August 30, 2013
Hon. Robert Petzel, MD
U.S. Department of Veterans Affairs
Office of the Under Secretary for Health
810 Vermont Avenue, NW
Washington, DC 20420
Dear Dr. Petzel,
On behalf of nearly 47,000 members of the American Association of Nurse Anesthetists (AANA) and our approximately 700 members serving in the Veterans Health Administration (VHA) which include members of the Association of Veterans Affairs Nurse Anesthetists (AVANA), we write to express our strong support for modernizing the VHA Nursing Handbook, which has undergone extensive VA Central Office concurrence procedures in accordance with agency policy, and to update you about the safe and effective practice of nurse anesthesia in the VHA. We also seek to correct statements made by the American Society of Anesthesiologists (ASA) in its July 2, 2013 ,letter to you. Sharing as we do a common interest in outstanding care and patient safety for our Veterans, we would welcome the opportunity to meet with you to discuss how the VHA's proposed update to its Nursing Handbook, based on recommendations of the Institute of Medicine, honors our commitment to our nation's Veterans through quality healthcare services delivery and evidence-based practice.
Background of the AANA and Certified Registered Nurse Anesthetists
From Civil War battlefields to the present day, nurse anesthetists have provided anesthesia and pain management care to those who have borne the battle. Certified Registered Nurse Anesthetists(CRNAs) are advanced practice registered nurses (APRNs) and anesthesia professionals who safely administer more than 34 million anesthetics to patients each year in the United States, according to the 2012 AANA Practice Profile Survey. Our members are fully committed to the mission of the VHA, where some 500 CRNAs proudly provide anesthesia and pain management care in service to our Veterans. Many of those VHA CRNAs are themselves Veterans of our U.S. Armed Forces, or were registered nurses in VHA healthcare facilities before undertaking their anesthesia education.
CRNAs practice in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms; critical access hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists; and U.S.military, Public Health Service, and, of course, Department of Veterans Affairs healthcare facilities. Within the VHA and in the civilian sector alike, CRNA services include providing a pre-anesthetic assessment, obtaining informed consent for anesthesia administration, developing a plan for anesthesia administration, administering the anesthetic, monitoring and interpreting the patient's vital signs, and managing the patient throughout the surgery. CRNAs also provide acute and chronic pain management services in VHA and private facilities. CRNAs provide anesthesia for a wide variety of surgical cases and in some states are the sole anesthesia providers in nearly 100 percent of rural hospitals, affording these medical facilities obstetrical, surgical, trauma stabilization, and pain management capabilities.
Peer-reviewed scientific literature shows CRNA services ensure patient safety and access to high-quality care, and promote healthcare cost savings. A landmark study published in August 2010 in Health Affairs
showed no differences in patient outcomes when anesthesia services are provided by CRNAs, physicians, or CRNAs supervised by physicians.1 Another important study published in 2010 in the journal Nursing Economic$
found that CRNAs acting as the sole anesthesia provider are the most cost-effective model for anesthesia delivery, and there is no measurable difference in the quality of care between CRNAs and other anesthesia providers or by anesthesia delivery model.2
Correcting Information about CRNA Care in the VHA
We were deeply disappointed to read in the ASA's July 2 letter so many inaccurate and misleading statements about CRNAs and the care they provide in VHA, military and civilian environments. We correct that record as follows with quotes from the ASA letter in italic
and our response in roman and bold:
* "...(The) handbook would designate all advanced practice nurses (APRNs) within the VHA, including nurse anesthetists, as licensed independent practitioners (LIP) who would be required to function without physician supervision, support or oversight."
While there is no question that CRNAs and other APRNs are fully qualified and consistently demonstrate their ability to provide safe, high-quality patient care without physician supervision, support, oroversight, the truth is that neither the VHA draft Nursing Handbook nor the term "Licensed Independent Practitioner" suggest that CRNAs and other APRNs would be "required" to function without physician involvement should the VHA designate APRNs as LIP. Understanding that the VHA looks to the Department of Defense for information and healthcare delivery standards, the agency should be aware that branches of our U.S. Armed Forces have recognized CRNAs as LIP for a decade or more, and that those military CRNAs have compiled an outstanding safety record delivering care in major stateside hospitals and in the most austere conditions in theater. The literature shows patient safety continues improving, and our experience is that care in these environments where CRNAs are LIP has remained collegial and professional. If the VHA similarly designates APRNs as LIP, its experience should be no different than that of our military services
- "Surgery is a complex medical procedure with many opportunities for complications and emergencies to arise. As practicing physician anesthesiologists, one of whom previously trained and practiced as a nurse anesthetist, we know that physician anesthesiologists play a critical role in surgery by serving as the patient' s advocate in the operating room, and by responding to emergencies when they arise. Often, these emergencies have nothing to do with anesthesia, but with the patient' s underlying medical condition or an unforeseen medical complication. Physician anesthesiologists, who have 12,000 - 16,000 hours of clinical training, are best prepared to address emergency situations especially in the patients served by the VHA." Through rigorous training and education, CRNAs are expert in provision of anesthesia and related services.
[FONT=TT15Ct00]1 [FONT=TT15Ct00]B. Dulisse and J. Cromwell, "No Harm Found When Nurse Anesthetists Work Without Physician Supervision."[FONT=TT15Dt00]Health Affairs. [FONT=TT15Ct00]2010; 29: 1469-1475.
[FONT=TT15Ct00]2 [FONT=TT15Ct00]Paul F. Hogan et. al, "Cost Effectiveness Analysis of Anesthesia Providers." [FONT=TT15Dt00]Nursing Economic$. [FONT=TT15Ct00]2010; 28:159-169.
"The Anesthesia Handbook further provides that 'state license scope of practice establishes the maximum breadth of practice allowable for a provider.' Most states require some level of physician involvement in the delivery of anesthesia care."
Forty states do not require physician supervision of nurse anesthetists in their nursing or medical board statutes or regulations and forty nine states do not require any anesthesiologist involvement in the care provided by CRNAs. Seventeen states have opted-out from the Medicare requirement for physician supervision of nurse anesthetists, and Medicare does not require anesthesiologist involvement in CRNA care.
"The draft Nursing Handbook conflicts directly with the longstanding Anesthesia Handbookby effectively eliminating physician-nurse team-based coordinated care."
The ASA statement is false. While the VA Anesthesia Handbook supports care provided in teams, it does not require anesthesiologist supervision of CRNAs. Consistent with the Anesthesia Handbook, several VHAs are staffed solely by CRNAs working without anesthesiologist supervision. Recognition of APRNs as LIPs emphasizes that each provider is responsible for his or her own acts, and that each professional is responsible to collaborate with or refer issues to others as appropriate. Overall care of the patient remains a collaborative effort among physicians, APRNs, nurses and other healthcare professionals, as it should.
"Moreover, local facilities wishing to continue team-based care are prohibited from doingso."
The ASA statement is false. Consistent with the recommendations of the Institute of Medicine report "The Future of Nursing: Leading Change, Advancing Health
," the Nursing Handbook revisions support innovative models of care, including team based care that maximizes use of the full knowledge, skills and abilities of APRNs consistent with their education and training.4
"ASA believes that the proposal to eliminate team-based anesthesia care could decrease the quality of care within the VHA. Physician involvement in the delivery of anesthesia remains the current standard of practice within the VHA and remains a requirement in the majority of states. We believe that physician involvement is in the best interest of all patients and is particularly appropriate and necessary for VHA patients."
The ASA statement misrepresents the proposal. The VHA proposal recognizes the value of team based care. Scientific evidence demonstrates that in anesthesia delivery, as a component of surgical care, there is no difference in outcomes between anesthesia care provided by CRNAs when compared to care provided by anesthesiologists or care provided by CRNAs supervised by anesthesiologists.
3 Department of Veterans Affairs, Anesthesia Handbook VHA-1123. March 7, 2007 .http://www.va.gov/vhapublications/Vi...sp?pub_ID=1548
4 Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health. National Academy of Sciences,Washington, DC, 2010. Recommendations are summarized in a monograph found at http://www.iom.edu/~/media/Files/Rep...mendations.pdf
We thank you for the opportunity to inform you about the value and commitment of CRNAs to excellent healthcare services for our nation's Veterans, and to set the record straight about the quality of CRNA care in the VHA. We look forward to meeting you in hopes of examining additional way sour membership can contribute improving health of and healthcare for the men and women who have served our country in the U.S. Armed Forces.
Should you have any questions regarding these matters, please feel free to contact the AANA Senior Director of Federal Government Affairs, Frank Purcell, at 202.484.8400, email@example.com.
Dennis C. Bless, CRNA, MS Sherry Swearngin, CRNA, MHS
AANA President AVANA President
cc: Wanda O. Wilson, CRNA, PhD, AANA Executive Director / CEOFrank J. Purcell, AANA Senior Director Federal Government Affairs
5 [FONT=TT15Ct00]Silber J, Kennedy S, et al, "Anesthesiologist direction and patient outcomes." Anesthesiology 2000;93:152-63.
[FONT=TT15Ct00]6 [FONT=TT15Ct00]66 Fed. Reg. 4674, 4677, January 18, 2001. [FONT=TT15Ct00]http://www.gpo.gov/fdsys/pkg/FR-2001...df/01-1388.pdf
[FONT=TT15Ct00]Further anesthesia patient safety research information is available from AANA, "Quality of Care in Anesthesia,"2012