AA question

[manowar88]

Hello, I have recently been accepted into CRNA school and will start this fall. I have been involved in a discussion in a nursing synthesis class this semester and I want to pose some of the discussion to the forum and get some feedback. The discussion goes as follows: Some of the issues facing CRNA's are the same as for the entire nursing

profession. The shortage of CRNA's is a current issue as many of the

CRNA's reach retirement age and school admission is limited. To combat

the problem, there are more CRNA schools opening to accomodate the

shortage and some schools are admitting more students each year.

Another solution found here in Georgia, or atleast the Atlanta area is

that the CRNA positions are being filled by AA's. For CRNA's in the

Atlanta area, this competition translates into having Ga CRNA salaries

being one of the lowest in the nation when compared to other states.

From what I understand, there is great animosity between CRNA's/AA's/and

physicians in this area. The doctors seem to like the use of AA's

because they have more control over them as they cannot practice alone

and are limited as to where they can practice. However, this may not

always be the case as the AA's lobby to gain rights in many other

states, the CRNAs may see greater competition for employment and

salaries. However, I do not think employment will be an issue for

quite some time given the shortage, but something to think about for the

future. Salaries on the other hand are already becoming an issue.The

hospitals I have had the opportunity to visit carry a ratio of 80-85%

AA's over CRNA's and the majority of the CRNA's are 45+ years old. ------------------I am primarily interested in the forum's thoughts on AA's and their possible threat to CRNA's. Is their a rivalry? Do you think they will affect CRNA hiring and salaries? How many work in the OR at your place of work? Thanks for the feedback and I will pass it on to my classmates....

[user69]

Does anyone know how training for a CRNA and an AA differ? I am aware that the AA program does not require a nursing degree before entering, but one they are in, what do they do?

Also I have seen posts that say that an AA has to be given every order by a MDA, which imply that in every operating room there will be one extra person. Am I reading this correctly? And in this thread there was a reference to a new law that will allow them to work with two AAs at a time, so are they doubling the opportunities for AAs?

How many people have actually worked with AAs in the past? Did they come off as arrogant or even as competent?.

Allen

[loisane]

Allen,

The two AA programs are at Case Western in Cleveland, and Emory in Atlanta. Go to their websites, and compare their course program with the CRNA education programs. I think I have heard that one program allows regional instruction, while the other does not-but I am not 100% sure of that point.

CRNA and AA practice are regulated by the states. So you will see state to state variation. Legislative consideration of AA practice has increased recently, and seems to be ongoing. Some states have dictated supervision ratios of 1 MDA to 4 AAs.

AAs (by education, certification and state law) are NOT allowed to practice in any environment that does not include MDA supervision of their practice.

This is not true of CRNAs. CRNAs have the education and certification to allow them to practice anesthesia without the involvement of a MDA.

AA practice is more common in Ohio and Georgia, but I understand they are in other states as well. I have not worked with any personally.

loisane crna

[manowar88]

it's my humble opinion that a few high profile AA screw ups with some dire patient outcomes would bring a little light to the subject (heaven forbid). please dont think this is what i'm looking for, but the fact remains that if AA's are being used interchangably with crna's, screw ups are bound to happen. unfortunately these types of situations have to occur before ppl of power wake up to see the light.

d

------I dont know if a few patient screwups (god forbid) is going to affect AA legislation. I reflect on high nurse patient ratios that are currently being used across the country. Many "screwups" have happened but only a handful of states have mandated ratio laws. I think the only way to affect legislation is to get involved politically through local AANA chapters. I am looking forward to participating with my local chapter this coming fall.

[Athlein1]

1. You do not necessarily need direct patient care experience to enter an AA program, though many applicants have medical volunteer hours or tech/medical assistant experience. That in itself is a major concern.

2. Case Western teaches regional anesthesia and allows students to perform those techniques. Emory gives you the foundational information for regional, but its students do not practice regional techniques.

3. I haven't worked with AAs as a SRNA, but I often ran into them as a bedside RN. Let's put it this way: Those AAs were kept on a short leash. And, might I add, for good reason.

4. A significant problem with CRNAs and AAs mixing in practice is this (among many other issues, of course): CRNAs, by virtue of their training, can function competently and safely as independent practitioners. AAs cannot - and should not. This is a troubling source of confusion for anesthesia departments implementing the "anesthesia care team model". Restrict the CRNAs or inadequately direct the AAs in a misguided (and foolish) attempt to make anesthesia practice fair and equitable for both types of practitioners? There is no easy answer, which is why AA practice is so onerous.

All you SRNAs and wannabes out there, this is a real issue. We need to get involved and stay involved on state and national levels to protect our future practice. There are solid plans to expand AA practice and programs. Think how hard you are working to reach your goals. Then ask yourself if it's worth your time to get politically active on this issue. The clear answer is yes, absolutely.

[loisane]

Athlein1,

What a great post. I am encouraged by your positive attitude. You have a great command of the facts on this issue.

Keep spreading the word!

loisane crna

[Athlein1]

thanks loisane! your post is much appreciated.

for inquiring minds, here is a link to emory's aa website:

http://www.emory.edu/whsc/med/anesthesiology/pa_program/faq.html

for inquiring minds short on time, here are a couple of salient exerpts (my comments are in bold underneath each paragraph):

what is an aa/apa?

aas/apas (anesthesiologist assistants/anesthesiology physician assistants) are qualified to assist an anesthesiologist in the delivery of anesthesia by virtue of their didactic and clinical training at the master's level in schools of medicine. the programs are specifically designed to educate anesthetists to work alongside anesthesiologists. aas/apas are the functional equivalent of nurse anesthetists, although their training is in the school of medicine rather than either a school of nursing or a hospital based educational program. aside from the educational aspects, aas/apas must work as a member of the anesthesia care team under the direction of a qualified anesthesiologist, whereas a nurse anesthetist may work under the direction of any physician or dentist according to prevailing state regulations. in most hospitals, a qualified anesthesiologist may direct up to four anesthetists simultaneously, depending upon applicable state laws and regulations, including any combination of aas/apas and certified registered nurse anesthetists

"aas/apas are the functional equivalent of nurse anesthetists"? clearly a misleading statement. aas are not the functional equivalent of crnas from an experiential, educational, or scope of practice standpoint!

[color=#0000a0]q. [color=#0000a0]do i need work experience in anesthesia or a minimum number of hours of contact with patients before i can be considered for admission?

a. no, there are no formal requirements for experience working with patients or specifically in anesthesia. however, if you have an interest in becoming an aa/apa, and currently have no association with a department of anesthesiology, it is expected that you would spend a minimum of eight hours with an anesthetist or anesthesiologist in the operating room to gain some insight into the profession. anesthesia is demanding profession with a high level of responsibility for direct patient care. we believe that candidates who understand their role as a member of the anesthesia care team will have a higher level of motivation to excel in the program. part of the application includes a document that is intended to verify the minimum time spent seeking information about the profession.

this is astounding. eight hours to "gain insight into the profession"? would you want someone with no direct patient care experience or medical background to be managing your anesthetic, your airway, your cardiovascular system? someone who has never even used a ventilator or titrated a drip before starting school? if this doesn't scare you....

[user69]

Does anyone know if the AAs have a discusion board like this one? And what the URL is?

[Athlein1]

Issue: Safety, not Bucher

April 6, 2004

Susan Bucher said campaign contributions bought a vote. For this, her

colleagues may reprimand her. Isn't truth the ultimate defense against

alleged slander?

Three weeks ago, the House Health Care Committee approved a bill that

would allow anesthesiologist assistants to administer anesthesia to

surgery patients. Current law allows only the anesthesiologist or a

certified nurse anesthetist to put patients under. The anesthesiologists

and the Florida Medical Association, the physicians' main lobbying

group, support the bill. They have thrown hundreds of thousands of

dollars into campaigns, and their lobbyists are working the halls.

After the vote, Rep. Bucher, D-Royal Palm Beach, said, "It's just

amazing what contributions have purchased here today... I think this is

a bad bill that was financially greased through the system." She's

right, of course. The link between donations and many votes is clear; a

classic example was last year's phone-rate increase. But legislators

aren't supposed to say so on the floor, and Rep. Bucher may get a

scolding from the leadership.

Rep. Bucher's caustic style can annoy even her allies. And in fact, she

took money from the nurse anesthetists, who stand to lose because some

anesthesiologists will hire the cheaper, less-trained assistants. For

all the discussion of what Rep. Bucher said, however, there wasn't much

discussion of an issue that goes directly to patient safety.

Under the bill, anesthesiologists simultaneously could supervise as many

as two assistants in two operating rooms of the same suite. "Supervise,"

though, would not mean direct supervision. The assistant could

administer the anesthesia. An amendment to require that the

anesthesiologist be in the same room was defeated.

The anesthesiologists claim that there would be adequate safeguards. It

is worth noting, though, that the House staff analysis of the bill does

not address safety. The Senate staff analysis discusses safety, but it

includes only comments from the anesthesiologists. Not surprisingly,

they see no problem. And the House analysis estimates that about 50

people per year would apply to be assistants, while the Senate staff

estimates the number of applicants at 20 per year. The Senate has passed

its version of the bill.

A bill to allow anesthesiologist assistants failed in 2002. Then, the

argument was a potential shortage of nurse anesthetists. But the

physicians' lobby could not document it. This year, the argument is that

the assistants will raise standards, not lower them. Whatever the case

against Rep. Bucher, the case for the bill has yet to be made.

[athomas91]

i was just doing some reading...and i found that Champus - the medical insurance for military families is supporting the use by our military of AA's - encouraging it in fact. sad - you can't send an AA with deployed troops (without a MDA) - but you could surely send a CRNA - ....makes you wonder.

[user69]

Back to my earlier question, how many of the people on this board work with AAs? Can you relate your personal experiences please?

Does anyone see the AMA pushing for the removal of CRNA as a specialty to be replaced with AAs? How much lobbying power do they have? From the earlier article it looks like they are not short of pork to dole out to our legislators.

Also, if our lobby is successful and AAs are prevented from practicing, will the existing AAs be grandfathered in? And if the AMA is successful, will the CRNAs be grandfathered in?

[mato_tom]

Back to my earlier question, how many of the people on this board work with AAs? Can you relate your personal experiences please?

Does anyone see the AMA pushing for the removal of CRNA as a specialty to be replaced with AAs? How much lobbying power do they have? From the earlier article it looks like they are not short of pork to dole out to our legislators.

Also, if our lobby is successful and AAs are prevented from practicing, will the existing AAs be grandfathered in? And if the AMA is successful, will the CRNAs be grandfathered in?

how much lobbying power does the AMA have? are you kidding?

AAs and CRNAs will not be prevented from practicing. CRNAs will keep what they got unless there is a rash of deaths/injuries, which based on many years of practice is not going to happen.

AAs will gain state licensure in more and more states beginning with florida. Schools and MDAs will start new programs to increase the supply. CRNAs and MDAs will battle on the scope of practice for AAs and the supervision levels required.

I admit to knowing very little about the application of anesthesia and the role of each profession,,,,but from what i gather it has been made very safe and even the ASA admits that MDAs are overtrained/overeducated for some of the routine processes that occur during surgery, which is why they want to have an assistant, that they can bill for, be there.

the key to the million dollar question, which is what will happen to CRNA salaries is, as usual, a simple supply and demand issue.

what % of cases to CRNAs do solo vs supervised by an MDA -- i would really like to know these numbers, but cannot find them.

how many educators are available to stock AA programs?

[loisane]

Does anyone see the AMA pushing for the removal of CRNA as a specialty to be replaced with AAs? How much lobbying power do they have? From the earlier article it looks like they are not short of pork to dole out to our legislators.

The ASA is pushing for AAs. The AMA is more conflicted. After all, the AMA also includes surgeons, who are (in general) very supportive of CRNA practice. Very unlikely they would speak against their MDA brothers, though. And remember, not all MDAs are pro AAs. It is their professional association that is promoting them.

Also, if our lobby is successful and AAs are prevented from practicing, will the existing AAs be grandfathered in? And if the AMA is successful, will the CRNAs be grandfathered in?

This is a state by state issue. There are some states in which AAs are already practicing. Recognizing and licensing AAs does not automatically remove CRNAs from the work force. We are regulated and licensed by BON. The presense of AAs in any work market will influence the economics of that market. It is these market influences that would ultimately determine the relative worth and marketability of either provider.

loisane crna