KANSAS CRNA PRACTICE
CRNA Scope of Practice
Certified Registered Nurse Anesthetists (CRNAs) are licensed professional registered nurses who have obtained, through additional education and successful completion of a national examination, certification as anesthesia nursing specialists. CRNAs are qualified to make independent judgments relative to all aspects of anesthesia care, based on their education, licensure, and certification. The practice of anesthesiology by nurses has been recognized by the courts as the practice of nursing since 1917.
All anesthesia professionals, CRNAs and anesthesiologists alike, provide anesthesia and anesthesia-related care upon request, assignment, or referral by a patient's physician. The nature of anesthesia, with limited exceptions, does not have as it's primary goal the diagnosis and treatment of pathology. 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 Registered Nurse Anesthetist statute (K.S.A. 65-1118, sec. 5) regulates the practice of CRNAs in Kansas. In 1996, this statute was opened up for review. Representatives of the Kansas Society of Anesthesiologists (KSA) and the Kansas Association of Nurse Anesthetists (KANA) met and hammered out language within the Registered Nurse Anesthetist statute that was acceptable to both. The result was S.B. 152, passed July 1, 1996, which included authorization language and defined the CRNA to "function in a interdependent role as a member of a physician or dentist directed health care team".
Physician or dentist direction does not imply that the physician or dentist is responsible for supervision of the anesthetic nor are they vicariously liable for the negligence of a CRNA. Physicians and CRNAs are health care providers who are qualified for coverage under the Health Care Stabilization Fund and cannot be held vicariously liable for the actions of each other (K.S.A 40-3403h). This was established by the Kansas Legislature July 1, 1987. Nurse anesthetists are legally responsible for the anesthesia care they provide.
The scope of practice of CRNAs includes, but is not limited to, the following:
- Performing and documenting a pre anesthetic assessment and evaluation of the patient. This includes requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering pre anesthetic medications and fluids; and obtaining informed consent for anesthesia.
- Developing and implementing an anesthetic plan.
- Initiating the anesthetic technique which may include general, regional, local, and sedation.
- Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities.
- Managing a patient's airway and pulmonary status.
- Managing emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support.
- Discharging the patient from a post anesthesia care area and providing post anesthesia follow-up evaluation and care.
- Implementing acute and chronic pain management modalities.
- Responding to emergency situations by providing airway management, establishing venous access, and/or administering emergency fluids and drugs.
- Additional nurse anesthesia responsibilities which are within the expertise of the individual CRNA.
Employment and Practice Arrangements
According the fiscal year 1996 American Association of Nurse Anesthetists (AANA) membership survey, the employment and practice arrangements of CRNAs nationwide are: hospital employed (39%), anesthesiologist group employed (36%), CRNA group or self employed (15%), and university, military, office, or surgery center/clinic employed (10%). CRNAs provide care for every age and type of patient, utilizing the full scope of anesthesia techniques, drugs, and technology which characterize contemporary practice. They work in every setting in which anesthesia is delivered: tertiary care centers, community hospitals, labor and delivery rooms, ambulatory surgical centers, diagnostic suites, and physician offices.
CRNAs are the sole anesthesia providers in more than 70% of American rural hospitals, affording anesthesia and resuscitative services to these medical facilities for surgical, obstetric, and trauma care. CRNAs practice in every state in the United States and in 110 countries worldwide.
With around 550 CRNAs and 200 anesthesiologists in Kansas, CRNAs makeup 70% of all providers of anesthesia. Anesthesia care provided by CRNAs is widely distributed across nearly every county in Kansas. This contrasts with the limited distribution of other anesthesia providers who remain primarily within urban areas. At last count, 110 of the 132 hospitals (83%) providing surgical services in Kansas rely solely on nurse anesthetists for anesthesia care. Kansas citizens have a long standing history of dedicated, progressive, and high quality CRNA care.
Quality of Nurse Anesthesia Care
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 given annually in America, CRNAs have compiled an enviable safety record. 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.
Overall, anesthesia today is as safe as it has ever been. Studies have shown a dramatic reduction in anesthesia mortality rates to approximately 1 per 240,000 anesthetics. In 1990, the Centers for Disease Control and Prevention (CDC) proposed to undertake research on morbidity and mortality in anesthesia; however, after review of preliminary data, the CDC concluded that the morbidity and mortality rates in anesthesia were too low to warrant a multimillion dollar study.
The expanded utilization of CRNAs in the provision of anesthesia services makes good financial sense, especially as patients, carriers, purchasers, and employers demand cost-effective services of high quality. This fact holds true regardless of whether the CRNA anesthesia service is provided in collaboration with an anesthesiologist or as a CRNA service alone.
Substantial cost savings are realized when salary comparison between CRNAs and anesthesiologists are considered. Data reported in 1994 by the Medical Group Management Association and by the AANA membership survey showed that the average CRNA salary was approximately 34% that of the average anesthesiologist salary. An examination of the educational expense of preparing anesthesia providers reveals that approximately eight CRNAs can be prepared for the cost of preparing a single anesthesiologist. In addition, those eight CRNAs will have entered the work force and cumulatively provided anesthesia services for a number of years by the time the one anesthesiologist is ready to practice.
CRNAs were the first specialty nursing group to receive direct Medicare Part B reimbursement under the Omnibus Budget Reconciliation Act of 1986. CRNA services are also reimbursed directly by other state and federal programs and a number of commercial carriers. Independently billing CRNAs provide savings for the government programs and for private payers either on the basis of their payment methodologies or because they typically charge less than their physician counterparts. For hospitals which employ the CRNAs who work in collaboration with anesthesiologists, the financial viability of a CRNA/MD service is clearly dependent upon the avoidance of high MD to CRNA working ratios as well as hospital competency in appropriately billing CRNA services. Hospitals which claim to lose money on CRNA services are likely billing inappropriately and therefore not receiving the revenue to which they are entitled.
CRNAs have traditionally made high quality anesthesia services accessible to undeserved populations despite the cost constraints and/or isolation of many geographic areas. For any service location, CRNAs are highly cost-effective, quality anesthesia providers on the basis of educational costs, cost of service, productivity, and substitutability for more expensive providers. Whether working with or without anesthesiologists, they serve as the key to cost savings in the provision of anesthesia and anesthesia related services.