American Association of Nurse Anesthetists: 4 key thoughts on expanding CRNAs' scope of practice


In May 2016, the Department of Veterans Affairs proposed a rule that would allow all advanced practice registered nurses in the VA, including certified registered nurse anesthetists, to provide care to "the full extent of their education, training and certification." The proposal has raised many questions concerning CRNAs' role and whether expanding their scope of practice could help solve various issues within the VA's healthcare system.

Here are four key thoughts:

1. Access to healthcare for veterans.  The proposal has struck discord between various parties, with the American Society of Anesthesiologists releasing a statement in opposition of the rule, saying the policy change is unnecessary given there is "no shortage of physician anesthesiologists in the VA."

Christopher Bettin, American Association of Nurse Anesthetists' senior director of public relations, noted while the VA may not have a shortage of anesthesiologists, there is still a "plethora of backlogged cases."

"We are interested in the patients within the VA system and giving them increased access to care while also getting them home sooner," said Cheryl Nimmo, DNP, MSHSA, CRNA, president of AANA. "The patient is the center of our focus and we feel we are the solution to the problem of VA patients enduring dangerously long wait times."

"We feel that by using CRNAs to the full scope of their practice, more patients will be seen in a timely manner," Dr. Nimmo added. "Opponents of the proposal say there isn't a shortage because there aren't any vacancies on their employee rosters. But if you grant CRNAs an expanded scope of practice, that frees up anesthesiologists to also provide anesthesia rather than supervising it. This increases the number of available providers."

2. The role of the anesthesiologist. Dr. Nimmo says anesthesiologists will be able to become hands-on providers of anesthesia if CRNAs have an expanded role, rather than fulfilling a supervisory role for CRNAs.

"Anesthesiologists are valued members of the patient care team and I have worked with a great number of anesthesiologists," she said. "It is a waste of their skills and education to spend their time supervising someone else when they could use that time on direct patient care."

3. Cost-effective nature of CRNAs. The Lewin Group published a 2016 study which analyzed the cost-effectiveness of anesthesiologists acting alone versus CRNAs acting alone at four stations per day. The study found the anesthesiologist acting alone yielded yearly revenue of $6.5 million and yearly total costs of $4.2 million. When subtracting costs from revenue, this figure hit almost $2.33 million in net revenue.  

Comparatively, CRNA's also had yearly total revenue of $6.5 million, but their total costs equaled $2.04 million. When subtracting costs from revenue for cases where CRNAs acted alone, this figure totaled $4.49 million in net revenue. Facilities employing CRNAs alone could save almost $2.16 million. The study authors concluded, "The results indicate the CRNA acting independently model is the least costly per procedure and produces the greatest net revenue."
4. Patient outcomes. When considering expanding the scope of practice, patient care is of paramount importance.

Health Affairs published a study titled "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians" in August 2010. Researchers analyzed patient outcomes in states where CRNA supervision by a physician is required to states where there is no such mandate between 2001 and 2005. The findings revealed there were no differences in patient outcomes. The study author Jerry Cromwell, PhD, noted, "We find no evidence that opting out of the oversight requirement harms patients in any way. Based on these findings we recommend that CMS repeal the supervision rule."

Dr. Nimmo attributes the similar quality outcomes to the advancements in anesthesia techniques, monitoring and drugs.

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