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A proposal from the Department of Veterans Affairs (VA) would allow full practice authority for advanced practice registered nurses, including certified registered nurse anesthetists (CRNAs). If enacted, the proposal would allow CRNAs to practice without physician supervision at VA facilities, regardless of state or local law.
The West isn’t the only place experiencing firestorms. A just-published proposal from the Department of Veterans Affairs (VA) to allow full practice authority for advanced practice registered nurses (APRNs), including certified registered nurse anesthetists (CRNAs), has ignited a battle with the American Society of Anesthesiologists over whether CRNAs should be allowed to practice without physician supervision at VA facilities. The proposed change would allow CRNAs to work without the collaboration, supervision, or other involvement of physicians.
The proposed change would not be affected by any state or local laws that restrict APRN practice, because VA facilities generally are considered exempt from state and local laws.
“The purpose of this proposed regulation is to ensure VA has authority to address staffing shortages in the future,” said VA Under Secretary for Health David J. Shulkin, MD, in a released statement. “Implementation of the final rule would be made through VHA [Veterans Health Administration] policy, which would clarify whether and which of the four APRN roles would be granted full practice authority.” Shulkin clarified that the VA is not seeking a change of CRNAs’ role at this point, but he said the VA would consider a change in the future if conditions require this change. “This is good news for our APRNs, who will be able to perform functions that their colleagues in the private sector are already doing,” Shulkin said.
The American Association of Nurse Anesthetists (AANA) says that underutilization of APRNs, including CRNAs, is one reason that veterans have long wait times, which can have tragic results. The proposed rule is consistent with recommendations in the Future of Nursing: Leading Change, Advancing Health report from the National Academies of Medicine, which formerly was the Institute of Medicine, according to AANA. (Readers can access the report online at http://bit.ly/1Y8VcVD.) Also, it is backed by the results of an independent assessment of the VHA health system that was ordered by Congress and published in 2015, the AANA said.1
The proposal comes at the same time as the release of a study on scope of practice (SOP) restrictions and physician supervision requirements for nurse anesthetists and their impact on anesthesia patient safety, according to the AANA. The study was conducted by The Lewin Group in Falls Church, VA. It was published online by the independent, peer-reviewed journal Medical Care. (To access the abstract, go to http://bit.ly/1USLk1l.)
“This study, the first of its kind, examined almost 6 million cases, reveals that scope of practice restrictions and physician supervision requirements for nurse anesthetists have no impact on anesthesia patient safety,” says Juan Quintana, DNP, MHS, CRNA, president of the AANA and president of Sleepy Anesthesia, Winnsboro, TX. The study also concluded that state SOP restrictions and physician supervision do reduce patient access to quality care and increase costs of healthcare services, the AANA said. Quintana says there are multiple studies that show “CRNAs are as safe as their physician anesthesiologist counterparts.” (For a list of those studies, go to http://bit.ly/1UEpnk7.)
The study was funded by the foundation of the AANA, and the American Society of Anesthesiologists (ASA) claims it is biased. “In fact, in the acknowledgements at the end of the Medical Care study, the authors thank members of the study’s technical expert panel. The first person listed is Juan F. Quintana, AANA president,” says Daniel J. Cole, MD, president of the ASA. The AANA says that the study was conducted by an independent research firm and the “AANA obviously had no say in the study’s outcome or influence on the reviewers or journal that published the research,” according to a spokesperson.
For direction on the role of physician anesthesiologists, look to the hospitals that are at the top of their game, Cole advises.
“This change would abandon a proven model of quality healthcare where physician anesthesiologists and nurse anesthetists work together, work together as a team, to ensure that our veterans get high quality, veteran-centered care, which is the standard of care in the 100 best hospitals in the United States,” Cole said at a press briefing. He pointed to the ASA’s analysis of the 100 best hospitals as recognized by Healthgrades, Truven Health Analytics, and U.S. News & World Report.
The VA’s own internal evaluation of relevant studies doesn’t support a policy change, according to the ASA, which says that evaluation states that the evidence is insufficient with a high likelihood of bias. Cole says the VA’s Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by nurse anesthetists.”
Penny Kaye Jensen, DNP, APRN, FNP-C, FAAN, FAANP, liaison for national APRN policy, Office of Nursing Services at the VA, says that the QUERI Evidence Synthesis Program reviewed the quality of care provided by advanced practice nurses. “Results revealed that in primary and urgent care settings, there was no difference in health status, quality or life, mortality, or hospitalizations favoring either APRN or physician care,” Jensen said. Readers can access the full report online by going to http://1.usa.gov/28LddA5.
At the press briefing, Cole said the proposal “removes physician anesthesiologists from surgical care and replaces them with nurses, lowering the standard of care for veterans and risking their lives.”
When asked by Same-Day Surgery about the standard of care in anesthesia, Cole says the primary standard is education and training, especially considering the life-and-death decisions in the OR. “Although nurse anesthetists are valued members of the anesthesia care team, the education and training difference between nurse anesthetists and physician anesthesiologists is stark,” Cole says. “As an example, ASA Past President Jane C.K. Fitch, MD, was a practicing nurse anesthetist, but went on for nine additional years of education and training to become a physician anesthesiologist.”
At the press briefing, Fitch said that physician anesthesiologists have 12-14 years of education, including medical school, and spend 12,000 to 16,000 hours in clinical training. She said that CRNAs have about half as much education, and only 2,500 hours of clinical training, “You know, some never even went to college,” Fitch said.
According to the AANA, CRNAs have a minimum of 7-8 years of focused education in nurse anesthesia, most CRNAs are masters prepared, and by 2025, new CRNAs will be required to have a doctorate degree to practice. Firing back, the association says that 25%, or approximately 12,000-13,000 anesthesiologists, are not board certified. “That’s a big number, a scary statistic, and a fact,” Quintana says.
The bottom line? “Nurse anesthetists are extremely well-prepared to provide the high-quality of care that they do, and as the research has shown, they do it as well as an anesthesiologist whether or not they are supervised by a physician,” Quintana says. “Another way to look at it is like this: Isn’t it amazing that the profession of nurse anesthesia has been able to achieve equal outcomes in anesthesia educating CRNAs in a lesser amount of time?”
When asked whether, if the same standards of care are followed, all anesthetists should have the same outcomes, Cole replied, “Anesthesiology is not a protocol-driven specialty. There are many unforeseen clinical issues that commonly occur during an anesthetic that require the education and training of a physician anesthesiologist to diagnose and treat to avoid complications and meet the standard of care that the American public expects.”
Cole also said that veterans “often have multiple medical conditions that put them at greater risk for unforeseen complications, e.g., brain function, injury to the heart.”
Steven A. Gunderson, DO, CEO and medical director at Rockford (IL) Ambulatory Surgery Center, says, “I believe we all feel CRNAs can provide quality anesthesia services to patients who do not exhibit significant health issues, especially severe cardiac, vascular, and respiratory.” Gunderson says his group has worked with CRNAs for several years, “and we have seen firsthand physician rescue techniques that will be lost to the VA patients if the CRNAs are able to achieve independent practice privileges. Sad, but everyone wants to be a doctor now, but everyone is not trained like a physician, including CRNAs.”
The VA proposal is opposed by more than 60 physician organizations, including the American Medical Association and the American Osteopathic Association. Opposition is being promoted at safeVAcare.org.
CRNAs were among the VHA’s specialties that were most difficult to recruit — what the report calls “occupations of critical need” — over four of the past five years, according to Jensen. She points to the Independent Assessment of the Healthcare Delivery Systems and Management Processes of the Department of Veterans Affairs report, which she says “identified several areas where anesthesia services staffing are short of what veterans require.” Specifically, these service areas identified as having anesthesia services shortages include gastrointestinal services such as screening colonoscopies, anesthesia conducted for orthopedic surgery, and cardiothoracic surgery. (Access the report online at http://1.usa.gov/1SBhQXr.)
The VHA proposal is supported by more than 60 organizations, including the American Nurses Association and AARP.
Based on comments to the rule so far, the AANA is optimistic that the proposed rule will stand and will be one factor that can help reduce wait times for veterans to receive healthcare. “It’s a logical solution to a serious problem,” Quintana says. “For that reason alone, we believe the likelihood is very slim that the VA’s proposed rule will be changed.”
The proposed rule ran in the May 25 Federal Register and can be accessed at http://1.usa.gov/1TXcdyq. The 60-day comment period for the proposed rule was scheduled to end July 25. Comments can be submitted at http://1.usa.gov/1V2hdls. At press time, more than 44,000 comments had been posted.
1. Rand Corp. Assessment B (Health Care Capabilities). Section 6.4.2. 2015. Accessed at http://1.usa.gov/28XQx9X.
Financial Disclosure: Executive Editor Joy Dickinson, Nurse Planner Kay Ball, Physician Reviewer Steven A. Gunderson, DO, and Consulting Editor Mark Mayo report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Stephen W. Earnhart discloses that he is a stockholder and on the board for One Medical Passport.