Anesthesia: The Practice of Nursing or the Practice of Medicine
Anesthesia has been called both the practice of nursing and the practice of medicine? How can this be?
Probably no where within nursing and medicine is there a greater overlap than in the field of anesthesiology. The courts have upheld that when the tasks of anesthesia is performed by a nurse anesthetist, the tasks constitute the practice of nursing. When the tasks of anesthesia are performed by a physician, the tasks constitute the practice of medicine.
Historically, this follows a logical line. In the United States, the nursing specialty of anesthesia preceded that of the medical specialty. Nurses were the principle providers of anesthesia services for the late 1870s until after World War II. CRNAs played a crucial role in the delivery of anesthesia in combat areas in every war in which the United States has been engaged since World War I.
In World War II, there were 17 nurse anesthetists to every one physician anesthetist. In Vietnam, the ratio of CRNAs to physician anesthetists was around 3:1. During the Panama strike, only CRNAs were sent with the fighting forces. Today, CRNAs administer the majority of anesthetics (65%) in this country, working with and without anesthesiologists.
Further the nature of anesthesia, with limited exceptions, does not have as its primary goal the diagnosis and treatment of pathology, long considered medicine's area. Rather, anesthesia is a service which permits physicians involved in diagnosis and treatment of patients to perform their work while the patient remains safe and comfortable. The nurse anesthetist or the anesthesiologist can collaborate with the physician to provide this essential service, each within the meaning of state law.
The most substantive difference between CRNAs and anesthesiologists is that prior to anesthesia education, anesthesiologists receive medical education while CRNAs receive nursing education. However, the anesthesia part of the education is very similar for both providers. They are both educated to use the same anesthesia process in the provision of anesthesia and related services. In a survey of practice conducted among anesthesiologists and CRNAs in 1986 by the Center for Health Economics Research, it was found that CRNAs perform the same range of anesthesia tasks and activities as anesthesiologists.
Today, the registered nurse's education as a nurse anesthetist requires a Bachelor of Science in Nursing (or other appropriate baccalaureate degree); a minimum of one year experience in critical care nursing; and completion of two to three years of Master's level graduate work, including both classroom and clinical studies, on the administration of anesthesia. The anesthesiologist's course of study requires a baccalaureate degree, completion of medical school, and a four year residency in anesthesiology.
CRNAs and anesthesiologists work together in a wide variety of settings and employment situations. Some settings involve self-employed providers working side by side, while other settings are employer/employee in nature.
Are Kansas CRNAs required by law to be supervised by an anesthesiologist?
No. The Registered Nurse Anesthetist (RNA) statute of Kansas (K.S.A. 65-1118, Sec. 5, #9c) reads as follows: "A registered nurse anesthetist shall perform duties and functions in an interdependent role as a member of a physician or dentist directed health care team." The language "supervised" and "anesthesiologist" is not included in the Kansas RNA statues.
In 1996, this statute was opened up for review. Representatives of the Kansas Society of Anesthesiologists and of the Kansas Association of Nurse Anesthetists met and hammered out language within the RNA statute that was acceptable to both. The result was S.B. 152, passed July 1, 1996, which was a bipartisan agreement on the practice of Kansas nurse anesthetists.
There is no state in America that requires supervision by an anesthesiologist. In 29 states, physician direction or supervision of a nurse anesthetist is not required at all by state statute. In addition, neither the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) nor Medicare require anesthesiologist supervision of CRNAs.
Bylaws determined by each individual facility may require the supervision of CRNAs by an anesthesiologist in spite of state law. Such restrictions have denied some patients access to the full scope of anesthesia services which should be available to them. These restrictions have no basis in practice and add to the expense of anesthesia care by requiring two providers when one is most frequently adequate. Furthermore, restrictive CRNA practice bylaws are often not followed in the interest of patient care or for greater operating room efficiency. Medical staff bylaws which allow CRNAs to practice within the professional authority granted by state law more accurately reflect "real world" practice. This benefits patients, the medical facility, and the anesthesia staff.
Nurse anesthetists have been providing quality anesthesia care in the United States for more than 100 years. In administering more than 65% of the 26 million anesthetics annually, CRNAs have complied on enviable safety record. No studies to date have demonstrated that there is a difference in anesthesia patient care outcomes based on type of anesthesia provider, that is, a nurse anesthetist or anesthesiologist.
This conclusion was recently confirmed in 1994 by the Minnesota Department of Health, which completed a legislatively mandated study concerning anesthesia care in that state. The department concluded that "there are no studies, either national in scope or Minnesota-specific, which conclusively show a difference in patient outcomes based on type of provider" (Anesthesia Practice Study. St. Paul, Minnesota: Department of Health. January 1995). Further information on this subject is contained in the document "No Significant Differences in Anesthesia Outcome by Provider: Synopsis of Available Published Information Comparing CRNA and Anesthesiologist Patient Anesthesia Outcomes" available from the American Association of Nurse Anesthetists.
Anesthesia is an appropriate specialty for either nurses or physicians. The evidence to date is compelling and comprehensive that CRNAs provide safe, quality anesthesia care. Patient outcome is similar regardless of whether the anesthesia provider is a CRNA or an anesthesiologist.
Is a surgeon more liable when working with a CRNA than with an anesthesiologist?
Those who seek to discourage physicians from working with nurse anesthetists have incorrectly asserted that a supervising physician becomes liable for the negligent acts of the CRNA. A physician or authorized provider is not automatically liable when working with a CRNA, nor is the physician immune from liability when working with an anesthesiologist
The principles governing the liability of a physician when working with a CRNA are the same as when working with an anesthesiologist. Whether or not a physician will be held liable for the negligence of the anesthetist depends on the facts of the case, not on the nature of the license held by the anesthesia provider.
Generally, the courts examine the degree of control the physician exercises over the anesthetist-- whether it be a CRNA or anesthesiologist. The more control that is exerted by the physician concerning the anesthetic, the more liable the physician becomes. Even where state laws require physician supervision of CRNAs, there is no requirement that a supervising physician control the acts of a CRNA. State laws do not require control, and mere supervision is insufficient to make the supervisor legally responsible for the negligence of a CRNA. The CRNA is the expert in anesthesia and supervising physicians, other than anesthesiologists, are not expected to have as much knowledge of anesthesia as the CRNA.
In 1987, the Kansas Legislature clarified the issue of whether a surgeon could be held vicariously liable for the actions or omissions of others who he/she requests undertake the care or treatment of the patient. Prior to the statutory regulation of vicarious liability, case law controlled the interpretation of a surgeon's vicarious liability for the acts of an anesthesia provider whether the provider be an anesthesiologist, resident anesthesiologist, or a CRNA.
As of July 1, 1987, health care providers (defined as physicians, CRNAs, hospitals, and professional corporations or partnerships) are qualified for coverage under the Health Care Stabilization Fund and cannot be held vicariously liable for the actions of another health care provider. This is clearly set out in K.S.A. 40-3403(h): "A health care provider who was qualified for coverage under the Fund shall have no vicarious liability or responsibility for any injury or death arising out of the rendering of or the failure to render professional services inside or outside this state by any other health care provider who is also qualified for coverage under the Fund. The provisions of this subsection shall apply to all claims filed on or after the effective date of this act (July 1, 1987)."