Ga. nurses want added autonomy for more treatment capacity in a crisis

Georgia's nurses are pressing for more authority to order tests like MRIs, as well as more leeway during the COVID-19 outbreak to help expand the state's health care capacity. Don Murray/Getty Images

Molly Bachtel was recently treating a patient who had taken a hard hit to the jaw while playing basketball, causing what Bachtel suspected was a fracture.

Bachtel, who is a family nurse practitioner in Atlanta, could order an X-Ray but when a radiologist reported that an MRI was needed, she had to refer the injured man on to a doctor.

“So, this fellow had to come back and see the physician and have it ordered,” Bachtel said. “It caused a couple days delay. For somebody in rural Georgia, it would probably create a longer delay.”

Under current Georgia law, nurses who have advanced medical training can order imaging tests in more dire circumstances. But for more routine matters – like the basketball player’s jaw injury – these nurses must defer to a physician.

“MRI is becoming a go-to tool to look for breast cancer and we cannot order a routine MRI of the breast,” Bachtel said. “So, it could cause a delay in care to getting a diagnosis or giving somebody reassurance, ‘No, you don’t have breast cancer.’”

Georgia is now the only state that bars its advanced practice registered nurses from ordering these imaging tests, and perennial efforts to expand the practice authority of nurses under the Gold Dome have run into powerful opposition.

This year, a bill that would allow nurses to order these routine imaging tests cleared a major hurdle – the Georgia House of Representatives – in the final hour of Crossover Day, when a bill must pass at least one chamber to have smoother journey toward becoming law.

Rep. Randy Nix, a LaGrange Republican, pushed his colleagues not to let “some small group control healthcare in this state.” Georgia House of Representatives photo

Rep. Randy Nix, a LaGrange Republican, railed against the medical community’s opposition to the proposal and said lawmakers should not “let just some small group control healthcare in this state.”

“It is a team sport. The physician is the quarterback and (the nurses) operate under them,” Nix, who chairs the House Ethics Committee, said to his colleagues.

“Let’s be serious about expanding healthcare in rural Georgia. Let’s maximize our resources out there and let’s make a common-sense decision,” Nix said.

The measure cleared the House with a 114-38 vote with bipartisan support and over the objections of Rep. Sharon Cooper, who said MRIs and CT scans have become increasingly complicated and that even physicians can puzzle over which test to order. Cooper chairs the House Health and Human Services Committee. The late-filed bill traveled through another committee.

The Medical Association of Georgia, which represents doctors at the Capitol, opposes the measure, which would also increase the number of advanced practice registered nurses a doctor can oversee from four to six.

Andrew Reisman, who is the association’s president and a physician, said in a statement that the bill would “undermine patient safety by increasing the physician-to-APRN oversight ratio and increasing the number of non-physicians who can order radiographic imaging, keeping in mind that the differences in education and experience and training between physicians and allied health care professionals are dramatic.”

“This bill would also result in higher health care costs by increasing the number of unnecessary tests that are performed,” Reisman said.

But proponents argue that even with the change, doctors would not be required to allow the nurses they oversee to order the imaging tests. A nurse’s legal authority depends on the terms of their protocol agreement.

“This bill gives doctors the ability to allow advanced practice nurses to order radiographic imaging,” said Rep. Jasmine Clark, a Lilburn Democrat who is a nursing instructor at Emory University. “It does not force the hand of doctors and instead empowers them to deliver a better patient experience by cutting down on wait times for patients.”

The measure’s fate remains uncertain, though. The bill now awaits Senate action, but state lawmakers were forced to abruptly suspend their session this month because of the worsening COVID-19 outbreak.

‘Our members stand ready’

The novel coronavirus, which has killed 25 people in Georgia and afflicted at least 620 others, will continue to stretch the state’s health care resources.

Gov. Brian Kemp has used a public health emergency declaration to more quickly issue licenses to out-of-state licensed practice nurses, registered nurses and advanced practice registered nurses who come here to provide care during the crisis.

But organizations that represent nurses, including the Georgia Coalition of Advanced Practice Registered Nurses, say existing state limits on nurse practitioners who hold advanced degrees limit their ability to aid in the response.

They have made the case for temporarily waiving some of the state rules that limit their practice authority to boost Georgia’s health care capacity during the pandemic, as Tennessee’s governor recently did. Specifically, they say a rule that requires nurse practitioners to work under the supervision of a physician should be lifted.

Kemp said Thursday that his legal team is reviewing the request. An executive order issued late Friday reduced some health care regulations but did not address the oversight of nurse practitioners.

“Our members stand ready, but regulatory bottlenecks, for not only out of state but also in state APRNs, must be suspended during this time of emergency,” multiple professional nurse organizations wrote in a joint letter to the governor last week. “This will enable APRNs to bring the fullest extent of their education, training, and national certification.”

Michelle Nelson, president of United Advanced Practice Registered Nurses of Georgia, which signed onto the letter, said temporarily giving nurses greater leeway to more fully provide care ensures patients with chronic illnesses – like diabetes and heart disease – aren’t overlooked in a moment of crisis.

She said that’s particularly true for already underserved communities, like much of rural Georgia.

“There is such a lack of people who are going to be able to deliver the care as our citizens get sicker from coronavirus,” Nelson said.

“If we had more practitioners who would be able to take care of a lot of the other issues that are still worrisome to our citizens, then we would not have such a vast interruption in the way that we deliver care,” she said.