Delegating

Delegating RT Authorized Acts

CRTO Members may delegate procedures within the controlled acts authorized to Respiratory Therapists, but only when all of the following conditions are met:

1. You have the authority (related to terms, conditions or limitations on your certificate of registration – specifically related to you as an individual or as a holder of a particular class of certificate of registration), and competence (knowledge, skills and judgment) to perform and to delegate the procedure safely, effectively, competently and ethically; and

2. You reasonably believe that the delegatee has acquired, through teaching and clinical supervision of practice, the competence to perform the procedure safely, effectively, competently, and ethically; and

3. You have no reason to believe that the delegatee is not permitted to accept the delegation; and

4. You verify, or reasonably believe an evaluation mechanism is in place to verify, the continued competence of the delegatee for performing the procedure; and

5. You have determined that delegation of the procedure is appropriate giving due consideration to:

a. the known risks and benefits of performing the procedure for the patient/client(s);

b. the predictability of the outcomes of performing the procedure;

c. the patient/clients’ wishes;

d. the safeguards and resources available in the situation; and

e. other elements specific to the situation.

PLEASE NOTE:

Due to the fact that tracheostomy tube changes are now listed as an exemption in the Controlled Acts regulation, Respiratory Therapists (RRT, GRT and PRTs) are no longer permitted to delegate tracheostomy tube changes.

Delegation Decision Flowchart

What Procedures Can I Delegate?

CRTO members may delegate any RT authorized act procedures to another regulated or non-regulated health care provider provided they meet their professional responsibilities which are outlined below.

What Are My Responsibilities When I Delegate?

You meet the Standards of Practice of the College and the profession before delegating a procedure

Confirm that the individual can safely perform the procedure to the same, accepted standard

Ensure a mechanism exists for education, supervision, and on-going competence evaluation of the delegate

Assuming responsibility for the delegation does not mean you assume responsibility for the delegatee’s performance of an individual procedure. It is your responsibility to ensure that, given consideration to all circumstances, the delegation is appropriate. As with any other intervention you undertake, it is your responsibility to ensure proper documentation of your actions by keeping records of the individuals to whom you delegate and the specifics of the procedures that you delegate. CRTO Members are encouraged to keep records of what and to whom they have delegated in their QA PORTfolio.

Records should include the following:

description of the procedure being delegated,

information related to the education that was provided to the delegatee (number of hours, curriculum, any handouts, tests, etc.),

who provided it (yourself or a team of RRTs for example),

description of the “certification process”, and

the quality management activities and any particular specifics related to ongoing quality monitoring and evaluation of the delegation.

Your employer may have specific requirements regarding delegation and documentation that you will need to be familiar with prior to delegating.

You are professionally accountable for your decision to delegate a procedure and you must ensure you have satisfied all the requirements outlined in this practice guideline. The “reasonably believe” concept requires that you act prudently. For example, if your employer has a policy that outlines an evaluation process for assessing the competence of delegatees, that you know in practical terms is not adhered to, it is your obligation not to delegate procedures until the reality matches the policy. It also means that you do not personally have to supervise, teach, and evaluate a delegatee but you are responsible to ensure that an appropriate process is in place. If you are reasonably satisfied that a certification program appropriately assesses competence, then it would be reasonable to accept that successful completion of the program means that an individual has the requisite competence to perform the procedure.

Making a decision to delegate your authority to perform a controlled act to another individual should not be taken lightly. The ultimate decision to delegate rests with you.

(Please refer to the Responsibilities of Members as Educators PPG for more standards of practice related to teaching and delegation.)

Under What Circumstances Am I Not Permitted To Delegate?

You must not delegate a controlled act procedure:

That is not authorized to you according to the Respiratory Therapy Act. For example, you cannot delegate a controlled act procedure, which you yourself require delegation from another RHP to perform (for example, ultrasound guided line insertion). This amounts to the concept of “sub-delegation” which is not permitted;
To an RHP (including a Respiratory Therapist) who is prevented from performing the procedure due to terms, conditions, or limitations on his or her certificate of registration; or
To an individual who you do not reasonably believe has the competence to perform the procedure.

Did You Know?

CRTO members who hold a General Certificate of Registration may not delegate an RT authorized act to a member with a Graduate certificate of registration, who is prohibited from performing the procedure due to terms, conditions and limitations on their certificate. For example, an RRT may not delegate chest tube insertion to a GRT.

What Are The Penalties If I Perform A Controlled Act Without The Authority To Do So?

If you or another RHP perform a controlled act when you are not permitted to do so, you may
be subject to professional misconduct proceedings. (See Professional Misconduct Regulation provision 1.4).

GLOSSARY

Authority the right to act – usually related to jurisdiction provided in a statute or to terms, conditions or limitations imposed on a certificate of registration – individually specified (by a panel) or related to an entire class of certificates of registration (specified by Council or a panel).

Authorized Act is a controlled act, or portion of a controlled act, that is authorized within a health profession act for a health professional to perform [there are four acts authorized to Respiratory Therapists by the Respiratory Therapy Act, that are created from three controlled acts defined in the RHPA]; the controlled acts authorized to Respiratory Therapists are:

1. Performing a prescribed procedure below the dermis;
2. Intubation beyond the point in the nasal passages where they normally narrow or beyond the larynx;
3. Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx;
4. Administering a substance by injection or inhalation; and
5. Administering a prescribed substance by inhalation.

Controlled Act one of the following 14 acts defined in the RHPA [section 27(2)] when it is performed “with respect to an individual”:

1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
3. Setting or casting a fracture of a bone or a dislocation of a joint.
4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
5. Administering a substance by injection or inhalation.
6. Putting an instrument, hand or finger,
  1. beyond the external ear canal,
  2. beyond the point in the nasal passages where they normally narrow,
  3. beyond the larynx,
  4. beyond the opening of the urethra,
  5. beyond the labia majora,
  6. beyond the anal verge, or
  7. into an artificial opening into the body.
7. Applying or ordering the application of a form of energy prescribed by the regulations under this Act.
8. Prescribing, dispensing, selling or compounding a drug as defined in subsection 117 (1) of the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept.
9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers.
10. Prescribing a hearing aid for a hearing impaired person.
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning.
12. Managing labour or conducting the delivery of a baby.
13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.
14. Treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception, or memory that may seriously impair the individual’s judgement, insight, behavior, communication or social functioning.

Competence having the requisite knowledge, skills and judgement to perform the procedure.

Delegatee the person receiving the authority to perform a procedure.

Delegator when the patient/client is apparently experiencing severe suffering or is at risk, if the procedure or treatment is not administered promptly, of sustaining serious bodily harm.

Emergency the person conferring the authority for another to perform a procedure.

Forms of Energy the following forms of energy are prescribed in regulation:

1. Electricity for,
  1. aversive conditioning
  2. cardiac pacemaker therapy
  3. cardioversion
  4. defibrillation
  5. electrocoagulation
  6. electroconvulsive shock therapy
  7. electromyography
  8. fulguration
  9. nerve conduction studies, or
  10. transcutaneous cardiac pacing
2. Electromagnetism for magnetic resonance imaging
3. Soundwaves for,
  1. diagnostic ultrasound, or
  2. lithotripsy

HPPC Health Professions Procedural Code – RHPA; Schedule 2.

Member a member of a regulatory college under the RHPA.

Reasonably sensible, rational often referred to as the reasonable person test – determined by case law – in the case of the CRTO, a panel would determine whether or not an individual, giving consideration to all circumstances, acted in a sensible, rational manner in the matter under discussion.

Respiratory Therapist a Member of the CRTO (refers to RRT, GRT, PRT, Inactive Member).

RHP / Regulated Health Professional a health care provider who is a member of a College and is regulated by the RHPA (e.g., nurse, physician, dentist, massage therapist, physiotherapist, dietitian, occupational therapist, etc).

RHPA Regulated Health Professions Act, 1991.

RTA Respiratory Therapy Act, 1991.

REFERENCES & LEGISLATION

REFERENCES

College of Nurses of Ontario (2020). Practice standard: Decisions about procedures and authority. Retrieved from https://www.cno.org/globalassets/docs/prac/41071_decisions.pdf

College of Physicians and Surgeons of Ontario (2021, March). Delegation of controlled acts. Retrieved from https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Delegation-of-Controlled-Acts

College of Respiratory Therapists of Ontario (2020, March). Professional practice guideline: Interpretation of authorized acts. Retrieved from https://interpretation.crto.on.ca

Health Profession Regulators of Ontario. An Interprofessional Guide on the use of Orders, Directives and Delegation for Regulated Health Professionals (2021). Retrieved from: http://www.regulatedhealthprofessions.on.ca/orders%2c-directives%2c-delegation.html

LEGISLATION

Regulated Health Professions Act, 1991. (see s.27)
www.e-laws.gov.on.ca/DBLaws/Statutes/English/91r18_e.htm

Respiratory Therapy Act, 1991. (see s.4)
www.e-laws.gov.on.ca/DBLaws/Statutes/English/91r39_e.htm

Prescribed Substance Regulation O. Reg. 596/94: GENERAL (ontario.ca) (see Part VII.1)
www.ontario.ca/laws/regulation/940596