How many CRNAs do you regularly supervise?

[BuzzPhreed]

Discuss. This would be what you normally do averaged over time. Default to the higher number, if (for example) you work routinely directing/supervising 3 -or- 4 CRNAs/AAs depending on the day/assignment.

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[IlDestriero]

2:1

 

[Ipassgas]

Day usually stays with 6 or 7 rooms. 2 MD/DOs. As the day thins, can drop as low as one to one. Or go up to >4 and become supervision if the "emergency add ons" are actually emergencies (super rare). When we hit 4 rooms, usually the post call doc leaves, and it's 4:1 until it thins again.

Why do you ask? What's your angle?

 

[BuzzPhreed]

Why do you ask? What's your angle?

I was in a situation where I was routinely 4:1 (and occasionally 3:1). I don't think this is what patients are "paying" for (recognizing that a large part of their care is subsidized by insurance and/or the gubmint). And I just don't think at 4:1 you can actually "direct" the care that goes on in an efficient and effective manner. You're essentially taking responsibility for the ****-hits-the-fan moments when you need to be there, while excusing what happens (positive, negative, or neutral) everywhere else.

No angle. Just trying to get a impression on what you guys/gals will tolerate out there. Me? I wouldn't tolerate it. So I left that kind of arrangement. And, I don't think our patients would tolerate it either if they really knew some fresh-outta-school 26 y.o. nurse was making all the key decisions in their care because you couldn't really be there to "direct" what was going on.

"That's not how I practice!" Yeah, yeah, yeah. Save it. I lived it. I know what really goes on.

I'm 2:1 when I direct CRNAs now. Rarely -- and I mean rarely -- 3:1. Anything else in more than ASA 1-2 patients is, in my opinion, unconscionable.

 

[Baller MD]

I was in a situation where I was routinely 4:1 (and occasionally 3:1). I don't think this is what patients are "paying" for (recognizing that a large part of their care is subsidized by insurance and/or the gubmint). And I just don't think at 4:1 you can actually "direct" the care that goes on in an efficient and effective manner. You're essentially taking responsibility for the ****-hits-the-fan moments when you need to be there, while excusing what happens (positive, negative, or neutral) everywhere else.

No angle. Just trying to get a impression on what you guys/gals will tolerate out there. Me? I wouldn't tolerate it. So I left that kind of arrangement. And, I don't think our patients would tolerate it either if they really knew some fresh-outta-school 26 y.o. nurse was making all the key decisions in their care because you couldn't really be there to "direct" what was going on.

"That's not how I practice!" Yeah, yeah, yeah. Save it. I lived it. I know what really goes on.

I'm 2:1 when I direct CRNAs now. Rarely -- and I mean rarely -- 3:1. Anything else in more than ASA 1-2 patients is, in my opinion, unconscionable.

How were the anesthesiologists at your former place? Why do you think they stayed there?

 

[Mman]

3:1 majority of time, 4:1 if case mix allows it, 1:1 or 2:1 if case mix requires it. We do whatever is appropriate. If one of your rooms is a 6 hour spine fusion and another room is a couple 3-4 hour robotic hysterectomies, you can handle an additional 1-2 rooms with ease.

There is nothing about 4:1 that is inherently bad if it's a distribution of rooms that allows you to be where you need to be when you need to be. I'm at every induction, I'm at every emergence, and I'm in the room about every 25-30 minutes in between. Is it easy? Of course not. Nobody said it was. But I work hard and make sure I'm around and know what's going on with every case. If I'm not in the room, I can quickly pull up a live view of the record showing me everything from vitals to vent settings to fluids/drugs/ebl that are charted.

 

[deleted126335]

I was in a situation where I was routinely 4:1 (and occasionally 3:1). I don't think this is what patients are "paying" for (recognizing that a large part of their care is subsidized by insurance and/or the gubmint). And I just don't think at 4:1 you can actually "direct" the care that goes on in an efficient and effective manner. You're essentially taking responsibility for the ****-hits-the-fan moments when you need to be there, while excusing what happens (positive, negative, or neutral) everywhere else.

No angle. Just trying to get a impression on what you guys/gals will tolerate out there. Me? I wouldn't tolerate it. So I left that kind of arrangement. And, I don't think our patients would tolerate it either if they really knew some fresh-outta-school 26 y.o. nurse was making all the key decisions in their care because you couldn't really be there to "direct" what was going on.

"That's not how I practice!" Yeah, yeah, yeah. Save it. I lived it. I know what really goes on.

I'm 2:1 when I direct CRNAs now. Rarely -- and I mean rarely -- 3:1. Anything else in more than ASA 1-2 patients is, in my opinion, unconscionable.

It may in your opinion be unconscionable, but it is very common and getting more so.

 

[BuzzPhreed]

How were the anesthesiologists at your former place? Why do you think they stayed there?

Broken and with no gumption.

It may in your opinion be unconscionable, but it is very common and getting more so.

Does that make it right? Do we regularly disclose to patients that this is how we function?

Man, if I was a plaintiff's attorney, I would be sure to ascertain this exact situation if something went horrible wrong in the OR.

 

[gasdoc77]

In a perfect world, I would LOVE to do my own cases. Unfortunately, the pencil pushers would LOVE for me to supervise unlimited rooms. Due to poor payer mix in my area, almost all groups have some kind of subsidy. I had a chance to do MD only in a small hospital, but ultimately felt they were sitting ducks for an AMC due to the subsidy. The group I joined had a more attractive track, large multi hospital coverage, aging partner demographic, slightly better package, and runs as lean as possible while complying with TEFRA. I am spread way too thin day to day and literally work like a dog, but I think it would be VERY difficult (although never impossible) for an outside group to provide this level of acuity while still finding a profit margin.One hospital is one of the biggest acute stroke centers in the country and another does complex hearts, etc. We typically run 3 or 4 to one and one individual covers all the hospitals solo at night (with backup people of coarse). Oh, and we NEVER pare down rooms in the evening. I might get called back in from home to relieve a CRNA at 7 oclock, even if the case might end at 745 since they have rigid schedules. Absolutely true. I doubt people would be swarming to this kind of model. If I weren't a partner here, there is no way in the world that I or anyone would work like this. It is unfortunate but when considering one's career and family, exposure to takeover has to be taken into consideration and I fear this is where we are all headed.

 

[Mman]

Does that make it right? Do we regularly disclose to patients that this is how we function?

Man, if I was a plaintiff's attorney, I would be sure to ascertain this exact situation if something went horrible wrong in the OR.

Our patients are all informed that it is an anesthesiologist supervising a CRNA or AA (although it's medical direction a patient won't know what that phrase means) in a care team model. I don't think we have a single hospital in our state (at least of any size > 100 beds) that has MD only anesthesia care.


MD only care sounds nice, but our system doesn't produce enough MDs to even come close to staffing it nationwide. There is also no evidence that it provides better outcomes. And to me it seems like a waste of our training. An ICU doc can be 100% responsible for 16 or 24 critically ill patients at a single time, but we can't even keep track of 4? Turning the dial on the Iso vaporizer up a click or down a click during a hernia on an ASA 1 patient is a waste of 12 years of training IMHO. ACT model is probably best in almost every situation.

 

[Sirach38]

Broken and with no gumption.



Does that make it right? Do we regularly disclose to patients that this is how we function?

Man, if I was a plaintiff's attorney, I would be sure to ascertain this exact situation if something went horrible wrong in the OR.

We need to start disclosing this!! This needs to become public knowledge. It is important to educate patients as to exactly how their anesthesia is being delivered. Patients have no idea what's going on. I imagine an ASA commercial detailing this might be very beneficial to the field.

It would be great if every patient asked their surgeon or anesthesiology, "How will my anesthesia be delivered?"

 

[chocomorsel]

Glad to say I just left an ACT model for a physician only model. Thank God.

 

[GA8314]

Our patients are all informed that it is an anesthesiologist supervising a CRNA or AA (although it's medical direction a patient won't know what that phrase means) in a care team model. I don't think we have a single hospital in our state (at least of any size > 100 beds) that has MD only anesthesia care.


MD only care sounds nice, but our system doesn't produce enough MDs to even come close to staffing it nationwide. There is also no evidence that it provides better outcomes. And to me it seems like a waste of our training. An ICU doc can be 100% responsible for 16 or 24 critically ill patients at a single time, but we can't even keep track of 4? Turning the dial on the Iso vaporizer up a click or down a click during a hernia on an ASA 1 patient is a waste of 12 years of training IMHO. ACT model is probably best in almost every situation.

I agree with this. Of course, I'm in an ACT model with both CRNA's and residents. I have recently likened my role as very similar to that of an "OR ICU doc". Exactly as Mman has stated, one intensivist can supervise many more than just 4 rooms, and these are critically ill patients on ventilators and pressors, often. All levels of nursing and RT are executing these functions.....

You are an ICU doc in the OR. It's possible to "triage" and focus your attention on what most requires ours skills. We need to stay hands on however, and it takes more effort to do so, but it is definitely possible. Find ways to integrate yourself even if it means mixing and then loading a stick of Remi into an infusion pump from time to time.

Stay on top of the hands on stuff and maintain, and adavnce your clinical knowledge and any anesthesiologist can be a very formidable force and not at all easy to replace.

 

[BuzzPhreed]

An ICU doc can be 100% responsible for 16 or 24 critically ill patients at a single time, but we can't even keep track of 4?

You only take care of 4 patients in a day when you are supervising CRNAs? And, ICU docs take care of 16-24 patients at the same time -- including rapidly moving between doing advanced (and potentially life-endangering) procedures like airway management and central venous access? The ICU turns over those 16-24 patients every 8-10 hours and that intesivist has a whole new set of patients to learn and take care of every day?

Come on. You are either making really unfair comparison here, or you really don't know what an intensivist does. Even in a big unit, an ICU doc rarely has more than one near-crises going on at the same time. And he doesn't have to worry about whether or not the nurse is going to call him when it does, which may or may not occur in the OR.

 

[seinfeld]

Being an ICU doc Favor the comments of Mman over yours. If you are in a practice where your 3-4 rooms are really that unstable then you need to get better CRNAs, or have a person doing the schedule divide the rooms up better.

 

[Mman]

You only take care of 4 patients in a day when you are supervising CRNAs? And, ICU docs take care of 16-24 patients at the same time -- including rapidly moving between doing advanced (and potentially life-endangering) procedures like airway management and central venous access? The ICU turns over those 16-24 patients every 8-10 hours and that intesivist has a whole new set of patients to learn and take care of every day?

Come on. You are either making really unfair comparison here, or you really don't know what an intensivist does. Even in a big unit, an ICU doc rarely has more than one near-crises going on at the same time. And he doesn't have to worry about whether or not the nurse is going to call him when it does, which may or may not occur in the OR.

ICU doc is managing a bunch of critically ill patients at once. You can keep track of 4 patients at a time, several of whom might be ASA 1s having minor procedures. Nobody said supervising 4 pediatric hearts at the same time was a good idea. A good ACT model distributes patients/cases between docs so that all have an equal work load. You don't dump a bunch of sick patients on anybody.

 

[GA8314]

Indeed, I think that one in a supervisory model SHOULD envision themselves more akin to an ICU doc in the OR. This means that not every patient requires your same level of expertise. You can focus on interventions and attention/time as the case and patient require.

I'll continue reiterating that ACT model docs MUST maintain their hands on skills, which in my experience isn't as hard to do as I thought it might which was a prior concern of mine. Plenty of ways to stay hands on relevant to the extent that if I had to I could sit the stool all day every day. I'm not sure that's the most efficient use of my time or expertise however......

Also, there is INDIVIDUALITY in how you "manage" your care. Just like ICU docs are to varying degrees more hands on or less. Allow more leeway with mid-levels or less. Allow mid-levels to do more procedures or less......

It's the same thing. Do I micromanage cases in our outpatient endo suite? Nope, not unless they are the rare bird. Am I more involved with the EGD in the ICU for the patient with an acute GIB? You bet I am.

On light days, I'll give residents and even CRNA's breaks IF possible. Weekly, I'll induce and intubate the patient myself and "tuck them in" before leaving the room, even when working with CRNA's. To be honest, I think the CRNAs and OR staff respect the hell out of that. Do I do it every case? No.

I feel my skills and knowledge as a new attending are growing and progressing just fine in an ACT model with 2:1 to 4:1 supervisory ratios. I enjoy and get a kick out of MOST days at work.

I love this gig.....

 

[jwk]

We need to start disclosing this!! This needs to become public knowledge. It is important to educate patients as to exactly how their anesthesia is being delivered. Patients have no idea what's going on. I imagine an ASA commercial detailing this might be very beneficial to the field.

It would be great if every patient asked their surgeon or anesthesiology, "How will my anesthesia be delivered?"

We disclose to EVERY patient exactly WHO does WHAT during the course of their anesthetic. Do you really think we're hiding the facts on this? The anesthesiologist that pre-ops the patient explains that they will be in charge of their care, be there when they go to sleep, wake up, and checking in periodically and that an AA/CRNA will be in the room with them at all times. When the AA/CRNA greets the patient, a similar discussion ensues. Nothing is hidden.

 

[Mman]

We disclose to EVERY patient exactly WHO does WHAT during the course of their anesthetic. Do you really think we're hiding the facts on this? The anesthesiologist that pre-ops the patient explains that they will be in charge of their care, be there when they go to sleep, wake up, and checking in periodically and that an AA/CRNA will be in the room with them at all times. When the AA/CRNA greets the patient, a similar discussion ensues. Nothing is hidden.

I tell them I am there when they go to sleep, there when they wake up, and periodically in between and if anything is amiss I can respond to a call within 30 seconds. I also let them know I'll be checking on them in PACU as they awaken to make sure their recovery is going well.

 

[deleted126335]

Broken and with no gumption.



Does that make it right? Do we regularly disclose to patients that this is how we function?

Man, if I was a plaintiff's attorney, I would be sure to ascertain this exact situation if something went horrible wrong in the OR.

Per the poll that you authored, 4:1 is the most common mode of practice. Something that you consider "unconscionable" Granted a very small sample size.
Patients are paying for and expecting a safe anesthetic. Of course how safe and at what cost are the questions. Every plane flight can't be Air Force One. Doesn't mean that it isn't safe.

 

[HenryH]

I'm just a pre-AA student who will hopefully be starting AA school this summer, but I talk pretty frequently with local professionals in the anesthesia field (anesthesiologists, AAs, and CRNAs). With that being said, I live in an area with a very poor payer mix, much like gasdoc77 described living/working in. The anesthesia group that took over the contract about 4 years ago with the local hospital network (about 4 hospitals, plus smaller outpatient facilities) is headed-up by a CEO who happens to be a politically-involved CRNA, and about a year ago, this group actually implemented the "supervision" (I.e., 1:8 ratio) practice model at at least one of the local facilities, which is actually a "major" medical center (at least regionally). Apparently, from people I've talked to at the local level as well as those who practice outside of my immediate locale but who are familiar with the situation here, this is apparently one of the only cases in the country of a major medical center adopting the supervision model in favor of the ACT model (which was previously followed for decades at this particular facility). Of course, it's interesting to ponder the question, are they utilizing such a lax (1:8) model because the payer mix is extremely poor and they're receiving hardly any subsidy (if one at all) from the hospital... or because they simply want to make as much $$$ as they can for their own company (as well as to make a political statement), and there are actually no cost savings being realized by the hospital network?

 

[norwood]

Of course, it's interesting to ponder the question, are they utilizing such a lax (1:8) model because the payer mix is extremely poor and they're receiving hardly any subsidy (if one at all) from the hospital... or because they simply want to make as much $$$ as they can for their own company (as well as to make a political statement), and there are actually no cost savings being realized by the hospital network?

To make as much $$$ as they can. Typical AMC.

 

[BuzzPhreed]

Per the poll that you authored, 4:1 is the most common mode of practice. Something that you consider "unconscionable"

That's not the part that I consider unconscionable.

The part that is unconscionable is not fully disclosing to patients that you are also "managing" three other patients at the same time and that, depending on what happens, you might not be able to be there if there is a crisis. Which happens.

Even 2:1 it can happen, but is far less likely that you can't be there. I work most commonly 2:1 when I work with CRNAs at all (about 30% of the time), and a freely disclose this to my patients.

It's about honest disclosure to your patients. And I for one have personally been in a professional situation where I know for a fact that what the patient expected and thought they were paying for -- and what they actually got -- were two very different things.

 

[jcat01]

I have decided to go the CRNA route, and I greatly appreciate reading these forums and seeing how the ACT model works. I don't want to be CRNA that thinks that I am equivalent to a MD, and I will not ever introduce myself as a resident. I want to be great at what I do. But I definitely understand the huge knowledge gap between anesthesiologists and midlevels. I hope one day I work with great anesthesiologist like ya'll

 

[jwk]

That's not the part that I consider unconscionable.

The part that is unconscionable is not fully disclosing to patients that you are also "managing" three other patients at the same time and that, depending on what happens, you might not be able to be there if there is a crisis. Which happens.

Even 2:1 it can happen, but is far less likely that you can't be there. I work most commonly 2:1 when I work with CRNAs at all (about 30% of the time), and a freely disclose this to my patients.

Tis about honest disclosure to your patients. And I for one have personally been in a professional situation where I know for a fact that what the patient expected and thought they were paying for -- and what they actually got -- were two very different things.

Again - what makes you think patients are routinely being lied to about their care? Was this common in your practice?

 

[deleted171991]

Again - what makes you think patients are routinely being lied to about their care? Was this common in your practice?

Unless specifically asked, I don't think many anesthesiologists voluntarily disclose their CRNA direction ratios to patients.

"Oh, by the way, I am covering two other rooms, but I'll be in yours immediately in case of a problem."

 

[Mman]

Unless specifically asked, I don't think many anesthesiologists voluntarily disclose their CRNA direction ratios to patients.

"Oh, by the way, I am covering two other rooms, but I'll be in yours immediately in case of a problem."

I tell everybody that I'm covering several other rooms. 99.95% of the patients I take care of aren't sophisticated enough in their medical knowledge to ask for any further clarification.