SUPERVISION REQUIRED or NO for CRNAs?

LPNer · Mar 20, 2005

The problem is that once you give into something in this kind of turf battle you can't change it back and the more powerful group will try to enact more restrictions on your practice. So you see, we can't simply give in to be directed because 1st we don't want to and 2nd they would try to exert more control over our practice.

That's what I came to understand to be your plight! I understand your arguement.

By applying it to the plight of the LPN, stuck as inferior subspecies who are unable to function as nurses, in many BONs and RNs eyes, not to mention the opinion that flows to the general population...Anyway, I was trying to understand if this is why CRNAs are against the "direction of MDAs."

I agree with ya'll 100%. And would carry a petition or whatever else y'all need to further your resistance to this change in your scope. No nurse needs to fall backwards, we all need to move forward!

smiling_ru · Mar 20, 2005

That's what I came to understand to be your plight! I understand your arguement.
By applying it to the plight of the LPN, stuck as inferior subspecies who are unable to function as nurses, in many BONs and RNs eyes, not to mention the opinion that flows to the general population...Anyway, I was trying to understand if this is why CRNAs are against the "direction of MDAs."
I agree with ya'll 100%. And would carry a petition or whatever else y'all need to further your resistance to this change in your scope. No nurse needs to fall backwards, we all need to move forward!

If you feel that you are considered inferior because you are an LPN, then change it. I started out as an LPN, and dealt with some of the same issues you have. The only solution for me was to further my education.

LPNer · Mar 20, 2005

If you feel that you are considered inferior because you are an LPN, then change it. I started out as an LPN, and dealt with some of the same issues you have. The only solution for me was to further my education.

This is changing the subject because I used that as an example, but I do not feel as though I am an inferior. I said in many RNs and BONs eyes, NOT my own. I know my value on the team and "fight" for others to also know that value.

yoga crna · Mar 21, 2005

LPN

Maybe you don't understand CRNA practice. We practice according to the laws of the state in which we practice. In all states, nursing is a separate function from the practice of medicine. We are not like the Physician Assistants who work under the supervision of a physician, by law.

Now, the other point, who do we answer to? I answer to the patient and essentially have a contractual relationship with the patient. That is well established in consent law and has been tested in the courts. The patient can sue us directly and as such we are responsible for our own actions. I am well aware that I don't do anesthesia in a vacuum and that there is always some type of surgical or diagnostic procedure going on. But, in my world, the surgeon is doing surgery and I am doing anesthesia. We talk, share what is going on with the patient and have a common goal. But, answer to the surgeon--NO WAY.

I think the previous suggestion that you need to spend some time with a CRNA is a good one. When you see the autonomy of our practice and how we make independent decisions on a moment to moment basis, you will understand our arguments.

Personally, I don't have anything against MD anesthesiologists. i have worked with some good ones in my career, but in my practice of the last 21 years, I have worked alone. If I believe I may need a pair of educated hands to assist me, I will pay another CRNA to help.

Yoga CRNA

loisane · Mar 21, 2005

Keep the MD, podiatrist, etc as we are nurses and our job is to carry out, look after, and evaluate (make suggestions as needed) and build on the care provided by the doc.

I know I am joining this thread a bit late, and much good discussion has already been covered. I'd like to offer a couple additional points.

LPN, you may have heard the term "professional nurse", as opposed to nurse. LPNs and CNAs are nurses, they are not "professional nurses". You sound interested in pursuing your career to the next level, and I think that would be great. When you do, one of the many things you will learn is that nursing is its own discipline. Nursing is not a subsection of medicine. So, no, our job is not to carry our physician orders. That is a very common misconception, even among nurses. Our job is to perform nursing, and the boundaries of nursing are defined by nurses, not physicians.

It is scarey to think that just any MD could "supervise" a CRNA!! In my experience, surgeons know nothing about the anesthestics & we rely on the orders of the anesthesia provider in PACU!

This seems like a reasonable attitude on face value. But the issue is complex, and you have to trace the history. CRNAs have been giving anesthesia before the medical specialty of anesthesiology was ever developed. Some state nurse practice acts allow for the autonomous practice of these CRNAs. There are some states in which the nurse practice act dictates that the CRNA work with/under a physician. No state requires that this physician be a anesthesiologist.

There have been multiple court cases through the decades that have held that the anesthesia provider is responsible for the anesthetic, regardless of their professional preparation, and regardless if the state's nurse practice act requires physician involvement. So the physician of record is not "supervising" the CRNA in the traditional sense of that word. If the non-anesthesia physician was dictating individual choices and making anesthesia practice decisions, your argument would be quite valid, but this is not the case. (BTW, a fairly recent post listed a very nice review of these court cases, with the citations, if anyone is interested in more specifics on this).

Supervision should not be needed. CRNAs are quite capable of performing their job. Yes, some people may see it as symantics, but direction and supervision are two very different things.

LPN, you are quite right, but there is even more to it than you realize. In the anesthesia world there is an incredible difference between direction and supervision. It is a function of federal government policy, so that goes a great way toward explaining why it is so much more complicated that it has any possible need to be, you know how government word games can get.

A lot of surgical patient care is paid by Medicare, so their rules have a big influence on anesthesia. Medicare provides for several ways anesthesiologists may be paid. We'll just talk about two-medical direction and medical supervision.

If a CRNA provides anesthesia, but the anesthesiologist is directly involved in many of the major aspects of the case (these are 7 clearly defined steps referred to as the TEFRA regs) the anesthesiolgist may bill as medically directing the case.

If a CRNA provides the anesthesia, and the anesthesiologist is involved, but does not complete the essential steps, the billing may be for medical supervision. The reimbursement is different for the two categories.

Many nurses have only experiences anesthesia departments in which the CRNA may not start the case without the anesthesiologist, etc. These are not laws that CRNAs must adhere to. They are departmental decisions based on reimbursement patterns. So it is easy to get the impression that CRNAs "must be supervised".

In a long winded way, I eventually worked my way back to address the OP question!

loisane crna

jubowen · Mar 21, 2005

Some states require a CRNA be under the supervision of an anesthesiologist or the surgeon. Actually, to be specific, Illinois does not recognize CRNA's as LIP's (our CRNA's want to ignore this fact!)

Our hospital is small, we do not have an anesthesilogist so our CRNA's work under the surgeon on the case.

I am looking only from advise from those states that have the same nurse practice act. What documentation do you require the CRNA have to prove discussion of anesthesia with a MD.

Sorry to cause such commotion!

Julie

loisane · Mar 21, 2005

Some states require a CRNA be under the supervision of an anesthesiologist or the surgeon. Actually, to be specific, Illinois does not recognize CRNA's as LIP's (our CRNA's want to ignore this fact!)
Our hospital is small, we do not have an anesthesilogist so our CRNA's work under the surgeon on the case.
I am looking only from advise from those states that have the same nurse practice act. What documentation do you require the CRNA have to prove discussion of anesthesia with a MD.
Sorry to cause such commotion!
Julie

I agree with the earlier answer from Brenna's dad. You do not want documentation of "discussion of anesthesia with a MD". The physician of record only opens themselves up for liability of anesthesia related problems if they assume "control" of the anesthetic. Simply fullfilling the requirement of being the physician of record, in a state that requires this, is not sufficient to assume the liability. But if they participate in the discussion and decision making, they open up this possibility.

In other words, in states in which the nurse practice act requires physician involvement, you only need documentation of the request for anesthesia from that physician. Many places handle this by having the surgeon write "anesthesia per CRNA" or something similar in his pre op orders. Perhaps you will get some additional, specific responses on this.

BTW, the only place I have heard the term LIP is in the context of JCAHO, and CRNAs are considered LIPs. (There recently was some problem with this, but it is my understanding we got this successfully resolved with JCAHO). Perhaps there is more to this term in Illinois.

loisane crna

jubowen · Mar 21, 2005

I see that I am not going to get any help from this discussion board. Thank you to "kitty kat" for sharing what your facility does to combat this issue. The rest of you were only territorial and led rough discussions.

I am a nurse. I will have my MSN within the next 2 years. One of the forces that drives me to continue my education today is my frustration with nurses. It seems no matter what the education level, we are only out for ourselves as individuals instead of out for the good of the profession. We will always have low salaries, poor work conditions and little hope with the divided state we are in. I am hoping to work in the education system once I have completed my MSN in hopes to educate nurses to stick together and work for a common cause.

I calmly step off my soap box now and will try to locate helpful information from other sources.

But for the record, Illinois Nurse Practice Act states verbatim "A licensed CRNA may provide anesthesia services pursuant to the order of a licensed physician in a licensed hospital. For anesthesia services, a physician, anesthesiologist, dentist, or podiatrist shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation and treatment of emergency medical conditions".

This is where my dilemma lies.

loisane · Mar 21, 2005

But for the record, Illinois Nurse Practice Act states verbatim "A licensed CRNA may provide anesthesia services pursuant to the order of a licensed physician in a licensed hospital. For anesthesia services, a physician, anesthesiologist, dentist, or podiatrist shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation and treatment of emergency medical conditions".
This is where my dilemma lies.

That certianly is a dilemma! I have not encountered such language before. I am only familiar with a handful of NPAs, but none of them specify the detail of physician involvement than this one does.

I have heard that Illinois was heavily anesthesiology country, and now I have better insight as to why. Your NPA language is a real barrier to sole CRNA practice. Even though it technically allows non-anesthesiologist supervision, it specifies a level of control that would deter many surgeons, as was described earlier. I applaud your facility's efforts to provide your patients access to care, and can see why you are looking for ways to be law compliant at the same time.

I think your best resource would be other facilities in your own state, who are operating under the same legal restrictions, although there may not be many. I am sorry you got the impression that I/we were giving you "rough discussion". Perhaps you were under the impression that these oppressive restrictions (that your state NPA dictates) are common everywhere, but that is not the case. My answers were based on more common practice patterns.

loisane crna

smiling_ru · Mar 21, 2005

I see that I am not going to get any help from this discussion board. Thank you to "kitty kat" for sharing what your facility does to combat this issue. The rest of you were only territorial and led rough discussions.
I am a nurse. I will have my MSN within the next 2 years. One of the forces that drives me to continue my education today is my frustration with nurses. It seems no matter what the education level, we are only out for ourselves as individuals instead of out for the good of the profession. We will always have low salaries, poor work conditions and little hope with the divided state we are in. I am hoping to work in the education system once I have completed my MSN in hopes to educate nurses to stick together and work for a common cause.
I calmly step off my soap box now and will try to locate helpful information from other sources.
But for the record, Illinois Nurse Practice Act states verbatim "A licensed CRNA may provide anesthesia services pursuant to the order of a licensed physician in a licensed hospital. For anesthesia services, a physician, anesthesiologist, dentist, or podiatrist shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation and treatment of emergency medical conditions".
This is where my dilemma lies.

O.K. This is how it works. The order for anesthesia is given, a discussion with the person ordering the anesthesia occurs ie.. general/local/block/MAC. This does NOT mean that the person ordering the anesthesia needs to discuss every drug. No matter the practice environment anesthesiologist only/ team/ crna only, type of anesthetic is discussed. As far as physicial presence generally when you provide an anesthetic the surgeon is providing a surgical service. It appears that hospitals may opt to provide services in a wholly different manner per the last paragraph. But, I did not look those regs up. Anyway, I hope that answers your question.

I looked at the SBN website, Illionois does have some very restrictivie language, especially in office based procedure. This is one of the areas the ASA has been pushing hard. Following is a cut and past.

Section 1305.45 Delivery of Anesthesia Services by a Certified Registered Nurse Anesthetist

a) A licensed certified registered nurse anesthetist may provide anesthesia services pursuant to the order of a licensed physician, licensed dentist, or licensed podiatrist in a licensed hospital, a licensed ambulatory surgical treatment center, or the office of a licensed physician, the office of a licensed dentist, or the office of a licensed podiatrist. For anesthesia services, an anesthesiologist, physician, dentist, or podiatrist shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical conditions, unless hospital policy adopted pursuant to Section 10.7(3)(B) of the Hospital Licensing Act [210 ILCS 85/10.7(3)(B)] or ambulatory surgical treatment center policy adopted pursuant to Section 6.5(3)(B) of the Ambulatory Surgical Treatment Center Act [210 ILCS 5/6.5(3)(B)] provides otherwise. (Section 15‑25(a) of the Act)

b) A certified registered nurse anesthetist who provides anesthesia services in a hospital shall do so in accordance with Section 10.7 of the Hospital Licensing Act and, in an ambulatory surgical treatment center, in accordance with Section 6.5 of the Ambulatory Surgical Treatment Center Act. (Section 15‑25(b) of the Act)

c) A certified registered nurse anesthetist is not required to possess prescriptive authority or a written collaborative agreement meeting the requirements of Section 15‑15 of the Act to provide anesthesia services ordered by a licensed physician, dentist, or podiatrist. Certified registered nurse anesthetists are authorized to select, order, and administer drugs and apply the appropriate medical devices in the provision of anesthesia services under the anesthesia plan agreed with by the anesthesiologist or the physician in accordance with hospital alternative policy or the medical staff consulting committee policies of a licensed ambulatory surgical treatment center. In a physician's office, dentist's office, or podiatrist's office, the anesthesiologist, operating physician, operating dentist, or operating podiatrist shall agree with the anesthesia plan, in accordance with the written practice agreement. (Section 15‑25(d) of the Act)

d) A certified registered nurse anesthetist may be delegated limited prescriptive authority under Section 15‑20 of the Act in a written collaborative agreement meeting the requirements of Section 15‑15 of the Act. (Section 15-25(e) of the Act)

e) In a physician's office, the certified registered nurse anesthetist may only provide anesthesia services if the physician has training and experience in the delivery of anesthesia services to patients. The physician's training and experience shall be documented in the written practice agreement and the training and experience shall meet the requirements set forth in 68 Ill. Adm. Code 1285.340.

f) In addition, in a physician's office, any certified registered nurse anesthetist and physician who enter into a practice agreement shall obtain ACLS certification by December 31, 2002, and shall thereafter maintain current Advanced Cardiac Life Support (ACLS) certification.

g) In a dentist's office, the certified registered nurse anesthetist may only provide those services the dentist is authorized to provide pursuant to the Illinois Dental Practice Act [225 ILCS 25] and rules (68 Ill. Adm. Code 1220). Licensed dentists are required to hold permits to administer anesthesia pursuant to 68 Ill. Adm. Code 1220: Subpart D.

h) In a podiatrist's office, the certified registered nurse anesthetist may only provide those services the podiatrist is authorized to provide pursuant to the Podiatric Medical Practice Act of 1987 [225 ILCS 100] and rules (68 Ill. Adm. Code 1360). Podiatrists may not administer general anesthetics.

i) A CRNA providing anesthesia services in a physician, dental or podiatrist office shall do so with the active participation, approval, presence and availability of the physician, dentist or podiatrist as well as in accordance with Standards 1‑11 of the "Standards for Office Based Anesthesia Practice", American Association of Nurse Anesthestists, 222 South Prospect Avenue, Park Ridge, Illinois 60068 (1999), which are hereby incorporated by reference, with no later editions or amendments. If there is a conflict between the Nursing and Advanced Practice Nursing Act or this Part and the Standards for Office Based Anesthesia Practice of the American Association of Nurse Anesthetists, the Act and this Part shall prevail.

(Source: Amended at 26 Ill. Reg. 7279, effective April 26, 2002)

Brenna's Dad · Mar 21, 2005

Interesting stuff. Section 10.7 (3)(B) states:

For anesthesia services, an anesthesiologist shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical conditions. In the absence of 24‑hour availability of anesthesiologists with medical staff privileges, an alternate policy (requiring participation, presence, and availability of a physician licensed to practice medicine in all its branches) shall be developed by the medical staff and licensed hospital in consultation with the anesthesia service.

It appears that if anesthesiologist coverage is not available, a hospital must simply have a policy in place that requires the presence of another physician (eg. surgeon) during the anesthetic.

Like many other indiividuals have stated, this requirement does not mean that the physician dictate the anesthesia, but rather be available for emergencies and agree with the anesthesia plan.

Brenna's Dad · Mar 21, 2005

I also thought it would be interesting to compare Illinois law with the laws in Washington, where I am completeing my training.

WAC 246-840-300 Advanced registered nurse practitioner.An advanced registered nurse practitioner is a registered nurse prepared in a formal educational program to assume primary responsibility for continuous and comprehensive management of a broad range of patient care, concerns and problems. Advanced registered nurse practitioners function within the specialty scopes of practice and/or description of practice and/or standards of care developed by national professional organizations and reviewed and approved by the commission. These statements form the basis for selection of test items or competency based evaluation processes and are derived from standard educational curricula for certain practice areas. ARNP members of the commission will review these statements on a biennial basis and will present substantive changes to the full commission for approval or disapproval. Advanced registered nurse practitioners are prepared and qualified to assume primary responsibility and accountability for the care of their patients. This practice is grounded in nursing and incorporates the use of independent judgment as well as collaborative interaction with other health care professionals when indicated in the assessment and management of wellness and conditions as appropriate to the ARNP's area of specialization.

Within the scope of the advanced registered nurse practitioner's knowledge, experience and specialty scope of practice statement(s), licensed advanced registered nurse practitioners may perform the following functions:

* Examine patients and establish medical diagnoses by client history, physical examination and other assessment criteria;

* Admit patients to health care facilities;

* Order, collect, perform and interpret laboratory tests;

* Initiate requests for radiographic and other testing measures;

* Identify, develop, implement and evaluate a plan of care and treatment for patients to promote, maintain and restore health;

* Prescribe medications when granted authority under this chapter;

* Refer clients to other health care practitioners or facilities.

An advanced registered nurse practitioner:

(1) Shall hold a current license to practice as a registered nurse in Washington;

(2) Shall have completed a formal advanced nursing education meeting the requirements of WAC 246-840-305;

(3) Shall present documentation of initial certification credential granted by a national certifying body recognized by the commission, approved ARNP specialty whose certification program is approved by the commission and subsequently maintain currency and competency as defined by the certifying body;

(4) Copies of statements of scope of practice or practice descriptions are maintained in the nursing commission's office. Specialty designations recognized by the commission and the date of the commission approved statement of scope of practice or practice description are:

(a) Family Nurse Practitioner (FNP) (American Nurses Association, 1998; American Academy of Nurse Practitioners, 1992).

(b) Women's Health Nurse Practitioner (WHNP) (American Association of Women's Health, Obstetric, and Neonatal Nurses, 1997).

(d) Adult Nurse Practitioner (ANP) (American Nurses Association, 1998; American Academy of Nurse Practitioners, 1992).

(e) Geriatric Gerontological Nurse Practitioner (GNP) (American Nurses Association, 1998).

(f) Certified Nurse Midwife (CNM) (American College of Nurse Midwives, 1997).

(g) Certified Registered Nurse Anesthetist (CRNA) (American Association of Nurse Anesthetists, 1996).

(h) School Nurse Practitioner (American Nurses Association, 1998).

(i) Neonatal Nurse Practitioner (NNP) (American Association of Women's Health, Obstetric, and Neonatal Nurses, 1997).

(j) Psychiatric Nurse Practitioner or Clinical Specialist in Psychiatric-Mental Health Nursing (American Nurses Association, 1998).

(k) Acute Care Nurse Practitioner (American Nurses Association, 1998).

(5) Shall be held individually accountable for practice based on and limited to the scope of his/her education, demonstrated competence, and advanced nursing experience;

(6) Shall obtain instruction, supervision, and consultation as necessary before implementing new or unfamiliar techniques or practices;

(7) Shall be responsible for maintaining current knowledge in his/her field of practice;

(8) Must be prepared to show documentation of any additional formal education, skills training, or supervised clinical practice beyond the basic ARNP preparation; and

(9) May choose to limit his or her area of practice within the recognized specialty or specialties.

(10) If recognized in more than one specialty area, must obtain and maintain certification in all areas and must obtain formal education and training for each area of specialization.

[statutory Authority: RCW 18.79.110 and 18.79.050. 00-21-119, 246-840-300, filed 10/18/00, effective 11/18/00. Statutory Authority: Chapter 18.79 RCW. 97-13-100, 246-840-300, filed 6/18/97, effective 7/19/97.]

Much more CRNA friendly...

*******SUPERVISION REQUIRED or NO for CRNAs?*******

SUPERVISION REQUIRED or NO for CRNAs?