado worked. UAPs assisting in the OR are working under the physicians license and direction. In Wisconsin the supervision is defined thus:

"A: For persons who are unlicensed, the performance of a delegated medical act must be " directed, supervised and inspected" by the physician. The unlicensed person presumably does not have the degree of knowledge, training or education as licensed health care professionals, such as a nurse, physician assistants, or advance nurse practice prescribers, therefore, the supervision requirement is heightened. Wis. Stats. 448.03 (2)(e)."

In Wisconsin the statue says:

448.03 License or certificate required to practice; use of titles; civil immunity; practice of Christian Science.

(2) Exceptions. Nothing in this subchapter shall be construed either to prohibit, or to require, a license or certificate under this subchapter for any of the following:

(e) Any person other than a physician assistant who is providing patient services as directed, supervised and inspected by a physician who has the power to direct, decide and oversee the implementation of the patient services rendered.

So essentially the law provides an exception to unlicensed personnel who are directed, supervised and inspected by the physician.

How this all plays out depends on how the BOM interprets it. Most states for example do not require the Physician to personally inspect each injection that an MA gives. They have to generally be available and have a knowledge of the UAPs work (having previously inspected it). So my thoughts are that a CFA could inject while the physician was there. Depending on how your state law they could probably inject while the physician was not there as long as the physician had knowledge and previously inspected the work. In reality injection has no special place in the medical pantheon. It is no different than the surgeon scrubbing out while the assistant closes the wound.

Overriding this is your hospitals bylaws. Any assist should be credentialled by the hospital and have defined scope of practice. This can be more restrictive than the state law. The most appropriate place to ask this question would be your medical staff office. If they do not credential first assists that is a different scarier Oprah.

David Carpenter, PA-C

It is outside the scope of practice for a CST or uncertified surgical technologist if they are staying a ST. CFAs and CSAs in most states fall in the category of midlevel card providers once they have passed the certification exams given by either the NBSTSA or NSAA.

As core0 points out; other factors besides state laws include facility policy which may be stricter than state laws. If the scrub is being paid by the surgeon or by the hospital makes a difference too (who the direct employer is). Many medical assistants inject in the office under "Respondant Superior". Many CSTs work for physicians in the office as MAs and in surgery as CSTs. If they are employed by a surgeon, they may have to be granted privileges to practice which would have more precise language in what they are allowed to do.

If the scrub is being precepted by the surgeon, it is really a clinical in which the surgeon is directing the student as a part of the program that is before the exam for certification (like how student nurses give injections but are not licensed but expect to eventually pass the NCLEX, etc...).

This is really one that would vary according to the scenario, facility policy, and or state laws.

A CST or a non-certified ST is no different than a CFA or CSA as far as scope of practice. They are all unlicensed assistive personnel except in the 2-3 states that license surgical assists. This also shows that the term mid-level is essentially useless.

Respondeat superior is not the provision that the MA (or CFA) operates under. Instead it is the principle that states that the physician in this case is responsible for the acts that are committed under their license. From a legal standpoint all non-licensed personnell operate under the rules for UAPs. These can either be found in the medical practice act or a similar section. UAP regulations can also be found in the nurse practice act as regards to delegating nursing duties.

Essentially a physician can delegate any medical act be it injections or suturing. The more invasive or risky the medical act the less the medical act is likely to permit the delegation. Just as the nursing practice act has several instances such as assessment that are not delegatable to UAPs so to will the medical practice act limit what a physician can delegate. If I am not mistaken in states where the RNFA role is not spelled out in the nurse practice act the RNFA operates under the delegated practice act although they remain liable under their nursing license also.

As far as the specific question asked, in most ORs that I have worked in (N=15-20) injecting local would be in the scope of practice for any first assist. We routinely do things that are much more invasive than that such as trocar placement. You also have to remember that there are substantial numbers of surgical assists out there that have never had any formal training or certification. It will again depend on the specific state and more likely the hospital credentialing. For unlicensed personnel it is also likely that having the physician present would be part of the scope.

David Carpenter, PA-C

Just an example of Respondeat Superior and how it works in applied law as seen in some Tennessee Cases: http://www.medscape.com/viewarticle/433873_2

This really shows how some state court systems look at similar issues.

I would agree that liability wise this is applicable. But liability only applies after the case. Scope of practice is determined by state law and medical privileges. This does bring up a point of who is liable for the actions of an SA (to use a generic term). Generally the surgeon is considered responsible. However, in credentialing any non-physician there has to be a responsible physician. In the case of SAs who work for a private company this is frequently a physician from a different practice and sometimes a different specialty. This can lead to difficulties in determining who is responsible for an SAs conduct. A number of hospitals are prohibiting SAs who are not W-2 employees of the physician group to minimize this problem.

David Carpenter, PA-C