CRNAs: We are the Answer

The American Association of Nurse Anesthetists makes a bold proclamation of their full practice, safety, independent capabilities, and economic advantage for our modern healthcare system. Specialties CRNA Article

CRNAs: We are the Answer

Before we begin a discussion on the topic you should probably follow this link to the AANA's original statement.

Firstly, I have to disclose that I am in my third year of nurse anesthesia training preparing for graduation, so I am not a board certified CRNA yet. Anything I say is coming from the perspective of a new generation of CRNA DNP training which I've noted can be slightly different from those of older generations. I am also the elected political representative of my class throughout our program so I do stay more engaged and informed than some other anesthesia trainees. Last disclosure, I do serve the AANA and work on a committee that serves the board of directors.

Now, to understand where this new bold statement from the AANA came from I think it's necessary to understand it is in response to the ASA's statement about the Anesthesia Care Team last fall. Their statement unabashedly self-aggrandizes themselves and downplays CRNAs actual role as experts and independent anesthesia providers. In fact, they use wording that implies better education and training from their own assistants (AAs) than nurse anesthetists who has been providing safe competent anesthesia since the civil war.

Although, most CRNAs don't blame them for making a political statement like this promoting themselves and downplaying their competitors in the marketplace. That is the duty of a professional organization, to promote that organization. Anesthesia has been aggressively political since the early 1900s when physicians decided to start learning anesthesia and tried to make it illegal in California for a nurse anesthetist to continue practicing anesthesia. Who wants competitors if you think you can eliminate them, it just makes business sense.

After the political statement made last October by the ASA large amounts of CRNAs were outraged and demanded an immediate defending response from the AANA. The AANA is always careful and intentional in what it does, so they created a task force of influential and level headed CRNAs who would investigate the issue and come up with a diplomatic response. They spent 6 months discussing this and coming up with the response you are now reading. This statement was intentional and well thought out. It is supported and celebrated by a huge majority of CRNAs/SRNAs judging from responses in person and in private CRNA forums consisting of tens of thousands of CRNAs.

It's disconcerting that I have seen some negative comments online by people who aren't physicians. You would expect many physicians to react negatively to a non-physician provider talking about their education, training, and similar patient outcomes but it is odd to see some others ill-informed negativity.

The biggest confusing issue I see people have is that in the AANA's statement that is in response to the ASA's care team statement is that billing methods are often fraudulent. What many may not understand is that in a medical direction billing model (which is what the ASA is wanting everywhere) involves meeting 7 TEFRA requirements to bill for CMS. These requirements are very often not met even when physicians bill in medical direction, which is Medicare fraud. This is not just anecdotal. The ASA produced research they performed themselves that was published recognizing that a huge number of medical direction practices are not meeting the 7 TEFRA requirements. Medical direction benefits the physician because they can bill for 4 different cases at once while they are not providing the anesthesia but 4 different CRNAs are performing the anesthesia. You can see why they would want this to be a standard delivery method of anesthesia. Even when their own research shows they are fraudulently billing in many places they continue to push this model. This model is oftentimes the most restrictive and oppressive to CRNAs who choose to work with that anesthesia group. It is also one of the more costly models for hospitals to sustain, so it's not economically responsible or sustainable for many facilities.

CRNAs mention these issues with medical direction because it supports the movement nationwide for the collaborative model of anesthesia care. This model requires that both CRNAs and MDAs be independent full practice providers who work together on a team. They are equal partners and practice under their own license to provide safe high-quality anesthesia to their patients. In this model, there are no 7 TEFRA regulations so Medicare fraud is not an issue. The economic reason some in anesthesia will not like this anesthesia delivery model is that you can not bill for services of 4 CRNAs at once providing anesthesia. Each provider can only bill for their own anesthesia for a single case. It would do away with someone sitting in the break room drinking coffee while 4 other providers are working and earning you profit. You can see why certain people would not want this to happen.

I just wanted to clear that portion up about the AANA's statement so it had some context and people who are not in the anesthesia realm understand where that came from. Those of us in anesthesia are just so used to that issue I think we forget others are not informed about it.

What do you guys think about the new statement?

7 Votes
Bluebolt

About Bluebolt

I'm a third-year SRNA and previously was a critical care RN for 4 years.

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Specializes in LTC.

I'd still rather have an M.D. if given the choice.

4 Votes
7 hours ago, Crystal-Wings said:

I'd still rather have an M.D. if given the choice.

I appreciate your input on the topic.

It's common for those not in the anesthesia community to get this confused. It is very very rare to find a group where MDs and DOs provide the anesthesia themselves. Almost always even if you speak to a physician in preop and they say they are "providing" your anesthesia today, it will actually be a CRNA who does your anesthetic. The CRNA often comes in right as it's time to roll back to the OR and gives Versed as a part of their anesthetic preop meds, which has an amnestic effect and many patients never remember meeting them. This is the billing model that physicians prefer and what I referred to above as a 4:1 ratio.

6 Votes
Specializes in Cardiology.

I suppose if I had a choice it wouldn't matter. Nurses were giving anesthesia long before it became a medical specialty and the military uses primarily CRNAs in place of anesthesiologists.

5 Votes
1 hour ago, OUxPhys said:

I suppose if I had a choice it wouldn't matter. Nurses were giving anesthesia long before it became a medical specialty and the military uses primarily CRNAs in place of anesthesiologists.

You're right but I don't want this to become a topic of "us versus them". That isn't what the purpose of the AANA statement or my posting here is about. Mutual respect with our physician colleagues is important currently and going forward as anesthesia progresses and grows.

The AANA statement is not really saying anything new that they haven't supported before or stated before, just simply using more direct wording. The idea is to reveal that CRNAs have been experts in anesthesia for a long time and as you mentioned, are the original anesthesia provider and the oldest advanced practice nursing specialty.

As my original post mentioned they bring up old billing models and delivery of care that is not the most cost-effective, and very possibly fraudulent. Many practices across the nation have been transitioning out of this model and into a more collaborative independent model that uses CRNAs to their full scope of training and licensure. Their statement is supporting this transition.

The only thing that is slightly more highlighted in recent statements is the fairly new descriptor, nurse anesthesiologist. The voting members of the AANA have stated they feel this term is more in line with the anesthesia expert they feel CRNAs represent. They have also stated that physicians were also called anesthetists until many decades ago they stated they were experts and would be called anesthesiologists instead. As an SRNA I am not a voting member on this topic and have no opinion.

2 Votes
13 hours ago, OUxPhys said:

I suppose if I had a choice it wouldn't matter. Nurses were giving anesthesia long before it became a medical specialty and the military uses primarily CRNAs in place of anesthesiologists.

This may be true in your reality, but in mine, my SIL an anesthesiologist is preparing to go to war in Afghanistan because the active duty CRNAs are all pregnant or breastfeeding continually....

Specializes in Cardiology.
5 minutes ago, twinsmom788 said:

This may be true in your reality, but in mine, my SIL an anesthesiologist is preparing to go to war in Afghanistan because the active duty CRNAs are all pregnant or breastfeeding continually....

That sucks. Its sad but there were women who always were pregnant just as a ship was ready to deploy. Must have been coincidence....

1 hour ago, twinsmom788 said:

This may be true in your reality, but in mine, my SIL an anesthesiologist is preparing to go to war in Afghanistan because the active duty CRNAs are all pregnant or breastfeeding continually....

This situation is an argument regarding the propriety of women in the armed services and not necessarily confined to the CRNA community. Hmm, when I was on active duty I certainly don't remember breastfeeding getting me out of anything. Guess I missed a modern perk.

4 Votes
1 hour ago, OUxPhys said:

That sucks. Its sad but there were women who always were pregnant just as a ship was ready to deploy. Must have been coincidence....

YEP I was active duty Army and was always ready to serve my country in deployment . Had my twins later.

1 minute ago, caliotter3 said:

This situation is an argument regarding the propriety of women in the armed services and not necessarily confined to the CRNA community. Hmm, when I was on active duty I certainly don't remember breastfeeding getting me out of anything. Guess I missed a modern perk.

It is what is the truth now. I hope I didn't imply it was just limited to CRNAs. I believe AD female anesthesiologists were also in this consideration.

Specializes in Trauma ICU/PCU.
On 5/29/2019 at 6:43 AM, Bluebolt said:

I appreciate your input on the topic.

It's common for those not in the anesthesia community to get this confused. It is very very rare to find a group where MDs and DOs provide the anesthesia themselves. Almost always even if you speak to a physician in preop and they say they are "providing" your anesthesia today, it will actually be a CRNA who does your anesthetic. The CRNA often comes in right as it's time to roll back to the OR and gives Versed as a part of their anesthetic preop meds, which has an amnestic effect and many patients never remember meeting them. This is the billing model that physicians prefer and what I referred to above as a 4:1 ratio.

The billing model seems to be the key word these days..

No disrespect to CRNA's, but they are NOT MD's! CRNA's are ICU nurses on steroids, they do not have the many years of rigorous and enduring training of MD's and should not claim they are as capable as the latter.

CRNA's are very well trained, but they are on a nurse track, not on physician track.

As a former ICU nurse I dealt with all kinds of anesthesia drips, and am very familiar with things that can go wrong, however that does not instill me with realization of being even remotely near a very specialized Anesthesiology MD's, whom I hold an utmost respect for.

I have also observed some ICU nurses being careless with Pent drips, Benzo's drips and Propofol drips, etc., and I would not want a CRNA to administer anesthesia to me based on my belief that CRNA's are just that - ICU nurses with anesthesia training along with false sense of confidence.

I'd worry about my HR and my own airway even in my sedated state, not knowing if there's an MD nearby :)))

I am of opinion we need CRNA's to operate strictly in the presence of Anesthesiology MD's and certainly, absolutely not autonomously.

2 Votes

This is a topic that has confused me or a while now. Am I understanding this correctly that the MD's are there for the initial induction but then leave for another OR while the CRNA stays with the patient and manages the anesthesia throughout the surgery, only calling the MD if an emergency arises? If so, how quickly do those MD's respond when called? Is it clear as to when the MD must be called? Seems somewhat fraudulent on the MD's part to talk to the patient as if they are the one making sure the patient gets through surgery safely when in fact it is the CRNA.

2 Votes
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