CRNA Independent Practice

[Victorinox]

So it seems while we've been dutifully sending in our ASAPAC donations, our nursing 'colleagues' have busily and aggressively been expanding.

I always thought they were allowed independent practice in 17 states:

17 States Opting Out of the Physician Supervision of Anesthesia Rule

But sometime in the recent past, this number has expanded to 27:

27 states where CRNAs can practice independently

I am curious when this happened. Is anyone able to shed light on this?

Unless I completely missed it, not a single word was uttered by the ASA about this. Just curious.

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[narcotics999]

i support CRNA independence practice.

In CA, it is. However, CA is predominantly MD solo.

I don't want to cover their axx, give breaks, relieve them when the clock hits the magic 3.

 

[It's lupus!]

i support CRNA independence practice.

In CA, it is. However, CA is predominantly MD solo.

I don't want to cover their axx, give breaks, relieve them when the clock hits the magic 3.

I have no skin presently in this game, but I have to ask, are you not concerned with how that can impact the specialty and potentially your career? Additionally are there no concerns about patient safety or outcomes?

Sent from my Pixel XL using SDN mobile

 

[AdmiralChz]

I’d ignore anything you get from Becker’s ASC (sidenote - how is it that all of us get signed up for those BS emails?).

Several of those states aren’t true independent practice. My home state is on there, and the only “independence” nurses have is they can be solo at MD office-based procedures (the surgeon “supervises”). And their malpractice rates are so high not many do it.

 

[chocomorsel]

Technically aren’t they allowed to practice “independently” everywhere?
It’s a Medicare Medicaid thing if I recall correctly that requires physician supervision and that can be “ any physician” like the surgeon correct? Or am I way off here?

 

[narcotics999]

I have no skin presently in this game, but I have to ask, are you not concerned with how that can impact the specialty and potentially your career? Additionally are there no concerns about patient safety or outcomes?

Sent from my Pixel XL using SDN mobile

I worked both in NY and CA. NY, crna is not independent. CA, crna is independent. Guess which state has a bigger crna presence?

Why do surgeons want a CRNA, not a physician anesthesiologist? Yes man mentality? While SDN sometimes says that the surgeons don't care there is a monkey or homo sapien behind the curtain, well, most of the time, they do.

I care for pt's safety very much. Working with crna shortens my lifespan. I love myself too.

 

[It's lupus!]

I worked both in NY and CA. NY, crna is not independent. CA, crna is independent. Guess which state has a bigger crna presence?

Why do surgeons want a CRNA, not a physician anesthesiologist? Yes man mentality? While SDN sometimes says that the surgeons don't care there is a monkey or homo sapien behind the curtain, well, most of the time, they do.

I care for pt's safety very much. Working with crna shortens my lifespan. I love myself too.

Fair enough. Just curious about your thoughts on those issues.

Sent from my Pixel XL using SDN mobile

 

[chocomorsel]

I worked both in NY and CA. NY, crna is not independent. CA, crna is independent. Guess which state has a bigger crna presence?

Why do surgeons want a CRNA, not a physician anesthesiologist? Yes man mentality? While SDN sometimes says that the surgeons don't care there is a monkey or homo sapien behind the curtain, well, most of the time, they do.

I care for pt's safety very much. Working with crna shortens my lifespan. I love myself too.

I am with you buddy. I hate supervising. But many like it.

 

[Psai]

I worked both in NY and CA. NY, crna is not independent. CA, crna is independent. Guess which state has a bigger crna presence?

Why do surgeons want a CRNA, not a physician anesthesiologist? Yes man mentality? While SDN sometimes says that the surgeons don't care there is a monkey or homo sapien behind the curtain, well, most of the time, they do.

I care for pt's safety very much. Working with crna shortens my lifespan. I love myself too.

Surgeons definitely care who is there. I've had them come into my room and complain to my attendings about the people in their room.

 

[IMGASMD]

Surgeons definitely care who is there. I've had them come into my room and complain to my attendings about the people in their room.

On paper they seem cheaper. Unless you do 1:4, I don’t think you’re really making money of them.

As long as the hospital administrators tolerates CRNA presence, even surgeon complaints will not do much.

 

[deleted126335]

I am with you buddy. I hate supervising. But many like it.

Some do. For most of us we evolve to need it.

First you take a job supervising because it is the only thing available or the best job in your preferred geographic area. After a few years you lose your slickness on doing things alone like icu transport on patients with 3 Imeds and invasive monitors. You can still do a plain vanilla case slicker than sh1t. Then you never learn the intraop module on the new EMR, then your ORs get Pyxis and you only become minimally proficient with them. Or if you were proficient, you only rarely need to get into them personally so you lose that skill. Then you rotate to different hospitals where every cart is set up differently. Since you never set up rooms you never really imprint each anesthesia cart so you look less slick at day to day tasks that CRNAs who don’t rotate facilities do. Continue the progression....

 

[coffeebythelake]

On paper they seem cheaper.

This.

I think the problem thought is that a lot of anesthesiologists like to supervise rather than do their own cases. I'm fine with either. But I also think the CRNAs at my institution are (for the most part) good to work with, very proficient skills, and know when to ask for help

 

[W19]

On paper they seem cheaper. Unless you do 1:4, I don’t think you’re really making money of them.

As long as the hospital administrators tolerates CRNA presence, even surgeon complaints will not do much.

Surgeons have a lot of power, so they can, as a whole, affect the dynamic of CRNA vs. anesthesiologist 'struggle.' I worked with a spine surgeon who would request his own anesthesiologist and no one would say a thing to him... Of course CRNAs called him an a$$... behind his back...

 

[LunchMD]

The only defensable position is either solo MD and/or medical direction ACT, with ratios determined by attending anesthesiologist based on case complexity. Supporting anything else is only motivated by laziness, greed, or a complete lack of respect for the profession and patient safety.

We are the experts in perioperative patient safety. This is well within our scope to dictate. Maybe some ASA +/- ACS collaboration laying out treatment guidelines stating as such are in order? Am I missing here? Can our profession please nut the F up?

 

[chocomorsel]

Some do. For most of us we evolve to need it.

First you take a job supervising because it is the only thing available or the best job in your preferred geographic area. After a few years you lose your slickness on doing things alone like icu transport on patients with 3 Imeds and invasive monitors. You can still do a plain vanilla case slicker than sh1t. Then you never learn the intraop module on the new EMR, then your ORs get Pyxis and you only become minimally proficient with them. Or if you were proficient, you only rarely need to get into them personally so you lose that skill. Then you rotate to different hospitals where every cart is set up differently. Since you never set up rooms you never really imprint each anesthesia cart so you look less slick at day to day tasks that CRNAs who don’t rotate facilities do. Continue the progression....

Lovely. Thanks for the comic relief. Funny and sad at the same time. I am supervising today and it’s so sweet. Feeling like I am stealing money. It’s more like 1:2 so very nice. I can see the appeal when it’s not a crazy busy 1:3 or 1:4.

 

[deleted126335]

Lovely. Thanks for the comic relief. Funny and sad at the same time. I am supervising today and it’s so sweet. Feeling like I am stealing money. It’s more like 1:2 so very nice. I can see the appeal when it’s not a crazy busy 1:3 or 1:4.

It wasn't meant at comic relief. I spent a few years right out of residency doing 100% supervision. Subsequently, Took a job with about 20% own cases. Wanted that. Picked it right up again in a few weeks. My happiest days were my solo room days. Job de-evolved over time. I have been 100% supervision 1:4 for more than a decade now in my late 50s. Would be harder to transition back now.

 

[Hoya11]

The only defensable position is either solo MD and/or medical direction ACT, with ratios determined by attending anesthesiologist based on case complexity. Supporting anything else is only motivated by laziness, greed, or a complete lack of respect for the profession and patient safety.

We are the experts in perioperative patient safety. This is well within our scope to dictate. Maybe some ASA +/- ACS collaboration laying out treatment guidelines stating as such are in order? Am I missing here? Can our profession please nut the F up?

We are the experts in perioperative safety whose opinion no one wants to hear unless it involves doing the case faster. An anesthesiologist in the capitalist US system is a tough gig, do the case or well find somebody else and you might have to find a new job.. want to have a discussion with me about doing the case? get ready to elegantly explain why it isnt a good idea to some GI or ortho ***** who has no idea

 

[jwk]

So it seems while we've been dutifully sending in our ASAPAC donations, our nursing 'colleagues' have busily and aggressively been expanding.

I always thought they were allowed independent practice in 17 states:

17 States Opting Out of the Physician Supervision of Anesthesia Rule

But sometime in the recent past, this number has expanded to 27:

27 states where CRNAs can practice independently

I am curious when this happened. Is anyone able to shed light on this?

Unless I completely missed it, not a single word was uttered by the ASA about this. Just curious.

Everyone needs to under stand the differences between "medical direction", "medical supervision", and the different types of "independent practice".

"Medical Direction" is a very specific term. It requires meeting the 7 requirements of TEFRA, with a maximum ratio of 1 anesthesiologist to 4 AAs/CRNA. When someone talks about "Anesthesia Care Team" practices, this is what they're talking about.

"Medical Supervision" means that the anesthesiologist is supervising more than 4 CRNAs. Could be 1:5, could be 1:8. It is not/cannot be used with AAs.

CMS allows CRNAs to bill independently of a physician in 17 states. That number hasn't changed in several years. Those 17 are the "opt out" states.

Outside of that, "independent practice" means different things to different people. While CRNAs will tell you they practice independently in every state, that's a matter of semantics. In many states, they have to have some type of arrangement or understanding with a physician. They don't have to be "supervised" by an anesthesiologist specifically. It can also be the operating surgeon. Depending on the state, it could even be a dentist or podiatrist.

There is also an increasingly common option known as "collaborative practice" where the CRNA does their own case but only calls the anesthesiologist for assistance or to confer about the case. Many CRNAs will claim that they are practicing independently under this mode of practice. Not exactly the case.

Also - remember that the allowable practice in a given hospital is determined by the hospital bylaws or medical staff regulations. If the hospitals wants anesthesiologists medically directing the anesthetists, that's the way it has to be done. If they want to allow independently practicing CRNAs, they can do that as well. Note that a hospital in an opt-out state can still require a medically-directed practice and not allow independent CRNAs.