Nurse Anesthetists, Anesthesiologists, and the VA System: Are Changes Needed?

Susan B. Yox, RN, EdD; Bret S. Stetka, MD; Juan Quintana, CRNA, DNP, MHS; Daniel J. Cole, MD


July 08, 2016

Updated: July 14, 2016

Editor's Note:
A newly proposed rule indicates that the Department of Veterans Affairs (VA) would like to amend its regulations to permit full practice authority to all VA advanced practice registered nurses (APRNs), including certified registered nurse anesthetists (CRNAs), allowing them to practice to the "full extent of their education, training, and certification, without the clinical supervision of physicians, regardless of individual state restrictions...." State laws would still prevail with respect to prescribing controlled substances. The rule is currently open to comments until July 25, 2016.

To clarify the issues and controversies around the proposed rule, Medscape asked representatives of the relevant professional organizations—the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA)—to answer the same questions regarding the proposed rule change via email. At the end of the process, we asked each organization to review the other's responses and provide a final comment. The interview follows.

What Is the Proposed VA Rule on Advanced Practice Nurses All About?

Medscape: What do you see as the goals of this proposed rule? Why is there so much concern, given the fact that this approach already is in practice in many parts of the country?

Daniel J. Cole, MD, President, American Society of Anesthesiologists

Daniel J. Cole, MD: The goal of the proposed rule is to address a shortage of some types of physicians in the VA by allowing full practice authority for advanced practice nurses, including nurse anesthetists. However, removing physician anesthesiologists from surgery and replacing them with nurse anesthetists lowers the standard of care for veterans and jeopardizes their lives. We strongly believe that the VA should protect veterans' safety and continue to follow the proven model of team-based, physician-led anesthesia care.

First, there is no shortage of physician anesthesiologists in the VA system, so the policy would lower the standard of care for veterans without improving wait times. Wait times for anesthesia are not an issue in the VA.

The VA's September 1, 2015, analysis of staffing capabilities—"Assessment B (Health Care Capabilities)," done for Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs[1]—reviewed shortages by provider type and did not list physician anesthesiologists as among the 12 identified in shortage. Shortages were found for cardiology, endocrinology, gastroenterology, hematology/oncology, internal medicine, mental health, neurologic surgery, neurology, obstetrics and gynecology, physical medicine and rehabilitation medicine, surgery, and thoracic surgery

More recently, the VA released the annual "Mission Critical Occupations Report,"[2] a document that "identifies the highest ranking ten mission critical (hard-to-fill) occupations (top 10)" in VHA. The document, dated December 10, 2015, lists the top 5 nursing and top 5 physician specialties' "hard-to-fill" occupations. Neither physician anesthesiologists nor nurse anesthetists were included.

Second, surgery and anesthesia are inherently dangerous and require physician involvement—particularly for veterans, who are sicker and have multiple medical conditions that put them at greater risk for complications. The policy would abandon a proven model of care where physician anesthesiologists and nurse anesthetists work together as a team to provide veterans with high-quality and safe anesthesia.

Forty-six states and the District of Columbia prohibit by law what the VA is proposing and require physician involvement for anesthesia care. Although 17 states have opted out of the Medicare supervision requirement, most of those states still have a state law that provides for physician involvement in anesthesia care. In addition, many of the hospitals in those states still follow a model of team-based anesthesia care.

Juan Quintana, DNP, MHS, CRNA, President, American Association of Nurse Anesthetists

Juan Quintana, DNP, MHS, CRNA: It is no secret that in recent years, far too many veterans have routinely had to endure long wait times to receive needed healthcare. This lack of timely access to care has even cost some veterans their lives. The goal of the VA's proposed rule is to help alleviate this terrible situation by allowing full practice authority for all APRNs, including CRNAs.

For CRNAs, the rule would standardize anesthesia services across the nation's largest healthcare system, the VA, and bring it in line with the Army, Navy, Air Force, Indian Health Services, and Combat Support Hospitals, which already allow CRNAs to work without physician supervision. CRNAs would have full practice authority to provide a patient's anesthesia and anesthesia-related care, including planning and initiating anesthetic techniques (general, regional, local) and sedation, providing postanesthesia evaluation and discharge, ordering and evaluating diagnostic tests, requesting consultations, performing point-of-care testing, and responding to emergency situations for airway management without oversight by a physician.

To ensure this standardization, CRNAs and other APRNs would not be limited by state or local laws in their ability to provide outstanding care to veterans. In addition, the rule would ensure more effective utilization of physician anesthesiologists—who, instead of needlessly supervising CRNAs, would be able to provide more hands-on anesthesia care to our nation's veterans, joining CRNAs in doing their part to help reduce dangerously long wait times for healthcare services.

There is no good reason for all the hand-wringing on the part of physicians over this proposed rule. CRNAs have a sterling safety record, confirmed by no fewer than nine studies published in highly respected, peer-reviewed journals since 2000. The former Institute of Medicine (now the National Academies of Medicine) and an independent assessment of the VA health system that was ordered by Congress and published in 2015 both recommend that APRNs, including CRNAs, be used to their full practice authority to improve patient access to safe, high-quality anesthesia care.

Yet despite all of the evidence of CRNA safety and support for APRN/CRNA-provided services, physician groups persist in making such vacuous statements as "removing anesthesiologists from surgery and replacing them with nurses" would be "lowering the standard of care and jeopardizing veterans' lives," even though there is no evidence to support their claims. It's interesting, too, that these same doctors don't insist on being assigned to the front lines in forward surgical teams to care for soldiers who have been horribly injured during battle, instead leaving this up to CRNAs to handle. Somehow, in their view, battlefield care is less complicated than caring for these same soldiers as veterans when they are stateside.

Add to this that CRNAs already provide the majority of healthcare in rural areas of the country—primarily as the only anesthesia providers available, and without the need for physician supervision in 17 states—and there simply is no way to justify physician groups attempting to limit the practice of CRNAs and other APRNs, to the benefit of physicians and the detriment of our veterans.


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