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Can anyone comment on groups that are running their practice with supervision of cRNA's instead of medical direction with higher ratios than 1:4??
When the ratio is > 1/4 it should not be called supervision because you are really not supervising anything, you are barely a consultant or a fireman available to handle mishaps.Can anyone comment on groups that are running their practice with supervision of cRNA's instead of medical direction with higher ratios than 1:4??
Only if the state allows independent CRNA practice, right?You should never bill for supervision as the group will lose money. You won't be reimbursed the full amount for the case. If you can't meet the Medical Direction requirements, just bill QZ (not medically directed) for the CRNA and the group will be reimbursed 100% of the allowable amount.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf140.4.3 Payment shall be made for reasonable and necessary medical or surgical services furnished by CRNAs if they are legally authorized to perform these services in the state in which services are furnished.
Anything above 1:2 is not really direction either, unless one has an anesthesiologist's "preference card", which tells the CRNA exactly what to give every patient for a certain surgery, the desired intervals for vitals for the specific patient, when to call the attending for instructions etc. Basically a good generic anesthesia plan customized specifically for that patient. Beats me why Epic does not have an anesthesia plan generator, as in a form with checkboxes, like for preop/postop notes.
Not if it were optional, well-designed and pre-filled, based on multiple personal customizable templates, and if it included only the most important things. Just a flight plan. Not necessarily checkbox based; it could be done with smartphrases, too... Evrika! That's how I'll do mine when needed.That's a great idea!
Sounds like a lot more clicks though![]()
Only if the state allows independent CRNA practice, right?
Anything above 1:2 is not really direction either, unless one has an anesthesiologist's "preference card", which tells the CRNA exactly what to give every patient for a certain surgery, the desired intervals for vitals for the specific patient, when to call the attending for instructions etc.
A well run medically-directed ACT practice can function very well at 1:4. It all depends on how it is set up and managed. Like most community hospital practices, we have a large variety of patients and specialties, and patients run the gamut from ASA 1-4. There aren't many ASA 5's in our practice. We're not crazy enough to put all the ASA 4 patients under one anesthesiologist at the same time. During the day, when the bulk of our cases are occurring, we usually run 1:2 or 1:3 in most areas. An anesthesiologist personally sees every single patient pre-operatively, is present for every induction and emergence, and fulfills all 7 steps of the TEFRA requirements. They come by at intervals during the case - more frequently on sicker patients, less frequently on healthier patients. They are immediately available by cell phone, and it would be rare that I can't have an anesthesiologist in my room within 30sec if I ask for one.Anything above 1:2 is not really direction either, unless one has an anesthesiologist's "preference card", which tells the CRNA exactly what to give every patient for a certain surgery, the desired intervals for vitals for the specific patient, when to call the attending for instructions etc. Basically a good generic anesthesia plan customized specifically for that patient. Beats me why Epic does not have an anesthesia plan generator, as in a form with checkboxes, like for preop/postop notes.
What is the difference between 1:2 and 1:3?
You are either in the room for the entire duration of the case (MD only) or you are not. The difference between 1:2 and 1:3 is essentially nil. Know why? Because at 1:2, the attending isn't in the room 50% of the time. They are there 10% of the time. They are in the other room 10% of the time. The rest of the time they are off doing whatever. 1:3 you are in the rooms the exact same amount contributing the exact same amount, you just have to do more work.
etc
Ever go see the line of anesthesiologists getting coffee at 8:30 in a university hospital once their first cases are under way? It's long. When I was a CA3 doing block rotations, the attendings would invite me to come on down and chill during their morning coffee break. They weren't in the rooms. They weren't preoping patients. They were having social hour. Every day.
Like it or not the future of anesthesia is loose supervision of independent CRNAs billed as QZ.
The anesthesiologist is basically there to share the liability with the hospital and the surgeons when things don't go as planned.
Surgeons have their preference cards for every single procedure and everybody considers them normal. Why wouldn't an attending anesthesiologist's preference list be less important, when supervising, especially in a big group?
It's still not clear to me whether you are a CRNA or an anesthesiologist, but I'll humor you this once.Ughhhh....you're comparing prolene, army/navy's and simm's retractors to anesthetics? In the first place those are things that are handed to the surgeon himself for HIS use, not some proxy. In the second, your suggestion that those 'preferences' of yours are as effective in someone else's hands is an indictment of what so many are passionate about here. You are bringing about your own demise. Good luck with that. How do you possibly justify this model of practice, at any level of involvement? Either you endorse your proxies as competent to act as they see fit or you do the case yourself. What a disaster.
I am not trying to restrict anybody's practice. It's just that I'm either medically directing or I am not. Malpractice law sees medical direction in black and white, and so should we.Unfortunately any anesthesiologist who attempts to restrict the practice of CRNAs will be seen as being obstructionist and not a team player.
This train has already departed and attempting to stop it is futile.
This should have been done 30 years ago!
I am a supporter of AAs but unfortunately they are no where close to being a serious player in this game.Yeah but where does that leave the AA's?? So many back and forth things I am hearing from people on this subject, not sure what to think
They will not let you put a detailed anesthesia plan on the chart, it will not happen my friendI am not trying to restrict anybody's practice. It's just that I'm either medically directing or I am not. Malpractice law sees medical direction in black and white, and so should we.
If you put a detailed anesthesia plan in your note, and the CRNA decides to ignore it, at least it's clear who did what.
The CRNAs and the administratorsWho are "they"?
I had... did not end well 🙂Give it a try. 🙂
I am not trying to restrict anybody's practice. It's just that I'm either medically directing or I am not. Malpractice law sees medical direction in black and white, and so should we.
If one puts a detailed anesthesia plan in one's note, and the CRNA decides to ignore it, at least it's clear who did what.
Have you ever provided anesthesia before? Because the statement above sounds a lot like cookie cutter anesthesia, and that what works for one will work for all. Clearly you've had enough experience to know that limiting fentanyl (or any medication) is not reasonable, maintaining 2 twitches is not always necessary, extubating awake is not always desirable, and full reversal has its own untoward sequelae. But, I'm sure you knew all of this before you wrote your response.. no?LImit 5 cc of fentanyl, maintain 2 twitches at all times, extubate AWAKE after full reversal keep sbp >140 . etc etc
Limiting fentanyl is not reasonable? It's the drug most associated with PONV, in my experience. Try giving 4+ mcg/kg/h, and see the incidence of PONV versus the group with less than 1.5-2. And patients hate PONV, almost as much as the person causing it.Have you ever provided anesthesia before? Because the statement above sounds a lot like cookie cutter anesthesia, and that what works for one will work for all. Clearly you've had enough experience to know that limiting fentanyl (or any medication) is not reasonable, maintaining 2 twitches is not always necessary, extubating awake is not always desirable, and full reversal has its own untoward sequelae. But, I'm sure you knew all of this before you wrote your response.. no?
What we consider as common sense in anesthesia, or basic knowledge, is simply unknown to certain recent CRNA grads.
By the way, what's the average rejection rate for CRNA schools nowadays?