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The American Society of Anesthesiologists is calling “ill-conceived” a draft document from the Veterans Health Administration that, it claims, would require nurse anesthetists to practice without physician supervision and in the process jeopardize patient safety.

The ASA says the new rules abandon “team-based anesthesia care” led by physicians and undermine the quality of care in VA hospitals in the service of further expanding the scope of practice of advanced practice nurses (APRNs) and other so-called physician extenders. But the language of the Nursing Handbook—a draft copy of which the ASA provided to reporters—is sufficiently vague to raise some questions about the society’s interpretation of its intent and impact.

‘In No Way Equivalent’

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Jane Fitch, MD

In a Sept. 9, 2013, conference call with reporters, Jane Fitch, MD, the incoming president of the society, said the ASA was “deeply disappointed” with the amended handbook. Allowing nurses to practice unsupervised raises “significant” concerns for the safety of patients in the VA system, Dr. Fitch said.

“The language of the policy indicates independent practice,” said Roxanne Pipitone, an ASA spokeswoman. “The handbook doesn’t get into procedure-specific scenarios for any of the four advanced practice nursing roles,” which, along with CRNAs cover certified nurse-midwives, clinical nurse specialists and certified nurse practitioners.

Dr. Fitch, who herself was a certified registered nurse anesthetist before receiving her medical degree, said the two positions “are in no way equivalent.” CRNAs receive far less training—five to seven years compared with 12 to 14 for physician anesthetists, and one-tenth the number of hours, she said.

Although Dr. Fitch said CRNAs often do not have even a college degree, according to the policy: “A CRNA is an APRN who has completed a master’s or doctoral degree and board certification in the specialty of anesthesia. CRNAs practice in all settings in which anesthesia services are delivered including traditional hospital surgical suites and ambulatory surgical centers.”

However, Ms. Pipitone said the society does not “interpret this to mean that the VA will only allow nurse anesthetists with advanced degrees to practice independently. There is nothing in the new handbook that addresses segmenting nurse anesthetist by education received, whether they have a two-year associate degree RN or three-year diploma RN. Regardless of their education or training, they all practice as nurse anesthetists.”

Some people familiar with the issue said the ASA’s aggressive response to what could be considered a matter of worst-case interpretation of an ambiguous policy indicated Dr. Fitch’s desire to assert her political bona fides as incoming president of the society on the eve of her ascension to the position. Dr. Fitch campaigned on a theme of “I didn’t know what I didn’t know” as a nurse anesthetist—a refrain she stressed more than once during the conference call. Indeed, the email alerting reporters to the call identified her as “President Elect of the American Society of Anesthesiologists and Former Nurse Anesthetist.”

Short on Specifics

The document does not highlight any new clinical duties for CRNAs in the VA system. But the ASA points to this passage as expanding nurses’ scope of practice intolerably:

“APRNs [advanced practice nurses] practice as independent providers without regard to State Practice Acts under a set of approved privileges. Advanced practice nursing education provides the foundation for APRN core privileges. Core privileges as defined by the profession are those sets of clinical practice, procedures or interventions that all APRNs are qualified to perform based on their educational background and training.” It then lists core privileges including the taking of a history and physical examination, prescribing under an earlier VA directive, developing a care plan and ordering diagnostic and laboratory studies.

Dr. Fitch said the ASA first learned about the policy change about five months ago. The group tried to meet with VA officials to discuss the document on three occasions but was rebuffed, she added.

Vulnerable Patients

In a July 2, 2013, letter to Robert Petzel, MD, the undersecretary for health in the Department of Veterans Affairs, the ASA said it was “concerned about the impact of these policies on surgical anesthesia care within the VHA. The policies are particularly troublesome given the population serviced” by VA hospitals.

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Percent of Veteran Population 65 Years and Older by State: Fiscal Year 2012
Source: Department of Veterans Affairs.

VA patients are nearly 15 times more likely to be in poor health than the general population, according to the society—raising their risk for complications during and after surgery. “We believe that physician involvement is in the best interest of all patients and is particularly appropriate and necessary for VHA patients,” the letter stated.

The ASA has been working with members of Congress—unsuccessfully, so far—to urge the VHA to reverse the policy change. The ASA also issued a “Call to Action” to members urging them to contact their Congressional representatives about the proposed policy change, which, it argues, is in conflict with the VHA’s anesthesia service handbook.

Federal/State Conflict

Forty states currently allow CRNAs to practice without physician supervision, while only one, New Jersey, mandates oversight by an anesthesiologist. But health care providers who work in the VA system fall under federal licensing laws, which trump state regulations. As a result, a CRNA working at a VA hospital in a state that required physician oversight would be permitted the wider scope of practice. Approximately 700 to 800 anesthesiologists, and a similar number of CRNAs, work in the VA system.

The VHA declined to make someone available to discuss the new policy. But Gina Jackson, a spokeswoman for the agency, said current policy “recommends that CRNAs and/or anesthesiologists work in a team together with the other nurses and physicians caring for our veteran patients, and does not require physician supervision of CRNAs. As a member of the anesthesia team, CRNAs are subject to the same professional practice review, evaluation and monitoring as all anesthesia providers.”

Ms. Jackson added, “The proposed Nursing Handbook and APRN full practice policy support the anesthesia team–based model of care that fully utilizes the knowledge, skills and abilities of CRNAs.”

VA Anesthesiologists Wary

However, the new policy evidently caught the VA’s own anesthesia providers by surprise. An internal email from the department’s central anesthesia service sent after the ASA teleconference stated that the VA’s nursing service made the change “without input from the National Anesthesia Service.” According to the email, several versions of the handbook are circulating, although “all drafts we have seen propose an increase in independence” over current policy.

“With input from our Field Advisory Committee (FAC) we have submitted several questions and concerns to ONS [Office of Nursing Services] regarding the proposed change in status. Concerns have also been submitted by Primary Care Physicians. To date, ONS has not responded to our questions,” according to the email, which concludes, “At this point there are more questions than answers.”

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Robert Katz, MD

Robert Katz, MD, chief of the anesthesiology service at the North Florida/South Georgia VA, based in Gainesville, said the new policy “will definitely have an impact” if it goes through. The typical CRNA working independently handles ASA status 1 and 2 patients, Dr. Katz said. In his facility, three-quarters of patients are ASA status 3 and 4, primarily elderly with many medical problems.

If the new policy simply means that CRNAs can work independently but don’t have to, and they are assigned to the healthier patients with an anesthesiologist nearby in case something goes wrong, “it probably isn’t going to affect what we do all that much. But if they are assigned to do really sick patients with no back-up from a physician, I think that would not be a good idea. I would expect that a fair number of really sick patients might get into trouble.”

CRNAs Respond

Frank Purcell, senior director of federal government affairs for the American Association of Nurse Anesthetists (AANA), said the VA change, which his group has been aware of for some time, is not a change at all but a “confirmation of what advanced practice nurses do”—not only in the VA system but elsewhere. Mr. Purcell said the draft document implicitly endorses a call from the Institutes of Medicine to allow CRNAs and other APRNs to practice independently. “This is something that physicians and nurses, some of the most distinguished experts in health care, have recommended.”

And Mr. Purcell disputed the notion that the nursing handbook disbands the care team in VA hospitals. “Nurse anesthetists would be continuing to serve in the interests of the veterans who are under their care and serve as part of a group of expert health care professionals. In the VA system, no provider of any type, physician or nurse, is an island.”

In an Aug. 30, 2013, letter to the VHA, the AANA and the Association of Veterans Affairs Nurse Anesthetists praised the new handbook while objecting to what the groups said were “inaccurate and misleading statements” from the ASA about the document.

For example, the letter states, “neither the VHA draft Nursing Handbook nor the term ‘Licensed Independent Practitioner’ [LIP] 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.”