Advanced-Practice Nurses Can’t Keep Power on for At-Risk Patients

Andrew Kitchenman | July 25, 2013 | Health Care
Doctors see expansion of scope of practice in APN's request for authority to stop utilities from shutting off electricity in medical emergencies

Meshell Mansor and other advanced-practice nurses -- also known as nurse practitioners -- want the same authority as doctors to prevent utilities from being shut off if doing so would pose a threat to their patient’s health.
Nurses who serve as primary-care providers for patients who rely on electricity to run respiratory machines and other equipment are concerned that they don’t have the authority to prevent that power from being shut off.

Advanced-practice nurses — also known as nurse practitioners — don’t have the same authority as doctors to prevent utilities from being shut off if doing so would pose a threat to a patient’s health.

They argue this rule puts patients’ lives at risk.

“It’s a major issue, especially for my patients because we don’t have a physician with the group,” said Meshell Mansor, an APN who said she was able to sign the orders to prevent utility shutoffs from 2005 to 2011, when the state Board of Public Utilities informed her that only doctors could sign such orders.

Nurses’ advocacy for widening the authority to sign these orders puts them on a collision course with family doctors, who have been concerned about the expansion of APN’s scope of practice.

“The BPU’s medical emergency exception is about ensuring the continuity of home-based healthcare for patients and should not be about any individual health professions’ interest to expand their scope of practice,” said Claudine Leone, director of government affairs for the New Jersey Academy of Family Physicians.

Primary-care doctors and APNs have been lobbying legislators and state officials over a separate bill that would allow APNs to prescribe medication without requiring joint protocol agreements with doctors. APNs argue that they fill a vital need for primary care, while doctors believe that expanding the APNs’ scope of practice would adversely affect the quality of care.

New Jersey State Nurses Association President Patricia Barnett rejected Leone’s contention that the APNs’ request to prevent power shutoffs has anything to do with the scope-of-practice debate.

“They’re basically saying if we can’t control you, then you can’t have this protection,” Barnett said, adding that only 40 percent of state doctors accept the Medicaid patients who are most likely to face utilities being disconnected.

“These are patients who have chosen their primary-care providers, who are practicing within their scope of practice,” Barnett said.

Mansor’s practice, which covers Cumberland, Salem, Gloucester, and Camden counties, has three full-time and three part-time APNs. She makes home visits for patients, adding that doctors aren’t visiting these patients’ homes. While she has a joint protocol agreement with a doctor that allows her to prescribe medication, the state regulations don’t allow a doctor to cosign her certifications that patients shouldn’t lose their utilities if they can’t pay.

She said her patients rely on nebulizers and other breathing equipment for conditions ranging from congestive heart failure to sleep apnea. She said she has had to send patients to the emergency room when they lost power in the past.

“A medical emergency can be avoided if their electricity isn’t shut off,” she said.

Along with patients who lose power due to not paying bills, other patients are at risk from power outages, Mansor noted.

“I can’t see why they would oppose an issue regarding patients’ health,” she said of doctors concerned about the nurses’ request to change the regulation.

Margie Neil, a Williamstown resident and caretaker for two uncles who rely on nebulizers, is concerned about the limits on APNs. While she is not worried about her family’s ability to pay for power at the farm where she and her uncles live, she is concerned about the loss of power during storms. Mansor is her uncles’ primary-care provider.

“These are people who don’t go out to the doctor’s offices, these are the people who need someone to come out to the home to care for them,” she said.

Neil doesn’t understand why APNs can’t sign the paperwork.

“It’s an electrical system — it’s not like they’re going to do surgery,” she said of scope-of-practice concerns. “It just doesn’t make sense that they couldn’t take care of their patient.”

Leone said care teams that include doctors should handle the issue.

“The NJAFP maintains that a patient’s healthcare needs are best managed by an entire team of healthcare professionals working together and strongly supports regulations that protect a patient’s ability to receive uninterrupted essential medical care in their home and encourages the utilization of healthcare teams to ensure the best possible outcomes for patients,” she said in a statement.

She also said that doctors should be informed if the BPU is investigating cases in which the regulation has been a barrier to a patient’s continuity of care.

Barnett said BPU officials initially responded positively to the nurses’ request for a change in the rule. But she said BPU officials later told her that BPU commissioners were concerned after having spoken with doctors. The issue was referred to the state Board of Medical Examiners. The minutes of that board’s open public sessions don’t reflect any discussion of the issue.

Barnett said BPU officials haven’t responded to her inquiries about the issue since October of last year. A request for comment to a BPU spokesman wasn’t returned yesterday.

Barnett hopes that public attention on the issue will prompt action.

“We’re just asking them to keep the electricity on, more or less,” she said. “It’s a problem for patients. It’s a problem for nurses.”