HOUSE BILL REPORT

HB 3072

As Reported by House Committee On:

Health Care & Wellness

Title: An act relating to wound care management in occupational therapy.

Brief Description: Including wound care management in occupational therapy.

Sponsors: Representatives Morrell, Driscoll, Crouse, Wallace and Parker.

Brief History:

Committee Activity:

Health Care & Wellness: 2/2/10 [DPS].

Majority Report: The substitute bill be substituted therefor and the substitute bill do pass. Signed by 13 members: Representatives Cody, Chair; Driscoll, Vice Chair; Ericksen, Ranking Minority Member; Bailey, Campbell, Clibborn, Green, Herrera, Hinkle, Kelley, Moeller, Morrell and Pedersen.

Staff: Jim Morishima (786-7191).

Background:

Occupational Therapy.

An Occupational Therapist is a person licensed by the Board of Occupational Therapy Practice (Board) to practice occupational therapy. An Occupational Therapy Assistant is a person licensed by the Board to assist in the practice of occupational therapy under the supervision, or with the regular consultation, of a licensed Occupational Therapist.

"Occupational therapy" is the scientifically-based use of purposeful activity that maximizes independence, prevents disability, and maintains the health of individuals who are limited by physical injury or illness, psychosocial dysfunction, developmental or learning disabilities, or the aging process. Examples of the practice of occupational therapy include:

• using specifically-designed activities and exercises to enhance neuro-developmental, cognitive, perceptual motor, sensory integrative, and psychomotor functioning;

• administering and interpreting tests such as manual muscle and sensory integration;

• teaching daily living skills;

• developing pre-vocational skills and play and avocational activities;

• designing, fabricating, or applying selected orthotic and prosthetic devices or selected adaptive equipment; and

• adapting environments for persons with disabilities.

Wound Care.

Statutory provisions relating to occupational therapy make no mention of whether wound care is within the scope of practice of Occupational Therapists or Occupational Therapy Assistants. The Board has issued an informal opinion stating occupational therapy includes wound care management and has considered adopting an official interpretive statement that occupational therapy includes wound care management and sharp debridement (the removal of dead or contaminated tissue from a wound). In response to a draft interpretive statement issued by the Board, the Attorney General issued an opinion concluding that sharp debridement is not included in the scope of practice for Occupational Therapists. The Attorney General's opinion did not address the issue of whether wound care in general is within the scope of practice.

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Summary of Substitute Bill:

Wound care management is made part of the scope of practice of an Occupational Therapist. An Occupational Therapist may provide wound care management under the referral and direction of a physician or other authorized health care provider. The referring provider must examine the patient prior to the referral.

"Wound care management" is defined as the part of occupational therapy treatment that facilitates healing, prevents edema, infection, and excessive scar formation, and minimizes wound complications. Wound care management includes:

• assessment of wound healing status;

• patient education;

• selection and application of dressings;

• cleansing of the wound and surrounding areas;

• application of topical medications;

• use of physical agent modalities;

• application of pressure garments and non-weight bearing orthotic devices;

• sharp debridement, which is defined as the removal of devitalized tissue from a wound with scissors, scalpel, and tweezers without anesthesia;

• debridement with other agents; and

• adapting activities of daily living to promote independence during wound healing.

In order to perform debridement, an Occupational Therapist must have training in:

• indications and contraindications for the use of debridement;

• appropriate selection and use of clean and sterile techniques;

• selection of appropriate tools;

• identification of viable and devitalized tissues; and

• conditions that require referral back to the referring provider.

Training in debridement may be provided through continuing education, mentoring, co-treatment, and observation. An Occupational Therapist must consult with a referring provider if the wound exposes anatomic structures underlying the skin, if there is an obvious worsening of the condition, or if there are signs of infection.

In order to be authorized to perform wound care management, an Occupational Therapist must submit an affidavit to the Department of Health attesting to his or her education and training. The Board must develop an affidavit form for these purposes. The requisite amount of training varies depending on the type of wound care involved:

• For wound care management that does not involve a scalpel, the Occupational Therapist must have at least 15 hours of mentored training. Mentored training includes observation, co-treatment, and supervised treatment. The training must include a case mix similar to the Occupational Therapist's expected practice and must include conditions necessitating referral back to the referring provider.

• For wound care management with a scalpel, the Occupational Therapist must have an additional 15 hours of mentored sharp debridement training in the use of a scalpel. Mentored training includes observation, co-treatment, and supervised treatment. The training must include a case mix similar to the Occupational Therapist's expected practice and must include conditions necessitating referral back to the referring provider.

The education and training requirements may also be satisfied if the Occupational Therapist is certified as a hand therapist by the Hand Therapy Certification Commission or as a wound care specialist by the American Academy of Wound Management, the National Alliance of Wound Care, or equivalent organization approved by the Board.

Substitute Bill Compared to Original Bill:

The proposed substitute bill:

• prohibits Occupational Therapists from delegating wound care, which means Occupational Therapy Technicians may not perform wound care;

• removes provisions allowing entry-level training in debridement (only continuing education is permitted);

• removes provisions establishing a deadline of July 1, 2011 by which Occupational Therapists whose current practice meets the requirements for wound care must submit the affidavit; and

• requires the Board to develop an affidavit form.

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Appropriation: None.

Fiscal Note: Requested January 28, 2010.

Effective Date of Substitute Bill: The bill takes effect 90 days after adjournment of the session in which the bill is passed.

Staff Summary of Public Testimony:

(In support) This bill is the result of collaborative discussions and keeps improving as it moves through the process. If this bill is not passed, there could be negative implications for patients because of the shortage of providers able to perform wound care services. The substitute bill addresses many of the concerns in the original bill by removing the ability of Occupational Therapists to delegate wound care management to Occupational Therapy Assistants and by making other changes.

(Neutral) This bill strikes a good balance.

(With concerns) There are benefits associated with an interdisciplinary approach to home health care and with allowing an Occupational Therapist to make home visits without a nurse having to come out and admit, etc. There is a gap between the main training requirements and the alternate training methods that must be closed. The substitute bill addresses many concerns relating to delegation and internal references, but there are concerns with expanding the scope of practice for Occupational Therapists. The definition of "sharp debridement" should be changed to reflect the definition of "conservative sharp wound debridement" in the Wound Ostomy Continence Nurse Position Statement. The bill should be changed to make sure topical anesthetics are used properly. Other states require extensive training for wound care. This bill does not impose any severity limits on the wounds an Occupational Therapist may treat. The training in this bill seems inadequate.

(Opposed) None.

Persons Testifying: (In support) JoAnn Keller Green, Washington Occupational Therapy Association; and Melissa Johnson, Physical Therapy Association of Washington.

(Neutral) Gail McGaffick, Washington State Podiatric Medicine.

(With concerns) Sofia Aragon, Washington State Nurses Association; Lisa Butler, Washington State Hospice and Palliative Care Organization, Homecare Association of Washington; and Sharon Ness, Washington State Council of the United Food and Commercial Workers Union.

Persons Signed In To Testify But Not Testifying: None.