Scope of Practice

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How is scope of practice defined for CRNAs? Is it based on training in CRNA school? Based on common usage of techniques by CRNAs?

Specializes in ICU, currently in Anesthesia School.
CRNA's have nothing to worry about this little insignificant trial. They should just go on practicing pain. Nobody will care, right? It'll take a few years for this to all shake out. As far as I'm concerned, I'll wait to hear the rulings by the courts.

Look at this way. If the Louisiana ruling does stand, why wouldn't some MDA in a different state feel emboldened to challenge any CRNA who does pain? People who think that this is contained just to Louisiana are fooling themselves. This has national implications.

Allow me to answer this question.

After this post, I will no longer try and get you to educate yourself as to how the courts work. Let me put it simply- It is not about a person becoming "emboldened" to sue over practice issues (If that were the true, I am sure that the ASA would keep as many autonomous CRNAs in court as possible.) One must have standing (i.e.-A reason) to have the courts hold more than a cursory review and summary dismissal. Yes, you can file a suit on anyone, any time, but you must have had a wrong that needs recourse to get to trial. In civil proceedings-If no laws or regulations have been broken causing a grievance and no damages to plaintiff occur, no trial will occur.There is no law that I am aware of against CRNAs doing pain management. There was a possible regulatory procedural violation in the LA case that allowed the court to hear argument. (I am not willing to concede that point yet, lets see how the higher courts rule.) Please see my previous post for an explanation as to why this case ruling was beyond the scope of the trial and would only be germaine in a suit of similar/exact circumstances.

And now back to the pending question- Your backround please?

Your refusal to answer the simple question of backround so that everyone can know where your bias lies speaks to character and honesty in a debate. Let everyone read your other posts and make a decision on whether to waste any more time on your statements and "advice" to APRN's. I for one will do my best to correct the fallacies and ignore the invectives you utter with regularity.

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My initial question was designed to gauge the CRNA perception of what defines the scope of practice.... Pain medicine has virtually nothing to do with anesthesiology and is a separate specialty. The scope of practice is partially defined by legislatures, state boards of medical and nursing practice, but the perception of what defines scope of practice is very interesting. For instance, since CRNAs treat heart conditions during surgery and in the ICU, what would prohibit CRNAs to train themselves in interventional cardiology and begin to do TEEs, echocardiograms, etc on patients? Then why not cardiac caths? The state boards of nursing defer to the AANA and the AANA may very well say the treatment of heart conditions is an extension of the practice of CRNA. This is exactly the parallel we are seeing in CRNAs experienced in OR and OB anesthesia beginning to practice spine surgery with one weekend of training by other CRNAs on cadavers. The scope of practice, as being defined by the AANA, permits treatment of ANY pain as long as the CRNA has training, even if the training is a single cadaver course without any proctoring or fellowship training. Since 80% of patient visits to physicians and NPs in the US are for pain, the CRNAs are in effect declaring war on medicine and are setting up their own parallel medical system based on weekend training courses. There is Zero interventional pain training available in CRNA schools throughout the country. Scope of practice is interestingly being defined by the AANA based on the POTENTIAL for being trained in a weekend course, rather than COA or AANA based long term training. There is simply no end to where CRNAs may take their scope of practice as they are now emboldened to take on the traditional medical boundaries. Ultimately, the practice of putting the cart before the horse may badly backfire for CRNAs that perceive their scope of practice to be whatever weekend course they can enroll into.

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Sheesh. Get your facts straight before you insist the sky is falling.

From the AANA press release:

"In early January 2008, the Louisiana District Court, Judge Janice Clark, issued a judgment in favor of an anesthesiologist pain management group (Spine Diagnostics Center of Baton Rouge), and against the Louisiana State Board of Nursing (LSBN) and an individual CRNA who had performed chronic pain management procedures."

District court.

One judge.

And BTW, ng, what ARE your qualifications?

??

I was referring to the first case.

The first case that went to the Louisiana Supreme Court that ruled that the BON has to go through the legislature to make these scope changes.

This is the second case. The ruling so far is that pain is medicine. I wouldn't be surprised if this goes all the way to the Louisiana Supreme Court as well.

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Specializes in Nephrology, Cardiology, ER, ICU.

Let's keep this friendly and to the point. I think the point - that of what is the scope of practice of a CRNA?, has been adequately addressed to say that it varies from state to state.

No need to get personal, though I too wonder why MDs would frequent a nursing board unless to stir and muddy the water. Perhaps an answer will be forthcoming from our physician colleagues???

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Specializes in Anesthesia.
.......For instance, since CRNAs treat heart conditions during surgery and in the ICU, what would prohibit CRNAs to train themselves in interventional cardiology and begin to do TEEs, echocardiograms, etc on patients? Then why not cardiac caths? ....

Good heavens. This is ridiculous. Since your bias is SO OBVIOUS, I say ... time to move on.

Anyone else have a question? A serious question?!

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Specializes in Anesthesia.
I was referring to the first case.

The first case that went to the Louisiana Supreme Court ....

FALSE.

I say again: please GET YOUR FACTS STRAIGHT.

This is the same case. Not two cases. NOT TWO SEPARATE CASES.

The LA Supreme Ct last year REFUSED to review a preliminary injunction regarding the case. They REFUSED to review it. Without comment, they REFUSED.

They have NEVER found that, as you say they did, Pain = Medicine.

!

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Mine was a serious question based on real life serious situations of CRNAs already performing surgery on patients. The skills acquired in CRNA school have nothing to do with interventional pain medicine. Having completed a survey of every CRNA nursing school, I have directly from the program directors CRNAs obtain zero training in interventional pain. Therefore every CRNA practicing interventional pain is obtaining their entire training at a weekend course. The scope of practice question helps me frame what CRNAs might be thinking since the only similarity between OR anesthesia/OB anesthesia and interventional pain medicine is that they both use needles, albeit for entirely different purposes, in entirely different approaches, and for entirely different populations. The differences are profound, but are not perceived as being any different by CRNAs, so the scope of practice question was not rhetorical. If CRNAs do not understand the vast gulf between anesthesiology/nurse anesthesia (yes, I am lumping both together) and interventional pain medicine, then what other differences do they not perceive between say cardiology and being a CRNA? The dismissal of the question as irrelevant is certainly your perogative but does little to forward the discussion of a very serious subject that you take so lightly. Scope of practice as defined by EDUCATION and background training will be in the forefront in the next year.

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Specializes in ICU, currently in Anesthesia School.
Mine was a serious question based on real life serious situations of CRNAs already performing surgery on patients. The skills acquired in CRNA school have nothing to do with interventional pain medicine. Having completed a survey of every CRNA nursing school, I have directly from the program directors CRNAs obtain zero training in interventional pain. Therefore every CRNA practicing interventional pain is obtaining their entire training at a weekend course. The scope of practice question helps me frame what CRNAs might be thinking since the only similarity between OR anesthesia/OB anesthesia and interventional pain medicine is that they both use needles, albeit for entirely different purposes, in entirely different approaches, and for entirely different populations. The differences are profound, but are not perceived as being any different by CRNAs, so the scope of practice question was not rhetorical. If CRNAs do not understand the vast gulf between anesthesiology/nurse anesthesia (yes, I am lumping both together) and interventional pain medicine, then what other differences do they not perceive between say cardiology and being a CRNA? The dismissal of the question as irrelevant is certainly your perogative but does little to forward the discussion of a very serious subject that you take so lightly. Scope of practice as defined by EDUCATION and background training will be in the forefront in the next year.

PD-

Can you elaborate by way of example of the surgical procedures being performed?

If a CRNA is doing a laminectomy or a discectomy, then absolutely- they are not qualified for the task (Then again, unless one has completed a residency in Neurosurgery or Orthopedic Surgery then no one else is either.) If you are referring to facet blocks and implantable device type procedures, then I would have to ask what makes PMR guys (who are performing them with limited specific training) any more qualified to perform these procedures than the MDA/CRNA?

Having worked in a IR lab in a previous life, I would propose that the skill set of IR is much more appropriate to the above pain management techniques than even the pain fellow as IR spends far more time in procedures and interpreting positioning of needles/pacers/implantable devices. If your argument is that the training you receive is better by virtue of time and experience with techniques, then I submit that the neurointerventionalist has far superior training than any other provider out there and the practice of interventional pain management should be limited to only their sub-specialty.

My impression after review of the postings here is that it is less of a scope of practice question, and more of a question as to what specifically allows CRNAs to perform a facet block or insert a nerve stimulator, thereby introducing further competition into an already tight market. (See previous post as to interested parties in the pain management business.)

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Specializes in Anesthesia.
Mine was a serious question based on real life serious situations of CRNAs already performing surgery on patients. The skills acquired in CRNA school have nothing to do with interventional pain medicine. Having completed a survey of every CRNA nursing school, I have directly from the program directors CRNAs obtain zero training in interventional pain. Therefore every CRNA practicing interventional pain is obtaining their entire training at a weekend course. The scope of practice question helps me frame what CRNAs might be thinking since the only similarity between OR anesthesia/OB anesthesia and interventional pain medicine is that they both use needles, albeit for entirely different purposes, in entirely different approaches, and for entirely different populations. The differences are profound, but are not perceived as being any different by CRNAs, so the scope of practice question was not rhetorical. If CRNAs do not understand the vast gulf between anesthesiology/nurse anesthesia (yes, I am lumping both together) and interventional pain medicine, then what other differences do they not perceive between say cardiology and being a CRNA? The dismissal of the question as irrelevant is certainly your perogative but does little to forward the discussion of a very serious subject that you take so lightly. Scope of practice as defined by EDUCATION and background training will be in the forefront in the next year.

Do you think Family Practice Physicians are qualified to specialize in pain management? I have met several so called specailists in pain management that were nothing more than family practice physicians that somewhere along the way decided they were going to specialize in pain medicine. They received no extra training, no fellowships, and had no further board certifications.

It is easy to sit and compare all these things over and over again, but where is the research to back up your claims that physicians are "better"/better for the patients than CRNAs at chronic pain management? It always comes down to the same thing.."I went to school longer than you did" or "I am a Doctor/Physician and you're not". It never comes down to the research to prove your position that one provider is better than another.

I highly doubt that any CRNA is basing their pain management skills all on one weekend course. It is more than likely a combination of OJT and formal training (some of which might be these weekend courses) that CRNAs learn these skills.

My school/USUHS gives several lectures that cover chronic pain management (although I don't think these lectures were given with any intent for us to practice chronic pain management).

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Lets see LESI vs lumbar labor epidural,

Both into the lumbar space, right

one inject local anesthetic and maybe narcotic, the other a steroid.

Not a big difference, do CRNA's use steroids in practice to limit the inflamitory process, yes.

Brachial plexus block vs any other block, a block is a block is a block. The procedures are not different the reasons for them are not different the only difference is the setting and the length of time or chronic vs acute pain.

There are significant differences in the pathophysilogy of these processes but the treatment in many cases is not.

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Actually, there ARE CRNAs of which I am aware that have started interventional pain practices without any training whatsoever and started performing spine surgery after one weekend course. The straw man argument frequently used by CRNAs is that there are no statistics demonstrating safety or efficacy differences between MDs. However, there are no statistics at all regarding CRNA pain medicine, therefore the argument is moot. CRNAs have not bothered to do the tough research to demonstrate safety or efficacy of their practices. They have ZERO fluoroscopic anatomy, pathology, physiology exposure in CRNA school. As blind interlaminar epidural steroid injections do not reach the epidural space in 15-40% of patients and do not reach the appropriate level in up to 50%, they should be reimbursed as a trigger point injection. These values ARE based on research based statistics from real studies, none of which have been performed by CRNAs.

The difference between doing a brachial plexus block for anesthesia purposes and for the the treatment of chronic pain demonstrates a lack of understanding of the process of chronic pain....brachial plexus blocks are NEVER indicated for the treatment of chronic intractable pain. They are useless to pain physicians.

Family physicians with fellowship training in pain medicine are indeed appropriate. CRNAs with training in OR/OB + a weekend warrior course are inappropriately practicing pain medicine just as it would be inappropriate for them to practice neurosurgery or cardiology. FPs with a weekend course are also equally at a disadvantage and should not be performing pain medicine interventions, HOWEVER, they do have much more exposure to chronic pain treatments, medications, etc compared to CRNAs.

Blind techniques have nothing to do with fluoroscopically guided precision diagnostic and therapeutic injections.

We will fight this battle in the courts, in PR, and with legislatures. CRNAs had their chance to develop a fellowship in pain, but their own credentialing organization dissed them....this should tell you something...perhaps they know what CRNAs performing interventional pain do not know.

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Specializes in ICU, currently in Anesthesia School.

From the UCSF pain fellowship site:

http://mountzion.ucsfmedicalcenter.org/pain_management/application.html

"Fellows and residents receive training in theory, indications, risks, complications, and practical applications of the following procedures and techniques:

  • Epidural injection
  • Selective nerve root block
  • Facet block
  • Sacroiliac joint injection
  • Sympathetic ganglion block
  • Gasserian ganglion block
  • Celiac plexus block
  • Hypogastric plexus block
  • Radiofrequency ablation
  • Intravenous regional anesthesia
  • Discography
  • Nucleoplasty
  • Annuloplasty
  • Spinal cord stimulation
  • Intrathecal infusion
  • Peripheral nerve block
  • Joint injection
  • Behavioral therapy
  • Physical therapy
  • Biofeedback
  • Acupuncture
  • Recognition and management of risks and complications of medications
  • Prevention, recognition and management of risks and complications of procedures
  • Airway management and cardiopulmonary resuscitation
  • Cancer pain management"

Other than the annuloplasty and nucleoplasty what is an MDA/CRNA unqualified to perform by virtue of education or backround? You would have to agree that both providers are certainly more qualified than the FP performing them. To not agree would take this from honest discussion into simple my rhetoric/your rhetoric.

For others interested-another reference as to pain management techniques taught in fellowship (yes I will grant the list is not comprehensive):

http://w3.ouhsc.edu/anesthesiology/PainFellow.asp

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