AANA Scope of Practice Document

Scope and Standards for Nurse Anesthesia Practice
The AANA Scope and Standards for Nurse Anesthesia Practice offers guidance for Certified Registered Nurse Anesthetists (CRNAs) and healthcare institutions regarding the scope of nurse anesthesia practice. The scope of practice of the CRNA addresses the responsibilities associated with anesthesia practice that are performed in collaboration with other qualified healthcare providers. Collaboration is a process which involves two or more parties working together, each contributing his or her respective area of expertise. CRNAs are responsible for the quality of services they render.

Scope of Practice
The practice of anesthesia is a recognized specialty in both nursing and medicine. Anesthesiology is the art and science of rendering a patient insensible to pain by the administration of anesthetic agents and related drugs and procedures. Anesthesia and anesthesia- related care represents those services which anesthesia professionals provide upon request, assignment, and referral by the patient’s physician or other healthcare provider authorized by law, most often to facilitate diagnostic, therapeutic and surgical procedures. In other instances, the referral or request for consultation or assistance may be for management of pain associated with obstetrical labor and delivery, management of acute and chronic ventilatory problems, or management of acute and chronic pain through the performance of selected diagnostic and therapeutic blocks or other forms of pain management. Education, practice and research within the specialty of nurse anesthesia promote competent anesthesia care encompassing the diversity of patient populations, age, ethnicity and gender. CRNAs practice according to their expertise, state statutes and regulations, and institutional policy.

CRNA scope of practice includes, but is not limited to, the following:

1. Performing and documenting a preanesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering preanesthetic medications and fluids; and obtaining informed consent for anesthesia.
2. Developing and implementing an anesthetic plan.
3. Initiating the anesthetic technique which may include: general, regional, local, and sedation.
4. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient's physical status.
5. Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic.
6. Managing a patient’s airway and pulmonary status using current practice modalities.
7. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering and administering medications, fluids, and ventilatory support.
8. Discharging the patient from a postanesthesia care area and providing postanesthesia follow-up evaluation and care.
9. Implementing acute and chronic pain management modalities.
10. Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques.
    

Additional nurse anesthesia responsibilities which are within the expertise of the individual CRNA include:

1. Administration/management: scheduling, material and supply management, development of policies and procedures, fiscal management, performance evaluations, preventative maintenance, billing, data management, and supervision of staff, students or ancillary personnel.
2. Quality assessment: data collection, reporting mechanism, trending, compliance, committee meetings, departmental review, problem-focused studies, problem solving, interventions, documents and process oversight.
3. Education: clinical and didactic teaching, BCLS/ACLS instruction, in-service commitment, EMT training, supervision of residents, and facility continuing education.
4. Research: conducting and participating in departmental, hospital-wide, and university- sponsored research projects.
5. Committee appointments: assignment to committees, committee responsibilities, and coordination of committee activities.
6. Interdepartmental liaison: interface with other departments such as nursing, surgery, obstetrics, postanesthesia care units (PACU), outpatient surgery, admissions, administration, laboratory, pharmacy, etc.
7. Clinical/administrative oversight of other departments: respiratory therapy, PACU, operating room, surgical intensive care unit (SICU), pain clinics, etc.

The functions listed above are a summary of CRNA clinical practice and are not intended to be all-inclusive. A more specific list of CRNA functions and practice parameters is detailed in the AANA Guidelines for Core Clinical Privileges for Certified Registered Nurse Anesthetists.
CRNAs strive for professional excellence by demonstrating competence and commitment to clinical, educational, consultative, research, and administrative practice in the specialty of anesthesia. CRNAs should serve on healthcare facility committees and actively participate in the development of departmental policies and guidelines, performance appraisals, peer reviews, and clinical and administrative conferences. In addition to these activities, CRNAs should assume a leadership role in the evaluation of the quality of anesthesia care provided throughout the facility and the community.
The scope of practice of the CRNA is also the scope of practice of nurse anesthetists who have graduated within the past 24 months from a nurse anesthesia educational program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), but have not yet passed their initial certification examination. Students enrolled in nurse anesthesia educational programs accredited by the COA practice pursuant to the council’s standards and guidelines.

Standards for Nurse Anesthesia Practice
These standards are intended to:

1. Assist the profession in evaluating the quality of care provided by its practitioners.
2. Provide a common base for practitioners to use in their development of a quality practice.
3. Assist the public in understanding what to expect from the practitioner.
4. Support and preserve the basic rights of the patient.

These standards apply to all anesthetizing locations. While the standards are intended to encourage high quality patient care, they cannot assure specific outcomes.

Standard I
Perform a thorough and complete preanesthesia assessment.
Interpretation
The responsibility for the care of the patient begins with the preanesthetic assessment. Except in emergency situations, the CRNA has an obligation to complete a thorough evaluation and determine that relevant tests have been obtained and reviewed.

Standard II
Obtain informed consent for the planned anesthetic intervention from the patient or legal guardian.
Interpretation
The CRNA shall obtain or verify that an informed consent has been obtained by a qualified provider. Discuss anesthetic options and risks with the patient and/or legal guardian in language the patient and/or legal guardian can understand. Document in the patient’s medical record that informed consent was obtained.

Standard III
Formulate a patient-specific plan for anesthesia care.
Interpretation
The plan of care developed by the CRNA is based upon comprehensive patient assessment, problem analysis, anticipated surgical or therapeutic procedure, patient and surgeon preferences, and current anesthesia principles.

Standard IV
Implement and adjust the anesthesia care plan based on the patient’s physiological response.
Interpretation
The CRNA shall induce and maintain anesthesia at required levels. The CRNA shall continuously assess the patient’s response to the anesthetic and/or surgical intervention and intervene as required to maintain the patient in a satisfactory physiologic condition.

Standard V
Monitor the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs.

1. Monitor ventilation continuously. Verify intubation of the trachea by auscultation, chest excursion, and confirmation of carbon dioxide in the expired gas. Continuously monitor end-tidal carbon dioxide during controlled or assisted ventilation, including any anesthesia or sedation technique requiring artificial airway support. Use spirometry and ventilatory pressure monitors as indicated.
2. Monitor oxygenation continuously by clinical observation, pulse oximetry and, if indicated, arterial blood gas analysis.
3. Monitor cardiovascular status continuously via electrocardiogram and heart sounds. Record blood pressure and heart rate at least every five minutes.
4. Monitor body temperature continuously on all pediatric patients receiving general anesthesia and, when indicated, on all other patients.
5. Monitor neuromuscular function and status when neuromuscular blocking agents are administered.
6. Monitor and assess patient positioning and protective measures, except for those aspects that are performed exclusively by one or more other providers.

Interpretation
Continuous clinical observation and vigilance are the basis of safe anesthesia care. The standard applies to all patients receiving anesthesia care and may be exceeded at any time at the discretion of the CRNA. Unless otherwise stipulated in the standards, a means to monitor and evaluate the patient's status shall be immediately available for all patients. When any physiological monitoring device is utilized, variable pitch and low threshold alarms should be turned on and audible in most circumstances. The omission of any monitoring standards shall be documented and the reason stated on the patient’s anesthesia record. As new patient safety technologies evolve, integration into the current anesthesia practice shall be considered. The CRNA shall be in constant attendance of the patient until the responsibility for care has been accepted by another qualified healthcare provider.

Standard Vl
There shall be complete, accurate, and timely documentation of pertinent information on the patient’s medical record.
Interpretation
Document all anesthetic interventions and patient responses. Accurate documentation facilitates comprehensive patient care, provides information for retrospective review and research data, and establishes a medical-legal record.

Standard Vll
Transfer the responsibility for care of the patient to other qualified providers in a manner that assures continuity of care and patient safety.
Interpretation
The CRNA shall assess the patient’s status and determine when it is safe to transfer the responsibility of care to other qualified providers. The CRNA shall accurately report the patient’s condition and all essential information to the provider who is assuming responsibility for the patient.

Standard Vlll
Adhere to appropriate safety precautions as established within the institution to minimize the risks of fire, explosion, electrical shock and equipment malfunction. Document on the patient’s medical record that the anesthesia machine and equipment were checked.
Interpretation
Prior to use, the CRNA shall inspect the anesthesia machine and monitors according to established guidelines. The CRNA shall check the readiness, availability, cleanliness, and working condition of all equipment to be used in the administration of the anesthesia care. When the patient is ventilated by an automatic mechanical ventilator, monitor the integrity of the breathing system with a device capable of detecting a disconnection by emitting an audible alarm. Monitor oxygen concentration continuously with an oxygen analyzer with a low concentration audible alarm turned on and in use.

Standard IX
Precautions shall be taken to minimize the risk of infection to the patient, the CRNA, and other healthcare providers.
Interpretation
Written policies and procedures in infection control shall be developed for personnel and equipment.

Standard X
Anesthesia care shall be assessed to assure its quality and contribution to positive patient outcomes.
Interpretation
The CRNA shall participate in the ongoing review and evaluation of the quality and appropriateness of anesthesia care. Evaluation shall be performed based upon appropriate outcome criteria and reviewed on an ongoing basis. The CRNA shall participate in a continual process of self evaluation and strive to incorporate new techniques and knowledge into practice.

Standard Xl
The CRNA shall respect and maintain the basic rights of patients.
Interpretation
The CRNA shall support and preserve the patient’s rights to personal dignity and ethical norms of practice.