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FAQ - Paramedics/EMTs in the Emergency Department (ED)


Can a RN delegate starting a peripheral IV saline lock to an EMT/Paramedic in the Emergency Department (ED)? Some of the "techs" in our ED are "licensed paramedics" who also work for EMS. What other kinds of tasks can be delegated to Emergency Medical Technicians (EMTs)/Paramedics in the ED setting?

The rules governing EMTs and Paramedics are located in Title 25, Texas Administrative Code, Section 157.2. This rule limits the scope of practice of EMTs/Paramedics to performing duties in the "pre-hospital and inter-facility transport" settings. Therefore, whether certified or licensed, the BON delegation rules view EMTs, Paramedics, or other similarly trained staff as "unlicensed assistive personnel" (UAPs) when working in acute care settings, such as the ED.
Each RN decides on a case-by-case basis what nursing tasks may be delegated to unlicensed personnel in accordance with Rule 224 (relating to RN delegation in acute care settings or for patients with acute conditions). It should be noted that position descriptions developed by employing institutions can neither mandate RN delegation, nor force RN delegation by facility policy or physician order.
The BON's delegation Rule 224 is not prescriptive to specific procedures or tasks that may or may not be delegated. Rule 224 permits a RN to delegate starting a peripheral IV saline lock to an unlicensed person providing all of the delegation criteria are met. The applicable section of Rule 224 in delegating this task is 224.8(b), Discretionary Delegation Tasks, under (2)(A), Sterile Procedures. Section 224.8(c)(5) does prohibit delegation of administration of IV fluids, so an unlicensed tech in the ED could not connect and administer a bag of IV fluid under RN delegation.
Other laws outside of the BON's jurisdiction may prohibit performance of certain tasks by unlicensed personnel, even if a physician is willing to delegate a task. Under physician delegation, the physician must willingly make the decision and delegate the task(s) and such delegation must be permitted by hospital/facility policy. BON staff cannot speak as experts on the Texas Medical Board's (TMB) rules; however, Rule 193 of the TMB Rules addresses "physician delegation." You may wish to contact the TMB at (512) 305-7010, or check their web site at http://www.tmb.state.tx.us for more information on this law.
The delegation rules also address the RN who may be supervising an unlicensed person to whom the physician has delegated tasks. The RN always has a responsibility to protect client safety [217.11(1)(B)], so the RN has a duty to intervene if he/she sees something being done incorrectly by the unlicensed person, and to notify the delegating practitioner of the incident. For additional information on EMTs and Paramedics in the pre-hospital and interfacility transport setting, check the Texas Department of State Health Services web site at http://www.dshs.state.tx.us/emstraumasystems/default.shtm, or, to access applicable laws, see Texas Legislature Online at http://www.capitol.state.tx.us.