Anesthesia provision in the United States
In the
Anesthesia providers
Anesthesiologists
Anesthesiologists are physicians (MD/DO) specializing in the practice of anesthesiology.
The training of a physician
Other specialties within medicine are closely affiliated to anesthesiology. These include
Certified Registered Nurse Anesthetists (CRNA)
CRNAs begin their education with a four-year Bachelor of Science degree, followed by at least one year of critical care nursing experience (most trainees enter with 3-6 years of critical care nursing experience), and completion of the CCRN certification. After 3 years of intensive didactic and clinical anesthesia training, they obtain a doctorate of nursing degree and they must then pass the NBCRNA national certification exam.[2]
CRNAs care for patients pre-, intra-, and postoperatively and practice in all facets of anesthesia care. They may care for patients independently but also work collaboratively as part of the healthcare teams. Some choose to narrow the focus of care to sub-specialize in the provision of cardiac, pediatric, pain, or obstetrical care. CRNAs administer anesthesia in all types of surgical cases, and are able to apply all of the accepted anesthetic techniques—general, regional, local, or sedation independently without supervision of a physician anesthesiologist.[3]
As of 2022, 19 governors opted out of the CRNA supervision requirement of the Centers of Medicare and Medicaid Services (CMS).
Anesthesiologist Assistants
Anesthesiologist assistants generally work in the hospital setting but can work at any location including pain clinics, dental offices and surgical care centers. Anesthesiologist assistants work under the medical direction of physician anesthesiologists in surgical environments such as cardiac surgery, neurosurgery, transplant surgery, and trauma surgery centers. The incorporation of anesthesiologist assistants into ACT teams across the country is a dynamic process, and currently there are sixteen states, as well as Washington, D.C., and the Veteran's Affairs Medical System. In each of these states, the anesthesiologist assistant falls under the regulatory authority of the State Board of Medicine.
As of 2017 there are twelve anesthesiologist assistant training programs in the United States all of which offer degrees at the Master's level.[citation needed] Approximately 97% of currently practicing anesthesiologist assistants hold a master's degree (some early anesthesiologist assistant graduates held bachelor's degrees). All newly credentialed and future anesthesiologist assistants must complete an accredited Master's program for anesthesiologist assistants. Upon completion of the educational program, graduates must sit for a credentialing exam that is co-validated by the National Board of Medical Examiners and National Commission for Certification of Anesthesiologist Assistants. All anesthesiologist assistant programs are credentialed by the Commission on Accreditation of Allied Health Educational Programs (CAAHEP)
CMS "Opt-Out" Federal Supervision Requirement
Effective November 13, 2001, CMS established an exemption for Certified Registered Nurse Anesthetists (CRNAs) from the physician supervision requirement. This exemption recognized a Governor's written request to CMS attesting that he or she is aware of the state's right to an exemption of the requirement for CRNA to be supervised by a physician. The attestation recognizes that it is in the best interests of the State's citizens to exercise this option in order to provide safe, cost-effective, valuable anesthesia services and especially helps assure the provision of those services to all citizens.[citation needed]
Requirements for “Opt-Out” Of Federal Supervision Requirement • The federal requirement has been that CRNAs must be supervised by a physician. The November 13, 2001 rule allows states to "opt-out" or be "exempted" (the terms are used synonymously in the November 13 rule) from the federal supervision requirement.
• For a state to "opt-out" of the federal supervision requirement, the state's governor must send a letter of attestation to CMS. The letter must attest that: a. The state's governor has consulted with the state's boards of medicine and nursing about issues related to access to and the quality of anesthesia services in the state; and b. That it is in the best interests of the state's citizens to opt-out of the current federal physician supervision requirement; and c. That the opt-out is consistent with state law.
As of March 2020, nineteen states have chosen to opt-out of the CRNA physician supervision regulation. The states are: Alaska, Arizona, Colorado, California, Idaho, Iowa, Kansas, Kentucky, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, Oklahoma, South Dakota, Washington, and Wisconsin.
Anesthesia Care Teams
According to the ASA statement on the Anesthesia Care Team, anesthesia care personally performed or medically directed by an anesthesiologist constitutes the practice of medicine. According to the American Association of Nurse Anesthetists and state law in all fifty states, anesthesia care provided by a Certified Registered Nurse Anesthesiologist is considered the practice of nursing. Certain aspects of physician directed anesthesia care may be delegated to other trained and credentialed professionals, including anesthesiologist assistants and CRNAs.[4]
Laws regarding anesthesia provision
It has been established that, under US law, anesthesia is practice of both medicine and nursing. Frank v. South,[5] Chalmers-Francis v. Nelson[6][7] and other court decisions determined that anesthesia was the practice of Nursing as well as Medicine.[8] As such, the practice of anesthesia in the US may be delivered by a physician anesthesiologist, an anesthesiologist assistant or a Certified Registered Nurse Anesthesist. The decisions have not been challenged since the Dagmar Nelson case.[9] In addition to legal decisions, individual hospital and surgical facility policies also regulate the granting of anesthesia clinical privileges and are often based on contractual agreements with provider groups.
See also
References
- ^ "ASA Fast Facts: Anesthesiologists Provide Or Participate In 90 Percent Of All Annual Anesthetics". ASA. Archived from the original on 2007-02-02. Retrieved 2007-03-22.
- ^ NBCRNA NCE http://www.nbcrna.com/certification/Pages/default.aspx. Retrieved 9 July 2016.
- ^ AANA. "Certified Registered Nurse Anesthetists Fact Sheet".
- ^ "The ASA Anesthesia Care Team statement" (PDF). American Society of Anesthesologists. October 13, 2013. Retrieved January 17, 2016.
- ^ 175 Ky 416, 194 SW 375 (1917)
- ^ 6 Cal 2d 402 (1936)
- ^ "Chalmers-Francis v. Nelson - 6 Cal.2d 402 - Mon, 05/18/1936 | California Supreme Court Resources".
- ^ "The Practice of Anesthesia (Position Statement)". American Association of Nurse Anesthetists. Archived from the original on 20 January 2016. Retrieved 17 January 2016.
- ^ "The administration of anesthesia and the practice of medicine". AANA. 2006-02-01. Archived from the original on 2007-10-21. Retrieved 2007-02-10.