SENATE BILL NO. 3278
(First Reprint)
To the Senate:
Pursuant to Article V, Section I, Paragraph 14 of the New Jersey Constitution, I am returning Senate Bill No. 3278 (First Reprint) with my recommendations for reconsideration.
This bill requires that the Commissioner of Health (the “Commissioner”) establish standards and application procedures for an emergency medical technician (“EMT”) to obtain a certification to administer glucose tests and to administer emergency glucagon with an auto-injector device when a patient is experiencing severe hypoglycemia, or low blood sugar, and cannot take sugar orally.
The bill requires that, to receive this certification, a candidate must complete an educational program approved by the Commissioner that includes training in the administration of blood glucose tests and emergency glucagon using an auto-injector device, and that the candidate pass an examination on these subjects. The Commissioner may suspend or terminate the certification if necessary for public health, safety or welfare reasons.
The bill further requires that the Commissioner maintain a publicly available registry of individuals certified to administer blood glucose tests and emergency glucagon using an auto-injector device. The bill provides that a fee may be charged to a person enrolled in an educational program to obtain this certification.
Hypoglycemia is a frequent, serious, and potentially fatal complication of living with and managing type 1 diabetes, the risk of which is increased with insulin therapy. When a person is experiencing hypoglycemia, that person’s blood sugar (glucose) level, has dropped below the standard range, and treatment must be rendered immediately to raise those levels. Glucagon -- a hormone made in the pancreas – helps regulate blood glucose levels and prevents these levels from falling too low. Manufactured forms of glucagon are currently available as an injection or nasal spray and function to raise blood glucose levels in a person experiencing hypoglycemia. After administration, a person’s blood glucose level must be measured again, and thus, the person is typically administered a blood glucose test thereafter.
Glucagon is the only approved treatment for severe hypoglycemia that can be administered by both health care professionals and non–health care professionals. However, although paramedics and advanced emergency medical technicians (AEMTs) are permitted to administer glucagon, many states, including New Jersey, restrict the administration of glucagon by EMTs authorized to administer basic life support. Since 2020, New Jersey has authorized mobile intensive care units to include a crew consisting of an EMT plus a paramedic.
I commend the sponsors for seeking to expand the availability of this life-saving treatment for individuals experiencing severe hypoglycemia. Indeed, some medical experts and recent reviews have suggested that there is an underutilization of the drug in the prehospital setting, and encourage a closer examination of restricting such administration, particularly when glucagon is routinely administered by family members.
While the majority of states currently restrict the administration of glucagon by EMTs, some states, including Alaska, Illinois, Kansas, Minnesota, Montana, Virginia and Wisconsin, as well as Washington, D.C., have recently moved to similarly expanded this authority and currently allow the administration of glucagon by EMTs under certain protocols and processes. Although glucagon administration has typically been excluded from the traditional EMT scope of practice sometimes based on protocols for somewhat more complex, multi-step reconstitution kits, advances in medicine have allowed forms of glucagon that do not require reconstitution and are instead available as ready-to-use, pre-mixed solutions for subcutaneous injection, or autoinjectors, as envisioned by the bill; these forms have been available in the United States since 2019.
This legislation demonstrates the need to be responsive to changes in medicine, particularly those that expand live-saving care, and to do so in a responsible way that promotes the safety of our residents. Because the bill specifies only administration by autoinjector, I am concerned that it might unnecessarily restrict the administration to one form, despite the potential for further medical advances over time. Therefore, I am recommending changes to allow the Commissioner of Health to determine the authorized forms of glucagon, which will at a minimum include the use of an autoinjector device, as other safe mechanisms of administration are available and others may become available in the future. Moreover, rather than statutorily requiring a certification process and examination, which can be administratively and financially burdensome and perhaps unnecessary, I am recommending that the Department of Health have flexibility to determine the appropriate mechanism for authorization of EMTs to administer glucagon and blood glucose testing, including through the issuance of written standards, protocols, or application procedures. This authority will also allow the department to ensure that measures to ensure the safety of glucagon and testing administration, including appropriate training, particularly to address any side effects of glucagon administration that could create additional health hazards, such as choking risks due to vomiting, which may be potentially serious.
Finally, my recommendations provide that the Commissioner may, by standards, protocols or regulation, require EMTs to transfer a patient to an acute care hospital after administration, unless the patient or their legally authorized representative refuses the transfer.
Therefore, I herewith return Senate Bill No. 3278 (First Reprint) and recommend that it be amended as follows:
Page 2, Section 2, Line 23: Delete “and” and insert “, protocols, or”
Page 2, Section 2, Line 25: Delete “certification” and insert “authorization”
Page 2, Section 2, Line 25: Before “administer” insert “independently”
Page 2, Section 2, Line 26: After “tests” insert “, which may include training and authorized forms of glucagon administration”
Page 2, Section 2, Line 26: Delete “The commissioner shall certify a candidate who:”
Page 2, Section 2, Lines 27-31: Delete in their entirety
Page 2, Section 2, Line 32: Delete “test and emergency glucagon using” and insert “, which authorized forms shall at a minimum include”
Page 2, Section 2, Lines 32-33: Delete “, as approved by the commissioner”
Page 2, Section 2, Line 34: Delete “certified” and insert “authorized”
Page 2, Section 2, Line 36: Delete “using an auto-injector device”
Page 2, Section 2, Line 40: Delete “certification” and insert “authorization”
Page 2, Section 2, Line 40: After “an” insert “individual”
Page 2, Section 2, Line 41: Delete “and” and insert “or”
Page 2, Section 2, Line 43: After “welfare.” insert “The commissioner may, by written standards, protocols, or regulation, require the emergency medical technician to transfer the patient to an acute care hospital, unless the patient or their legally authorized representative refuses the transfer.”
Page 2, Section 2, Line 44: Delete “shall” and insert “may”
Page 3, Section 2, Line 1: Delete “certified” and insert “authorized”
Page 3, Section 2, Line 1: Delete “shall” and insert “may”
Page 3, Section 2, Line 4: Delete “certification” and insert “authorization”
Page 3, Section 2, Line 5: Delete “shall” and insert “may”
Page 3, Section 2, Line 6: Delete “certification” and insert “authorization”
Page 3, Section 2, Line 7: After “and” insert “/or”
Page 3, Section 2, Lines 7-8: Delete “using an auto-injector device”
Page 3, Section 2, Line 13: Delete “using an auto-injector device”
[seal]
/s/ Philip D. Murphy
Governor
Attest:
/s/ Kate E. McDonnell
Chief Counsel to the Governor