The authority to delegate is found in Chapter 157 of the Texas Occupations Code, and Title 22 of the Texas Administrative Code, Section 193. A physician is allowed to delegate certain duties to a qualified and properly trained person acting under the physician’s supervision:

1) if in the opinion of the delegating physician the act can be properly and safely performed by the person to whom the medical act is delegated;
2) the act is performed in its customary manner; and
3) the performance of the act by the delegate is not in violation of any other statute.

It is clear that AAs can be delegated certain tasks under Chapter 157. The question is the extent allowable of such delegation. The key provision that needs to be examined is likely “not in violation of any other statute.”

Although the Nursing Act describes what a CRNA can do in regard to anesthesia, there is overlap of regulation of CRNAs between the Medical Board and Nursing Board. CRNAs are subject to physician delegation under the Medical Practice Act. The delegating physician can limit what a CRNA is allowed to provide under a Prescriptive Authority Agreement (PAA) or Standing Order, despite what may be allowed under Nursing Board rules and regulations.

The level of supervision required for any AA (or any delegated provider) is determined based on training, knowledge, and experience, as determined by the physician. For CRNAs, whether any level of physician supervision is required will depend upon those same factors, in addition to applicable federal and state statutes, regulations, bylaws, and ethical standards, if any. However, AAs and CRNAs cannot practice independently and require physician delegation. A hospital or facility can set their own standards, policies, etc., related to delegation and supervision as long as it does not violate Chapter 157, board rules, or other applicable federal and state statutes and regulations. Although AAs most commonly work under an anesthesiologist physician, any physician may supervise and delegate to AAs; however, the standard of care must be met and the delegating physician remains responsible for the AA’s actions.

One difference between an AA and CRNA is the ability to order and prescribe dangerous and controlled substances to patients for anesthesia and anesthesia-related services. Under section 157.058, a CRNA pursuant to the physician’s order and in accordance with facility policies or bylaws may select, obtain, and administer those drugs appropriate to accomplish the order. The physician’s order for anesthesia or anesthesia-related services is not required to specify a drug, dose, or administration technique.

As previously stated, the Nursing Act describes what a CRNA can do in regard to anesthesia. However, the delegating physician or facility can limit what a CRNA is allowed to provide under a PAA or Standing Order, despite what may be allowed under Nursing Board rules and regulations.

While AAs are not allowed to select drugs, determine dose, or administration technique for anesthesia or anesthesia-related services without specification by the supervising physician through an order, they perform many of the other same key duties performed by CRNAs. These duties include conducting preoperative physical exams, administering medications, evaluating and responding to life-threatening situations, setting up external and internal monitors, and implementing general and site-specific anesthetic techniques.

Another area of concern relates to handing-off patient care from CRNAs to AAs. RNs have the authority to delegate certain nursing tasks to unlicensed individuals; however, a CRNA and AA do not have any specific delegation authority concerning anesthesia tasks. A physician has the authority to delegate the process of anesthesia-related patient care, including the transfer or hand-off of care from a CRNA to an AA through an order (standing or patient-specific) or protocol. A CRNA or AA cannot set-up or independently delegate a hand-off or step-down process.

While the Nursing Act places responsibility for patient hand-off on a CRNA, if the physician orders a hand-off process from CRNA to AA, and this is memorialized in orders, protocols, etc., then the CRNA does not have the authority to determine the AA is not competent. The reason is that the physician has already made the determination of competency under Chapter 157.001.

Because the CRNA’s authority also arises through the delegating physician, and is not independent of that physician, a CRNA cannot override a physician Order related to this hand-off scenario. If this hand-off became an issue, the CRNA would have a defense (absolute) because the physician has already determined the competency of the AA to accept this patient. 

Registering a supervising physician for an NCT will no longer be required.  However, an NCT will still need to obtain and maintain placement on the MRT Board’s general registry, or have an approved a hardship exemption, prior to starting practice.  

You can register a new supervising physician through the Online Supervisions and Prescriptive Delegation Registration System. Please note that this is a 2 step process and that the supervising physician must complete the registration.

The addition of a new supervising physician does not terminate any other supervision that is currently in place. Any current supervising physician relationship can be terminated using the Online Supervisions and Prescriptive Delegation Registration System.

Yes, the PAs supervising physician must delegate prescriptive authority allowing a PA to sign prescriptions for controlled substances, also called scheduled drugs, as well as Dangerous Drugs. However, PA's are generally limited to Schedules III – V (Schedule IIs are allowed in very limited circumstances). All prescription drugs that are not controlled substances fall into the category of "dangerous drugs." Physician assistants with prescriptive authority must have their own DEA numbers to prescribe controlled substances. In addition, physician assistants must have the name of their current delegating physician authorizing prescriptive authority on file with DEA.

Please note: Under Senate Bill 195, the requirement for controlled substances registration (CSR) with the Texas Department of Public Safety (DPS) was eliminated as of September 1, 2016.

Effective 1/31/2010, registration by physicians of delegated prescriptive authority to PAs or APNs is required.

There is no limit to the number of supervising physicians a PA may have.

Within 30 days of the change or addition. This can be done through the Online Supervisions and Prescriptive Delegation Registration System.

This is done through a log kept at the facility.

Yes, both the anesthesiologist and the physician performing the procedure should be registered for OBA. Statute states that each physician who administers anesthesia or performs a procedure for which anesthesia services are performed in an outpatient setting shall register for OBA and comply with current OBA regulations. Please note, an anesthesiologist who contracts out their services to multiple physicians is not required to register each location where they perform OBA, but only the highest level of OBA services that they provide.

Yes. Physicians need to complete at least 24 hours of continuing medical education each year, at least half of which must be in formal courses. One hour of formal CME must be in medical ethics and/or professional responsibility. A physician must report on the registration form if she or he has completed the required CME. However, newly licensed physicians are exempt from the CME requirements the first time they register.

Yes. A physician on an official retired status is exempt from the registration fee. To be eligible for retired status, a physician's license cannot be under investigation, under a Board order, or be otherwise restricted. Physicians on a retired status must not engage in clinical activities or practice in any state, must not prescribe or administer drugs to anyone, nor may the physician possess a DEA or Texas controlled substance number. Additionally, the physician's license may not be endorsed to any state. A physician whose license has been placed on official retired status must obtain the approval of the board before returning to active status. The physician should contact the board for information on the approval procedure.

Not at this time.

Yes. A retired physician whose only clinical practice is the provision of voluntary charity care to indigent populations shall be exempt from the registration fee but must register the license as well as report CME. The physician's practice of medicine must not include the provision of medical services for either direct or indirect compensation which has monetary value of any kind and the physician's practice is limited to voluntary charity care to indigent populations and receives no direct or indirect compensation of any kind for medical services rendered. Also, the physician's practice cannot include the provision of medical services to family members or the self-prescribing of controlled substances or dangerous drugs. A physician who violates the provisions of this exemption may be subject to disciplinary action. Action may be based on unprofessional or dishonorable conduct likely to deceive, defraud, or injure the public if the physician engages in the compensated practice of medicine, provides medical services to members of the physician's family, or self-prescribes controlled substances or dangerous drugs. Additionally, a physician who attempts to obtain this exemption by submitting false or misleading statements shall be subject to disciplinary action pursuant to the Medical Practice Act, in addition to any civil or criminal actions provided for by the state or federal law.

There is no limit to the number of physicians who may delegate prescriptive authority to an APRN or PA provided all requirements for such delegation are met.