Nurse Anesthetists

From The Floor

Nurse Anesthetists

The controversy surrounding physician supervision of CRNAs

By Genevieve M. Clavreul, RN, Ph.D.
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I once asked an anesthesiologist I knew to explain his area of expertise in as few words as possible. “To bring the patient to the brink of death and back again,” he replied. A scary thought, perhaps, but in many ways an apt description of what anesthesiologists and nurse anesthetists do for their patients.

Over the past decade, the question of who should be allowed to perform that task has become the center of a political and legal firestorm, sparked by a 2001 rule implemented by the Centers for Medicare & Medicaid that can allow nurse anesthetists to administer anesthesia without a doctor’s supervision.

Then and Now
The nurse anesthetist is one of the oldest nursing specialties in the United States. According to the American Association of Nurse Anesthetists (AANA), nurses have been providing anesthesia care in the U.S. for nearly 150 years, going back as far as the American Civil War. The first recognized specialist nurse anesthetist was Sister Mary Bernard, a Catholic nurse who practiced in the late 1870s at St. Vincent’s Hospital in Erie, Pa.

Today, the nurse anesthetist, also known as the certified registered nurse anesthetist (CRNA), is one of four recognized advanced practice nurse (APRN) certifications, the others being nurse practitioner, certified nurse midwife and clinical nurse specialist. CRNAs are the third largest of those practice areas: According to the results of a national survey released in September 2010 by the U.S. Department of Health and Human Services, there were an estimated 34,821 nurse anesthetists in the United States in 2008, up 7.1 percent from 2004.

The same survey reports that CRNAs are also the highest-paid of all APRNs, with an average annual salary of $135,776, and the most satisfied with their jobs, with 93.5 percent reporting being moderately or extremely satisfied with their work.

However, the role of the nurse anesthetist has changed a great deal in recent decades. Prior to World War II, the delivery of anesthesia was considered primarily a nursing function, with an estimated 17 nurse anesthetists for every anesthesiologist. The 1960s saw anesthesiologists greatly expand their specialty, while a new legal distinction was established between anesthesia delivered by a nurse anesthetist (which was deemed nursing practice) or by a physician or dentist (which were deemed to be the practice of medicine or dentistry). Since then, CRNAs have fought — both individually and as a group — to defend their ability to provide anesthesia, with or without physician supervision.

Physician Supervision
In November 2001, the Centers for Medicare & Medicaid (CMS) instituted the anesthesia care rule, which allows states to opt out of a federal requirement that CRNAs at Medicare-participating hospitals administer anesthesia only with physician supervision.        

Under the new rule, individual governors may elect to opt out of the requirement if they determine that doing so would be in their citizens’ best interests. The governor is required to consult with the state’s boards of medicine and registered nursing before deciding, but as long as opting out doesn’t violate state law, the final decision is the governor’s.

At present, 16 states have taken advantage of the anesthesia care rule. The Oct. 26, 2010 issue of Becker’s ASC Review included the following list of states that have opted out and the dates of each decision:

1.    Iowa (December 2001)
2.    Nebraska (February 2002)
3.    Idaho (March 2002)
4.    Minnesota (April 2002)
5.    New Hampshire (June 2002)
6.    New Mexico (November 2002)
7.    Kansas (April 2003)
8.    North Dakota (October 2003)
9.    Washington (October 2003)
10.    Alaska (October 2003)
11.    Oregon (December 2003)
12.    Montana (January 2004)
13.    South Dakota (March 2005)
14.    Wisconsin (June 2005)
15.    California (June 2009)
16.    Colorado (September 2010).

Why are states electing to opt out of this requirement? In most cases, the rationale is that a large percentage of the state’s hospitals rely solely or primarily on nurse anesthetists to provide anesthesia care. In many areas, particularly in rural communities, there simply aren’t enough doctors to go around, much less specialists like anesthesiologists, which makes the supervision requirement impractical.

Controversy Boils Over
Allowing states to opt out of the requirement for physician supervision of CRNAs has been controversial, to say the least. In states that have opted out or are considering opting out, various hospital and physicians’ groups have actually gone to court in an attempt to block or overturn those decisions.

In California, no sooner had Gov. Schwarzenegger informed CMS of his decision to opt out than the California Society of Anesthesiologists (CSA) and the California Medical Association (CMA) filed a motion intended to force the governor to withdraw the letter. A lower court denied that motion in October 2010, but the CSA and CMA appealed the matter all the way to the California Supreme Court, supported by an amicus brief from the AMA Litigation Center. In June 2012 the Supreme Court refused to hear the case, allowing the lower court’s decision to stand. Opponents’ only recourse now would be for Gov. Brown to reverse his predecessor’s decision (as briefly happened in Montana in 2005) or for the Legislature to rewrite state law to mandate physician supervision of anesthesia.

In Colorado, where Gov. Bill Ritter opted out of the federal requirement in September 2010, the Colorado Society of Anesthesiologists and the Colorado Medical Society promptly sued the state, arguing that the governor’s decision would endanger patients. After a nearly two-year battle, a Colorado appeals court ruled in July that anesthesia was a nursing function, not a delegated medical function, and therefore does not require a doctor’s supervision under current Colorado law.

Conflict of Interest?
Adding fuel to the fire are two 2010 studies conducted by the Lewin Group and the Research Triangle Institute (RTI).

The Lewin study, published in the May-June 2010 issue of The Journal of Nursing Economics, examined the cost effectiveness of various anesthesia delivery models and found that anesthesia administered by a CRNA acting as the sole anesthesia provider was fully 25 percent less expensive than the next cheapest model.

The RTI study, written by Brian Dulisse and Jerry Cromwell and published in the August 2010 issue of Health Affairs, used Medicare data to compare patient outcomes in states that opted out of the supervision requirement with those in states that had not. After examining almost 500,000 cases between 1999 and 2005, the authors concluded that there was no significant difference in patient outcomes for anesthesia administered by an anesthesiologist, a physician-supervised nurse anesthetist or an unsupervised CRNA.

The American Society of Anesthesiologists (ASA), which strenuously opposes allowing CRNAs to practice without physician supervision, has dismissed those studies as biased and inherently flawed, since both were funded by the AANA and based on Medicare billing records, rather than clinical data. The ASA’s official statement, released Aug. 5, 2010, was particularly scathing toward the Health Affairs paper, calling it “an advocacy manifesto masquerading as science.”    

Jerry Cromwell, one of the authors of that paper, retorted in a letter to the editor in the November 2010 issue of Health Affairs that even the federal Agency for Healthcare Research and Quality now uses Medicare discharge abstracts to examine patient outcomes and safety. As for the charges that a study being funded by the AANA constitutes a conflict of interest, Abby Hitchcock of the healthcare blog American Healthcare remarks, “If we dismiss the research on this topic that’s funded by the AANA or the ASA, there’s not much left.”

The Faithful Handmaid?
As CRNAs advance their profession, they will undoubtedly continue to face challenges from physicians, particularly anesthesiologists. That battle has raged at least since the end of the 19th century. An article in the July-December 1896 issue of The Practitioner, a Journal of Practical Medicine contains this telling quote: “Anesthesia was born a slave; and she has ever remained the faithful handmaid of her master surgeon.” That antiquated sentiment remains at the root of the debate to this day. In that sense, CRNAs have fought long and diligently to free anesthesia from its bonds, a struggle that is unlikely to be resolved anytime soon.

Fortunately, strides continue to be made and there is a growing recognition that the CRNA can and does provide safe anesthesia to the patients under his or her care — as well as providing an important safety net for rural and medically underserved areas where physicians are few and far between.

In many ways, the role of the CRNA is coming full circle. Once, anesthesia was practically the sole domain of the nurse; today, the CRNA is returning to a role of prominence. Time will tell if anesthesiologists will ever allow CRNAs to attain an entirely equal status when it comes to administering anesthesia. Either way, it is crucial that whichever specialty administers anesthesia — be they physicians or CRNAs — is thoroughly trained, highly educated and fully competent in the risky but vital function of taking us to the brink of death and back.  

Geneviève M. Clavreul RN, Ph.D., is a healthcare management consultant who has experience as a DON and as a lecturer on hospital and nursing management.

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