HOUSE BILL REPORT

HB 1076

As Reported by House Committee On:

Health Care & Wellness

Health & Human Services Appropriations & Oversight

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

Brief Description: Including wound care management in occupational therapy.

Sponsors: Representatives Moeller, Cody, Warnick, Green, Hinkle, Parker, Crouse, Kelley, Miloscia, Finn, Dammeier, Kenney and Harris.

Brief History:

Committee Activity:

Health Care & Wellness: 1/19/11, 1/31/11 [DPS];

Health & Human Services Appropriations & Oversight: 2/15/11, 2/16/11 [DPS(HCW)].

Majority Report: The substitute bill be substituted therefor and the substitute bill do pass. Signed by 11 members: Representatives Cody, Chair; Jinkins, Vice Chair; Schmick, Ranking Minority Member; Hinkle, Assistant Ranking Minority Member; Bailey, Clibborn, Green, Harris, Kelley, Moeller and Van De Wege.

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. "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. In 2008 the Board issued an informal opinion stating occupational therapy includes wound care management and considered adopting an interpretive statement on wound care and sharp debridement. In 2010 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. The Board subsequently determined not to adopt an interpretive statement on wound care and sharp debridement and instead encouraged the Department of Health to work with stakeholders to develop legislation to clarify the issue.

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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 non-surgical removal of loose or loosely adherent devitalized tissue with scissors, scalpel, or tweezers without any type of anesthesia other than topical anesthetics;

• debridement with other agents; and

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

In order to perform sharp 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 or if there is an obvious worsening of the condition or signs of infection.

In order to be authorized to perform wound care management, an Occupational Therapist must submit an affidavit to the Board 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 management 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 by a licensed Occupational Therapist authorized to perform wound care management or a health care provider whose scope of practice includes wound care management. The training must include a case mix similar to the Occupational Therapist's expected practice and must be in a clinical setting.

• For wound care management with a scalpel, the Occupational Therapist must have at least 2,000 hours in clinical practice and an additional 15 hours of mentored sharp debridement training in the use of a scalpel. Mentored training includes observation, co-treatment, and supervised treatment by an Occupational Therapist authorized to perform wound care management with a scalpel or a health care provider whose scope of practice includes wound care management with a scalpel. The training must include a case mix similar to the Occupational Therapist's expected practice and must be in a clinical setting.

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 National Alliance of Wound Care or equivalent organization approved by the Board.

The Board and the Department of Health must adopt any rules necessary to implement the new requirements relating to wound care.

Substitute Bill Compared to Original Bill:

The substitute bills requires the Board and the Department of Health to adopt any rules necessary to implement the act.

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Appropriation: None.

Fiscal Note: Available.

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 has been in development since 2007. Wound care has been part of the practice of occupational therapy for some time, but the authority has to be placed in statute due to an Attorney General Opinion. This legislation provides needed clarity with respect to what Occupational Therapists can and cannot do. When an Occupational Therapist sees a patient with a surgical or traumatic wound, it is impossible for the Occupational Therapist to perform his or her job without addressing the wounds.

(With concerns) It should be clarified that wound care does not include treatment of the eye.

(Opposed) This bill negatively affects patient safety. This bill authorizes Occupational Therapists to perform minor surgery. The Attorney General has already opined that wound care is not included in the practice of occupational therapy. The bill does not contain a clear definition of what type of wound may be treated. Decisions that must be made with respect to wounds take a lot of experience. In cases where there is an infection, misdiagnosis can be disastrous, especially since Occupational Therapists do not have the authority to prescribe antibiotics. Nurses and physicians have years of training in wound care; this bill only requires hours of training for Occupational Therapists.

Persons Testifying: (In support) Representative Moeller, prime sponsor; Mark Gjurasic, JoAnn Keller Green, and Jim Bevier, Washington Occupational Therapy Association; and Melissa Johnson, Physical Therapy Association.

(With concerns) Brad Tower, Optometric Physicians of Washington.

(Opposed) Jim Richards, Washington Osteopathic Medical Association.

Persons Signed In To Testify But Not Testifying: None.

Majority Report: The substitute bill by Committee on Health Care & Wellness be substituted therefor and the substitute bill do pass. Signed by 10 members: Representatives Dickerson, Chair; Johnson, Ranking Minority Member; Schmick, Assistant Ranking Minority Member; Cody, Green, Harris, Kagi, Overstreet, Pettigrew and Walsh.

Staff: Amy Skei (786-7109).

Summary of Recommendation of Committee On Health & Human Services Appropriations & Oversight Compared to Recommendation of Committee On Health Care & Wellness:

No new changes were recommended.

Appropriation: None.

Fiscal Note: Available.

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 is a compromise bill that clarifies the scope of practice for occupational therapists and confirms the education and training requirements for therapists who are practicing in the area of wound care. Our understanding is that the funds to support this will come out of the Health Professions Account and if additional fees are needed they will come from the licensees. We highly support the mandated rule-making authority in the bill.

(Opposed) None.

Persons Testifying: Joann Keller Green and Mark Gjurasic, Washington Occupational Therapy Association; and Melissa Johnson, Physical Therapy Association of Washington.

Persons Signed In To Testify But Not Testifying: None.