BILL ANALYSIS                                                                                                                                                                                                    Ó

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          SB 233 (Pavley)
          As Amended  August 25, 2011
          Majority vote

           SENATE VOTE  :37-0  
           HEALTH              17-0        APPROPRIATIONS      17-0        
          |Ayes:|Monning, Logue, Ammiano,  |Ayes:|Fuentes, Harkey,          |
          |     |Atkins, Bonilla, Eng,     |     |Blumenfield, Bradford,    |
          |     |Garrick, Gordon, Hayashi, |     |Charles Calderon, Campos, |
          |     |Bonnie Lowenthal,         |     |Davis, Donnelly, Gatto,   |
          |     |Mansoor, Mitchell,        |     |Hall, Hill, Lara,         |
          |     |Nestande, Pan,            |     |Mitchell, Nielsen, Norby, |
          |     |V. Manuel Pérez, Silva,   |     |Solorio, Wagner           |
          |     |Williams                  |     |                          |
          |     |                          |     |                          |
           SUMMARY  :  Clarifies existing law to explicitly permit appropriate 
          licensed personnel to perform consultations and treatment in an 
          emergency department (ED) if within their existing scope of 
          practice.  Specifically,  this bill  :   

          1)Revises the existing definition of "emergency services and care" 
            to mean medical screening, examination, and evaluation by a 
            physician or surgeon, or, to the extent permitted by applicable 
            law, other appropriate licensed personnel under the supervision 
            of a physician and surgeon, to determine if an emergency medical 
            condition or active labor exists.

          2)Clarifies that, upon a determination that an emergency medical 
            condition or active labor exists, "emergency services and care" 
            also includes the care, treatment, and surgery, if within the 
            scope of the appropriate licensed personnel's license and 
            clinical privileges, necessary to relieve or eliminate the 
            emergency medical condition, within the capability of the 

          3)Includes the rendering of a decision regarding hospitalization 
            or transfer by telephone or other means of communication in the 
            existing definition of "consultation" and authorizes other 
            appropriate licensed personnel acting within their scope of 
            licensure to provide consultation.


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          4)Requires the request for consultation to be made by the treating 
            physician and surgeon, or by other appropriate licensed 
            personnel acting within their scope of licensure, provided that 
            it is made with the contemporaneous approval of the treating 
            physician and surgeon.

          5)Permits the treating physician and surgeon to request to 
            communicate directly with the consulting physician and surgeon, 
            and requires, when determined to be medically necessary, jointly 
            by the treating physician and surgeon and the consulting 
            physician and surgeon, the consulting physician and surgeon to 
            examine and treat the patient in person. 

          6)States that the consulting physician and surgeon is ultimately 
            responsible for providing the necessary consultation to the 
            patient, regardless of who makes the in-person appearance. 

          7)Authorizes, in addition to a physician or surgeon, other 
            appropriate licensed personnel acting within their scope of 
            licensure to determine when a patient's emergency condition has 
            been stabilized. 

          8)Prohibits this bill from being construed to expand the scope of 
            licensure for licensed personnel providing services in the ED.

           FISCAL EFFECT  :  According to the Assembly Appropriations 
          Committee, negligible direct state fiscal impact.  This bill 
          clarifies state law and conforms state law to existing federal law 
          and current practice, and is not likely to significantly change 
          the delivery of emergency medical care.  

           COMMENTS  :  According to the author, this bill is prompted by a 
          recent situation in which a physician was requested to provide a 
          consultation in the ED at Mission Hospital in Orange County and 
          sent his physician assistant (PA) to provide the further 
          assessment.  The PA was subsequently prohibited from providing the 
          consultation.  The author maintains that although these types of 
          services are routinely authorized by supervising physicians at 
          hospitals, in this case, the hospital pointed out that existing 
          law does not explicitly authorize a PA to perform consulting and 
          treatment services in an ED setting.

          The author argues that this bill would make state law consistent 
          with federal law, which permits PAs to provide consults in the ED. 
           The author adds that PAs working in specialty practice areas 


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          provide an essential service to the ED as they can expedite the 
          admission or surgical preparation of the patient under the 
          supervision of the physician and surgeon, and, in doing so, vacate 
          a bed for an incoming ED patient.  The author contends that as 
          long as evaluation, consultation, and treatment is performed 
          pursuant to a PA's scope of practice, delegation of services 
          agreement, and under the supervision of a physician and surgeon, 
          this type of care by a PA is routine and should not be unduly 
          restricted by omissions and lack of clarity in the current 
          definition of emergency services and care in state law.

          The sponsor of this bill, the California Academy of Physician 
          Assistants (CAPA), states that existing law allows PAs to perform 
          a variety of medical services set forth in state regulations when 
          rendered under the supervision of a physician and surgeon.  CAPA 
          argues that this bill clarifies an inconsistency in state law by 
          explicitly authorizing PAs and other mid-level practitioners to 
          perform consultative and treatment services in the hospital ED, 
          thereby increasing the provision of urgent medical care and 
          decreasing patient overcrowding.  

          The California Nurses Association (CNA) objects to this bill and 
          views it as an expansion of scope of practice and an encroachment 
          into the practice of medicine.  CNA asserts that the law is clear 
          that physicians may provide emergency consults, care, treatment, 
          and surgery; and, allowing "other appropriate personnel" to 
          provide these services raises concerns over whether or not any of 
          these types of personnel retain the appropriate levels of training 
          and competence to perform these services.  CNA believes this bill 
          lessens standards of care for patients by promoting the broad 
          delegation of certain aspects of care, including consultations and 
          stabilization determinations, to non-physician practitioners. 

          The California Chapter of the American College of Emergency 
          Physicians opposes this bill unless it is amended to clarify that 
          the definitions of emergency services, care, and consultation 
          include delivery by appropriate licensed personnel to the extent 
          permitted by hospital by-laws or rules and regulations as provided 
          under federal law. 

          Analysis Prepared by  :    Cassie Royce / HEALTH / (916) 319-2097FN: 


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