'Don't get rid of us in the OR,' perioperative nurses plead

HCFA rule change would eliminate RN, physician supervision in OR

Is the latest proposed rule change from the Health Care Financing Administration (HCFA) an attempt to remove RNs from the oper-ating room? Yes, according to the Denver-based Association of Operating Room Nurses (AORN). "Our whole membership feels this would be an attempt to eliminate perioperative nursing," says Candace Romig, legislative program coordinator at AORN.

In proposed changes to Medicare rules published in the Federal Register, HCFA proposes to remove RNs from supervisory authority in the OR and eliminate all prescriptive staffing.1 "That means they are leaving it up to hospitals to rely on their state's scope of practice and other licensing laws to guide them on appropriately staffing hos-pital services," Romig says.

The proposed rule change does not adequately protect patient health and safety in the operating room, without specifying an RN as the perioperative team supervisor, AORN maintains in its official response to the HCFA rule change.

"By outlining the nurse staffing requirements of hospitals, this section identifies requirements to ensure that an RN is responsible for managing nursing care for patients," the response reads. "However, it does not prevent a hospital from reducing nursing staff and replacing them with less educated and qualified personnel in the operating room. Having one RN supervising a bank of eight operating rooms does not ensure quality patient care."

Staffing needs to be more prescriptive in surgical and anesthesia services, AORN says in its official response. Ironically, surgical technologists also are calling for more prescriptive staffing, although they want their own role expanded.

HCFA is unlikely to return to more prescriptive staffing requirements, however, because agency officials are committed to a more outcomes- oriented approach, explains William J. Teutsch, executive director of the Association of Surgical Technologists in Englewood, CO.

"What we mean by prescriptive staffing is that surgical technologists do a broad range of activities: scrubbing, assisting, circulating, and even having a supervisory role in the OR," he says. "However, we think it's unlikely that's the direction HCFA is going to move. Having said that, we support the current [proposed changes]."

Teutsch does raise a concern with the direction in which OR staffing is moving, though. "One downside with the greater utilization of non-credentialed assistive personnel is that people can be hired off the street to be perioperative nursing technicians or patient technicians," he says.

Why are nurses so concerned?

If RNs aren't performing patient assessments, patient outcomes are likely to decline, Romig says. "However, there are no studies that at this time have been completed or even initiated that give solid care outcomes, especially in the OR. HCFA doesn't know the effects of moving nurses from the OR. We think this is playing with people's lives."

AORN officials believe it is essential that LPNs, surgical technologists, and other unlicensed assistive personnel who perform scrub and circulating tasks in the operating room be supervised by professional RNs. In its official response, AORN points to the need for critical thinking skills and clinical judgment regarding patient assessment, care planning, and care evaluation by RNs.

"While the surgeon still may be considered the `captain of the ship' in some hospitals, it cannot be reasonably expected that the surgeon will have either the knowledge or the inclination to supervise and be responsible for nursing functions being performed by lesser-prepared personnel," the AORN statement reads.

"The surgeon's focus and attention should be toward the operative procedure that he or she is performing," the statement continues. "Requiring only that `surgical procedures are performed by practitioners with appropriate clinical privileges' does not guarantee that personnel authorized by the hospital to perform surgical assisting duties have the education, the experience, or the credentials under state scope of practice laws."

AORN proposes that the wording in the current rule be retained: "Qualified RNs may perform circulating duties in the operating room. In accordance with applicable state laws and approved medical staff policies and procedures, LPNs and surgical technologists may assist in circulatory duties under the supervision of a qualified RN who is immediately available to respond to emergencies. The hospital must have sufficient numbers of personnel, including doctors of medicine or osteopathy, RNs, and other practitioners, to meet patient needs for surgical care."

AORN representatives met with HCFA officials, including the director of clinical standards and quality, to explain their position.

"We felt good," Romig says. "We're not sure [the director] was aware nurses were being removed from the OR and the exact significance of what that would mean to surgical procedures. It would mean the person who is responsible for ensuring patient safety would no longer be in OR."

The deadline to respond to the proposed rule change has been extended to April 17. (See information on Internet access to the regulation and how to contact HCFA, at right.)

Anesthesiologists question safety

RN supervision isn't the only concern being raised about the proposed HCFA rule change. HCFA also would get rid of physician supervision of certified registered nurse anesthetists (CRNAs). Anesthesiologists say that change may harm patient care.

"Our biggest concern is that there would be a misadventure - that the patient would develop a medical problem that requires physician expertise," says Stephen Pyles, MD, director of anesthesia at Munroe Regional Medical Center in Ocala, FL. "That occurs in our practice on a daily basis." For example, CRNAs may need help with airway management if they're unable to intubate, says Pyles, who formerly worked as a CRNA.

The American Society of Anesthesiologists (ASA) in Park Ridge, IL, says anesthesiologists always should be readily available and should participate in the anesthesia care plan, including cases with local anesthesia and local with intravenous sedation. In its position statement responding to the proposed rule change, ASA says: "This step would deny millions of Medicare and Medicaid patients an important quality of care protection that has been in place since 1966. If approved, the change would leave the issue of nurse anesthetist supervision to the states with no minimum standard or uniformity.

"HCFA's proposal to eliminate a three-decades-old policy of physician supervision that it reconfirmed just five years ago can only be described as unwise at best and irresponsible at worst, and it severely jeopardizes the safety of the millions of Medicare and Medicaid recipients."

Pyles points to a study of two million patients that suggests an increase in the number of physicians is primarily responsible for improvement in patient outcomes.2

Larry Hornsby, CRNA, regional director of the ASA and president of Anesthesia Resources Management in Birmingham, AL, and Anesthesia Professionals in Montgomery, both CRNA group practices, says the results of that study reflect the improvements in technology, particularly monitoring technology, and pharmacology.

HCFA's proposal to delete supervision of CRNAs is more of a reimbursement than a practice issue, Hornesby says. "This will allow hospitals and ambulatory surgery centers that employ CRNAs to be paid for services that CRNAs are providing," he says.

In the past, if CRNAs were employed by facilities, and anesthesiologists were contracting service to those facilities, both providers might submit a bill. In that scenario, the anesthesiologists received 100% of their bill, and the facilities were "stuck"with providing a CRNA with no reimbursement for services, Hornesby explains. Under the proposed HCFA rule change, the fee would be split 50/50 between the anesthesiologist and the CRNA (or the CRNA's employer), he says.

The proposed change would bow to state law when it requires physician supervision of nurse anesthetists. "In the majority of states, nothing will change," he says. "And individual facilities can mandate the direction of CRNAs through policy and procedure."

The deference to state law is inappropriate, the ASA says. "While many states do require such supervision, many do not," its position statement reads.

Working side by side

Despite the political wrangling, both anesth-esiologists and CRNAs point out that the two groups work well together in the OR. Pyles' facility uses an anesthesia care team in which CRNAs administer the anesthesia and anesthesiologists supervise two or three rooms. "We have worked in this format for fifteen years, and we have not had a suit" involving anesthesia care, he says.

Hornesby agrees that there are no problems being reported in the ORs. "One of things that really is not being stated is that CRNAs and anesthesiologists have a good track record of working together very well," he says. "Every day, all across the country, we work together to take good care of our patients."


1. 62 Fed Reg 66,725-66,763 (Dec. 19, 1997).

2. Bechtoldt AA Jr. Committee on anesthesia study. Anesthetic-related deaths: 1969-1976. NC Med J 1981; 42:253-259.