The California Department of Public Health sent a letter to hospitals last week clarifying the scope of practice for certified nurse anesthetists.
The state guidance was applauded by physician anesthesiologists, who recently have been in conflict with nurse anesthetists, who increasingly administer anesthesia to patients before surgeries and scoping procedures.
“CRNAs play a vital role in the anesthesia care team in California, but it’s important to recognize that physician leadership remains essential to ensure patient safety and compliance with state and federal regulations,” Todd Primack, a division chair for the California Society of Anesthesiologists, said in a statement.
Hospitals in Modesto have been marked by confusion over the role of CRNAs. Federal and state surveys at Stanislaus Surgical Hospital found CRNAs were in charge of anesthesia services and had been given full prescriptive and diagnostic authority at the hospital. The inspectors issued a notice of violation in January, declaring that the lack of oversight over CRNAs placed patients in jeopardy.
The survey quoted executives at the short-stay hospital expressing opinion that CRNAs perform the same work as physician anesthesiologists and have the same authority. The inspections in August 2023 and January-February sharply criticized the work of nurse anesthetists, causing the California Association of Nurse Anesthesiology (CANA) to allege the survey team was biased.
The survey concluded that lack of oversight of CRNAs, who were working as independent practitioners, was to blame for negative health outcomes of 10 patients who required transfer to a higher level of care.
Stanislaus Surgical Hospital also didn’t have bylaws and policies for the use of CRNAs, but had only older policies on the books for staffing operating rooms with anesthesiologists.
CDPH, in a Sept. 6 all-facilities letter, reminded hospitals about CRNA scope-of-practice definitions and also stressed that anesthesia services must be well-organized, with bylaws and policies for using CRNAs.
The agency said the use of CRNAs in acute care hospitals must be approved by administration and must be at the discretion of physicians. The letter also said CRNAs may administer only anesthesia medications ordered by a physician.
In addition, CRNAs are not authorized to practice medicine, the letter said.
The state’s clarification seems to contradict claims by nurse advocates that California allows CRNA-only independent practices.
What nurse anesthetist group says
A spokeswoman for CANA, representing nurse anesthetists, said Friday that physician anesthesiologists are trying to spin the CDPH policy letter in their favor. CANA says studies show no evidence that nurse anesthetist services are less safe for patients than the services of physician anesthesiologists.
Nurse anesthetists are not required to be supervised by a surgeon or anesthesiologist but may provide only services within their scope of practice, said Kaitlin Perry, speaking for CANA. Perry cited a 2010 court decision stating: “It is the Nursing Practice Act that gives CRNAs legal authority to administer anesthesia after a physician orders a course of treatment that includes anesthesia.”
Perry said the same reasoning applies to physician anesthesiologists, who administer anesthesia after a patient’s physician or surgeon orders a course of treatment.
Earlier this year, the CDPH and federal regulators scolded Doctors Medical Center for not having credentialing procedures for an anesthesia group that heavily used CRNAs in operating rooms. The agencies sent the CNRAs home from the hospital in May, requiring the hospital to reschedule hundreds of surgeries as it scrambled to find anesthesiologists for operations.
The CRNAs were required to complete proctoring before resuming work at DMC.
People associated with the hospital said DMC has tried to hire more physician anesthesiologists to create a higher ratio of MDs to CRNAs in the anesthesia department. The hospital did not comment Friday on the CDPH policy letter.
The state guidance also stresses that:
- Hospital anesthesia services must be provided in a well-organized manner under the direction of a qualified doctor.
- Policies and procedures for anesthesia service must be developed in consultation with appropriate health professionals and administration, and approved by the hospital’s governing board.
- CRNAs not employed directly by the hospital where they administer anesthesia are subject to the facility’s bylaws.
Hospitals are dealing with a shortage of both physician anesthesiologists and CRNAs. Certified nurse anesthetists are nurses with college degrees and critical care experience who have completed a two- or three-year anesthesia program.
To enable broader use of CRNAs in rural areas, former Gov. Arnold Schwarzenegger sent a letter for California in 2010 to opt out of restrictions in the federal Medicare program, which require physicians to oversee the work of nurse anesthetists.
CRNAs have asserted the opt-out gives them greater freedom to provide services. But their services still are under the prescriptive authority of physicians.
The state Board of Registered Nursing defined CRNAs’ scope of practice in an email to The Modesto Bee in June: “A certified registered nurse anesthetist may lawfully administer anesthesia and provide anesthesia services when their professional service is ordered on a patient-specific basis by a physician, dentist, podiatrist or clinical psychologist. The involvement of a physician (or other healthcare professional, as outlined in statute) is required in issuing an order for anesthesia, however direct supervision is not necessarily required.”
Dr. Antonio Hernandez Conte, immediate past president of California Society of Anesthesiologists, contended the state letter does not create new standards but provides clarification on what has been established policy and statutory law for over a decade.
“Anesthesia care is a physician-led care team model,” Hernandez Conte said. “Under state law, CRNAs are under the prescriptive authority of physicians and anesthesia care policies and procedures fall under the auspices of physician oversight.”
(Failure to comply with different standards of the Medicare program forced Stanislaus Surgical Hospital to cease operations Saturday.)
Local News
