Back

College of Respiratory
Therapists of Ontario

 

ORDERS FOR MEDICAL CARE

Professional Practice Guideline

 

 

October 2024

  PROFESSIONAL PRACTICE GUIDELINE

College of Respiratory Therapists of Ontario (CRTO) publications contain practice parameters and standards that should be considered by all Ontario Respiratory Therapists in the care of their patients/clients and in the practice of the profession. CRTO publications are developed in consultation with professional practice leaders and describe current professional expectations. It is important to note that these CRTO publications may be used by the CRTO or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

It is important to note that employers may have policies related to orders for medical care. If an employer’s policies are more restrictive than the CRTO’s expectations, the RT must abide by the employer’s policies. Where an employer’s policies are more permissive than the expectations of the CRTO, the RT must adhere to the expectations of the CRTO.

RETURN TO THE CRTO WEBSITE

QUESTIONS OR FEEDBACK?

    This Professional Practice Guideline will be updated as new evidence emerges or as practice evolves. Comments on this guideline are welcome and should be addressed to:
    College of Respiratory Therapists of Ontario, 90 Adelaide Street West, Suite 300, Toronto, Ontario M5H 3V9
    Phone 416-591-7800 | Toll Free 1-800-261-0528 | Fax 416-591-7890 | E-mail questions@crto.on.ca

    INTRODUCTION

    The College of Respiratory Therapists of Ontario (CRTO), through its administration of the Regulated Health Professions Act (RHPA) and the Respiratory Therapy Act (RTA), is dedicated to ensuring that respiratory care services provided to the public by its Members are delivered in a safe and ethical manner.

    This Orders for Medical Care Professional Practice Guideline was developed by the CRTO to serve both the interest of the public and RTs, by ensuring that healthcare providers who perform procedures involving controlled acts are authorized to do so in accordance with the legislation, regulations, policies, and guidelines that govern their practice.

    Healthcare professionals, such as RTs, are permitted to perform certain, specific tasks via the following authorizing mechanisms:

    9

    Controlled acts authorized by profession-specific legislation (e.g., RTA);

    9

    Exceptions permitted by the RHPA;

    9

    Delegation of Controlled Acts; and

    9

    Public Domain.

    Controlled Acts

    1. Controlled Acts Authorized to RTs

    Under section 4 of the RTA, Members of the CRTO are authorized to perform five controlled acts1:

    9
    1.  Performing a prescribed procedure below the dermis
    9
    2.  Intubation beyond the point in the nasal passages where they normally narrow or beyond the larynx
    9
    3.  Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx
    9
    4.  Administering a substance by injection or inhalation
    9

    5.  Administering a prescribed substance by inhalation2.

    In addition, under the Controlled Acts Regulation, Members of the CRTO are authorized to perform3:

    9
    Diagnostic ultrasound (s. 7.1)
    9
    Tracheostomy tube change (s. 14).

    1 Subject to any terms, conditions and limitations imposed on their certificate of registration.

    2 This authorized act refers to the independent initiation, titration, and discontinuation of oxygen without the requirement of an order.

    3 Subject to any terms, conditions and limitations imposed on their certificate of registration.

    2. Orders for Controlled Acts

    The RTA requires an order from an authorized prescriber for all controlled acts authorized to RTs, regardless of the practice setting except for:

    9

    Authorized Act #3 – Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx; and

    9

    Authorized Act #5 – Administering a prescribed substance by inhalation.

    However, a regulation under the Public Hospitals Act (O. Reg. 965, Hospital Management) requires an order for every treatment or diagnostic procedure. Therefore, authorized act #3 requires an order in a public hospital setting, and authorized act #5 can only be performed by a Registered Respiratory Therapist (RRT) and Respiratory Therapist (Emergency) [RT(E)] outside of a public hospital setting.

    Authorized Acts #1, 2, and 4 may only be performed upon receipt of a valid order from a Member of one of the following health regulatory bodies:

    9
    the College of Physicians and Surgeons of Ontario or an out-of-province physician
    9
    the College of Midwives of Ontario
    9

    the Royal College of Dental Surgeons of Ontario; or

    9

    the College of Nurses of Ontario – provided the healthcare professional holds a Certificate of Registration in the Extended Class (RN[EC])4 (Nurse Practitioner) or is an out-of-province registered nurse in the Extended Class.

    4 RNs(EC), commonly referred to as Nurse Practitioners, have the authority to order a defined list of medications, diagnostic and laboratory tests. To view an updated version of this list, please visit the College of Nurses of Ontario website at CNO – Nurse Practitioners.

    Diagnostic ultrasound can only be performed upon receipt of a valid order from a Member of:
    9
    the College of Physicians and Surgeons of Ontario or an out-of-province physician
    9

    the College of Nurses of Ontario – provided the healthcare professional holds a certificate of registration in the Extended Class (RN[EC])5 or is an out-of-province registered nurse in the Extended Class.

    Tracheostomy tube changes can only be performed upon receipt of a valid order from a Member of:
    9

    the College of Physicians and Surgeons of Ontario or an out-of-province physician

    9
    the College of Midwives of Ontario
    9
    the Royal College of Dental Surgeons of Ontario
    9

    the College of Nurses of Ontario – provided the healthcare professional holds a certificate of registration in the Extended Class (RN[EC])6 or is an out-of-province registered nurse in the Extended Class.

    The Integrated Community Health Services Centres Act (and the regulations made under the Act) may impact the ordering of a diagnostic or therapeutic procedure, depending on the practice setting.

    5 6RNs(EC), commonly referred to as Nurse Practitioners, have the authority to order a defined list of medications, diagnostic and laboratory tests. To view an updated version of this list, please visit the College of Nurses of Ontario website at CNO – Nurse Practitioners.

    3. Delegation of Controlled Acts

    Delegation is the transfer of legal authority to perform a controlled act (by a regulated healthcare professional) to a person not authorized to perform that controlled act (regulated or non-regulated healthcare professional). It is important to note that delegation is a formal process that is procedure-specific and may also be specific to:
    9

    an individual patient/client;

    9

    a specific patient/client population;

    9

    a specific situation;

    9

    a specific health care provider, and/or;

    9

    groups of patient/client populations or health care providers.

    For more information on the delegation process, please review the CRTO Delegation of Controlled Acts Professional Practice Guideline.

    PLEASE NOTE:

    It is the CRTO’s position that there is no provision in the RHPA to allow a physician or any other regulated healthcare professional to delegate the ordering of a controlled act.

    RHPA Exceptions and Public Domain

    4. Exceptions within the RHPA

    Section 29(1) of the RHPA permits healthcare professionals (regulated and non-regulated) as well as others (e.g., family members, unpaid care providers) to perform certain controlled acts under the following specific conditions:

    9

    rendering first aid or temporary assistance in an emergency;

    9

    fulfilling the requirements to become a member of a health profession and the act is within the scope of practice of the profession and is done under the supervision or direction of a member of the profession;

    9
    treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment;
    9
    treating a member of the person’s household and the act is a controlled act set out in paragraph 1, 5 or 6 of subsection 27 (2); or
    9
    assisting a person with his or her routine activities of living and the act is a controlled act set out in paragraph 5 or 6 of subsection 27 (2).
    Controlled Acts – Paragraphs 1, 5 & 6 in s.27 of the RHPA
    1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
    1. Administering a substance by injection or inhalation.
    1. Putting an instrument, hand or finger,

    i.    beyond the external ear canal,

    ii.   beyond the point in the nasal passages where they normally narrow,

    iii.  beyond the larynx,

    iv.  beyond the opening of the urethra,

    v.   beyond the labia majora,

    vi.  beyond the anal verge, or

    vii. into an artificial opening into the body.

    5. Acts within the Public Domain

    If the activity is not a controlled act, it is within the public domain and may be performed by any care provider, whether they are a regulated or non-regulated healthcare professional. Administering oral medications is an example of a task that is within the public domain. The expectation for an RT performing an intervention within the public domain is that they are competent to do so and act in the best interest of the patient/client(s).

    PLEASE NOTE:

    The Health Care Consent Act also supports intervention in emergencies by removing the usual requirement for consent in most circumstances.

    Forms of a Valid Order

    6. Forms of a Valid Order

    An order is a direction from a regulated healthcare professional with legislative ordering authority (e.g., physicians, registered nurses in the extended class, dentists, midwives) that permits the performance of a procedure by another healthcare professional (regulated and non-regulated).

    There are two forms of a valid order:

    6.1. Direct Orders

    A direct order is one that is authorized by an individual prescriber at the time care is to be delivered for a specific patient/client for a specific treatment or intervention. The date and time that the intervention should occur may also be specified in a direct order. Note, the intervention does not have to happen at the time of the order, depending on the nature of the act (for example, an order for a CT scan that may take six months to be performed).

    A direct order may be written in the patient/client’s medical records7:, or maybe in the form of prescriptions or requisitions, and should include the following information:

    9

    when the order is given (i.e., date, time);

    9

    who the order is for (i.e., patient/client identification);

    9

    who the prescriber is – accompanied by the prescriber’s signature; and,

    9

    details of the intervention (e.g., treatment/procedure to be undertaken, when the order is to be carried out, dose/frequency/mode of administration, etc.)

    Controlled substances require a direct order for administration by an RT.

    Example…

    Patient: Mr. Brown

    Jan.1/19 (1000) – RT to administer 4 puffs of Salbutamol (100 mcg/puff) QID.

    Signed: Dr. One

    7 Direct orders may be given in writing, electronically and verbally. Please review the sections in this document entitled Verbal Orders and Electronic Orders.

    PLEASE NOTE:

    An RT-driven protocol is a type of direct order. These protocols outline a pre-designed plan of care to be delivered to a specific patient; often with the use of an algorithm to guide the RT’s decision-making processes (e.g., Ventilation-Weaning Protocol).

    An Order Set (either in a paper-based or digital format) can be used to implement a direct order, provided it contains all the necessary information (e.g., patient identifiers, name of authorizer, etc.).

    6.2. Medical Directives

    A medical directive is an order that is authorized in advance by either an individual prescriber or a group of prescribers for a specified range of patients who meet specific conditions.

    A properly constructed medical directive must include the following:

    9

    the name and description of the procedure, treatment or intervention being ordered;

    9

    the recipient patients/clients;

    9

    the authorized implementer(s) who are permitted to release the medical directive and either:

    9

    perform the intervention themselves; or

    9

    request that a co-implementer perform the intervention.

    9

    indications and contraindications8 (e.g., Indications – Signs and symptoms of respiratory distress associated with bronchospasm)

    9

    any educational requirements required (e.g., only Respiratory Therapists who work in a certain area and have advanced certification or have completed continuing education, etc.);

    9

    the physician(s) or other health care professional authorizing the medical directive;

    9

    a list of administrative approvals from the facility with dates and signatures; and

    9

    all relevant appendices attached to the medical directive.

    8 May attach an appendix that provides a detailed outline.

    Example…

    All RNs on a paediatric unit may be listed as the implementer of a medical directive for bronchodilator administration, and all the RTs in the hospital may be listed as the co-implementers. When the RN feels that a patient/client meets the criteria outlined in the medical directive, they may contact the RT and ask that the medical directive be implemented. The RT would then perform their own assessment and if they agreed that the patient/client meets the criteria, they can administer the bronchodilator.

    PLEASE NOTE:

    To be a valid order, a medical directive must be signed by at least one authorized prescriber (e.g., physician). However, employers often have policies regarding who must sign a medical directive. For example, an employer can stipulate that the Chief of Emergency Medicine must sign all ER directives on behalf of the entire department, or they may require signatures from all physicians whose patients will be impacted by the directive.

    Sample Medical Directive

    7. Sample Medical Directive

    Title: Bronchodilator Administration

    Number: 123-456

    Activation Date: Jan. 1, 2024

    Review due by: 2021

    Sponsoring/Contact Person(s):
    (name, position, contact particulars)

    Director of Cardiorespiratory Services
    Chief of Paediatrics
    Chief of Emergency Medicine
    Chief of General Internal Medicine
    Order:

    Appendix Attached: No
    Title:

    Administration of Salbutamol Sulfate via meter dose inhaler (MDI) and aerochamber or small volume nebulizer (SVN).
    Recipient Patients:

    Appendix Attached: No
    Title:

    Any inpatient. Also, any patient receiving services in the Emergency Department or in an outpatient clinic.
    Adult: 18 years of age and older
    Paediatric: 1 to 18 years of age
    Neonate/Infant: birth to 1 year of age
    Authorized Implementers:

    Appendix Attached: No
    Title:

    All RRTs in this organization. RT(E)s, and GRTs may also implement this directive provided they do so under the general supervision of another regulated healthcare professional.
    Indications:

    Appendix Attached: Yes
    Title: Indications

    Signs and symptoms of respiratory distress with bronchospasm.

    Contraindications:
    Known allergy to Salbutamol Sulfate.
    Patient/Substitute Decision Maker (SDM) does not consent

    Consent:
    Appendix Attached: Yes
    Title: Consent Policy

    All RRTs, RT(E)s and GRTs implementing this medical directive will first obtain informed consent from the patient/SDM in accordance with this organization’s Consent Policy, the CRTO’s Standards of Practice and the Health Care Consent Act.

    Guidelines for Implementing the Order:
    Appendix Attached: Yes
    Title: Dosage Chart

    The RRT/RT(E)s/GRT will:

    1. Perform respiratory assessment pre-treatment and determine if bronchodilator administration is necessary.
    2. Administer the bronchodilator in accordance with the attached dosage chart.
    3. Assess the patient’s response to treatment.
    4. Document in patient medical record and inform Most Responsible Physician (MRP) if the patient requires any further intervention(s).
    Documentation and Communication:

    Appendix Attached: No
    Title:

    Documentation should include:

    1. Date and time of administration.
    2. Dosage of bronchodilator given.
    3. Results of pre and post respiratory assessment.
    4. Name and number of the medical directive (e.g., “As per Bronchodilator Administration Medical Directive # 123-456”).
    Review & Quality Monitoring Guidelines:

    Appendix Attached: No
    Title:

    MRPs, RRTs/RT(E)s/GRTs, and RNs will monitor patients for any unintended outcomes arising from the implementation of this medical directive.

    Administrative Approval (as applicable):

    Appendix Attached: Yes
    Title: MAC approval letter
    Medical Advisory Committee (approved December 12, 2018)
    Approving Physician(s)/Authorizer(s):

    Appendix Attached: No
    Title: 

    Dr. One – Chief of Paediatrics

    Dr. Two – Chief of Emergency Medicine

    Dr. Three – Chief of General Internal Medicine

    PLEASE NOTE:

    The Health Profession Regulators of Ontario has developed templates for both medical directives and medical directive/delegation combined.

    The Difference between a Medical Directive & Delegation

    8. The Difference Between a Medical Directive & Delegation

    It is important to understand that Medical Directives and Delegation are two completely different processes. Delegation is the transfer of legal authority (from a healthcare professional who has the authority to perform a controlled act to an individual not authorized to perform the controlled act, whereas a Medical Directive is a type of order.

    As outlined previously, there are two types of orders:

    9

    1.  A Direct Order (naming an individual patient)

    9

    2.  A Medical Directive (for a broad group/type of patient)

    The flowchart below may help you determine whether an order or both an order and delegation is required.

    Does the task fall under a controlled act authorized to RTs?

    Yes

    No

    An Order is required

    An Order is required

    Delegation is also required

    Verbal & Electronic Orders

    9. Verbal Orders

    It is acceptable for an RT to accept a verbal order received in-person or by telephone, provided the order is:

    9

    received directly from the prescriber and not their designate; unless the designate is another regulated health professional;

    9

    transcribed into the patient’s medical record by the regulated healthcare professional who received the order with a notation that it was a verbal order; and,

    9

    signed by the prescriber within a reasonable amount of time.

    PLEASE NOTE:

    You may wish to have a verbal order heard and co-signed by another regulated healthcare professional.

    10. Electronic Orders

    Electronic ordering, or e-ordering, refers to medical orders that are transmitted from the prescriber via an electronic format (e.g., electronic medical record).

    RTs are permitted to accept electronic orders, provided that the:

    9

    order meets all the requirements of a valid order;

    9

    method of transmission of the e-order is secure to ensure the privacy and confidentiality of the patient/client’s personal health information; and,

    9

    digital or electronic signature generated can be authenticated.

    RT Responsibilities Related to Orders and Disagreement with an Order

    11. RT Responsibilities Related to Orders

    Whether performing an act authorized to Respiratory Therapists under delegation, via an exception or within the public domain, RTs must consider:

    9

    the professional Scope of Practice of Respiratory Therapy;

    9

    their own personal scope of practice (i.e., competency);

    9

    their practice setting (i.e., hospital, community setting) and the policies in that practice setting;

    9

    whether they are authorized to perform the ordered intervention (e.g., not prevented due to terms, conditions, and limitations on their certificate of registration);

    9

    whether implementation of the order is in the best interest of the patient/client; and

    9
    other relevant legislation (e.g., Public Hospitals Act, Integrated Community Health Services Centres Act.).

    12. Disagreement with an Order

    If an RT receives an order for an intervention that, in their professional judgment, is not in the best interests of the patient/client, then they must not implement the order and make every possible attempt to contact the prescriber to discuss the order. If, after that discussion, the RT is still convinced that carrying out the order would be detrimental to the patient/client, then they must refuse to implement the order, ensure that the prescriber is informed that the order will not be carried out, and document all details related to their decision.

    For more information regarding documenting a disagreement, please review the CRTO Documentation Professional Practice Guideline.