Please note that the timelines regarding tracheostomy tube changes of > and < 24 hours refers to surgical tracheostomies, not Percutaneous Tracheostomies. When changing percutaneous tracheostomy tubes, RTs must ensure they are doing so in accordance with their organizational policy with respect to timelines.
On March 28, 2014 the Ministry of Health and Long-Term Care (MOHLTC) approved the CRTO’s revised Prescribed Procedures Regulation (O. Reg 596/94). The performance of prescribed procedures below the dermis is one of the controlled acts authorized to Respiratory Therapy through the Respiratory Therapy Act. The Prescribed Procedures Regulation lists the procedures authorized to RTs by the nature of their training and role as health care providers (“prescribed” in this context meaning “listed in regulation”). The original Regulation categorized those procedures as Basic, Added or Advanced based on the amount of training required to perform them safely and the risks associated with the procedures.
However, over the 20 years since the Regulation was drafted, the practice of Respiratory Therapy and clinical practice in general has evolved. Some of the procedures originally listed are now rarely seen in clinical practice, while others that were considered advanced at the time – such as the insertion of arterial lines – have become commonplace and part of the entry-to-practice training of RTs. As a result, the Regulation has been updated and amended to better align the current practice of Respiratory Therapy with the needs of patients.
There have been substantial changes to the Regulation. For a detailed list, click here.
Summary of Changes
Basic Procedures
- “Insertion of a cannula” was moved to the Basic category, along with removal, manipulation, aspiration and suturing as this procedure is now entry-to-practice and common RT practice. This enables Registered Respiratory Therapists (RRTs) to perform procedures like an arterial line or IV insertion without the requirement of a CRTO approved certification program. Also, Graduate Respiratory Therapists (GRTs) may now perform these procedures to obtain skills essential to their practice.
- “Tracheostomy tube change for an established stoma” was removed from the regulation and placed in the Controlled Acts Regulation (please see section below).
- “Transtracheal catheter change for an established stoma” was removed from the Regulation, as it is no longer part of common clinical practice. If required, it can still be performed under delegation.
Added Procedures
- Removing the Added classification eliminates confusion about which procedures required advanced certification, or were prohibited from being performed by GRTs and Practical Respiratory Therapists (PRTs). Former Added procedures are now listed as either:
- Basic – can be performed by all GRTs, and can be performed by PRTs only if prior permission is granted by the CRTO and;
- Advanced – cannot be performed by either GRTs or PRTs.
- “Tracheostomy tube change for a fresh stoma that is less than seven days but not less than 24 hours” was removed from the Regulation and placed in the Controlled Acts Regulation (please see section below).
Advanced Procedures
- Other procedures below the dermis that have become more common in clinical practice (e.g., intraosseous needle insertion and bronchoscopic tissue sample) have been included in list of Advanced procedures. Newer procedures (e.g., subcutaneous electrode placement) that reflect the evolution of RT clinical practice since 1994 have also been added to the Advanced list.
Controlled Acts Regulation
It was identified that the Regulation dealing with procedures below the dermis was not the optimal place to authorize tracheal procedures. Therefore, the MOHLTC removed tracheal procedures from the Prescribed Procedures regulation and placed it in the Controlled Acts Regulation (s. 14, O. Reg. 87/14), changing how these procedures are authorized to RTs. This exemption allows RRTs to do the following:
1) Perform a tracheostomy tube change for a stoma that is more than 24 hours old; and
2) Perform a tracheostomy tube change for a stoma that is less than 24 hours old.
The table below illustrates who is permitted to perform tracheal procedures under the exemption in the Controlled Acts regulation:
|
Tracheal Procedure |
RRT |
GRT |
PRT |
|
Perform a tracheostomy tube change for a stoma that is more than 24 hours old. |
√ |
√ |
* |
|
Perform a tracheostomy tube change for a stoma that is less than 24 hours old. |
√ |
|
|
*can be performed if permitted by the terms, conditions and limitations on the Member’s certificate of registration.
What Hasn’t Changed
Successful completion of an approved certification program is still required prior to any RT performing an Advanced Procedure. The existing Clinical Best Practice Guidelines will still be available from the CRTO website as a reference. They will not be updated and at a future date will be removed from the CRTO website.
You still need an Order
Any prescribed procedure must be appropriately authorized prior to performance (I.e., you still need an order to perform them).
You must be competent to perform a procedure
As with any activity, (regardless of whether a procedure is authorized to the profession) you must ensure that prior to performing the activity, you have the knowledge, skills and judgment to perform the procedure safely and competently.
Terms, Conditions and Limitations
RTs with terms, conditions or limitations on their certificates of registration related to prescribed procedures below the dermis will have their certificates updated and reissued to reflect these Regulation changes. Terms, conditions or limitations will be maintained at the same level as they are currently. The Public Register and your online printable certificate will also reflect these updates.
Notifying Your Employer
The CRTO will be sending notices to employers outlining how these changes affect Respiratory Therapists. In addition, each RT is responsible for informing their employer(s) of any change to the terms, conditions or limitations on their certificate of practice.
For More Information
Please contact Carole Hamp, Deputy Registrar, if you have additional questions or concerns. She can be reached at hamp@crto.on.ca or 416.591.7800 ext. 33.