Tips on Implementing Medical Directives

At last year’s CAPA conference I attended a session on Medical Directives and produced a primer on Medical Directives for practicing PAs in Ontario based off that session. I was pleased to see that CAPA offered yet another Medical Directive session, and I was hoping to expand upon topics discussed in the previous forum.

Natalie Dies, KenThis was an early morning session on the Friday of the conference, led by Natalie Dies and Ken Crosby. They also attended the 2015 CAPA conference in Toronto and were sitting at the same table during the Medical Directives session. After discussion, they put together a CAPA Medical Directive Working Group of 12+ CAPA volunteers who were dedicated to helping out fellow PAs have access to a medical directive resource. The goals were to define current problems with directives, post directives for reference, develop a standard directive universal to all PAs and determine the “do’s” and “don’ts” of medical directives.

To date, 17 medical directives have been compiled by this working group, and these are available in the “Members Only” “resources” section of the CAPA website

For an overview of the Basics of Medical Directives (e.g. format, implementation, etc.), please see my Primer on Medical Directives

The Necessity for Medical Directives

  • Medical Directives serve as an “authorizing mechanism” to allow Physician Assistants to performed controlled acts.
  • There are 14 controlled acts as listed by the College of Physician Assistants in Ontario. PAs may be delegated  12 out of the 14 acts may be delegated via direct order.
  • As an unregulated health professional, direct orders or medical directives required for PAs to legally perform delegated controlled acts and provide patient care.
  • Although medical directives can be cumbersome and challenging to create, they do improve efficiency of PA practice and allow for some practice autonomy as they avoid need for constant verbal orders from supervising physicians.
  • Medical directives should be implement as soon as possible, as it requires approval from different levels of hospital or clinic administrations and decision makers, which can take 4-6 months or more . These changes may reflect changes in staff/supervising physicians and expansion of PA knowledge and skills.
  • Proper medical documentation is essential for liability purposes. 

Working with Nurses

Through a medical directive, the PA acts as “vehicle” of delegation. Therefore the nurse and PA are co-implementing the order.

RNs and PAs

From: CNO’s “Accountability & Collaboration – Working With a Physician Assistant” presentation

Characteristics of Medical Directives

In the 17 medical directives, the working group determined that the medical directives included some or all of the following components:

  • History and Physical Examination (should encompass or mention)
  • Medical Documentation
  • Ordering lab investigations
  • Ordering Investigations:
    • X-rays
    • ECGs
    • Ultrasound
    • Echocardiogram
    • CT
    • MRI
  • Prescribing Medications: Some allow PAs to prescribe from drug formularies that are small, and some are larger formularies.
    • An example of a general statement in a medical directive that does not list any medications, but instead say, “PA may order medications, but this does not include narcotics or benzodiazepines).
  • Performing Procedures
    • Sutures
    • Casting and Splinting
    • PAP smear
    • Surgical Assist
  • Ordering IV Fluids
  • Referrals:
    • Referral to allied health professionals (e.g. referring to a dietitian, massage therapy, physiotherapy, occupational therapy assessment).
    • Referral to other MD
    • May sign CCAC referral
  • Verbal Orders – More recently some medical directives have included the ability to transcribe verbal order sin chart. Recently CNO resource. Check your institution policy.

Extra Points to Include in the Medical Directive

Indications and Contraindications to Implementing the Medical Directive should be included

  • Some directives are very specific (e.g. in case of GI bleed, medication should not be prescribed) or very vague (e.g. in the case of medical directove for history taking, indication is any patient admitted in X hospital, under X service, with X physician).
  • Some directives advise to refer to external resources (e.g. Clinical Practice Guidelines or Rx Files) for indications and contraindications of medications and procedures.

Certification/Education Requirements

There should be a statement defining the Certification and Education requirements of Physician Assistants that are to implement the medical directive. This may include:

  • “Physician Assistant passed the PACCC, or be PA-C
  • “Physician Assistant must have liability insurance”

Without title protection that may come with PA regulation in Ontario, education that is listed in directive helps define “Physician Assistant” role (i.e. Physician Assistant is someone who went to PA school)

Optional: Additional Competency Assessment

If a PA is performing a delegated controlled act, they must be capable of performing it safely and competently. Without regulation in Ontario, there is no official process for determining an individual’s competence other than the PA Entry to Exam. The medical directives may have a component of “competency assessment”.

For example, perhaps an MD is to observe you doing 3 lumbar punctures are your own properly, and sign off on the medical directive before you can start doing this on your own.

Tips on Creating Medical Directives

  • Start working on your medical directives as early as possible, as time of creation to full implementation maybe 4-6 months or more
  • Educate your supervising physicians on medical directives and how they will be implemented.
  • Approach health care team members (RN, allied health, administrators) about supervising physicians, and offer to be present at meetings where your medical directives will be discussed
  • Provide examples of other medical directives implemented in similar areas of practice
  • Contact CAPA if you are having any difficulty with any aspect of your medical directives. They are an excellent resource.
  • Respect and understand that supervising physician and administrators may be hesitant in implementing them

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