Canadian Association of Physician Assistants (CAPA)
Response in PDF format:
Nurses are accountable to the CNO and must meet rigorous standards. They are not unregulated. They are highly governed professionals who contribute significantly to patient outcomes. Injecting medications, including neuromodulators and dermal fillers, is not outside the scope of practice for regulated nursing professionals.
Moreover, delegation by regulated Nurse Practitioners is not only appropriate-it's foundational to interdisciplinary care. Undermining this reality with ambiguous policy will only disrupt care and place strain on an already overwhelmed healthcare system. Ontario is facing record wait times, surgery backlogs, and ER closures. Regulatory efforts should focus on system pressures-not micromanaging the work of qualified nurses in collaborative clinics.
Nurses are accountable to the CNO and must meet rigorous standards, including continuing education, documentation, and malpractice insurance. They are not unregulated. They are highly governed professionals who contribute significantly to patient outcomes. Attempts to limit delegation under the guise of 'protecting the public' often mask efforts by select physician groups to monopolize services like aesthetic medicine. This consultation must prioritize patient access, not protectionism.
In addition, delegation has existed for decades in Ontario and is safely implemented in chronic disease management, public health, and home care. This is not a new or experimental model-it is an established and effective approach to care delivery.
Ontario Medical Association (OMA)
Response to Consultation on Delegation of Controlled Acts Policy
In the context of community-based care, delegation plays a vital role in supporting a healthcare system that relies on the collaborative efforts of multidisciplinary teams. The current policy on delegation provides clear and reasonable expectations when applied to regulated healthcare professionals working within their defined scope of practice. In these cases, it offers appropriate guidance to physicians and supports safe, accessible care delivery across various settings.
Nurses, for example, are highly trained, accountable, and governed by strict regulatory standards. Delegating controlled acts to nurses ensures continuity of care, increases system efficiency, and allows physicians to extend care safely through trusted professionals. In the community, where access to primary care may be delayed or limited, this model enables patients to receive timely interventions without compromising safety or clinical standards. For these reasons, I believe the current policy serves its purpose well when applied to the appropriate professionals.
However, I would recommend one significant revision: the policy should explicitly prohibit delegation to individuals who are not licensed to practice in Ontario, regardless of their credentials or licensure elsewhere in the world. Delegation should be reserved solely for regulated health professionals in Ontario—those who are accountable to a governing body and authorized to perform acts within a defined scope. This change would address a current gap in the policy and prevent inappropriate or unsafe delegation practices.
In summary, delegation to regulated professionals is working and should remain status quo across all healthcare sectors, including aesthetics, palliative care, and primary health services. The only necessary refinement is a stricter boundary around who may receive delegation, to protect the public and uphold the integrity of our healthcare system.
Coalition of Aesthetic Medical Practitioners
Medical specialists make play to monopolize Botox industry
Groups representing dermatologists and plastic surgeons banded together to lobby the College of Physicians and Surgeons of Ontario (CPSO) in a thinly veiled bid to monopolize the province's aesthetic injection industry. Here is why we should care. Under our current health care system, responsibility for assuring the safety of all medical treatments and procedures based on solid science falls within CPSO's jurisdiction. That means that the policies and procedures that physicians and nurses must put into practice are informed by real evidence that is both observable and repeatable. It is the very foundation of the scientific method upon which good health care is built. This is as it should be. When the system works as it is intended, it works really well. The trouble is this latest power grab by plastic surgeons and skin specialists offers up absolutely no medical or health-related evidence to support so radical a change to how aesthetic injections and treatments are administered and by whom. Currently in Ontario, general practitioners (GPs), registered nurse practitioners and nurses are all licensed to provide aesthetic injection services to clients. It is a basic but lucrative business for hundreds of doctors and nurses throughout the province. None of these elective treatments and procedures are critical to health, nor are they covered by Medicare. Nonetheless, they are in growing demand, benefiting an industry that prides itself on a decades-long patient safety record. Despite this, Ontario's dermatologists and plastic surgeons have joined forces in an effort to drive GPs and nurses virtually out of the business altogether. By petitioning the CPSO, they aim to change the province's rules governing aesthetic injection, thereby requiring a "specialist" to oversee all such procedures and treatments. The net result would be a highly lucrative monopoly for a relative handful of skin specialists while sacrificing the livelihoods, investments, and growth opportunities of countless skilled GPs and nurses. For the CPSO to bend to this lobby effort is to completely shelve the evidence-based decision-making model that fuels the quality health care Ontarians cherish. This is nothing more than a thin edge of the wedge that can rob our health care system of the integrity that Ontario's doctors and nurses labour daily to preserve and protect. If such decisions are to be no longer guided and disciplined by the rigours of science, where does that leave us? And what of fairness to those who have already invested so much of their own resources and of themselves? The rules governing health care in Ontario, the rest of Canada, and much of the Western Hemisphere were long ago entrusted to physicians — experts on the front lines of medicine. That is the CPSO's lifeblood — its raison d'être. Its authority stems from a covenant between those whom we trust to put our health interests front and centre, and the rest of us — health interests that must always be placed well ahead of money, authority, or political clout. Any measure that weakens that covenant is to tear at the very fabric of the public trust that defines the system. Once that trust is in tatters, what then? The College of Physicians and Surgeons of Ontario will do well to deny specialists their specious claim to exclusive control of the aesthetic injection marketplace. It is misguided, unscientific, unwarranted, and just plain wrong. - Respectfully CAMP (Coalition of Aesthetic Medical Practitioners)
Delegation of controlled acts from physicians to regulated healthcare professionals—particularly nurses—has long been a foundational and effective model across multiple domains of healthcare, not just in aesthetic medicine. This model is supported by peer-reviewed literature highlighting improved access to care, optimized healthcare resources, and safe patient outcomes when delegation occurs within structured protocols and proper oversight (College of Nurses of Ontario, 2020; CNA, 2019).
Nurses operate within a clearly defined scope of practice that includes comprehensive education, clinical training, and rigorous accountability through their regulatory bodies. They are also equipped to recognize and respond to complications, making them well-positioned to carry out delegated medical procedures safely.
The issue at hand is not with competent, regulated professionals, but rather with the growing prevalence of unregulated, unqualified individuals providing care outside the healthcare system. Restricting access to services performed by trained professionals will likely drive patients toward unregulated providers or even black-market alternatives, increasing the risk of adverse events and placing further strain on an already overburdened healthcare system where access to even primary care remains a challenge.
In my own experience working with palliative care patients, I’ve seen firsthand how delegation supports continuity of care. When palliative physicians were no longer able to provide home visits, care was seamlessly transitioned to nurses following an initial assessment by the GP or oncologist. This collaborative model ensured patients continued receiving safe, compassionate care in their most vulnerable moments—without interruption or compromise.
Delegation, when done correctly, enhances safety, preserves access, and supports the healthcare system. Undermining it would jeopardize not only the integrity of care but the very trust patients place in our healthcare model.
Hello,
As a mature member of the public, I have reviewed the discussion, the policy and the advice documents.
The College of Nurses of Ontario and the Ontario Trial Lawyers Association both submitted discussion feedback I agree with.
Considering the significant lack of doctors, nurses and other health care professionals, to recruit and delegate to a qualified, competent health care professional is challenging and critical to safe patient care and ultimate accountability for the doctor who delegates.
With respect to documentation, I wasn’t certain there would be requirement for patient signing informed consent aside from perhaps at a dermatology/aesthetic appointment that may include a waiver to limit liability of the aesthetic staff in event of complication following cosmetic procedure (Botox or other).
Fortunately I have not experienced any adverse events in my health care experience.
Dear CPSO,
Delegation of controlled acts—particularly in medical aesthetics—has long been a safe, effective, and professionally regulated component of healthcare in Ontario. Nurses, including RNs and NPs, are highly trained, licensed, and accountable. Under appropriate medical directives, they routinely administer neuromodulators and fillers, supported by the same training programs and pharmaceutical education as physicians.
Restricting or over-regulating this delegation model would be a step backward. It would reduce patient access, overburden physicians, and do little to improve safety. In fact, by limiting access to qualified professionals, such restrictions may inadvertently drive patients toward unregulated providers—where risk truly exists.
The current concern should not be with regulated nurses practicing under proper delegation, but with illegal activity—unlicensed individuals performing procedures without oversight. The CPSO’s role should focus on strengthening enforcement against those actors, not dismantling a system that works.
Ontario’s healthcare system is already stretched. Forcing physicians to be present for every aesthetic injection is not only impractical but also misaligned with how delegation is successfully implemented in long-term care, palliative care, and community health. Remote oversight with clear directives is already the norm in many settings—and it works.
Effective policy must be guided by evidence, not fear or professional turf protection. Delegation in aesthetic medicine is not a loophole—it’s a legitimate, regulated model that supports access, safety, and system efficiency.
Delegation of controlled acts—such as the administration of neuromodulators and fillers by trained nurses—has been safely and effectively practiced in Ontario for decades. Restricting this would be an unnecessary overreach that limits patient access, overburdens physicians, and disrupts a model that works.
Nurses, including RNs, RPNs, and NPs, are licensed, regulated, and extensively trained. They operate under medical directives, adhere to rigorous clinical standards, and are often the educators teaching these procedures. Delegation in this context is not a safety risk—it’s standard, evidence-based practice.
The real risk lies in unlicensed individuals performing controlled acts illegally. This issue should be addressed through stronger enforcement, not by targeting qualified professionals.
Physicians are best used where they’re needed most: ERs, ORs, and primary care. Forcing them into aesthetic clinics undermines system efficiency and restricts access to elective services that nurses are fully capable of providing under proper oversight.
Delegation is a cornerstone of modern healthcare. It works safely across multiple settings and should not be selectively restricted in aesthetic medicine. The CPSO should focus on preventing illegal practice—not dismantling a regulated, proven model of care.
Delegation is essential in today’s healthcare climate. With increasing wait times and a shortage of physicians, the system is under significant strain. Empowering qualified nurses to take on more responsibilities is not only practical—it's critical. Nurses are accountable professionals who meet rigorous education, licensing, and continuing competency standards.
Multiple studies have shown that delegation to trained nurses leads to high patient satisfaction without increasing the risk of adverse outcomes. In many cases, these professionals undergo more focused training than physicians in specific areas, particularly in medical aesthetics, where procedures like Botox and dermal fillers require both technical skill and a nuanced understanding of facial anatomy.
Specialized nurses are certified, licensed, insured, and governed by regulatory colleges. They practice with oversight, standards of care, and a deep commitment to patient safety. There is no credible evidence suggesting these roles must be physician-exclusive. On the contrary, the evidence supports that nurses can—and do—perform these procedures safely and effectively.
Where is the evidence to support the notion that only physicians should perform aesthetic procedures? It doesn’t exist. What does exist is a growing body of evidence that supports interdisciplinary models of care, where each professional practices to the full extent of their training and licensure.
CPSO
Thank you for giving us the opportunity to review.
At this time Ontario has record wait times in emergency rooms, wait list for surgery or specialist.
I can't see a positive to pulling our physicians, plastic surgeons and dermatologists who serve a vital purpose in managing complex and often life-threatening conditions-like reconstructive surgery, cancerous lesions, and autoimmune disorders to micro-manage qualified nurses.
This consultation must prioritize patient access.
Thank you.
Let’s call this what it is: a blatant attempt to strip back the authority of highly trained, experienced nurses under the false flag of “public protection.” RNs, RPNs, and NPs have spent 10, 20, even 30+ years working on the front lines of Ontario healthcare—delivering safe, regulated, compassionate care long before it was trendy or profitable.
These aren’t just roles—they’re lives. People who have built careers, opened clinics, and helped thousands of patients, especially in underserved areas where doctors were never present.
Now, under the pretense of safety, we’re watching efforts to restrict their scope—not because there’s a problem with the care they provide, but because certain physician groups want to protect their financial turf in aesthetic medicine.
This isn’t about patient safety—it’s about power, greed, and control. And it’s shameful.
If we care about public health, we need to protect access to care, not limit it. This consultation should be focusing on supporting the professionals who’ve earned their place—not sidelining them for profit.
Thank you for the opportunity to review the Delegation of Controlled Acts Policy.
Delegation is an essential component to allow better access of care for patients and promote patient safety whether in a hospital setting or in an independent practice.
I was a nurse injector in Ontario for 32 years. 24 of those years were with a plastic surgeon within the office setting. The remaining 8 years was an independent practice under the supervision of a Physician and/ or Nurse Practitioner.
To inject a substance below the dermis is a controlled act authorized to nurses but may only be performed when delegated by an authorized prescriber, and after a therapeutic relationship has been established between the client, prescriber and the nurse.
Prior to performing the controlled act the nurse must be competent - have the knowledge, skill and judgement to perform the process and to manage potential negative outcomes.
This is outlined to the CNO practice standards 'Medications' and 'Scope of Practice'. Nurses continue this competency but furthering their education by attending conferences, seminars, webinars and collaborating with like minded colleagues.
Nursing is a self regulated profession. We are accountable to our college by strictly adhering to Practice Standards and Guidelines, Code of Ethics and Public Health Infection Prevention Control (not an all inclusive list)
I did not feel that my patients were 'safer' while being treated in a physicians office compared to a practice where the NP/MD was always accessible when needed. Competency with ongoing evidence-based education, authorization, evaluation of treatment outcomes and adjusting the plan when necessary will ensure the safest treatment and outcomes for the patient. In my opinion, having the physician on-site will not change the level of care the patient receives.
Submitted with respect.
Ontario is facing record wait times, surgery backlogs, and ER closures. Regulatory efforts should focus on system pressures-not micromanaging the work of qualified nurses in collaborative clinics.
Multiple studies have shown that delegation to trained nurses results in high patient satisfaction and no increase in adverse events. There is no clinical evidence suggesting that restricting delegation improves safety outcomes in outpatient or aesthetic settings.
This consultation must guard against becoming a battleground for professional turf wars fueled by greed. Restricting delegation would not protect patients- it would reduce access, increase wait times, and remove qualified providers from roles they are fully capable of performing under the guise of 'protecting the public'. This is NOT protecting the public, this is an effort by select physician groups to monopolize services like aesthetic medicine. This consultation must prioritize patient access, not protectionism.
Patients deserve choice. The system deserves efficiency. Let's not let a small but vocal group undermine both.
Ontario Trial Lawyers Association (OTLA)
College of Nurses of Ontario (CNO)
Thank you for the opportunity to review and provide feedback on the Boundary Violations policy, the Delegation of Controlled Acts policy and Advice to the Profession companion documents. Overall, we found the documents to be clear, comprehensive and relevant. The information shared in all documents provide important accountabilities for physicians that will serve to protect the public from harm.
Please see below considerations that may support your update of these resources.
Delegation of Controlled Acts policy
Our feedback relates to footnote 9 in the policy which states “Examples of appropriate circumstances in which delegation may occur in the absence of a traditional physician-patient relationship include but are not limited to…the provision of primary care in remote and isolated regions of the province by registered nurses acting in expanded roles”.
The language “expanded roles” is not in line with CNO’s language and classes of registration. We recommend removing this language. All Registered Nurses (RNs) have the same legislated scope of practice and, regardless of setting, are expected to use appropriate authorizing mechanisms which may include delegation. The clearest language would be “…the provision of primary care in remote and isolated regions of the province by registered nurses or registered practical nurses” since the use of delegation is not limited to RNs. This language also creates confusion with Nurse Practitioners who are referred to as registered nurses in the extended class, but they can autonomously order and perform many of these controlled acts and would not need delegation.
Thank you for the opportunity to review.
Delegation of controlled acts is an essential component of Ontario’s healthcare system, allowing regulated healthcare professionals to provide safe and efficient patient care while alleviating the burden on physicians and the system as a whole. When appropriately implemented, delegation ensures that qualified professionals can work to the full extent of their scope of practice, maximizing access to care without compromising patient safety.
The current policy correctly stipulates that only authorized regulated health professionals may perform controlled acts. However, the primary area that requires revision is the delegation of these acts to individuals who are not licensed to practice in the province or in the country or to non-regulated individuals. Physicians should only delegate to professionals who are licensed and regulated by their respective colleges, ensuring that standards of care, accountability, and professional oversight are upheld. Allowing delegation to unregulated individuals or those who are not licensed within Ontario poses risks to patient safety and undermines the integrity of the regulatory framework.
It is also concerning that there appears to be a targeted effort by certain individuals to use this consultation as a means to impose stricter regulations specifically on medical directors “delegating” neuromodulator treatments to nurses in cosmetic medicine. The practice of medical aesthetics is predominantly led by nurses, who have been safely and effectively administering these treatments for years. Those advocating for tighter restrictions seem to be doing so for financial gain rather than for patient safety, attempting to shift control away from experienced providers. It’s important to note that delegation, as defined by the CPSO, occurs only when a physician directs an individual to perform a controlled act that the individual has no statutory authority to perform. Therefore, when nurses perform controlled acts that are within their scope of practice, such as administering neuromodulators under an appropriate order, this does not constitute delegation. The CPSO’s policy states: “Delegation does not include… orders that authorize the initiation of a controlled act that is within the scope of practice of another health care professional (e.g., nurses are legally authorized to ‘administer a substance by injection’ when the procedure has been ordered by a specified regulated health professional).” This distinction is crucial to prevent misinterpretation of the policy in contexts like medical aesthetics, where nurses have been safely and effectively providing care within their professional scope for years.
Restricting delegation or enforcing physicians to be on site for neuromodulator injections would force physicians to leave their practices to administer these treatments themselves, further straining an already overwhelmed healthcare system. The current framework allows for safe, regulated, and efficient care, and any changes should focus on preventing delegation to unregulated individuals rather than disrupting an established and effective system.
I urge the CPSO to maintain strong support for delegation within this framework while tightening policies around delegations to unlicensed or non-regulated individuals.
While delegation of tasks can help reduce pressure on the health care system, it has to be done carefully not to erode the trust in physicians. In my opinion, delegation of tasks is unsafe for an initial consultation and for any procedure including Botox injection. Except for answering patient phone calls, any other delegated task should only be allowed when the physician is physically present. The patient should be informed up front that they can request a direct physician contact at any point of the delegated task if they feel necessary.
I have reviewed the policy and as is typical for the CPSO it is very well written and comprehensive as a no retired family physician who practised family medicine, obstetrics and addiction medicine for 30 years I worked very closely with RNs, NPs and PAs. The addition of two PAs to my practice kept me in practice five years beyond the point where I would have retired without their assistance. I believe strongly you get out of it what you put into their training and my only question would be around the issue of psychotherapy. I am familiar with the PA who has an undergraduate and post graduate degree in clinical psychology and counseling, should this person not be allowed to do psychotherapy when in fact significant amounts of psychotherapy you're done by social workers and other allied health professionals with far less training.
The feedback from my patients regarding their interactions with a physician assistants was almost universally positive and in spite of my very explicit instruction that they were physician assistants and not physicians, and that I have the ultimate responsibility for their actions, the point was often lost on the patients.
I am a huge believer in the benefits of team-based care and think that position extenders are critical to preventing further burned out by primary care providers and specialists a like.
Kudos on another clear and concise policy.
Professional Association of Residents of Ontario (PARO)
Dear CPSO Policy Department,
Thank you for the invitation to provide feedback on the CPSO Delegation of Controlled Acts policy draft.
We have reviewed the document and overall find it to be thorough and provide clear direction. We have no further feedback to provide at this time.
We once again appreciate being included in the CPSO's consultative process.
While patient safety and regulatory oversight are paramount, restricting the delegation of controlled acts—such as Botox injections—would be an unnecessary overreach that undermines a system that has functioned safely and effectively for decades. Highly trained and experienced nurse injectors, such as Nurse Practitioners (NPs) and Registered Nurses (RNs) (RPNs) under proper delegation, have been safely performing aesthetic procedures across Canada and worldwide for years.
Physicians play a critical role in the healthcare system, but their expertise is best utilized in high-acuity settings such as the OR, ER, and primary care clinics. The idea that a doctor must be directly involved in every aesthetic procedure is not only impractical but also detracts from their ability to provide urgent and necessary medical care. Aesthetic medicine, while important to patient well-being and confidence, is an elective service that does not require a physician’s constant presence—especially when trained nurses can perform these treatments competently under proper delegation.
The concerns raised regarding unlicensed practitioners and improper delegation should be addressed through better enforcement of existing regulations, rather than a blanket restriction on delegation itself. It is critical to distinguish between unqualified individuals performing procedures illegally and licensed healthcare professionals operating within their regulated scope of practice. The latter group has extensive education, clinical training, and ongoing certification requirements to ensure safe and effective patient care no different than the education that MD’s have. Nurses attend the same cadaver labs, the same conferences, receive the same training by pharmaceutical companies, and attend the same educational webinars, and often are the ones that are the clinical educators that represent the major Pharma companies that teach everybody how to inject neuromodulators and filler.
By preventing or restricting delegation in aesthetics, Ontario risks overburdening its already stretched physician workforce and limiting patient access to safe, medically supervised cosmetic treatments. The focus should be on improving accountability, ensuring compliance with existing regulations, and cracking down on illegal practices—not restricting a well-established, safe, and efficient system that has benefited both patients and the healthcare system for decades.
As a Registered Practical Nurse in Ontario with several years of hands-on experience in the aesthetic industry specifically in the administration of neuromodulators (e.g., Botox) and dermal fillers, I firmly believe that nurses (RPNs, RNs, and NPs) possess the knowledge, skill, and clinical judgment necessary to safely and effectively provide these treatments under a medical directive or direct order.
Nurses are extensively trained in anatomy, pharmacology, and clinical best practices, and we continue to update our competencies through ongoing education and hands-on training. In aesthetic medicine, patient safety and outcome quality are paramount and nurses have consistently demonstrated their ability to uphold these standards.
Restricting nurses from performing aesthetic injections not only undervalues our professional capabilities, but also places additional strain on physicians, diverting their attention from more complex clinical responsibilities where their expertise is most needed. Nurses have been leading the way in aesthetic practices for many years, often serving as the first point of patient contact and maintaining long-term care relationships that support safety and satisfaction.
Rather than limiting the scope of nurses in this field, healthcare policy should recognize and support the collaborative model where nurses and physicians work together to provide accessible, high-quality aesthetic care to patients.
I agree with the comment stating the application of this policy is misused in aesthetic medicine.
Medical Directors should have the necessary qualifications and commitment to delegate these procedures to those they oversee. It is far too common to see medical directors who are completely absent or completely unaware of what they are overseeing. Combined with a complete lack of standard of care or assessment of competence for these procedures, patients are at risk of serious complications including vascular occlusions and scarring.
As physicians we must uphold a certain standard of care, safety and practice, which is not being met.
I also urge the CPSO to implement stronger safeguards to prevent the inappropriate use of delegation, particularly in non-essential and elective procedures.
While the intent of this policy is to improve access to care when resources are limited, its application has been increasingly misused, particularly in the aesthetic medicine sector.
There is a growing trend of businesses exploiting this framework for financial gain by allowing unlicensed foreign-trained healthcare professionals—who have no recognized credentials or licensure in Ontario—to perform controlled acts such as neuromodulator and filler injections, minor surgical procedures, and lesion excisions. This raises serious concerns about patient safety and the integrity of medical practice.
I was recently called for a patient who suffered significant bleeding following a lesion excision performed by an unlicensed individual (IMG). When I requested a formal referral, I discovered that the individual was acting under the delegation from a family physician who had no involvement in the patient’s care and was unable to issue a referral. This incident highlights the dangers of loosely regulated delegation and the potential harm to patients.
This issue is particularly prevalent in private-pay services such as non-OHIP-covered mole removals and medical aesthetic treatments. Stricter oversight is needed to ensure that delegation is not used as a loophole to circumvent proper licensure and regulatory standards. I urge the CPSO to implement stronger safeguards to prevent the inappropriate use of delegation, particularly in non-essential and elective procedures.
We need to allow for more video/virtual contact for the definition of patient relationship as this can often be the only contact for patients in the far north at nursing stations where the attending physician cannot be local and cannot know the patient Beforehand. And this can apply to other scenarios and should be equivalent over all platforms.
We are moving in a digital age and that implies that new technologies should have defined allowance. If a competent nurse is able to provide a controlled act under my guidance or order, I should be able to delegate over video/phone after speaking at least with the patient. It often happens to me when working in the far north, so should be applicable even in the south.
Note: Some content has been edited in accordance with our posting guidelines.
I am a physician and researcher at [redacted]. [redacted]. My expertise is in the role of community health workers, delegation of healthcare services to improve community health, and first aid for underserved communities.
I am writing to provide feedback on the Delegation of Controlled Acts consultation. Specifically, I would like to add comments to footnote 9, and recommend that it be edited as seen below.
I would be happy to discuss the rationale and benefit of these changes.
Thanks,
9. Generally, a patient’s best interests will be served by delegation that occurs in the context of an existing or anticipated physician-patient relationship. However, in some instances a patient’s best interests might be served by receiving care in the absence of a conventional physician-patient relationship. For example, in instances where access would otherwise be compromised to the point of risking patient safety, or where patient or public safety might be otherwise compromised. Examples of appropriate circumstances in which delegation may occur in the absence of a conventional physician-patient relationship include, but are not limited to:
the provision of care by paramedics under the direct control of base hospital physicians or within community paramedicine programs;
the provision of primary care addressing the needs of underserved populations such as in remote and isolated regions of the province by registered nurses acting in expanded roles;
the provision of public health or population-based programs, such as vaccinations, tobacco cessation, harm reduction interventions, or communicable disease screening;
postexposure prophylaxis following potential exposure to a blood borne pathogen or the provision of vaccines in the context of occupational health;
hospital emergency departments for routine protocols;
lay person first responders performing controlled acts for the purposes of care within the scope of first aid;
administration of over-the-counter medications or products otherwise approved for use by the general public.