CS FOR SENATE BILL NO. 120(HSS) "An Act relating to administration of psychotropic medication to a patient without the patient's informed consent; and providing for an effective date." 9:04:06 AM Vice-Chair Ortiz invited the sponsor and her staff to the table. SENATOR CATHY GIESSEL, SPONSOR, explained that SB 120 related to the administration of psychotropic medications. She emphasized that the legislation was an emergency response bill requested by the Alaska Psychiatric Institute (API). The state had a shortage of psychiatrists which was impacting API. Presently, they had one psychiatrist on staff. The provider was on call 24/7 working long hours. The bill proposed to improve patient safety during those times when the psychiatrist was not present at the hospital and unable to be reached by cell phone at a time when a patient crisis was occurring. Senator Giessel continued that psychotropic drugs were medications prescribed or administered in a psychiatric crisis. The individuals that were hospitalized had very serious psychiatric issues. When a patient had a psychiatric crisis, it was an emergency. The goal was to protect the patient, people around the patient, and staff. Psychotropic medications were administered to help a patient calm down. She listed several of the medications used. Only one of the drugs was a controlled substance. The rest of them were medications that physician assistants (PA) and advanced practice registered nurses (APRN) could prescribe and administer. However, there was a rule in place requiring that the psychiatrist be consulted before the medication was administered. Senate Bill 120 would authorize the PA or APRN who was with the patient to administer the medication, thereby, calming the patient and protecting the patient and others nearby. Currently, the psychiatrist was the only person that could conduct an initial assessment on a patient and prescribe medication in a crisis. By allowing the APRN or the AP the opportunity to administer needed medication, it would keep everyone much safer. She added that because of API's issues, patients with behavioral health issues often times assault people and end up in jail. The more that could be done to help patients get immediate care to ramp down a crisis situation, the more patients would be protected from a worse environment. Vice-Chair Ortiz relayed the names of available testifiers. 9:09:36 AM JANE CONWAY, STAFF, SENATOR CATHY GIESSEL, explained there were only 2 sections in the bill. She was happy to review them if it was the will of the committee. Vice-Chair Ortiz indicated the committee would move on to questions. 9:09:56 AM Representative LeBon asked if additional training would be necessary for a PA or APRN to administer the medications. Senator Giessel deferred to the representative from API who could better answer the question. She noted that the medications fell within the scope of practice for a PA and APRN. She also pointed out that the practitioners working in the environment at API understood the treatment of the patients with specialized needs. Representative LeBon restated his question about additional training. He wondered if PAs and APRNs would be able to act immediately. Senator Giessel believed so but would to defer to the APRN online. CYNTHIA MONTGOMERY, ADVANCED PRACTICE REGISTERED NURSE, ANCHORAGE, responded that APRNs and PAs that practiced at API were very familiar with the medications that were used in crisis periods. They were often the same medications already prescribed on a daily basis to patients. No additional training would be necessary. 9:12:20 AM Representative Knopp had a question for Dr. Alexander if he was available. He referred to the fifth paragraph in the sponsor statement which read: "The psychiatrist being unfamiliar with the case may decline to prescribe needed medication." He wondered if there was any reason a psychiatrist would not want to have a drug administered. MICHAEL ALEXANDER, DOCTOR, CHIEF OF PSYCHIATRY, ALASKA PSYCHIATRIC INSTITUTE, ANCHORAGE, replied that all of the mid-level practitioners including PAs and APRNs had previously been in a position of prescribing crisis medications. About a year prior it was discovered that the law did not include mid-level practitioners. He continued that when the laws were originally established, mid-level practitioners were not working at API. In 2007, when he was working at API, it was unheard of to have a mid-level provider working at the facility. Mid-level practitioners started working at API in 2010 or 2011. Currently, API had four mid-level providers who had been administering psychotropic drugs for the previous several years until it was discovered that the law prevented them from doing so. Representative Knopp was wondering if there was any scenario in which a patient should not receive the medication. However, it sounded like it was a matter of updating statutes with changing times. Dr. Alexander responded, "That is correct." 9:15:09 AM Representative Josephson asked Dr. Alexander if he thought the bill should read that the mid-level practitioners should be able to provide medication via teleconference. Dr. Alexander responded that traditionally in the past mid-level practitioners had been able to via teleconference. The Alaska Psychiatric Institute was not a 24-hour manned facility. Mid-level practitioners provided on-call services just like physicians. They worked their regular day then took calls from home through the call system. In the night there was an on-call provider to direct services, but no one was physically in the building. Representative Josephson asked the protocol. Dr. Alexander responded that providers received calls from nurses working on the floors who would evaluate the patient. If the patient went into a psychotic state and became extremely violent, a nurse on duty would call the on-call psychiatrist or mid-level practitioner. They would discuss the case and start a crisis period providing medications over objection. The following morning, the provider would interview the patient and decide if the crisis period should continue or end. The process was done over the phone. Representative Josephson asked the credential for the person administering medication. Dr. Alexander replied that a registered nurse would be giving the medication. Vice-Chair Ortiz recognized that Representative Carpenter had joined the meeting. Representative Sullivan-Leonard asked if there had been increased situations with patients which had necessitated the legislation. Dr. Alexander responded that there had been a number of incidents in which staff or patients had been assaulted. He wanted to ensure that the institute was a safe place equipped with all of the right tools. Representative Sullivan-Leonard confirmed that the need for the legislation was based on the need to be able to immediately control a situation that could become dangerous when it occurred at API. She wondered if her assessment was accurate. Dr. Alexander responded that API needed immediate help to control a situation whether a patient was trying to hurt themselves or others. Representative Wool asked if there were limitations to what an APRN or a PA could prescribe. Senator Giessel responded that presently an APRN had the privilege of independent practice in Alaska, and full prescriptive authority. The Advanced Practice Nurse could prescribe controlled substances if they had applied and received a DEA number. The same was true for a PA except that they practiced in a collaborative agreement with a physician. Typically, PAs were rather independent and with a DEA number could prescribe and administer controlled substances. 9:20:55 AM Representative Wool assumed that if an APRN or a PA already had DEA approval to write prescriptions for controlled substances they could already do what was being proposed in the bill. He asked if he was correct. Senator Giessel replied that there was a law in place that prior to 2010 there were no PAs and APRNs in API. There was also a rule in place that only a psychiatrist could authorize the administration of medications which the bill was trying to change. She pointed to page 1, line 11 of the bill. She read directly from the bill: "Harm to the patient or another person as determined by the licensed physician." She was adding: "or physician assistant or advanced practice registered nurse." She was reading from a committee substitute. Next, she referred to page 2, line 4 which read: "The medication is ordered by a licensed physician, physician assistant, or advanced practice registered nurse." The same was repeated on line 16. It was an update to get rid of the restrictive law currently in place. Representative Wool thought the law already allowed PAs and APRNs to prescribe controlled substances with a DEA endorsement. He asked for additional clarity. Ms. Conway responded that it was a section of law (AS.47.30.838) that governed Psychotropic medications in crisis situations. Currently, the only person that could determine that a person was in a crisis situation was a physician. The bill added PAs and APRNs to the list of those that could prescribe medications immediately. Rather than having to call the psychiatrist, they would be able to make an assessment on the scene. Representative Wool brought up the issue of a patient's consent. He relayed he had experience working in a psychiatric hospital in Boston that had about the same number of patients as API. He relayed that anytime someone had to administer drugs a doctor had to be called first. The process could be done over the phone. He suggested that the law would allow a PA or an APRN to be called avoiding a conversation with a doctor entirely. He remarked that there should be more than one physician at API, a matter that he thought should be dealt with as soon as possible. He wondered why a doctor could not be contacted within 72 hours. He understood the immediacy of an acute situation and the need for someone to be medicated quickly. However, he thought a physician could be reached within 3 days. He asked for clarification. 9:26:14 AM Senator Giessel thought Representative Wool was referring to the section on page 2, beginning with line 15 in Section C. She explained that it was referring to line 4. She read from the bill: "The medication is ordered and valid for only 24 and may be renewed for a total of 72 hours." The restriction was in current law and related to the renewal of the medication previously administered. If the person was requiring the medication for 72 hours, further intervention might be necessary. She deferred to Dr. Alexander. Dr. Alexander responded that in order for API to prescribe medications with patients who did not want to take any medications the institute had to either appeal to a judge for permission or enter a crisis period. Judges were not available for 72 hours considering weekends. Court occurred at the institute 3 days per week. Often times, the time between court days was significant. It allowed API to administer medications over 72 hours. The client was seen immediately the following day with necessary adjustments being made. Being able to prescribe medication for the period allowed API to get control. Otherwise, the patient might receive a medication, but reoffend once the medication wore off. He added that for every day a person was psychotic, it became more difficult to control and maintain safety. The length of time a person was on medication was limited because a decision by the court would be necessary for any length of time. 9:30:37 AM Representative Sullivan-Leonard wondered why the bill was referred to the House Finance Committee rather than the House Health and Social Services Committee, as the fiscal notes were zero-impact notes. She wondered if the bill would be heard in the House Health and Social Services Committee. Senator Giessel did not know. Representative Sullivan-Leonard commented that it struck her curiosity because of a zero-impact fiscal note. She wondered if the bill would be heard in the House Health and Social Services Committee or the House Labor and Commerce Committee. Vice-Chair Ortiz offered that the deputy commissioner from DHSS was available for questions. Representative Sullivan-Leonard questioned the route of the bill. She asked if the Medical Board had taken a position on the bill. Senator Giessel responded that she had several letters of support. She noted the authors of the support letters. She mentioned that the bill was heard in the Senate Health and Social Services Committee with no objections to the legislation. Representative Josephson asked Ms. Conway for clarification about mid-level practitioners being on the seen at the time of an incident versus on the phone. Ms. Conway responded that the representative was correct. A mid-level practitioner might not be on the scene. Senator Giessel added that clarity was critical. The practitioners were not new healthcare providers. She relayed that the APRNs and PAs had been practicing at API for 10 years. Nurse practitioners practiced independently in Alaska since 1984 with prescriptive authority. She could not confirm the same longevity for PAs, but they were not new clinicians. 9:34:41 AM Representative Wool thought it was astonishing that the patients would be jailed for their behavior. He asked if calling the police was a recent phenomenon. He asked if it happened elsewhere. Senator Giessel deferred to Dr. Alexander. Dr. Alexander responded that it was not a recent phenomenon or limited to API. The Alaska Psychiatric Institute tried diligently to keep patients at the facility. However, the institute also tried to keep its staff safe. In the prior year, there had been over 100 assaults on staff by patients. He clarified that not all of the patients that did the assaulting were sent to jail. However, the staff had the right to file charges against a patient. Representative Tilton wanted to know whether a guardian could give permission to administer drugs rather than having to get permission from a court. Senator Giessel deferred to Dr. Alexander. Dr. Alexander replied that the statute specified that once a patient arrived at API, no guardian or any other representative of the patient could mandate any kind of medication other than by going through a crisis period or going to court. He thought API's attorney could cite the statute. 9:38:48 AM Representative Josephson thanked the sponsor for the legislation. He clarified his previous statement. His intended point was to make them a new group that would be dually authorized to expressly administer or deputize others to administer psychotropic drugs. Senator Giessel appreciated Representative Josephson's remarks. She reminded members that until recently, when the law was noted by someone else, the PA and APRN were actually functioning in the role. Vice-Chair Ortiz announced that amendments were due by the end of the day at 5:00 p.m.