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| KANSAS CRNA PRACTICE |
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CRNA Scope of Practice |
Employment and Practice Arrangements |
Quality of Nurse Anesthesia Care | Cost Effectiveness
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 420 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 St. Paul Fire and Marine Insurance Company is the largest medical malpractice insurer in the
country and also the largest provider of professional liability insurance to CRNAs. In 1995, the
St. Paul insurance company reported that medical malpractice insurance rates for its insured nurse
anesthetist policyholders decreased, on the average, nationwide, between 6 to 13% each year from
1988 to 1993 and have been stable through 1997. Falling malpractice premiums further testify to the
safety and quality of anesthesia administered by nurse anesthetists. Kansas CRNAs have seen a 60%
decrease in medical malpractice premiums through St. Paul over the last ten years.
Cost Effectiveness
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.
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