Doctors Sue To Stop Unsupervised Nurse Anesthetists from Administering Anesthesia

Surgical patients are being put at risk because a new California regulation allows nurse anesthetists to administer anesthesia without the supervision of a physician, claims a lawsuit filed against California Gov. Arnold Schwarzenegger by two large physician groups Tuesday.  Continue to HealthLeaders Media Article.

Wanda Wilson, CRNA, PhD, Executive Director, AANA (2/3/2010 at 11:42 PM)  The inaccuracies in the article, "Doctors Sue to Stop Unsupervised Nurse Anesthetists from Administering Anesthesia" are simply staggering

That the reporter didn't fact-check readily confirmable information and relied on a clearly uninformed and possibly biased source should be embarrassing to this e-publication. The following facts can be easily confirmed through any number of reliable sources:

1) First, it needs to be made perfectly clear: The federal rule in question allows states to opt out of the requirement that Certified Registered Nurse Anesthetists (CRNAs) be supervised by a physician, not an anesthesiologist. The physician can be a surgeon, dentist, podiatrist, anesthesiologist, etc. No matter how much Dr. Hertzka, an anesthesiologist and apparently the reporter's primary source, might wish it were different, there is no federal requirement that anesthesiologists supervise CRNAs, and only one state has such a requirement for very specific types of cases.

2) The comment attributed to Dr. Hertzka that allowing nurse anesthetists to deliver anesthesia to surgical patients is a bad idea because they're not trained for it is patently ridiculous. CRNAs provide more than 32 million anesthetics to patients each year in the United States. They provide anesthesia for all types of surgeries, including heart, brain, transplants you name it, CRNAs are involved in it. They provide the majority of obstetrical (OB) anesthesia, are the only anesthesia providers in two thirds of all rural hospitals, and have been the primary anesthesia providers to our nation's military personnel on the front lines since WWI, and that includes the current action in the Middle East. CRNAs work with every kind of surgeon, and provide every type of anesthesia. They work in many, many facilities where there are no anesthesiologists. Additionally, the statement attributed to Dr. Hertzka is an insult to the thousands of diligent, responsible, and intelligent classroom and clinical instructors who educate nurse anesthetists, many of whom are anesthesiologists themselves.

3) Dr. Hertzka's comments concerning the huge gulf of training and experience between CRNAs and anesthesiologists and equating the difference between these providers as similar to the difference between cardiologists/coronary care nurses are borderline slanderous. CRNAs are not physicians, nor do they want to be. CRNAs are educated and trained to provide anesthesia, including development of a patient's care plan, providing the anesthetic, monitoring the patient throughout the procedure, bringing the patient out of the anesthetic, and responding to any anesthesia-related emergency.

Coincidentally, since there are only so many ways to provide anesthesia and both CRNAs and anesthesiologists adhere to the same standards of safe patient care, both types of providers have similar curriculum when it comes to providing anesthesia. This doesn't mean they're the same: As physicians, anesthesiologists can provide medical care long before and long after the anesthetic has been administered. But many anesthesiologists prefer not to fully utilize their knowledge, background, and skills, instead settling for making most of their income supervising the providers (CRNAs) who are actually giving the anesthesia and working with the patient.

When you're in a airplane, don't you want the person at the controls to be the one who's at the controls all the time? Many anesthesiologists do actually administer anesthesia, but all CRNAs always administer anesthesia. It's what they do, and do well. In fact, CRNAs are the hands-on providers of most of the anesthesia provided in the United States. Often, when an anesthesiologist is working with nurse anesthetists, they are supervising up to four cases at a time, basically floating between the ORs while the CRNAs stay with the patient from start to finish.

At night, in facilities where CRNAs and anesthesiologists are both employed, the "sundown" rule often takes effect in the emergency room and OB suites, which essentially means the anesthesiologists retire to their call rooms or go home for a good night's sleep while the CRNAs suddenly, magically become safe enough to provide patient care without them around. Interesting, isn't it?

4) The reporter and Dr. Hertzka, and now the readers of this article, need a brief history lesson on the opt-out rule, all of which is easily verifiable. Prior to California, there were 14 states that opted out of the federal supervision rule, not "only about seven" as attributed to Dr. Hertzka. That's nearly 33% of all states; among the others are states with large urban areas such as Minnesota, Washington, and Oregon.

5) The reporter attributes to Dr. Hertzka a statement that the federal rule allowing states to opt out of the physician supervision rule for nurse anesthetists "came out of the blue" in 2001 thanks to President Clinton whose mother was a nurse anesthetist.

In reality (anyone can read the history of this rule in the Federal Register), the initial rule was put forth by the Centers for Medicare & Medicaid Services (CMS) and was intended to remove the supervision requirement entirely because it has nothing to do with safety and everything to do with hospital reimbursement for anesthesia services. After careful consideration and a lengthy comment period, CMS decided that the rule was cumbersome and out of date, and that research showed CRNAs and anesthesiologists to be equally safe providers to boot.

President Clinton signed this rule shortly before leaving office, President Bush put a hold on it, and ultimately it was President Bush who signed the opt-out rule that we now have (rather than a blanket removal of the supervision requirement). And yes, President Clinton's mother was a nurse anesthetist. However, President Bush's mother was not, and he still signed the opt-out rule into effect!

6) The reporter notes that the complaint filed by the anesthesiologist society and the medical association states that Gov. Schwarzenegger "had no authority to submit" an opt-out request to CMS. It is safe to say that such an assertion is completely contrary to what the rule itself says. Gov. Schwarzenegger was completely within his right to submit the letter to CMS if he consulted with the state boards of nursing and medicine; if the rule was not contrary to state legislation/regulations (California does not have a state law, rule, or regulation requiring supervision of nurse anesthetists); and if he determined that the change was in the best interests of the citizens of California. Obviously, that is exactly what he determined.

7) Dr. Hertzka's comments about surgeon liability are completely unfounded. As case law has shown over and over again, surgeons assume no more liability when working with a CRNA than they do when working with an anesthesiologist. Additionally, malpractice insurance rates for CRNAs are 33% lower than 20 years ago, and recent data shows they are even lower in opt-out states than in non-opt out states.

Again, I encourage all readers of this comment to check the facts for themselves in the Federal Register and elsewhere. The fact that this article is so fraught with errors is truly indefensible.

Wanda Wilson, CRNA, PhD, MSN
Executive Director
American Association of Nurse Anesthetists