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

Crunching the Numbers: Are CRNAs Needed in the VA System?

Medscape: How many anesthesiologists and CRNAs are currently employed full-time by the VA? How does supervision work now on a day-to-day basis? Who provides the hands-on care, and what is the nature of supervision of CRNAs whose state licenses require it? It must be very confusing if CRNAs hold different state licenses within a single VA.

Dr Cole: There are 1188 physician anesthesiologists in the VA system. Currently, the VA uses a team-based approach to anesthesia care, which is a proven model of care. The VA Anesthesia Service Handbook directs that anesthesia be delivered in a "team fashion" and consistent with state licensure. As noted before, 46 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, and many of the hospitals in those states still follow a model of team-based care in which physician anesthesiologists and nurses work together to provide anesthesia.

Dr Quintana: Currently, more than 900 CRNAs work in the VA system. As anesthesia experts, CRNAs are the hands-on providers of the vast majority of anesthesia care for veterans and civilians alike, staying with their patients during their procedures to ensure their safety and comfort throughout. In addition to planning the patient's care, vigilantly monitoring the patient's vital signs, and modifying the anesthesia as needed, CRNAs also analyze situations, make critical decisions, communicate clearly with the other members of the surgical team, and respond quickly and appropriately. In fact, outside the VA, CRNAs safely provide nearly 40 million anesthetics to patients each year in the United States.

CRNAs are not required by federal or state law (except under very specific circumstances in New Jersey) to be supervised by an anesthesiologist. In addition, 17 states have opted out of the federal Medicare physician supervision requirement for nurse anesthetists, and 40 states do not have a physician supervision requirement for CRNAs in their nurse practice acts, board of nursing rules/regulations, medical practice acts, board of medicine rules/regulations, or their generic equivalents.

CRNAs are prepared to provide the full range of anesthesia services and related care, including pain management. CRNAs work with the surgeon and the rest of the patient care team; sometimes they also work with an anesthesiologist. However, in the VA, there are many instances where hospitals have CRNAs supervised by anesthesiologists. Not only is that unnecessary, but it is also tremendously expensive and diverts resources needed to care for veterans in other areas. Approval of a clear statement from the VA on full practice authority for CRNAs and other APRNs would help the VA address this commonsense management issue.

Medscape: Are there enough anesthesiologists in the VA system at this time to provide MD-led care everywhere, without making any changes? And would the new rule require that VAs institute independent CRNA practice—or, if appropriate staff are available, could a VA keep a well-functioning, collaborative, MD/CRNA model in place?

Dr Quintana: Both CRNAs and anesthesiologists are needed. The VA's independent assessment[1] identified delays in cardiovascular surgery owing to lack of anesthesia support, rapidly increasing demand for procedures requiring anesthesia outside of the operating room, and slow delivery of colonoscopy services compared with the private sector.

Current VA policy recommends that CRNAs and anesthesiologists work together but does not require CRNAs to be supervised by anesthesiologists or other physicians. The proposed policy change supports a surgical team-based model of care to fully utilize the knowledge, skills, and abilities of CRNAs to practice to their full authority.

AANA recognizes the significant healthcare needs of the nation's veterans and wants to assist the VA in providing excellent and cost-effective patient care for those who have fought for our country. Given rising healthcare costs, it is important to remove costly inefficiencies and find ways to improve patient access to quality care without unduly burdening the healthcare system.

Dr Cole: There is no shortage of physician anesthesiologists in the VA system, and the change is not needed to improve access to anesthesia care. The rule specifically says that nurses would practice "without clinical oversight of a physician." Abandoning the current team-based model of anesthesia care and implementing a nurse-only model lowers veterans' standard of care and jeopardizes their lives. It remains unclear how the VA will use physician anesthesiologists if the new policy is implemented.

Medscape: In the current VA system, aren't there areas of the country that currently have CRNA-only anesthesia services on site? Are there any specific concerns within the VA system where this is the practice?

Dr Cole: The VA operates the nation's largest healthcare system, with more than 1700 hospitals, clinics, and other facilities across the country. If there are facilities in the system that practice with only a nurse anesthetist providing anesthesia care, they are extremely limited and would only be in one of the four states (Utah, Montana, New Hampshire, and Oregon) that allow a nurse-only model. Even in those states, facilities often use a team-based model where physicians provide clinical oversight. This clinical oversight and team-based model is the proven model and standard of care used for almost every American. The veterans who served our country do not deserve any less.

Dr Quintana: In US rural counties, 35% have only CRNAs, 4% have only anesthesiologists, 27% have both anesthesiologists and CRNAs, and 34% have neither. Currently in several VA facilities, CRNAs are the sole providers of anesthesia care, and there are no specific concerns about this within the VA system. CRNAs care for countless soldiers on the front lines, without anesthesiologists to be found anywhere; these soldiers then become the veterans whom CRNAs care for stateside. Soldiers who were injured in battle and received lifesaving anesthesia care on the front lines admire the courage, skills, and compassion of the CRNAs who cared for them; the same feelings translate back home.

There are no anesthesia services in the VA or in private practice that can be provided by a physician only and not by a CRNA. CRNA education and training equip CRNAs to provide the full range of anesthesia care and related services, including chronic pain management. CRNAs are qualified by their education, training, and licensure to safely provide anesthesia services to all patient populations regardless of setting and are as qualified as anesthesiologists to provide anesthesia for complicated cases. The cases they cover range in complexity from simple procedures, such as appendectomies, to complex heart surgeries. They are qualified to provide anesthesia in all settings and all patient populations.


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