Nurse Anesthesia Practice

Anesthesia: The Practice of Nursing or the Practice of Medicine

Probably nowhere within nursing and medicine is there a greater overlap than in the field of anesthesiology. The courts have upheld that when a nurse anesthetist performs the task of anesthesia, it constitutes the practice of nursing. When a physician performs the tasks of anesthesia, it constitutes the practice of medicine.
Historically, this follows a logical line. In the United States, the nursing specialty of anesthesia preceded that of the medical specialty. Nurses were the principle providers of anesthesia services from the late 1870s until after World War II. CRNAs played a crucial role in the delivery of anesthesia in combat areas in every war in which the United States has been engaged since World War I.
In World War II, there were 17 nurse anesthetists to every one physician anesthetist. In Vietnam, the ratio of CRNAs to physician anesthetists was around 3:1. During the Panama strike, only CRNAs were sent with the fighting forces. Today, CRNAs administer the majority of anesthetics (65%) in this country, working with and without anesthesiologists.


Further the nature of anesthesia, with limited exceptions, does not have as its primary goal the diagnosis and treatment of pathology, long considered medicine's area. Rather, anesthesia is a service that permits physicians involved in diagnosis and treatment of patients to perform their work while the patient remains safe and comfortable. The nurse anesthetist or the anesthesiologist can collaborate with the physician to provide this essential service, each within the meaning of state law.

Education
The most substantive difference between CRNAs and anesthesiologists is that prior to anesthesia education, anesthesiologists receive medical education while CRNAs receive nursing education. However, the anesthesia part of the education is very similar for both providers. They are both educated to use the same anesthesia process in the provision of anesthesia and related services. In a survey of practice conducted among anesthesiologists and CRNAs in 1986 by the Center for Health Economics Research, it was found that CRNAs perform the same range of anesthesia tasks and activities as anesthesiologists.


Today, the registered nurse's education as a nurse anesthetist requires a Bachelor of Science in Nursing (or other appropriate baccalaureate degree); a minimum of one year experience in critical care nursing; and completion of two to three years of Master's or Doctoral level graduate work, including both classroom and clinical studies, on the administration of anesthesia. The anesthesiologist's course of study requires a baccalaureate degree, completion of medical school, and a four-year residency in anesthesiology.

Working Together
CRNAs and anesthesiologists work together in a wide variety of settings and employment situations.Some settings involve self-employed providers working side by side, while other settings are employer/employee in nature.
Are Colorado CRNAs required by law to be supervised by an anesthesiologist?
No. In a recent ruling the Colorado Denver District Court stated: “finds that both the Colorado statutes and regulations authorize the delivery of anesthesia by a CRNA without physician supervision.
As stated in the Nurse Practice Act, the practice of “advanced practice nursing” includes and goes beyond the scope of practice of “professional nursing.” C.R.S. § 12-38-103(8.5)(a) & (10). The Nurse Practice Act defines a “delegated medical function” as:
[A]n aspect of care that implements and is consistent with the medical plan as prescribed by a licensed physician . . . and is delegated to a registered professional nurse or practical nurse by a physician . . . . Nothing in this subsection (4) shall limit the practice of nursing as defined in this article.
Id. § 12-38-103(4). Thus a “delegated medical function” is delegated only to a registered professional nurse or a practical nurse and not to an “advanced practice nurse.”
A CRNA is a licensed “advanced practice nurse” who has obtained education and training in the administration of anesthesia and has been accepted by the BON for inclusion in an advanced practice registry. Id. § 12-38-111.5. A CRNA who is engaged in an independent practice of professional nursing (such as administering anesthesia) must maintain and be covered by professional liability insurance. Id. § 12-38-111.8. A CRNA performing what she or he has been specially trained and licensed to perform, i.e. the administration of anesthesia, is performing an “independent nursing function” and not a “delegated medical function.”
The legislative intent to permit a CRNA to independently deliver anesthesia is further evidenced in the section of the Nurse Practice Act that exempts the delivery of anesthesia by a CRNA from the heightened physician interaction requirements imposed for a nurse to have the authority to prescribe prescription drugs. Id. § 12-38-111.6(8)(c)(II).
Plaintiffs further argue that because a “medical plan” may include the selection of medication and because anesthesia is a medication, the delivery of anesthesia is always a “delegated medical function.” (Compl. ¶¶ 18–21, 24 (citing C.R.S. § 12-38-103(4).) This cuts way too broadly. Under Plaintiffs’ interpretation, virtually everything a nurse did would be deemed a “delegated medical function”—a function that implements or is consistent with the physician’s medical plan. Moreover, the very statutory section that defines a “delegated medical function” and discusses a “medical plan” provides that “nothing in this subsection (4) shall limit the practice of [advanced practice] nursing.” C.R.S. § 12-38-103(4).
That the delivery of anesthesia by a CRNA is not a violation of Colorado law is also demonstrated in the standards for Hospitals and Health Facilities promulgated by the Colorado State Board of Health. These standards expressly provide that anesthesia may be administered only by a qualified physician or a “registered nurse anesthetist graduated from a certified school,” i.e. a CRNA. 6 C.C.R. 1011-1, ch. 4, pt. 17.101(2).”


There is no state in America that requires supervision by an anesthesiologist. In 29 states, physician direction or supervision of a nurse anesthetist is not required at all by state statute. In addition, neither the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) nor Medicare require anesthesiologist supervision of CRNAs.


Bylaws determined by each individual facility may require the supervision of CRNAs by an anesthesiologist in spite of state law. Such restrictions have denied some patients access to the full scope of anesthesia services, which should be available to them. These restrictions have no basis in practice and add to the expense of anesthesia care by requiring two providers when one is most frequently adequate. Furthermore, restrictive CRNA practice bylaws are often not followed in the interest of patient care or for greater operating room efficiency. Medical staff bylaws that allow CRNAs to practice within the professional authority granted by state law more accurately reflect "real world" practice. This benefits patients, the medical facility, and the anesthesia staff.

Outcome and Quality
Nurse anesthetists have been providing quality anesthesia care in the United States for more than 100 years. In administering more than 65% of the 26 million anesthetics annually, CRNAs have complied on enviable safety record. A 2010 study representing nearly half a million anesthetics, demonstrated; “There are no differences in patient outcomes when anesthesia services are provided by Certified Registered Nurse Anesthetists (CRNAs), physician anesthesiologists, or CRNAs supervised by physicians.”
http://www.aana.com/newsandjournal/News/Pages/080310-Study-in-Health-Affairs-Confirms-Quality-Safety-of-Nurse-Anesthetist-Care.aspx

Nurse Anesthetists: Working with Surgeons
Surgeon's Liability

Is a surgeon more liable when working with a CRNA than with an anesthesiologist?
Those who seek to discourage physicians from working with nurse anesthetists have incorrectly asserted that a supervising physician becomes liable for the negligent acts of the CRNA. A physician or authorized provider is not automatically liable when working with a CRNA, nor is the physician immune from liability when working with an anesthesiologist

The principles governing the liability of a physician when working with a CRNA are the same as when working with an anesthesiologist. Whether or not a physician will be held liable for the negligence of the anesthetist depends on the facts of the case, not on the nature of the license held by the anesthesia provider.

Generally, the courts examine the degree of control the physician exercises over the anesthetist-- whether it be a CRNA or anesthesiologist. The more control that is exerted by the physician concerning the anesthetic, the more liable the physician becomes. Even where state laws require physician supervision of CRNAs, there is no requirement that a supervising physician control the acts of a CRNA. State laws do not require control, and mere supervision is insufficient to make the supervisor legally responsible for the negligence of a CRNA. The CRNA is the expert in anesthesia and supervising physicians, other than anesthesiologists, are not expected to have as much knowledge of anesthesia as the CRNA.

Adapted from KANA.org webpage