A WORD TO THE WISE:
Know Your Anesthesia Provider
By Kris Ellis
Anesthesiologists are perhaps the most visible and identifiable anesthesia specialists, but they are certainly not the only anesthesia providers. Certified registered nurse anesthetists (CRNAs) first began administering anesthesia more than 100 years ago, and continue to play a significant role in the field today. “CRNAs have a long history of providing superb patient care,” says Marc Koch, MD, MBA, president and chief executive officer of Somnia, Inc.
“When you talk about skilled anesthesia providers, they are certainly people who need to be mentioned.”
According to the American Association of Nurse Anesthetists (AANA), the basic qualifications for CRNAs applying for clinical privileges include:
- State licensure as a registered professional nurse. Compliance with state regulatory requirements in those states regulating advanced practice for nurse anesthesia.
- Graduation from a program of nurse anesthesia education accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs or its predecessor.
- Certification by the Council on Certification or recertification by the Council on Recertification or their respective predecessors or, if pending initial certification, evidence of graduation from an approved nurse anesthesia educational program.
Nurse anesthesia educational programs generally consist of 24 to 36 months of classroom and clinical experience, and offer a master’s degree upon completion.
A 2003 survey conducted by the AANA shows approximately 37 percent of practicing CRNAs are employed by a physician group, which may provide services in a number of different facilities and environments, while 32 percent are hospital employees, 16 percent are independent contractors, and 3 percent are employees of freestanding surgical centers. AANA estimates that 80 percent of CRNAs work as partners in care with anesthesiologists, while 20 percent are sole anesthesia providers, working with surgeons or other physicians.
Rick Hoffman, CRNA, BSN, BA, who practices with a physician-owned group that provides services for four facilities, including Beavercreek, Ohio-based Beavercreek Surgery Center, explains that ASCs often present a unique set of circumstances for anesthesia providers. “Most anesthetists really enjoy surgery centers because they tend to be cases that are shorter, less involved, and it gives you a chance to practice a different set of skills,” says Hoffman. “Having your patient awake in the recovery room vs. taking somebody who’s asleep down the hallway to the recovery room in a hospital is a big difference in terms of the way you give the drugs and the way you take care of your patient.”
The Centers for Medicare and Medicaid Services (CMS) regulations for ASCs specify that CRNAs must be supervised by the operating physician when administering anesthesia.1 However, an ASC can be exempted from this requirement if the state in which it is located submits a letter, signed by the governor, to CMS requesting exemption. To date, 12 states have opted out: Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon and Montana.
“It’s a fairly contentious issue because many anesthesiologists say CRNAs should function under the aegis of an anesthesiologist or, perhaps less ideally in their impression, under the aegis of a physician who has training or experience in anesthesia,” says Koch of the supervision requirement. “From the CRNA’s point of view, their point is, ever since the start of anesthesia in the United States, we’ve been doing this and we can do a fine job; we don’t need to be supervised by a physician and we don’t need to be supervised by an anesthesiologist — we can work independently. This is a serious issue that involves mindsets, beliefs and morés, both among and between anesthesiologists and CRNAs.”
Koch’s own approach involves the formation of a cohesive team that attends to all aspects of patient care when it comes to anesthesia. “The team environment consists of one or more CRNAs who work under an anesthesiologist who gives them input, ideas, suggestion, direction and supervision in the effort to provide the best quality of care to patients,” he explains. “That team approach is something that I’ve worked with for almost 10 years that I think works very well and underscores what an important part I think they (CRNAs) are to the anesthesia team.”
Since Hoffman works with a physician group, his day-to-day duties always involve collaboration with a physician. “Together we’ll do a preoperative interview with the patient, we’ll take the patient back and hook up all of the monitors, then they’ll come back while we induce and make sure we’ve secured the airway,” he says. “Then they go out to interview the next patient.”
In assessing what kinds of anesthesia services individual ASCs will offer, and what providers they utilize, Koch suggests that surgeons and anesthetists must work together with facilities to assess and determine what makes the most sense. “There are a lot of moving parts to this issue,” he says. “It would be unfair to say that a provider, whether it be a CRNA or an anesthesiologist, both of which I would collectively call skilled anesthesia providers, with training and experience, would feel comfortable in all environments or would not feel uncomfortable in some environments. It’s really up to the CRNA and the surgeon and the anesthesiologist. Each of those people really needs to define what setting they’re most comfortable in and what makes the most sense for them and their patients.”
“The providers need to be experienced,” says Beverly K. Philip, MD, director of the Day Surgery Unit at Brigham and Women’s Hospital, and past president of the Society for Ambulatory Anesthesia (SAMBA). “To work in a setting where there’s not a great deal of back-up like there is in a hospital, you want to have a provider who is not green, who has had a fair amount of post-training experience to be able to handle most situations by themselves.”
Philip also notes that accreditation is an important foundation for many aspects of patient safety. “Surgery centers are required to do it because it shows the way; it makes sure that nothing has been overlooked in the facility aspect of providing safety,” she says. “The point of accreditation is you have some outside body who can make sure that you’ve taken care of all the process steps to make sure there’s excellent patient safety.”
Although they are widely regarded as skilled anesthesia specialists, the definition of a CRNA’s scope of practice varies. For example, the American Society of Anesthesiologists (ASA) and the AANA differ in their views of how much independence a CRNA can exercise in the evaluation of patients and in developing and implementing an anesthetic plan.2-3
RN-Administered Anesthesia
Debate continues over the practice of propofol administration by registered nurses (RNs), which typically takes place in endoscopy suites. Touted by some as a safe, practical and cost-effective means of patient care, others contend that it constitutes a tangible risk to patient safety.
Cost is a prominent factor with regard to this issue, according to Koch. “Medicare began to provide site-of-service differentials to gastrointestinal (GI) doctors in an effort to promote migration of cases to physicians’ offices,” he explains. “This basically provides a forum for cost containment and the ability to open up capacity in hospitals, and that capacity can be used for patients who are older and sicker and need the resources more.
“Now, what happens is, when you say to a GI physician or colorectal surgeon, ‘We want you to bring your masses out to your office; there’s no intensive care unit upstairs, there’s no emergency room downstairs, there’s no team of anesthesiologists down the hallway, and we want you to provide the standard of care that any patient would welcome in any setting,’ it’s hard to do that.”
Koch notes that settings lacking a wealth of critical-care resources may not be looked on as favorably by payors. “That’s why most payors embrace having an anesthesiologist provide care for GI procedures — it provides the GI doctors and the colorectal surgeons an environment which is equivalent to the hospital-based setting.
There’s a skilled anesthesia provider who’s administering the medication, who is an intensive care specialist by training, and who can help during critical care events. That really sets the foundation for the migration of procedures from the hospital to the surgery center. For a GI doctor to be expected to give his own sedation or have his RN give it, this, in many ways, takes the cost containment model and puts it on kind of a slippery slope where it brings it too far, and in doing so perhaps places the health, safety and welfare of patients in peril’s way.”
John Walker, MD, president of Medford, Ore.-based Gastroenterology Consultants, P.C., is also concerned with cost containment. “I’m aware of the cost of some procedures going up about 250 percent with the use of an anesthesia specialist — the exam costing 250 percent more,” he says. “Then there’s the supply issue. In our community if we were to call for an anesthesiologist for even 10 percent of the GI endoscopy cases, it would just break the system; we don’t have that kind of capability. When we do need one legitimately, they’re available. We judge carefully whether we need an anesthesiologist or not. I think supply and cost are the two biggest factors.”
As with many aspects of this issue, there are conflicting experiences, opinions and viewpoints surrounding the availability of anesthesiologists. “I am unaware of any specific shortages that relate to covering endoscopy suites,” Koch contends. “There is no data to suggest that endoscopy suites are short of coverage; there is no conclusive evidence that there is a problem in that vein. Furthermore, would you downgrade the anesthesia provider because you want to open access even though it’s a risky proposition perhaps? It’s a tough call. My thought is safety first.”
Koch also questions the impact of cost. “If Medicare pays an anesthesiologist $100 for the anesthetic for a colonoscopy patient, and this is just a sample number, and in doing so they create a forum where that GI doctor feels safe bringing that case from the hospital to the office-based setting, they save a tremendous amount of money in the facility fee of the hospital — maybe upwards of $600 to $700,” he says. “So, they save the $600, and yes they have to pay the anesthesia fee, but that’s far less than the facility fee that they would have to pay. It creates a forum where safety and cost containment can work in concert to create a paradigm shift that serves several directives.”
Walker has been involved in the development, practice and dissemination of nurse-administered propofol sedation (NAPS) for years. He acts as president and CEO of Dr. NAPS, Inc., a training program that is dedicated to educating endoscopists and nurses on the intricacies of NAPS.
Walker says that his own track record using this protocol is excellent. “We’ve only had to mask ventilate one person out of more than 31,000 for more than 2 minutes,” he points out. “Such an occurrence is rare, and we feel pretty capable of doing that when it’s required — about one time in 1,700 cases, somebody needs the mask on their face for about 20 to 40 seconds. Gastroenterologists should be able to do that.”
Airway management is a vitally important issue, and is also a frequent point of discussion. Koch points out that the manufacturer’s language on the drug’s packaging insert specifies that propofol should only be used by persons trained in the administration of general anesthesia. “It’s a tough call because it’s a dangerous drug that can cause respiratory depression. The risks of the drug are almost entirely mitigated when you have a skilled anesthesia provider giving it, who may be most familiar with cardio-respiratory alterations and some of the side effects that could occur. When an anesthesiologist gives the medication, a fair amount of time patients may obstruct their airway with their tongue or oral structures, so an anesthesiologist or CRNA treating that is second nature.”
Walker again points to his years of experience with propofol. “In terms of rescue, we’ve had to mask ventilate one person longer than two minutes,” he says. “We’ve required no other intervention — no intubation.”
In terms of the package insert,Walker feels the information is less relevant than it was when the drug was initially released. “I think that the package insert has served its purpose of delaying dissemination until techniques were developed and refined that tame this drug and make it walk a straight line. We have shown, in Medford, Ore., that the light touch, the nuances of administration, the physiologic feedback, the total wherewithal, well-described in my syllabus, should cause people of wisdom, knowledge and circumspection to rethink the whole thing about the package insert.”
Walker cites the rapid onset and offset of propofol as a distinct advantage of using the drug. “One of my partners doesn’t use propofol in the hospital setting, only in the outpatient surgery center, for personal reasons. He had a patient who, at the termination of his endoscopic procedure, wasn’t breathing. He gave the patient reversal agents — full reversal, and then double-full reversal — and the patient still needed to be on a respirator due to lack of response for an hour. I chided him that if you had used propofol, the patient would’ve been talking to you in three to four minutes rather than on a respirator for 60 minutes. So which is safer? With the proper technique, which I take pride in teaching, and in practiced hands, I think propofol is a darn safe medication.”
What do participants learn from Walker’s course? “The right opening dose, the subsequent dosing that leads up to scope passage, the interval doses according to a chart I have created that pits the patient profile vs. reading the body language,” he explains.
Attentiveness to the patient’s body language and responsiveness are particular areas of emphasis in the course. “We’re very much into the person part of this feedback loop and de-escalating our reliance on machines, which tend to distract and to disappoint more often than not,” Walker continues. “There’s a wealth of other concepts, but I think everyone who has come here and spent two days with us and goes through the syllabus, sees the videos, sees how we do things and hears us talk about it all day long — everyone who’s left here has felt capable of doing this comfortably back home.”
While many anesthesia specialists are concerned about this practice, Philip notes that the debate over propofol is also taking place within the GI community. “There are two sides, from what I’ve read, inside the gastroenterology literature as well,” she says. “It’s not really anesthesiologists vs. gastroenterologists,” she says, pointing to a recent American Gastroenterological Association (AGA) publication.4
Philip also explains that context is important in reviewing scientific literature that is supportive of nurse-administered propofol. For example, if a study is conducted in a large, university-based setting with extensive support, the results may not be applicable to smaller practices in which RNs may not have relevant experience or training. “In the ASA’s Continuum of Depth of Sedation document are the definitions of sedation and general anesthesia, which are the same definitions used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Accreditation Association for Ambulatory Health Care (AAAHC),”5 she says. “The practitioner assesses the depth of sedation by responsiveness; if the patient is unresponsive to any kind of stimulus, that’s the generally understood definition of general anesthesia.
That’s the problem — most of the time I think that they’re probably giving general anesthesia. If it were deep sedation, the issue is that you should expect that the patient’s ventilation may be inadequate and you may need to support the airway; you need to be able to control ventilation while the patient lightens back up again. For most RNs, it is way out of their comfort zone.”
Relevant professional associations take varying positions when it comes to the propofol issue. A joint statement by the AANA and ASA clearly discourages propofol administration by anyone other than anesthesia specialists, as do standards from the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF).6,7 The Society of Gastroenterology Nurses and Associates, Inc. (SGNA) takes a more supportive stance on this practice, however.8
Ultimately, patient safety, satisfaction and acceptance (or lack thereof) may prove to be the driving factors in the future of nurse-administered propofol. Walker contends that increased education and exposure will support this practice. “In my community it’s not controversial,” he says. “The two physicians who made the most fuss about this in 1998 eventually had NAPS themselves for endoscopic procedures. It just takes time.”
Koch believes that it is incumbent upon clinicians to be open and honest with patients regarding propofol administration. “There’s no hubris here; we’re not saying we have all the answers or all the solutions, but we do have some of the facts at our disposal and I think patients, at the very least, should have an understanding about what propofol is, the people who can deliver it, and the events that could occur and the experience of the people of involved in administering it to intervene if those things occur,” he says. “Patients can make their own judgments; they should be able to make their own choice here.”
References:
1. Medicare and Medicaid programs; hospital Conditions of Participation: anesthesia services. Final rule. Fed Regist. 2001 Nov 13; 66(219): 56762-9.
2. www.asahq.org/Washington/nurseanesscope.pdf
3. www.aana.com/crna/prof/scope.asp
4. www.gastro.org/pubs/pdf/perspectives/05/FebMar.pdf
5. www.asahq.org/publicationsAndServices/standards/20.pdf
6. www.asahq.org/news/propofolstatement.htm
7. www.aaaasf.org/surgicenters.php
8. www.sgna.org/resources/Sedation.html
