VA to Allow Direct Access to Advanced Practice Nurses

Alicia Ault

December 14, 2016

The Veterans Administration (VA) says it will allow advanced practice registered nurses (APRNs) to work independently without physician supervision everywhere in its network, the largest integrated health system in the United States.

But notably, certified registered nurse anesthetists (CRNA) were left out of the rule, and not given the same privileges as other APRNs.

The final rule, issued December 13, was applauded by nurses and nurse practitioners, but drew a frustrated response from physician organizations.

"We are pleased the VA will move forward with allowing veterans throughout the country to have direct access to nurse practitioner provided health care," said Cindy Cooke, DNP, FNP-C, FAANP, president of the American Association of Nurse Practitioners (AANP), in a statement.

The VA first proposed allowing APRNs to work to the full extent of their education, training, and certification, without physician supervision, in May 2016. The proposal won the support of many nursing organizations and several veterans' groups, including the Military Officers Association of America, and the Air Force Sergeants Association.

At the time, VA Under Secretary for Health David J. Shulkin, MD, said in a statement that the purpose of the rule was "to ensure VA has authority to address staffing shortages in the future."

Cooke said that nurse practitioners are "a zero cost, zero risk solution and a significantly positive step to strengthening care for those who served our nation."

The American Nurses Association (ANA) said that 6000 APRNs work within the VA. The rule "puts veterans' health first, and will help improve access to the timely, effective and efficient care they have earned," said ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, in a statement.

The American Medical Association (AMA), which led the charge against the VA proposal, issued a statement of frustration. "While the AMA supports the VA in addressing the challenges that exist within the VA health system, we believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans," said Stephen R. Permut, MD, JD, chairman of the AMA's board.

"We feel this proposal will significantly undermine the delivery of care within the VA," he said, adding, "All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine."

The VA rule allows three types of APRNs — certified nurse practitioner, clinical nurse specialist, and certified nurse-midwife — to practice to the full extent of their training and education, regardless of state laws. Among the duties envisioned: providing physical examinations and other health assessment and screening activities; diagnosing, treating, and managing patients with acute and chronic illnesses and diseases; ordering laboratory and imaging studies and integrating results into clinical decision-making; prescribing medication and durable medical equipment; and making referrals.

Under the final rule, APRNs may not perform, supervise, or interpret medical imaging exams, which the American College of Radiology (ACR) said it had backed.

"We thank the VA for acting on our input and for recognizing the outstanding work performed by radiologists in [the VA] system," said the ACR, in a statement.

CRNAs Not Approved

The VA said that for now, certified registered nurse anesthetists will not be given full-practice authority. It is seeking more comment "on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking," according to the final rule.

The decision to seek more information might be in reaction to what the VA termed a dubious lobbying campaign by the American Society of Anesthesiologists (ASA) to prevent CRNAs from getting independence. The agency said it received 104,256 comments against granting CRNAs full-practice authority.

"The American Society of Anesthesiologists lobbied heavily against VA CRNAs having full practice authority," said the VA in the final rule. "They established a website that would facilitate comments against the CRNAs, which went as far as providing the language for the comment. These comments were not substantive in nature and were akin to votes in a ballot box," wrote the agency.

The VA said the ASA made a straw argument, claiming CRNA independence would doom team-based care — a claim that was not substantiated, said the agency. However, the VA said it "does believe that evidence exists that there is not currently a shortage of anesthesiologists that critically impacts access to care," so more study is needed.

The ASA, for its part, said it was "extremely gratified" by the decision to exclude CRNAs, and took credit for the anti-CRNA comments.

"We commend VA's leadership for their recognition that the operating room is a unique care setting and that surgery and anesthesia are inherently dangerous requiring physician leadership," said ASA President Jeffrey Plagenhoef, MD, in a statement.

Both Cooke from the AANP and Dr Cipriano from the ANA said they're hopeful CRNAs will be included in the future.

"We join with our colleagues in continuing to advocate for CRNAs to have full practice authority within the VA health care system," said Dr Cipriano.

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