MDs, CRNAs and Care Teams: The Ins and Outs of 4 Anesthesia Care Models

Surgery centers have several options for anesthesia provider models, depending on surgeon preference, local anesthesia market conditions, surgery center size and revenue and federal or state regulatory requirements. Thomas Wherry, MD, founder of Total Anesthesia Solutions and medical director with Health Inventures, discusses the details of several anesthesia models — all-MD, all-CRNA, the anesthesia care team and the MD/CRNA model.  

"When it comes to staffing an ASC, there is really no one perfect model," Dr. Wherry says. "There is no cookie cutter approach. Each situation is unique and one must weigh all the pros and cons.”

All-MD model: Dr. Wherry says the all-MD anesthesia model is often seen in one- or two-room surgery centers. The small size of one- or two-room ASC makes it inefficient to staff with both MDs and CRNAs. However, he says the all-MD model is less common in larger ASCs because of the cost required to staff the center with multiple anesthesiologists. "An all-MD model can be cost-prohibitive in a larger surgery center, especially if the group is expected to provide a 'floating' anesthesiologist to cover pre-op and PACU,” Dr. Wherry says. "If you have four rooms, it's really hard to have five MDs there.”

Clear-cut policies for patient handoff are important in any model, but particularly important when using a model that does not have a 'floating provider.' Surgery center leaders should also explore how the staff handles problems in pre-op or the recovery room. If there is any question about the patient's condition, the anesthesiologist must remain with the patient in the recovery room, precluding him or her from starting another case.

This can be a source of frustration if there are frequent case delays. If any patient suddenly becomes unstable, the nurses in the recovery room must be fully trained to handle such problems. Dr. Wherry says all PACU nurses should be ACLS-trained for this reason.

All-CRNA model:
An all-CRNA model allows certified registered nurse anesthetists to function independently without the assistance of an anesthesiologist. Certain states require CRNAs to be supervised a physician, but not by an anesthesiologist. "The surgeon could be considered the supervising physician," Dr. Wherry says. "There are CRNAs that function independently in the ASC setting. This is a broad level of supervision and there is little to no risk of the supervising physician being vicariously liable. This model will run in to the same problem as the all-MD model: no 'floating provider.'" Thus, the ASC must have all the proper protocols in place to handle any emergencies if the CRNA is tied up in the operating room.

Furthermore, Dr. Wherry says ASCs that use an all-CRNA model should be sure to discuss emergency care and transfer procedures, including what will happen if the patient has a "life or death" issue. Dr. Wherry adds that these issues should be discussed during the quality review process, and any complications should be tracked and analyzed.

Care team model: The "anesthesia care team model" or "ACT"  is a term coined by the American Society of Anesthesiologists to describe "anesthesiologists supervising resident physicians in training and/or directing qualified non-physician anesthesia providers in the provision of anesthesia care wherein the physician may delegate monitoring and appropriate tasks while retaining overall responsibility for the patient."

According to Dr. Wherry, the care team involves the anesthesiologist in all key elements of anesthetic provision but allows CRNAs to administer the anesthetic themselves. "The anesthesia care team model is a highly supervised environment where the MD is involved in all aspects of the care," he says. This means the anesthesiologist is present for pre-, intra- and post-operative processes and must be available at all times to consult with the CRNAs.

Dr. Wherry says for the care team model to work, the anesthesiologists must be invested in the model's efficacy. If the anesthesiologist believes that only MDs should treat patients, he or she may create a hostile environment for the CRNAs and the patient. This type of anesthesiologist might also be a poor CRNA supervisor.

Anesthesiologists who use the care team model may have different billing requirements than anesthesiologists who participate in a less-strict MD/CRNA model. When billing Medicare for services, anesthesiologists must determine whether they should bill for medical direction based on their level of supervision over the CRNA. "Seven steps of supervision are required to meet medical direction, making it more of a billing term than a medical term," Dr. Wherry says.

MD/CRNA model:
The MD/CRNA model functions much like the care team model but with fewer supervision requirements, and it allows the CRNAs to function according to their full scope of practice, Dr. Wherry says. In this looser supervision model, the MD is present in the surgery center to supervise the CRNAs but may leave the operating room to attend a meeting, staff another room or answer another provider's questions. "It depends on the physician's comfort level, as well as the local and state requirements [governing CRNA practice]," Dr. Wherry says. This model marries the advantages of anesthesiologist involvement in patient care, the skills and scope of practice of the CRNAs and the cost efficiency of CRNAs.

Dr. Wherry says the MD/CRNA model provides larger facilities with more flexibility when the center needs to cover an extra room. If the center is consistently running three rooms and occasionally needs to cover a fourth room, the MD/CRNA model is useful because the center can choose between an MD and a CRNA for coverage. "If it's all MD, you've got to find another MD," he says. "With this model, you can pull one or the other, and you have a greater chance of finding someone to cover that room."

Read more about Health Inventures and Total Anesthesia Solutions.

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