It's Still "No!" For N.J. CRNAs
Monday March 27, 2006
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Photo courtesy of Rebecca C. Bergeron
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According to the American Association of Nurse Anesthetists (AANA), 65% of anesthesia delivered in the United States is administered by certified registered nurse anesthetists (CRNAs). Carla Romano,* a CRNA who provides anesthesia to patients in a plastic surgeon's office in New Jersey, is well aware of the regulations that were recently implemented that could significantly affect both her practice and her profession.
At issue are the New Jersey Board of Medical Examiners (BME) rules that now require supervision of N.J. CRNAs by a physician with either hospital or BME privileges in anesthesia, or an anesthesiologist, in all offices where surgery or special procedures are performed. The New Jersey Association of Nurse Anesthetists (NJANA), with support from the American Association of Nurse Anesthetists (AANA), the New Jersey State Nurses Association (NJSNA), the American Nurses Association (ANA), and state and national unions challenged the restrictive regulations, first with the Appellate Court and then with the New Jersey Supreme Court.
Arguments against the ruling
Extensive briefs were filed and argued by NJANA attorney Alma L. Saravia, who asserted that the BME "did not have sufficient empirical medical evidence to adopt the regulations, thereby making them arbitrary and capricious," and although the BME had authority to oversee the practice of medicine, with these regulations it had overextended its authority over nursing practice. Saravia maintained that there was no evidence to suggest differences in patient outcomes when anesthesia is delivered by a CRNA vs. an anesthesiologist, which would warrant such a regulation.
Angela Richman, CRNA, executive director of NJANA, says this assertion is supported by previous studies that have found that when anesthesia is delivered by physicians the outcomes are no different from anesthesia administered by CRNAs.
It was argued that the BME regulations were not aligned with the nationwide movement to remove, rather than add, restrictions to the practice of nurse anesthesia. While legal proceedings ensued, the supervision regulations were put on hold because stays were granted that enabled New Jersey CRNAs to continue to administer anesthesia without supervision in office settings, as had been past practice.
Together with backing and filing of amicus curiae (friend of the court) briefs by numerous state and national professional organizations, including the state and national American Federation of Teachers, and AFL-CIO, New Jersey CRNAs worked tirelessly to remove the supervisory restrictions. But in the end the ruling was not in their favor, says Saravia; on June 29, 2005, the Supreme Court upheld an earlier Appellate Court ruling that the BME did have sufficient evidence to regulate the training a physician must possess in order to practice in an office setting.
Response to the ruling
In its decision, the court ruled that (in its opinion it is fundamentally reasonable that) the education and training of anesthesiologists better prepares them to protect patients and to respond to emergencies. The court also found that there was insufficient evidence relative to available research to demonstrate identical safety levels between anesthesia delivered in office settings by physicians and CRNAs.
This statement, says Carolyn Torre, RN, MA, APN, C, director of practice at NJSNA, "sends out a negative message that the educational preparation of all physicians, regardless of prior education in anesthesia, is at a higher level than that of CRNAs."
Torre points out that even when a supervising physician becomes BME-credentialed in conscious sedation with the required eight continuing medical education hours in anesthesia, the CRNA ultimately will have more preparation and experience than that of the supervising physician. Nurse anesthesia programs average between 24 and 36 months in duration, and upon completion, candidates graduate with more than 1,500 hours of clinical experience. It is often the case that anesthesiologists and CRNAs train and work side by side.
Although the court concluded that the administration of anesthesia by physicians falls under the regulatory authority of the BME, it is the contention of NJSNA, ANA, NJANA, and AANA that anesthesia delivered by a nurse anesthetist falls under the regulatory jurisdiction of nursing. This ruling, considered narrow in scope, did not address the issue of whether CRNA-delivered anesthesia is the practice of nursing, and Richman says it only addressed the legality, not the wisdom of the regulations.
Torre says, "Based on nurse anesthetists' excellent record of safety since its inception a century ago, this restrictive regulation is both unnecessary and without justification."
This sentiment is echoed by Richman, who says, "With or without a supervision regulation, the focus of CRNAs has been, and will always be, the safety of patients."
Far-reaching implications
For CRNAs, the Supreme Court decision is considered a major setback at many levels. NJANA president Antonio Luciano, BSNA, CNOR, a CRNA who practices in a plastic surgery/ENT office, says that there will be sweeping consequences as a result of the new regulations.
The most immediate will be growing costs to patients as physicians are faced with anesthesiologists' salaries, which on average in New Jersey can be two to four times higher than the income of CRNAs. The expected increased costs for office anesthesia, together with the rising cost of health care in general, will compel patients to find less expensive anesthesia options in the nearby states of New York and Pennsylvania.
Luciano says it is unlikely that surgeons will hire both a CRNA and an anesthesiologist in their practices, a situation that will take away the choice surgeons currently exercise in their selection of CRNAs as anesthesia providers. Subsequently an employment monopoly for anesthesiologists will be created as opportunities for CRNAs in office settings begin to disappear.
With the expansion of health care into community settings, the need for skilled, safe, and cost-effective care by nurse anesthetists has been in demand. But as opportunities in N.J. physicians' offices dwindle, CRNAs will have to seek employment in different and/or out-of-state settings.
Anesthesiologists and physicians with BME anesthesia privileges also will feel the effects of these regulations, because they might be held responsible, in their supervisory roles, for the actions of other licensed professionals.
On the horizon
Two years ago, reports Torre, CRNAs petitioned the N.J. Board of Nursing (BON) for the development of a process through which they could become certified as advance practice nurses (APNs); the BON accepted this petition and has drafted regulations that were approved (in draft in March 2005) as part of an entire APN regulatory change. The rule has not yet been published in the form of a proposed rule, but if it is ultimately adopted, it may pave the way for another look at the BME CRNA in-office supervision regulation.
Currently in New Jersey, APNs designated by law are nurse practitioners (NPs) and clinical nurse specialists (CNSes), independently licensed/certified providers who, if they wish to prescribe drugs and devices, must do so in accordance with a mutually agreed upon joint protocol with a collaborative physician. The Office of the N.J. Attorney General is currently reviewing the entire APN proposal, including the provision that would allow CRNAs to apply to become certified as APNs.
Speaking for Carla Romano* and all N.J. CRNAs, Richman suggests that if a study were conducted following the eight years of the stay, it is not likely that any untoward outcomes would be found as a result of CRNA-administered anesthesia. Luciano concurs and adds that if the issue driving the BME regulations was based on patient safety, there is no doubt CRNAs would support this ruling. But just the opposite is true: "CRNAs have demonstrated time and time again a record of safety and proficiency in all settings. This testimony to past practice does not support the BME regulation that supervision by physicians with anesthesia privileges or by anesthesiologists will in any way improve patient outcomes."
The NJANA and NJSNA, together with other professional organizations that have been supportive since the inception of this legal challenge, will be closely investigating how the BME supervision regulations that went into effect Sept. 1, 2005, have affected CRNAs and the profession of nurse anesthesia in New Jersey.
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