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Nurse Anesthetists Say They Practice Safely Without Physician Supervision

Cheryl Clark, for HealthLeaders Media, February 8, 2010

Nurse anesthetists across the country are vehemently defending their ability to administer anesthesia to Medicare patients without physician supervision, saying there's never been a study showing the practice to be unsafe, as alleged by two large physician groups who filed a lawsuit last week.

On the contrary, several representatives of the American Association of Nurse Anesthetists (AANA) say studies have shown that certified registered nurse anesthetists (CRNAs) perform the service with equal safety, or even more safely, than anesthesiologists.

"It's fine for an anesthesiologist to sit in Los Angeles and say this can't go on; but it's another thing to create a policy that says you can't take care of an accident victim until a surgeon wanders in with his glorious presence," says Dan Simonson, a member of the AANA board and a nurse anesthetist and researcher in Spokane, WA.

"This is not about patient safety. It's about access to care," he says.

Nurse anesthetists say that if they were not allowed to independently administer medication to stop pain or cause a loss of consciousness to prepare a patient for surgery, many patients—especially those in rural areas especially would not get emergent care within the time they need it. A supervising physician cannot always be on-site and ready to "immediately [conduct] a hands-on intervention, if needed," as Medicare payment rules require, AANA officials say.

Today, nurse anesthetists in those states give pain relief to women going into labor who may never see a physician. They start sedation for patients undergoing brain surgery, heart operations, and many other procedures, and do so safely, AANA officials add.

The nine-year controversy reverberated nationally last week when the large and influential California Medical Association and the California Society of Anesthesiologists went to San Francisco Superior Court in an effort to rescind the ability of nurse anesthetists to work independent of physician or anesthesiology supervision.

They sued California Gov. Arnold Schwarzenegger, who last year signed a letter to the Centers for Medicare and Medicaid Services "opting out" of the requirement that a physician supervise all CRNAs. In doing so, he joined 14 states—all with large rural populations—whose governors had exercised the opt-out provision, which took effect in 2001. The 14 states are: Alaska, Iowa, Idaho, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin.

The CMA and CSA said in their lawsuit the governor ignored protocol, which their complaint said required him to check with the state's nursing and medical licensing boards, which he did not do.

But their real concern is patient safety, according to CMA General Counsel Francisco Silva.

Former CMA president and San Diego anesthesiologist Robert Hertzka, MD, told HealthLeaders Media last week that nurse anesthetists didn't have sufficient training to practice solo. He said that even in the states that have opted out, hospital policies or medical staffs rarely allow CRNAs to work without a surgeon of physician's presence.

Wanda Wilson, executive director of the AANA, called Hertzka's comments "an insult to the thousands of diligent, responsible, and intelligent" instructors who educate nurse anesthetists, "many of whom are anesthesiologists themselves."

As a practical matter, in California and other states, many CRNA and hospital officials say, Medicare rules are frequently overlooked by rural hospitals because they are so impossible to follow all the time. For example, the Centers for Medicare and Medicaid Services' rules require "supervision" that's "immediately available," but those words have been subject to interpretation.

How close to the nurse anesthetist does the supervising physician, perhaps the anesthesiologist, need to be? Is it OK if he or she is in the building but doing another procedure? What if he or she is in the car, and will arrive in 20 minutes?

Over the years, CMS has tried to narrow down those definitions.

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