Introduction to APRN Protocol Agreements
An APRN Protocol Agreement is how Advanced Practice Registered Nurses (APRN) in Georgia maintain collaboration with physicians. Collaboration is a requirement of law for the licensure and practice of all APRNs. APRN Protocol Agreements are between physicians and APRNs that allow physicians to retain some supervision of the APRN in order for the APRN to get privileges in healthcare facilities. It is a way for employers/facilities, such as hospitals, to satisfy their "collaborative protocol agreement" requirement. The Georgia Composite Medical Board (GCMB) sets forth the requirements for these physician-APRN collaboration agreements in the Nurse Practice Act . It is basically a written agreement that sets out protocols used in the APRN’s practice and fulfills Georgia’s requirement that physicians and APRNs collaborate.
Sub-advanced practice nurses, i.e., Physician Assistants (PAs), Nurse Midwives (CNMs) and Nurse Anesthetists (CRNA) in Georgia, are not allowed to enter into collaborative practice agreements. Therefore, PAs, CNMs and CRNAs work under supervision of their MDs/DOs without having collaborative practice agreements. The difference between protocols and supervision, in terms of calling them collaborative practice agreements, is simply that the APRN performs medical acts under protocols to which they are delegated authority, the PA does it under supervision.
Legal Requirement in Georgia
There are specific legal requirements associated with APRN protocol agreements in Georgia. Read on to find out more about what these requirements mean for you as an APRN.
Georgia APRNs must have a specific, written, and immediately available agreement. This document needs to be prepared by an "APHCP," meaning "advanced practice healthcare provider," which includes any psychiatrist, nurse, pharmacist, or physician’s assistant certified to provide direct patient care, and signed by both the APHCP and the approving/advising/consulting MD or DO. In addition, the APRN must file a copy of this agreement with the relevant board.
In order to satisfy this agreement, the APRN must demonstrate "sufficient access to" the approved physician. This means the APRN should have the ability to obtain the physician’s online or phone consultation at any time if necessary. Meanwhile, the approved physician must have sufficient access to the APRN.
What are the components of a protocol agreement?
A Georgia APRN Protocol Agreement is among the essential documents the Georgia composite state board of medical examiners or the Georgia composite state board of nursing will require to issue a Georgia nursing license to an advance practice registered nurse (APRN). The Protocol Agreement must meet the requirements set forth in the APRN Practice Act, O.C.G.A. § 43-26-3, and the Board’s Rules, Ga. Comp. R. & Regs 410-11-.01 through .12. In the Protocol Agreement, the APRN identifies his or her "Protocol or Supervising Physician," who is a M.D. or a D.O., and who must maintain an unrestricted Georgia license in good standing at all times. The APRN may identify more than one Physician on the agreement if they have more than one supervising physician. If there is a change in the supervising physician, a copy of the Protocol Agreement, showing the new physician, must be provided to the Board. The supervising physician must have a form of collaborative agreement with Georgia APRN assuring the physician possesses special qualifications in the area of the APRN’s advanced practice and/or necessary training for the APRN to practice. Over time, this has opened the door to allow physicians with limited or no clinical practice involving the APRN’s specialty to serve as the APRN’s supervisory physician. The APRN must provide evidence to show that he or she possesses the skills and educational background to work with the physician’s patients. The APRN must have completed at least five hundred (500) hours of coursework or equivalent experience in the same area of specialization. Otherwise, the APRN must have at least one year of full-time experience with a physician licensed to practice medicine in Georgia with expertise or specialized training in the area of advanced practice. The APRN Supervisor may require additional supervision, collaboration, training, and/or education. The Protocol Agreement delineates specific tasks to be performed by the APRN and the supervising physician. Generally, the APRN is responsible for the day-to-day care of the physician’s patients under the physician’s occasional supervision. However, the signature of the supervising physician on an APRN’s patient charts or files is a conscious signature with the express purpose of attesting to the contents and accuracy of the information, treatment and procedures contained in the patient chart. Thus, although the physician may not review the patient’s entire chart, if his signature is found on the chart, the physician will be held responsible for the information and treatment therein. Any attempts to avoid liability or responsibility through the use of "countersignatures" on patient charts will not work. APRN protocols must authorize the APRN to work with patients with various degrees of illness and at various stages of maturity. They usually do so by identifying specific tasks that may be performed by the APRN. For example, the APRN may not be authorized to perform care or treatment for terminally ill patients or for babies less than six months of age. At all times, the APRN must practice within his or her scope of practice and may not treat patients outside of their specialty for which they have received the necessary education or training. And, the APRN must consult the supervising physician under certain circumstances, including if the APRN believes the patient’s condition requires treatment beyond the APRN’s capacity. The APRN and his/her Delegates must have current CPR, ACLS, BLS or PALS certification. At all times, the APRN and the physician must remain in geographic proximity for supervision, collaboration and/or consultation.
How does an agreement get put into effect?
In Georgia, all protocol agreements must contain certain information. The Georgia Board of Nursing protocol agreement rule (Georgia Board of Nursing, Rule 410-11-.03, Form and Content of a Protocol Agreement) provides that a protocol agreement must: (a) Set forth the name of the physician or dentists; (b) Specify the types of drugs or devices that may be prescribed and contain adequate instructions for their use(1); and (c) Identify the general type of supervision to be exercised by the physician or dentist.
This GBN rule essentially accompanies Georgia Code Section 43-34-23.2(d), which requires protocol agreements to "specify the delegate’s level of supervision, access to the delegating physician’s or dentist’s advice and consultation, the types of drugs that may be prescribed, and any other appropriate information."
In addition to complying with the statute and the GBN rule, APRNs should also be aware of the following guidelines:
The protocols should also address: What are the standard values and parameters for the patient condition being treated? Are there reported case studies or published papers about the condition which provides a guideline on treatment parameters for this protocol agreement? What are the requirements or clinical indications for referral to the physician or dentist? What are the requirements for referral or consultation for specialty care? What are the consulting and referral indications? Are all indications of referral clearly stated in the protocol agreement? Is the protocol specific enough to cover all reasonable instances that would occur considering the disease process and settings in which the protocol will be used? Have the physician and nurse practitioner/nurse midwife discussed and agreed on the roles of each in the protocol agreement? Are there any limitations or restrictions placed on the nurse practitioner referring, admitting or discharging a patient to a hospital? Are there any special circumstances that address the referral of the patient to a specialist? Are there any circumstances where the nurse practitioner/nurse midwife and the physician will need to co-manage the patient’s care? Are there any circumstances in which the nurse practitioner/nurse midwife will co-sign a physician’s order? Have both parties discussed the medical record requirements for patients presenting with the condition being treated?
In addition, it is helpful for the two parties entering into the agreement to discuss their expectations. It would be very helpful for the nurse practitioner to provide the physician or dentist with a list of referrals that the nurse practitioner is currently making to other referral sources, hospitals or emergency departments. In addition, it is important to talk about what the standard values and parameters are for the patient condition being treated, whether there are any published case studies or papers that provide a guideline on treatment parameters for the protocol agreement and whether there are any indications for referral for specialty care. Have both parties discussed and agreed on their role in the protocol agreement? Are there any limitations or restrictions placed on the nurse practitioner referring, admitting or discharging a patient to a hospital? Are there circumstances that address the nurse practitioner referring the patient to a specialist? Are there circumstances in which the nurse practitioner will co-sign a physician’s order? Have both parties discussed the medical record requirements for patients presenting with the condition being treated? Lastly, the protocol agreement has to be signed and dated by the physician and nurse practitioner/nurse midwife. Both signatures should be witnessed by a third party.
Finally, it is always best to keep careful notes of the discussions regarding protocol agreement(s) with each party and retain these notes in the APRN’s confidential file. This will serve as documentation of the discussions and the protocol agreement that was mutually agreed to between the physician/physician group and the APRN In addition, both parties will want to be mindful that protocol agreement(s) must be updated annually, as the GBN rule requires protocol agreements to be reviewed and revised as necessary at least every year.
Benefits and burdens related to protocol agreements
Benefits and challenges of protocol agreements for APRNs
Navigating the complexities of GA APRN protocol agreements can be both rewarding and challenging. The overwhelming benefit lies in the ability of the APRN to more fully exercise the extensive knowledge and skills he or she has spent years accumulating through higher-level education and clinical practice. Protocol authorizations result in increased autonomy, increased physician support, improved safety and quality of care, and an enhanced ability to deliver better healthcare services to the public. In short, protocol authorizations ensure timely and consistent access to healthcare by allowing APRNs to practice to the fullest extent of their education and clinical training .
While the renewals for these protocols are streamlined, the initial approval and establishment of a new protocol can be time-consuming. Practitioners must complete the development of the protocol and enter the online eNotarization process, which will then be approved by the State Office of Regulatory Services department. This process may take several weeks. Although delays in the process are not uncommon, it is important for practitioners to have a plan for handling such delays and document and explain to their clients why there may be a delay in service. It is also necessary to maintain open channels of communication as such delays occur.
APRN Protocol FAQ
What are the revisions required for a GA APRN protocol agreement?
AS A REMINDER, revisions are as follows:
- Verify that all required signatures are present on the protocol agreement.
- Add the date of the protocol agreement.
- Indicate jurisdiction of the NP’s home state in the agreement.
- Obligations of the physician and APRN must be indicated in the agreement.
- The APRN may prescribe any drug in the approved formulary as permitted by the APRN’s specialty certification and advanced practice registered nursing role with an established medical protocol to do so.
- State whether or not the Georgia APRN must have a specialty certification in pediatrics to prescribe retardant diphenhydramine to a child.
- State if the APRN has the ability to provide physical therapy services.
- Indicate that deliberation between the physician and the APRN is not required prior to issuing new orders with respect to a previously issued order for a surgical procedure. If the physician decides to retract or not to issue a specific order for a surgical service, that decision should be made after deliberation with the requesting APRN.
- Include approval to refer patients to a physical therapist.
- Indicate that the physician should consult with the APRN prior to issuing a written order for the transfer of a patient to another physician.
- Include special conditions related to the use of weight loss medications.
- Indicate that a Georgia APRN may prescribe Schedule II controlled substances only during an inpatient hospitalization setting and only in settings deemed appropriate by the Georgia Composite Medical Board.
- Indicate that a Georgia APRN maintains the authority to prescribe certain non-scheduled substances.
- Include special conditions related to prescribing buprenorphine containing products for the treatment of opioid addiction.
- Include proficiency in cardiac and advanced cardiac life support practices.
- Include special conditions related to treating chronic venous insufficiency.
- Include an acknowledgement that the new agreed upon protocol agreement does not alter or affect the status of any applications for renewal or reinstatement of Georgia APRN and designation as an APRN or prescribing authority.
So what happens if an APRN protocol agreement is terminated?
AS A REMINDER, upon termination of any protocol agreement, the APRN will have six (6) months to arrange a new protocol agreement with a new supervising physician in order to maintain an active APRN license and designation as an APRN with the GeorgiaNP/PA/AA Composite State Board. If an APRN cannot find a new protocol agreement with another supervisory physician within six (6) months, the APRN’s APRN license will lapse and the designation as an APRN will be inactivated.
What happens if there is a dispute between my Georgia APRN and physician supervising physician?
In the event of a dispute with your supervising physician, the matter should be thoroughly discussed in person or by telephone, with any pertinent records reviewed and the colleague involved invited to give their views. If you and your supervising physician cannot resolve the dispute after a mutually accepted period of time, then the dispute shall be submitted to the Office-Based Adjudication Panel of the GeorgiaNP/PA/AA Composite State Board. You may need to postpone the date of any written orders until the dispute has been resolved. Patients must be informed of the dispute.
Will I get a copy of the original and revised protocol agreement for my files after it is approved by the Board?
No. If the protocol is approved, the Board will only provide its written approval of the Board approved protocol agreement.
The future for APRN protocols in Georgia
In the next few years, we will see the introduction of bills that will expand the privileges of APRNs to practice in greater capacity, with as little oversight as possible. Nurse practitioners are seeking autonomy in their scopes of practice, with the least amount of supervision by physicians. Nurse practitioners, along with other advanced practice registered nurses, plan to introduce a bill to the Georgia General Assembly that would allow APRNs more autonomy within their scopes of practice.
Currently, the Georgia Association of Nurse Practitioners is advocating for an advanced practice registered nurse to be able to work independently, without the oversight of a physician. To date, the GANP has garnered support from the Georgia House of Representatives, including from Speaker David Ralston of Blue Ridge, Governor Nathan Deal, House Minority Leader Stacey Abrams of Atlanta, and Senate President Pro Tem David Shafer of Duluth.
As phrased in their public position statement, nurse practitioners want "physician supervision replaced with a collaborative relationship between the nurse practitioner and the physician." The gist of this post is to help you avoid some of the legal pitfalls related to this attempt in Georgia to achieve what other states have achieved — some APRNs working independently without a supervisory or collaborative physician.
Georgia APRNs should know that any legislation related to APRN protocol agreements will not change the current law. No matter what happens with the Georgia Assembly , APRNs with our without autonomy are still required by Georgia law to enter into a protocol agreement with a supervisory physician. This includes certified registered nurse anesthetists, certified nurse midwives, nurse practitioners, and clinical nurse specialists.
In order to cover all the bases related to protocol agreements and their future, I have decided to take a three-part approach to this series of blog posts on APRN protocol agreements. Here is the first category, those who should enter into APRN protocol agreements — APRNs in Georgia that are subject to the current law and individuals looking to enter into protocol agreements with APRNs. Here is the second category, those who are exempt from APRN protocol agreements — APRNs in Georgia that are exempt under the current law from entering into protocol agreements. Because supervised APRNs are currently required to enter into a protocol agreement with a supervisory physician, the third category is one that only exists for the purposes of this series of posts.