By Roy Pologe
Seven years ago at Night Nurse, one of our staff RNs encountered an after-hours triage call from a Vermont patient of a Massachusetts medical practice. Our nurse triaged the call, but noted concern for having done so. The nurse was credentialed in Massachusetts, and the call was from Vermont. Were her nurse credentials (RN) in jeopardy for having provided medical care advice across state lines? Although Medicaid, HMO, and medical insurer guidelines do not inhibit or prohibit patient care by physicians across state lines, we didn’t dismiss our nurse’s concern.
Our Massachusetts triage nurse’s encounter with the patient residing in Vermont prompted a conversation with Vermont Board of Nursing (BoN). “Your nurse was in violation of both Vermont and Massachusetts nursing regulations,” said a representative of the Vermont BoN.
“Why is that?” asked Tami Regan, Night Nurse’s director of nursing services. “We’re allowed to triage Massachusetts residents who travel out of state. What makes this situation so different? How should we have assisted the patient?” The Vermont BoN advised us to redirect Vermont patients to their own physicians for assistance.
Certainly this patient encounter provoked questions for further discussion. Practically considered, by following Vermont BoN guidelines, the Vermont patient would have had care advice significantly delayed; alternatively the patient might have dialed 911 or gone to the emergency room. Possibly all those scenarios would have resulted in reasonably positive outcomes (aside from additional costs accrued to the practice, HMO, or government, as well as needless risk for the patient). But what if the circumstances surrounding the call were potentially life-threatening, such as symptoms akin to meningitis? Then the scenario endorsed by the Vermont BoN and deemed acceptable by the Massachusetts BoN could have resulted in serious complications or even death for the patient.
Our triaging that Vermont patient was an oddity, but it was also an eye-opener. The absurdities of Massachusetts and Vermont nursing regulations may be more self-serving than lifesaving. Regulatory authority that deters achieving good patient outcomes must be thoughtfully examined and revised. Current Massachusetts nursing regulations is antithetical to good medical practice, as stated by the Massachusetts BoN Regulations, Section 244 CMR 9.00 subsection 4/9.03, which reads in effect that triage of an out-of-state resident by a Massachusetts RN is a violation of the statute. Thought this regulation has never been tested and is open to interpretation, the safe course of action is to abide by it.
Soon after our Vermont patient encounter, we discovered unheralded legislation languishing in the Massachusetts legislature, proposing that the Commonwealth of Massachusetts join an existing “Compact” – that is, the Nurse Licensure Compact (NLC), which is similar to other reciprocal licensure agreements and allows nurses properly licensed in one state of residency to have their credentials honored in all NLC states, now numbering twenty-four.
Maine, New Hampshire, and Rhode Island have already aligned with the NLC. However, Connecticut, Massachusetts, and Vermont are not NLC states. Night Nurse services all six of these New England states, as well as seventeen other states.
Reciprocal accreditation of our staff nurses across state lines would expedite delivery of cost-efficient medical services, with benefits for all concerned. The cumulative effect of more states enlisting in the NLC would facilitate the consistent delivery of timely triage across state borders.
Disease and catastrophe do not respect state lines. In an endemic situation, nursing forces are stretched thin. During pandemic events, nurses themselves are subject to illness. Also, nurses are among first responders during emergent events. Restrictive state nursing regulations limit the flexibility for appropriate assignment of available nurses in response to weather-related disasters, as occurred in 2012 when Hurricane Sandy struck the eastern seaboard. During such emergencies, it would be highly beneficial and much more efficient to assign emergent calls to the next available nurse rather than the next available nurse with licensure matching the patient’s state of residence.
Tami Regan recently testified before the Massachusetts legislature in Boston, citing specific occurrences during a past H1N1 influenza pandemic. Our Massachusetts licensed nurses were barraged with patient and caregiver calls, while our non-Massachusetts licensed nurses were not. Although these other nurses were free to assist with call management, they were restricted from supporting our Massachusetts nurses licensed by the Massachusetts BoN. Night Nurse persevered and managed to maintain patient services throughout that H1N1 pandemic, but Massachusetts patients were subject to unnecessary risk, while competent NLC nurses were prepared and available to provide much-needed assistance.
Conversely, when NLC nurses were struggling to keep up with extraordinarily heavy call volume (H1N1 peaked in other states before arriving in Massachusetts), the Massachusetts BoN refused our request for a limited two-week waiver to allow Massachusetts staff nurses to support beleaguered nurses serving other states.
Tami Regan’s parting comment upon conclusion of her testimony in Boston in support of Massachusetts’ passage of NLC legislation was, “Boston Strong becomes Boston Stronger by Massachusetts joining the Compact.” It’s time for legislatures in Massachusetts and other non-NLC affiliate states to provide their residents with the many benefits and lessened vulnerability to disease or disaster that results from joining the NLC.
Roy Pologe is the CEO of Night Nurse Inc. Night Nurse’s staff nurses average eighteen years of clinical experience, and their primary concern is delivering competent, understandable care advice to patients of over 1,500 physicians, clinics, hospitals, and educational institutions. Since 1999 Night Nurse has triaged more than two million patient encounters without incident.
[From the April/May 2014 issue of AnswerStat magazine]