Professional & Practice Information

GANA Practice Committee

The Members of the GANA Practice Committee are representative of current CRNA Practice settings in Georgia. The Committee reviews GANA member's questions/comments concerning the practice of nurse anesthesia in Georgia and the implications concerning patient safety, work environment, reimbursement and practice management/concerns. When requested by the member, the Committee formulates recommendations for consideration by the GANA Board of Directors. Please contact us at ganapractice@hotmail.com.

Reality Check: The Truth Behind the Distortions
There's No Denying the Differences Between CRNAs and AAs

AANA NewsBulletin, March 2008

Distortion

Recently, according to a February 2008 ASA Newsletter article, the American Society of Anesthesiologists’ (ASA) Committee on the Anesthesia Care Team (CACT) sought to conduct an “objective investigation and documentation” of the question: “Do differences in the education and practice of anesthesiologist assistants (AA) and nurse anesthetists (NAs) indicate the superiority of one profession over the other in either ability or capability?” One might wonder, “Can a committee that is part of an organization which vigorously endorses the proliferation of AAs be objective in answering this question?” The answer is no. The committee’s conclusions are way off the mark on many points and provide nothing new, except that they are now framed as being the result of “an objective investigation.” But unframed or framed, misinformation is misinformation.

It is interesting that the ASA article refers to a document prepared by the committee, titled “ASA Statement Comparing Anesthesiologist Assistant and Nurse Anesthetist Education and Practice,” that is posted only on the member side of the ASA website. You can read the ASA article about the CACT’s “investigation,” written by Jeffrey S. Plagenhoef, MD, chair of the CACT, in its entirety at www.asahq.org/Newsletters/2008/02-08/plagen02-08.html.

Following are the facts about the differences and similarities between CRNAs and AAs—everything you won’t find in the CACT’s investigation results.

CMS Conditions of Participation

Contrary to what the ASA article states, the Centers for Medicare & Medicaid Services (CMS) does not share the ASA’s position that AAs and nurse anesthetists have “identical clinical capabilities and responsibilities” or that the two professions are “equivalent.” In fact, CMS recognizes critical differences between CRNAs and AAs.

A key difference is reflected in the CMS Conditions of Participation (CoP) for hospitals and ambulatory surgical centers that require AAs to work under anesthesiologist supervision. In contrast, those conditions of participation generally require that CRNAs work under physician supervision, but allow CRNAs to work without physician supervision in states that have opted out of the CMS physician supervision requirement. What this means is CMS does not require anesthesiologist supervision of CRNAs, and in many states does not require any physician supervision of CRNAs. In fact, 14 states (Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, and Wisconsin) have opted out of the CMS physician supervision requirement for CRNAs. Is it any wonder that the ASA would promote AAs rather than CRNAs, given that CMS requires AAs to work under anesthesiologists?

State Laws/Regulations

Many state laws and regulations do not require physician supervision of CRNAs. Thirty-nine states do not have a physician “supervision” requirement for CRNAs in nursing or medical laws or regulations. If clinical “direction” requirements are considered in addition to “supervision,” 31 states do not have a physician supervision or direction requirement for CRNAs in nursing or medical laws or regulations. Taking into account state hospital licensing laws or regulations as well, 33 states still do not require physician supervision. Taking into account state hospital licensing laws or regulations, 24 states still do not require physician supervision or direction.

AAs, in contrast, must be supervised by anesthesiologists in the nine states where they are licensed or certified to practice.

Quality of Anesthesia Care

CRNAs have been studied extensively throughout their long history (125+ years), and numerous studies show that they deliver excellent quality care. In fact, a study published in 2007 demonstrated that there is no difference in obstetrical anesthesia safety between hospitals that use only (CRNAs) and those that use only anesthesiologists. (See “Anesthesia Staffing and Anesthetic Complications During Cesarean Delivery,” at the Nursing Research Online website www.nursingresearchonline.com.) Registration is required.

In administering 27 million anesthetics annually, CRNAs have compiled an enviable safety record. No studies to date that have addressed anesthesia care outcomes have found that there is a significant difference in patient outcomes based on whether the anesthesia provider is a CRNA or an anesthesiologist. Studies to date demonstrate that there is no statistically significant difference between the anesthesia care provided by CRNAs working alone, CRNAs working with anesthesiologists, or anesthesiologists providing care alone.

In contrast, there are no published studies regarding the quality of care that AAs provide. In fact, the Kentucky legislative report “A Study of Anesthesiologist Assistants” (Kentucky Legislative Research Commission, February 2007) that is referenced in the ASA article, not only supports this fact, but concludes that “No studies have been published in peer-reviewed journals assessing the impact of anesthesiologist assistants on patient safety.…Overall, the lack of data limits the conclusions that can be made about patient safety outcomes for anesthesiologist assistants.” It is amazing that, despite these incriminating observations, the ASA article nonetheless states that, “The committee was greatly aided in its mission by the coincidental publication of an impartial study comparing the education and practice of AAs and NAs commissioned by the Kentucky Legislature.” Further, it remains difficult to understand why the ASA, without any scientific evidence upon which to base its support, is unwavering in its endorsement of AAs’ qualifications and safety record.

The Importance of a Critical Care Nursing Background

A key difference between AAs and CRNAs is a CRNA’s critical care nursing background. All applicants to nurse anesthesia masters’ degree programs are registered nurses, and the vast majority of them have acquired extensive clinical experience in areas such as coronary, respiratory, postanesthesia, and surgical intensive care units before they begin their nurse anesthesia programs. (The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires a minimum of one year of such experience. Frequently, programs prefer additional years of experience.)

In contrast, AAs are not required to have any nursing, medical, anesthesia or healthcare education, experience, licensure, or certification before they begin their programs.

There is no evidence to support the contention that a CRNA’s critical care nursing background is irrelevant. Logic dictates that CRNAs who have critical care experience working with the sickest patients are far preferable to AAs who generally have no or very little healthcare experience. Somehow, though, the lack of a healthcare background for most AAs is irrelevant to the ASA.

The ASA article grossly misstates the Kentucky report. The report includes no finding, as asserted by the ASA, that “the requirement for clinical experience may constitute a temporary aid to those beginning their [nurse anesthesia] or AA education, but it makes no difference to the final outcome of that training.” To the contrary, the Kentucky report found that nurse anesthesia educational programs’ “admission requirements differ significantly” from AA program admission requirements “because [AA] programs require only a bachelor’s degree in any field and completion of specific science, math and English courses.”

CRNAs are Professional Full-Service Anesthesia Providers

CRNAs are dedicated healthcare professionals who are experts in all aspects of anesthesia care. They are competent to provide services within their full scope of practice. They are not technicians or merely proceduralists. CRNAs are qualified to make independent judgments regarding all aspects of anesthesia care, based on their education, licensure, and certification. CRNAs provide anesthetics to patients in cooperation with surgeons, anesthesiologists, dentists, podiatrists and other qualified healthcare professionals. CRNAs practice with a high degree of autonomy. The laws of every state permit CRNAs to work with physicians (such as surgeons) or other authorized healthcare professionals.

CRNAs are capable of high-level independent function and receive instruction in the administration of all types of anesthesia including general and regional anesthesia, selected local and conscious sedation, monitored anesthesia care, and pain management. They are trained to provide anesthesia to patients of all ages for all types of surgery, from simple to the most complex cases. The ability to make independent judgments and provide multiple anesthetic techniques is critical to meeting an array of patient and surgical needs.

Despite ASA contentions, nurse anesthesia educational programs ensure students have intensive clinical experience placing invasive monitors. In fact, the COA requires that all nurse anesthesia educational programs provide this experience to students in order to maintain accreditation.

In contrast, the scope of training for AAs is severely limited. The AA curriculum is characterized by training that allows them to “assist” the anesthesiologist in technical functions. For example, one of the largest AA programs, Emory University, does not provide clinical instruction in the administration of regional anesthesia. All nurse anesthesia programs provide both didactic and clinical instruction in regional anesthesia, providing CRNAs with a solid professional foundation to administer regional anesthesia and handle regional anesthetic complications.

National Authority to Practice

Every state authorizes CRNAs to provide anesthesia care. In contrast, only nine states and the District of Columbia authorize AAs to practice as licensed or certified anesthesia providers. As the Kentucky report concluded, “The majority of states do not currently allow anesthesiologist assistant practice…[Some] view anesthesiologist assistants as not having the required educational or other background to safely administer anesthesia care.” Based on this and other assertions in the Kentucky report, it is difficult to see how the CACT “was greatly aided in its mission” by the document.

Practice Location

CRNAs practice in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms; critical access hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and other medical professionals; and U.S. Military, Public Health Service, and Veterans Administration healthcare facilities. CRNAs can provide anesthesia care anywhere it is needed, whether urban, rural or suburban.

AAs, in contrast, can only practice where anesthesiologists practice. In other words, they can only practice where anesthesiologists are on-site in the facility and available to provide close supervision. This requirement of anesthesiologist supervision precludes AAs from helping to solve problems of inadequate access to anesthesia care in rural and underserved communities. CRNAs, in contrast, are the main provider in these communities. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals.

Practice in the Military

CRNAs are the predominant anesthesia provider in the armed forces and the Veterans Affairs healthcare system. AAs are not authorized to work as anesthesia providers in the armed forces, and reportedly at press time no Veterans Affairs facilities have hired AAs.

CRNA Practice Autonomy

A fundamental and crucial distinction between CRNAs and AAs that the ASA article ignores is that nurse anesthetists are educated to be able to practice with or without anesthesiologist involvement in anesthesia care. This is why CRNAs can practice in many settings and areas, such as rural communities, where anesthesiologists are unavailable. AAs are educated solely to support and serve as an assistant to an anesthesiologist, and they cannot work unless an anesthesiologist is onsite. CRNAs can provide the full array of anesthesia care without an anesthesiologist.

Cost Effectiveness of CRNA Practice

Because CRNAs do not need to practice with an anesthesiologist, they are much more cost effective than AAs. With an AA, the need exists to educate and use two providers – the supervising anesthesiologist and the AA — to provide anesthesia care to one patient. With a CRNA, only that individual is needed to provide total anesthesia care to the patient. Essentially, compared with the anesthesiologist-AA staffing arrangement, one CRNA can provide the care of two providers.

Provider Numbers

There are more than 36,000 practicing nurse anesthetists. They safely administer approximately 27 million anesthetics to patients each year in the United States. CRNAs are the primary anesthesia providers in rural America. In contrast, according to reports by the American Academy of Anesthesiologist Assistants (AAAA), there are only about 700 AAs. Further, as indicated earlier in this column and corroborated by the Kentucky report, there is no scientific evidence of AA safety, just the unsupported arguments of anesthesiologists.

Summation/Conclusion

CRNAs are better qualified by far to provide quality anesthesia services than AAs. CRNAs are better prepared, have a superior breadth of clinical experience, and can be utilized more flexibly. There is no comparison between CRNAs and AAs in terms of education, experience, history, ability to work without anesthesiologist supervision, recognition by surgeons, and presence as the predominant anesthesia provider in the military. It is in the best interests of America’s healthcare system to prepare more CRNAs, not AAs.

Contrary to the ASA article’s assertions, neither CMS nor the Kentucky Legislature have recognized CRNAs and AAs as being “equivalent.” Indeed, CMS and the Kentucky Legislative Report each recognize the substantial and critical distinctions between CRNAs and AAs. These distinctions demonstrate why U.S. healthcare policy should prefer CRNAs, who are high quality, cost-effective and flexible providers well positioned to help resolve the nation’s current healthcare crisis.

It is impossible to explain how the CACT and the ASA can so completely misinterpret the information in the Kentucky report and the CMS Conditions of Participation.

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AANA-ASA Joint Statement Regarding Propofol Administration*

April 14, 2004

Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonistic medications, agents such as propofol require special attention.

Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. This restriction is concordant with specific language in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.

Similar concerns apply when other intravenous induction agents are used for sedation, such as thiopental, methohexital or etomidate.

*This statement is not intended to apply when propofol is given to intubated, ventilated patients in a critical care setting.