OHIO LEGISLATIVE SERVICE COMMISSION
Office of Research Legislative Budget
www.lsc.ohio.gov and Drafting Office
H.B. 224 Bill Analysis
133rd General Assembly
Click here for H.B. 224’s Fiscal Note
Version: As Passed by the House
Primary Sponsors: Reps. Cross and Wilkin
Effective Date:
Elizabeth Molnar, Attorney
SUMMARY
Grants a certified registered nurse anesthetist (CRNA) authority to select, order, and
administer drugs, treatments, and intravenous fluids for conditions related to the
administration of anesthesia, but only during the time period established by the bill and
in accordance with a health care facility’s required policy.
Permits a CRNA – under certain circumstances – to direct nurses and respiratory
therapists to perform specified tasks, including administering drugs.
Authorizes a CRNA to perform additional activities or services, including ordering and
evaluating diagnostic tests.
Allows a supervising practitioner or health care facility to prohibit a CRNA from
performing an activity or service authorized by the bill if the supervising practitioner or
facility determines that is not in a patient’s best interest for the CRNA to do so.
DETAILED ANALYSIS
Certified registered nurse anesthetists
Supervision and practice
The bill retains the current law requirement that a certified registered nurse anesthetist
(CRNA) practice under the supervision of a physician, podiatrist, or dentist. Supervision is
described as being under the direction of a supervising practitioner acting within that
practitioner’s scope of practice.1 In relation to this supervision, the services a CRNA is
authorized to provide under existing law are described as follows:
1 R.C. 4723.43(B). See also R.C. 4723.01(M), 4723.432(B), 4731.27(C), and 4731.35(A), not in the bill.
February 10, 2020
Office of Research and Drafting LSC Legislative Budget Office
1. With supervision and in the immediate presence of the supervising practitioner, a CRNA
may administer anesthesia and perform anesthesia induction, maintenance, and
emergence;
2. With supervision, a CRNA may perform preanesthetic preparation, postanesthesia care,
and clinical support functions.2
The bill maintains the services that a CRNA currently may perform with supervision and
also authorizes a CRNA to perform other services with supervision. The bill retains an existing
provision specifying that a CRNA must act in a manner that is consistent with the CRNA’s
education and certification and in accordance with rules adopted by the Ohio Board of
Nursing.3
Selecting, ordering, and administering drugs, treatments, and IV
fluids
Current law grants each advanced practice registered nurse (APRN) specialty, other than
the CRNA specialty, authority to prescribe or furnish most drugs and therapeutic devices as part
of the APRN license.4 Accordingly, CRNAs lack authority at present to select and order drugs.5
The bill, however, permits a CRNA to select, order, and administer drugs, treatments, or
intravenous (IV) fluids for conditions related to the administration of anesthesia. This may occur
as necessary for patient management and care and only during the time period that begins on a
patient’s admission to a health care facility for a surgery or procedure and ends with the
patient’s discharge from recovery.6
When a CRNA selects, orders, and administers a drug or treatment or IV fluids, the bill
requires the CRNA and his or her supervising practitioner to both be physically present at the
health care facility. In addition, the CRNA must indicate the administration in the patient’s
medical or electronic health record. The bill also requires the facility to have adopted a written
policy (see “Written policy” below).
The bill further provides that it does not authorize a CRNA to prescribe a drug for use
outside the facility or other setting where the nurse provides anesthesia care. 7
2 R.C. 4723.01(M), not in the bill, and 4723.43(B).
3 R.C. 4723.43(B).
4See R.C. 4723.43 and 4723.481, not in the bill, with respect to certified nurse practitioners, certified
nurse-midwives, and clinical nurse specialists.
5 R.C. 4723.43(B).
6 R.C. 4723.434.
7 R.C. 4723.434.
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Clinical support functions and delegation
Current law permits a CRNA to perform clinical support functions, but does not define or
describe those functions.8 Under the bill, a CRNA – while performing clinical support functions –
may direct a registered nurse (RN), licensed practical nurse (LPN), or respiratory therapist to do
either of the following:
1. Provide supportive care, which may include monitoring vital signs, conducting
electrocardiograms, and administering IV fluids;
2. Administer drugs, treatments, and IV fluids to treat conditions related to the
administration of anesthesia, but only if a physician, podiatrist, or dentist ordered
them.9
Delegation generally
The bill authorizes a CRNA to direct RNs, LPNs, and respiratory therapists to do the
following as necessary for patient management and care:
1. Administer drugs, treatments, and IV fluids for the treatment of conditions related to
administration of anesthesia;
2. Provide supportive care, including monitoring vital signs, conducting
electrocardiograms, and administering IV fluids.10
However, a CRNA may direct such actions only during the time period that begins on the
patient’s admission to the facility for a surgery or procedure and ends on the patient’s
discharge from recovery and in accordance with the facility’s required policy. The bill also
requires the CRNA and supervising practitioner to both be present at the facility when the
CRNA directs the actions. Moreover, the CRNA must indicate his or her direction in the patient’s
medical or electronic health record.11
Note on delegation
The bill’s conditions on a CRNA’s authority to delegate drug, treatment, or IV fluid
administration differ depending on whether the CRNA does so (1) during the time period from
admission to discharge from recovery or (2) while performing clinical support functions. For
example, when a CRNA delegates administration as part of performing clinical support
functions, the bill requires the drug, treatment, or IV fluid to have been ordered by a
physician.12 A physician’s order is not specifically required, however, when a CRNA delegates
administration during the period from the patient’s admission for a surgery or procedure to
discharge from recovery.
8 R.C. 4723.43(B).
9 R.C. 4723.433.
10
R.C. 4723.434 and 4761.17.
11 R.C. 4723.434(B).
12 R.C. 4723.433.
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It is unclear from the text of both current law and the bill, though, when clinical support
functions are performed. It is possible that they could occur during the period from admission
to discharge from recovery. If so, it remains uncertain whether a physician’s order would be
required before the CRNA could delegate to an RN, LPN, or respiratory therapist the
administration of drugs, treatments, and IV fluids.
Additional services and activities
In addition to the changes in a CRNA’s practice described above, the bill permits a CRNA
to do all of the following:
1. Perform and document evaluations and assessments, which may include ordering and
evaluating one or more diagnostic tests for conditions related to the administration of
anesthesia;
2. Obtain informed consent for anesthesia care;
3. Perform postanesthetic preparation and evaluation. (Existing law refers only to the
authority to perform postanesthesia care.)13
In the event a CRNA performs and documents evaluations and assessments, the bill
requires both the CRNA and supervising practitioner to be present at the health care facility.14 It
also requires the CRNA to indicate those evaluations and assessments in the patient’s medical
or electronic health record.15
The bill retains current law provisions specifying that a CRNA is authorized to perform
anesthesia induction, maintenance, and emergence in the immediate presence of a supervising
practitioner.16
Written policy
The bill prohibits a CRNA from (1) performing and documenting evaluations and
assessments, (2) selecting, ordering, and administering drugs, treatments, and IV fluids for
conditions related to the administration of anesthesia, and (3) directing RNs, LPNs, and
respiratory therapists to perform certain actions unless the health care facility where the nurse
practices has adopted a written policy that meets the bill’s requirements.17
Under the bill, the policy must be developed by the health care facility’s medical,
nursing, and pharmacy directors.18 It also requires the adopted policy to establish standards
and procedures to be followed by CRNAs when ordering and evaluating diagnostic tests;
selecting, ordering, and administering drugs, treatments, and IV fluids; and directing RNs, LPNs,
13 R.C. 4723.43(B) and 4723.434.
14 R.C. 4723.434(B).
15 R.C. 4723.434(B).
16 R.C. 4723.43(B).
17 R.C. 4723.434(B) and 4723.435.
18 R.C. 4723.434(B).
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and respiratory therapists to administer drugs, treatments, and IV fluids or provide supportive
care.19
In adopting a policy, a health care facility must not authorize a CRNA to select, order, or
administer any drug that a supervising physician, podiatrist, or dentist is not authorized to
prescribe. Also, the health care facility must allow a supervising practitioner to issue every
order related to a patient’s anesthesia care.20
Opt-out provisions
Under the bill, a CRNA is prohibited from doing any of the following if the CRNA’s
supervising practitioner or the health care facility where the CRNA practices determines that it
is not in a patient’s best interest:
1. Performing and documenting evaluations and assessments, including ordering and
evaluating diagnostic tests;
2. Selecting, ordering, and administering drugs, treatments, and IV fluids for conditions
related to the administration of anesthesia;
3. Directing RNs, LPNs, and respiratory therapists to administer drugs, treatments, and IV
fluids or provide supportive care.21
If the supervising practitioner or health care facility makes such a determination, the
patient’s medical or electronic health record must indicate that the CRNA is prohibited from
performing the activity or activities.
The bill also specifies that it does not prohibit a CRNA from implementing a supervising
practitioner’s verbal order.22
HISTORY
Action Date
Introduced 04-29-19
Reported, H. Health 01-28-20
Passed House (94-2) 01-29-20
H0224-PH-133/ks
19 R.C. 4723.435(A).
20 R.C. 4723.435(B).
21 R.C. 4723.434(B).
22 R.C. 4723.434(C).
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As Passed by the House
Statutes affected: As Introduced: 4723.43, 4729.01, 4761.17
As Reported By House Committee: 4723.43, 4729.01, 4761.17
As Passed By House: 4723.43, 4729.01, 4761.17