Court case, study raise question: Should your CRNAs be supervised?
A patient goes in for a colonoscopy in which a certified registered nurse anesthetist (CRNA) provides anesthesia care. According to the subsequent lawsuit filed by the family, the patient told the CRNA that he had sleep apnea and used a continuous positive airway pressure machine (CPAP) when sleeping.1 The CRNA looked at the patient's neck, said it looked normal, and administered a reduced dose of propofol, the lawsuit says.
The patient deteriorated, and the CRNA tried to intubate but couldn't, according to the lawsuit. The CRNA performed a cricothyroidotomy to open the airway and administered CPR for 45 minutes, it says. The patient died. The family maintains that because the patient had a history of sleep apnea and difficult intubations in prior surgeries, the CRNA should have been supervised by an anesthesiologist and should not have used propofol. The CRNA and the hospital have maintained that they were not negligent.
"I think this case is an excellent example of why an anesthesiologist should be involved in difficult or potentially difficult cases and/or why an anesthesiologist should be available to immediately to respond to a problem," says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI.
A CRNA must understand when to call an anesthesiologist and should be required to do so when merited, Trosty maintains. "The fact that there had been previous problems with intubation, coupled with the sleep apnea, are indications that this should have been done by an anesthesiologist and not a CRNA," he comments.
The history of prior problems with intubation, combined with the sleep apnea, make this a more difficult case than usual, Trosty says. "To say that 'the neck looked normal' is not adequate in a case such as this," he says.
The Centers for Medicare & Medicaid Services (CMS) prohibits Medicare payments to hospitals and ambulatory surgery centers (ASCs) when CRNAs provide anesthesia care in the absence of physician supervision, although the requirement does not specify that the physician must be an anesthesiologist, according to the American Association of Nurse Anesthetists (AANA). However, starting in 2001, CMS began allowing states to "opt out" of this requirement for CRNAs, the AANA says. Since that time, 15 states have opted out.
Even if a governor elects to opt out of the requirement, hospitals and ASCs still can require physician supervision of CRNAs through their own bylaws, the American Society of Anesthesiologists (ASA) points out. In addition to bylaws, your policies can designate when and where CRNAs can provide anesthesia, says Patricia S. Calhoun, JD, associate at Buchanan Ingersoll & Rooney, Tampa, FL. "For example, some bylaws require the anesthesiologist to be present during intubation, and some require anesthesiologist to administer spinal anesthesia," Calhoun says. Also, many states have their own statutory physician supervision requirements, according to the ASA. There are no accreditation requirements regarding anesthesiologists' supervision from The Joint Commission, the Accreditation Association for Ambulatory Health Care (AAAHC), or American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
Although the colonoscopy patient's death occurred in a state (Kentucky) that hasn't opted out of the federal supervision requirement, there was a supervising physician: the gastroenterologist performing the colonoscopy, Calhoun says. "The bigger question might end up being should that facility permit CRNAs to administer anesthesia to patients with known sleep apnea and a history of difficult intubations," Calhoun says.
The controversy over physician supervision recently gained strength after a published study found no differences in outcomes when anesthesia was provided by CRNAs, anesthesiologists, or CRNAs supervised by physicians.2
Tips for avoiding liability with CRNAs
State laws control the scope of practice for CRNAs, so managers should "review that state's nurse practice act to determine the scope of practice for CRNAs in their state," Calhoun says.
Additionally, outpatient surgery managers should determine clinical privileges for CRNA based on their qualifications: "education, training, experience, and expertise," Calhoun says.
In the case of an actual or potential high risk patients, an anesthesiologist should have input regarding the type and amount of anesthetic to be used, says Trosty, who adds that "the CRNA has to recognize his/her more limited education and more limited skills."
Trosty says to consider the example of a patient with sleep apnea, which "presents a potentially more hazardous patient when it comes to anesthesia." Patients with sleep apnea can have somewhat obstructed airways, he says, "which makes it even more imperative that there be the involvement of an anesthesiologist, at least in the selection and amount of the anesthetic, and that there be an anesthesiologist available to step in immediately if there should be a problem, as was true in this case" above.
However, in the recently published study on CRNA supervision, the authors controlled for all manner of comorbidities, says AANA President Paul Santoro, CRNA, MS, chief executive officer of Anesthesia Staffing Consultants in Bingham Farms, MI. The AANA's position is that decisions regarding physician supervision "need to be made at the local level, where patient acuity and provider competencies are all taken into account. Those decisions are best made at local level, and not at Washington, DC."
With the implementation of health care reform coming by 2014, there will be 30 million new insured Americans, Santoro says. "Medicare and our entire health care system need to look at ways of improving efficiency in delivery of high quality care," he says. "We should start with elimination of unnecessary federal regulations which drive up costs and decrease access to care."
References
- Curtis v. Hohlbein. No. 1 (US District Court, Western District of KY) April 27, 2010.
- Dulisse B, Cromwell J. No harm found when nurse anesthetists work without supervision by physicians. Health Affairs 2010;29:1469-1475. Doi: 10.1377/hlthaff.2008.0966.
Resources
For more information on physician supervision of certified registered nurse anesthetists, see the following:
- Scope of Practice of Nurse Anesthetists, American Society of Anesthesiologists. Web: www.asahq.org/Washington/nurseanesscope.pdf.
- The American Association of Nurse Anesthetists. Web: www.aana.com. Select "Advocacy," and then "State Issues." Under "Resources," Select "Information on Opt-Outs and Federal Supervision Requirements."
List of "Opt-out" States
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Source: Limit number of CRNAs being supervised Role of anesthesiologist debated If an anesthesiologist is supervising a set number of certified registered nurse anesthetists (CRNAs) during procedures, the number being supervised should be kept to a manageable level, says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI. Trosty's previous employer, a medical liability insurer, would not insure an anesthesiologist who supervised more then four CRNAs at one time, he says. Additionally, "there had to be a backup anesthesiologist available at all times if the supervising anesthesiologist is required to go and help a CRNA, and another anesthesiologist should be available to take over the supervision of the other CRNAs," he says. "Ideally, we there should be only three CRNAs being supervised while doing procedures, but four was acceptable." The president of the American Association of Nurse Anesthetists, however, takes a different stance. Paul Santoro, CRNA, MS, chief executive officer of Anesthesia Staffing Consultants in Bingham Farms, MI, points out that Medicare requirements are for physician but not specifically anesthesiologist supervision, and that supervision is required only for facility reimbursement, not physician reimbursement. "I think it's important to note that in all 50 states, CRNAs can practice safely without anesthesiologist supervision," Santoro says. |
Associations debate meaning of research Study finds no harm with no supervision There are no differences in patient outcomes when anesthesia services are provided by certified registered nurse anesthetists (CRNAs), physician anesthesiologists, or CRNAs supervised by physicians, according to the results of a new national study conducted by RTI International.1 "The RTI findings demonstrate that the Medicare physician supervision rule for CRNAs is obsolete and unnecessary," the American Association of Nurse Anesthetists (AANA) said in a statement. The study, titled "No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians," was sponsored by the AANA and appears in the August issue of Health Affairs. The study examined nearly 500,000 cases. The authors compared patient outcomes in states where the Medicare requirement for physician supervision of CRNAs is in place with outcomes in 14 states that had opted out of the requirement between 2001 and 2005. It found that the opt-out requirement did not result in increased deaths or complications. The study also compared outcomes by provider type and found no differences in patient outcomes of anesthesia services delivered by solo CRNAs, by solo anesthesiologists, or by CRNAs being supervised by anesthesiologists. The authors recommend that the Centers for Medicare and Medicaid Services (CMS) allow CRNAs to work without physician supervision. The authors say that repealing supervision "would free surgeons from the legal responsibility for anesthesia services provided by other professionals [and] would also lead to more-cost effective care as the solo practice of CRNAs increases." James Walker, CRNA, DNP, former president of the AANA, said, "The results validate what we have known all along: that the quality of care and safety record of nurse anesthetists is of the highest caliber, regardless of physician supervision." The research shows no disparity in care in states that have opted out of the supervision requirement, Walker says. "In fact, the opt-out states have given nurse anesthetists the opportunity to prove, beyond a shadow of a doubt, what patients are most interested in knowing, and that is whether anesthesia is equally safe when provided by CRNAs or their physician counterparts," he says. "I'm happy to emphatically report that yes, it is." AANA President Paul Santoro, CRNA, MS, chief executive officer of Anesthesia Staffing Consultants in Bingham Farms, MI, said, "This study should encourage other states to think critically about their health care needs and how nurse anesthetists can expand access to anesthesia services." The American Society of Anesthesiologists (ASA) retorted with a strong response calling the study "an advocacy manifesto masquerading as science." "It makes dangerous public policy recommendations on the basis of inadequate data, flawed analysis and distorted facts," according to the ASA statement. It is impossible to perform meaningful analysis of anesthesia outcomes solely from billing codes, the association said. "The paper acknowledges that anesthesiologists care for patients undergoing the most complex procedures, but does not recognize that this is also true for the sicker patients undergoing even routine surgery," the ASA said. The authors claim that the training of nurse anesthetists and anesthesiologists is basically equivalent, the ASA said. "Since nurse anesthetists receive approximately two and a half years of training following the bachelor's degree and anesthesiologists spend eight years preparing for practice after the pre-medical undergraduate education (four in medical school and four in residency), this claim defies arithmetic," the association said. The authors also claim that unsupervised nurse anesthesia is more "cost effective," the ASA said. "Considering that the payment for anesthesia services under Medicare's system (adopted by most private insurers, too) is identical whether provided by an unsupervised nurse, solo physician or the physician/CRNA team, the fallacy of the 'cost effective' claim is evident," it said. (For more information on the study, go to www.aana.com/optoutstudy). Reference
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