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The decision by the Health Care Financing Administration (HCFA) to eliminate the requirement for physicians to supervise nurse anesthetists is in limbo while the Bush administration spends 60 days reviewing recent decisions by the Clinton administration. However, the president of the American Association of Nurse Anesthetists (AANA) in Park Ridge, IL, expressed optimism that the new administration will support the rule change.
"The interesting thing with our rule, even though it was from a prior administration, is that it had wonderful bipartisan support," says Larry G. Hornsby, CRNA. "We are in line with Republican platform and Bush’s campaign statement to give power back to the state."
Under the new rule, published in the Jan. 18 Federal Register, all decisions relating to the supervision of nurse anesthetists will take place at the state level. (Copies of the Federal Register can be found at www.access.gpo.gov/su_docs/aces/aces140.html.) The nurse practice acts, board of nursing rules and regulations, medical practice acts, and board of medicine rules and regulations in 29 states do not require physician supervision of nurse anesthetists, according to the AANA.
"In those areas, nothing will change," notes Candace L. Romig, director of government affairs for the Association of periOperative Registered Nurses in Denver. Also, any hospital can establish stricter standards than required by state law, HCFA points out. At press time, the new regulations, which affect 21 states, were scheduled to take effect March 19, 2001. Nurse anesthetists are most prevalent in rural areas, Romig points out.
And HCFA specifically named critical access hospitals as one of the areas included in this rule change, Hornsby notes. "Honestly, those are places anesthesiologists are not, have never been, and are not going to be."
Hospitals and other facilities, including ambulatory surgery centers, now will have more opportunities to use nurses to administer anesthesia to their patients, Romig points out.
The American Society of Anesthesiologists (ASA) in Park Ridge, IL, has called on President Bush to reverse the rule change, which it says will place every Medicare and Medicaid patient having surgery at increased risk of injury or death. The ASA maintains that the rule change will jeopardize the lives of seniors who undergo surgery by eliminating the requirement for a doctor to supervise if a nurse gives the anesthesia.
Neil Swissman, MD, president of ASA, says the ASA would explore every avenue to have this issue redressed, including legal or legislative action. Rep. Dave Weldon (R-FL) plans to reintroduce legislation that would repeal the final rule, according to his office.
The practice of anesthesiology is not simply administering anesthetic agents, Swissman says. "It requires continuous medical judgment before the surgery to diagnose the patient and determine the best anesthetics to use, during surgery when split-second decisions are made, and even after surgery when recovery of the patient and their pain treatment are critical," he says. "Nurses are not doctors and should not be expected to make those decisions."
In the July 2000 issue of Anesthesiology, published by the ASA, a University of Pennsylvania study reviewed the care of 235,000 Medicare patients and identified 25 unnecessary deaths per 10,000 cases when an anesthesiologist was not involved in the care.1 A HCFA press release referred to this study, but called the results "not relevant to the issue involved in this rule." The study, HCFA said, did not compare certified registered nurse anesthetist (CRNA) practice with nonanesthesiologist physician supervision. And it said the study "did not provide sound and compelling evidence to support maintaining federal preemption of state law," the standard that HCFA has set in order for the federal government to step in.
In the final rule, HCFA said it received many comments from surgeons asking about the surgeon’s liability as well as questions about who would be considered in charge of the patient’s care. "This final rule does not require supervision, direction, or oversight of any independently licensed practitioner administering anesthesia by the operating surgeon," HCFA said. "The surgeon would still be able to involve an anesthesiologist as a consultant or in any other capacity."
This rule does nothing to restrict that relationship, the agency pointed out. "CRNAs, as well as anesthesiologists, are accountable for their own practices, the care they deliver, patient outcomes, as well as insurance liability coverage," it said.
HCFA received several comments asserting the physician supervision requirement was responsible for surgeons choosing not to practice in some settings because they don’t want the liability associated with the supervision responsibility. "The rule makes no legal change in the scope of malpractice liability, traditionally a state issue," HCFA said.
1. Silber JH, Kennedy SK, Even-Shoshan O. Anesthesiologist direction and patient outcomes Anesthesiology 2000; 93: 152.
For more information on physician supervision of nurse anesthetists, contact:
• Larry G. Hornsby, CRNA, President, American Association of Nurse Anesthetists, 222 S. Prospect Ave., Park Ridge, IL 60068-4001. Telephone: (205) 629-3919. Fax: (847) 692-6968. E-mail: Lhornesby@compuserve.com. Web: www.aana.com.
• Neil Swissman, MD, President, American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068. Telephone: (847) 825-5586. Fax: (847) 825-1692.