Controlled Acts Authorized to Respiratory Therapists
Controlled Acts Authorized to RTs
The Respiratory Therapy Act (RTA) is the profession-specific legislation that lists the five controlled acts authorized to Respiratory Therapists (RTs)* in Ontario. These five controlled acts are referred to as the profession’s authorized acts** and are as follows:
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.
4. Administering a substance by injection or inhalation.
* In this practice guideline, “Respiratory Therapists (RTs)” refers to CRTO Members who hold an Active General Certificates of Registration with the CRTO with no terms, conditions or limitations preventing them from performing any authorized acts. Graduate Respiratory Therapists (GRTs) and Practical (Limited) Respiratory Therapists (PRTs) have specific terms, conditions and limitations that are outlined below.
** All five authorized acts may be performed on adult, pediatric and neonatal populations.
Authorized Act #4 enables RRTs, PRTs & GRTs to perform all procedures that fall under the authorized act Administering a substance by injection or inhalation, provided they have a valid order.
Authorized Act #5 enables only RRTs to administer a substance that is “prescribed” in regulation. In this case, the regulation is the Prescribed Substance Regulation and the substance is oxygen. This authorized act does not have the requirement of an order. Therefore, an RRT can independently administer oxygen, provided they are not prevented from doing so by any other piece of legislation or polices. More information can be found on this act in the Administering a prescribed substance by inhalation section of this practice guideline.
Authorized Acts #1
Performing a prescribed procedure below the dermis
In this first authorized act, “prescribed” means prescribed in regulation. The Prescribed Procedures Regulation lists the specific procedures included under the controlled act of “performing a prescribed procedure below the dermis” and separates them into two categories: basic and advanced. Table 1 outlines what procedures are contained within the regulation and provides some examples of specific procedures. Please note that the list of examples is not exhaustive and is offered simply as a point of clarification.
Table 1: Prescribed Procedures below the Dermis
|i. Arterial, venous, and capillary puncture.||● Arterial Blood Gas|
|ii. Insertion, suturing, aspiration, repositioning, manipulation and removal of an arterial cannula.||● Arterial line|
|iii. Insertion, suturing, aspiration, repositioning, manipulation, and removal of a venous cannula.||● Peripheral IV
● Internal Jugular Vein cannulation
|i. Manipulation or repositioning of a cannula balloon.||● Pulmonary Capillary Wedge Pressure (PCWP)
● Intra-Aortic Balloon Pump (IABP)
|ii. Chest needle insertion, aspiration, reposition, and removal.|
|iii. Chest tube insertion, aspiration, reposition and removal.|
|iv. Bronchoscopic tissue sample for the purpose of bronchoalveolar lavage and endobronchial brushing.*|
|v. Intraosseous needle insertion.|
|vi. Subcutaneous electrode placement for interoperation and perinatal fetal monitoring.|
Specific Requirements for Performing Prescribed Procedures below the Dermis
To perform any procedure classified as Advanced, a Registered Respiratory Therapist (RRT) must have completed a CRTO approved certification/recertification program within the past two years. More information is available in the CRTO’s Certification Programs for Advanced Prescribed Procedures below the Dermis PPG.
Graduate Respiratory Therapists (GRTs) and Practical Respiratory Therapists (PRTs) must not perform any procedure classified as Advanced, even if they have successfully completed an approved certification program.
PRTs must not perform any procedure classified as Basis unless they have been granted to do so by the CRTO’s Registration Committee (i.e., have specific terms and conditions applied to their certificate of Registration).
Table 2: Procedures Below the Dermis & Tracheostomy Tube Changes
|Basic Prescribed Procedures||✓||✓||**|
|Advanced Prescribed Procedures||✓|
** PRTs are only able to perform tracheostomy tubes change for a stoma that is more than 24 hours old if explicitly permitted to do so by the terms and conditions of his/her certificate of registration.
The insertion of spinal, epidural blocks and peripheral nerve blocks are not authorized under the current Prescribed Procedures regulation; therefore, delegation is required. The injection of medication through these routes; however, falls under “administering a substance by injection or inhalation”, which is authorized to RTs.
Authorized Acts #2
Intubation beyond the point in the nasal passages where they normally narrow or beyond the larynx
The second controlled act authorized to RTs is intubation beyond the point in the nasal passages where they normally narrow or beyond the larynx. “Beyond the larynx” is interpreted by the CRTO as at or below the level of the larynx, whether you are referring to the airway or the esophagus, including access by oral, nasal, and artificial
Examples of tasks an RT can perform under this authorized act are:
Endotracheal intubation, including nasal and oral routes, as well as bronchoscopic assisted techniques;
Laryngeal mask insertion;
Nasogastric tube insertion and the insertion of specially designed nasogastric tubes with EMG electrodes that cross the diaphragm for the purpose of Neurally Adjusted Ventilatory Assist (NAVA);
Nasal airway insertion; and
Feeding tube insertion.
Authorized Acts #3
Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx
The third controlled act authorized to RTs is suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx. Beyond the larynx is interpreted as at or below the level of the larynx, whether you are referring to the airway or the esophagus, including access by oral, nasal, and artificial opening routes.
An RT may perform suctioning via a number of routes, including nasopharyngeal, tracheal, nasogastric, and bronchoscopic. The RTA does not require an order for this authorized act; however, other pieces of legislation may have an impact on whether or not an order is required (e.g., Public Hospitals Act – Hospital Management Regulation). In addition, an RT must comply with their employer’s policies and procedures regarding suctioning.
Authorized Acts #4
Administering a substance by injection or inhalation
The fourth controlled act authorized to RTs is administering a substance by injection or inhalation.
1. Under this act, an RT may administer a substance by inhalation in the following forms:
- Liquids (e.g., surfactant, epinephrine instillation)
- Powders (e.g., Turbuhaler™, Diskus™)
- Aerosols (e.g., wet nebulization, bronchodilators, narcotics, antibiotics, bronchoprovocators (e.g., Methacholine))
- anesthetic (e.g., Nitrous oxide)
- non-anesthetic (e.g., Oxygen, Heliox, Nitric Oxide, Compressed Air)
- specialized (e.g., Carbon Monoxide, Helium, Nitrogen)
- pressurized (e.g., invasive and non-invasive positive pressure ventilation – including CPAP, BiPAP, Hyperbaric Oxygen Therapy)
- Vapors (e.g., anesthetic agents such as Isoflurane)
2. Under this act, an RT may administer substances by injection via the following routes:
- Intravascular (e.g., Intravenous D5W, Normal Saline, Ringers Lactate, blood products)
- Intramuscular (e.g., Vaccines, Vitamin K, Narcan, Epinephrine)
- Intradermal (e.g., TB test)
- Sub-cutaneous (e.g., Xylocaine, Heparin)
Non-Invasive Positive Pressure Ventilation (NIPPV)
It is the position of the CRTO that air that has been augmented, whether by changing the concentration of the constituent gases (e.g., adding oxygen) or by adjusting the pressure beyond atmospheric, constitutes “administering a substance by…inhalation”. Therefore, the application of NIPPV is a controlled act and should only be performed by health care professionals who have the statutory authority (4th authorized act in the Respiratory Therapy Act) as well as the requisite education, training and clinical competence.
Vaccines administered by RTs must only be those recommended in established guidelines (e.g.,ATS, CTS) for the management of cardiorespiratory and associated disorders (e.g., COVID, Influenza, Pneumococcal Pneumonia).
Authorized Acts #5
Administering a prescribed substance by inhalation
The Prescribed Substances Regulation currently lists oxygen as the substance that RTs can administer. RRTs, PRTs & GRTs have always been able to – and still are able to – administer oxygen on the order of a physician, midwife, dentist or nurse practitioner. The difference with the 5th authorized act is that, similar to suctioning, it does not have the requirement of an order. This means that RRTs, depending on where they work, can independently initiate, titrate or discontinue oxygen-based solely on their own professional judgment. Please note that this authorized act only applies to RRTs.
It is important to understand, however, that there are other pieces of legislation and policies that limit where RTs can independently administer oxygen. The most applicable piece of legislation, in this instance, is the Public Hospitals Act – Hospital Management Regulation, which stipulates that every act performed in a public hospital requires an order and limits who can provide those orders. However, this restriction does not apply to non-public hospital/community practice settings (e.g., Home Care, Family Health Teams, private community-based clinics, etc.).
In addition, the Home Oxygen Therapy Policy and Administration Manual (October 2019) currently stipulates that the initiation and discontinuation of oxygen must be ordered by a physician and that any changes to the prescription are the responsibility of the ordering physician.
An RRT working in the community who has been asked to provide oxygen to a patient who is self-paying for the therapy. In this situation, the RRT may initiate, titrate and/or discontinue therapeutic oxygen based solely on their own professional judgement. The RRT must make their own determination on the patient’s oxygen settings and set their own fee structure. As with any situation when charging for clinical services, the RRT will need to ensure that:
- the therapy is clinically indicated;
- they are not in a conflict of interest;
- the patient is making a fully informed decision on their course of care; and
- they are charging a fair and reasonable rate for their services*.
* Currently, RRTs do not have the ability to bill OHIP for services.
Hyperbaric Oxygen Therapy (HBOT)
The 5th authorized act, in combination with the Prescribed Substances regulation, permits RTs to independently administer therapeutic oxygen. Therefore, in a hyperbaric clinic located outside of a hospital, RRTs can administer oxygen without the additional requirement of an order from a physician or other authorizer. However, this administration of oxygen must occur in accordance with a diagnosis and prescribed treatment plan (e.g., dive depth/pressure, time, etc.) that has been determined by the most responsible physician. RRTs cannot independently initiate hyperbaric therapy.
In both the hospital and community setting, certification as a Hyperbaric Technologist by the Undersea and Hyperbaric Medical Society (UHMS) sets the industry standard and that any RRT administering HBOT would be expected to perform to. In the Oxygen Therapy CBPG, the CRTO outlines the list of 14 indications for hyperbaric oxygen therapy that are established by the UHMS. Health Canada supports the application of HBOT that is based on the UHMS guidelines and warns against “off label” uses that have not been scientifically proven to be effective. Therefore, the CRTO does not endorse “off label” use of HBOT and the engagement of an RT in such activity by an RT may be considered professional misconduct (Professional Misconduct Regulation (s.7) – Recommending, dispensing or selling medical gases or equipment for an improper purpose). In addition, the CRTO’s Standards of Practice states that RTs must refrain from making a representation about a remedy, treatment, device or procedure for which there is no generally accepted scientific or empirical basis. (Standard 8 – Evidence Informed Practice)
Considerations when Performing Authorized Acts
When determining if it is appropriate to perform an authorized act, an RT must first consider the following:
Is the performance of the authorized act in the best interest of the patient?
Do they possess the requisite competencies (knowledge, skills & abilities) to perform the authorized act safely?
Is the performance of this particular task within the Scope of Practice of Respiratory Therapy?
Does their Certificate of Registration permit them to perform it (i.e., do they hold the appropriate certificate of registration required, and are there any terms, conditions, or limitations on their Certificate of Registration preventing them from performing this task?)
Is an Authorizing Mechanism (Direct Order or Medical Directive) required to perform this authorized act, and, if so, do they have a valid order (direct order or medical directive) from an authorized prescriber?