Medical direction vs. supervision

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etomidator3

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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??
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etomidator3 said:
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??
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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.
 
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.
 
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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.
 
Well, you COULD bill for supervision but you shouldn't. If you bill for supervision, the CRNA will be reimbursed 50% of the allowable rate. The anesthesiologist will be allowed to be for 3 units (4 if they are present for induction). You end up leaving money on the table if you bill supervision. Instead, bill QZ like you said.
 
goosegas said:
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.
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Only if the state allows independent CRNA practice, right?

140.4.3 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.
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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
 
FFP said:
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.
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That's a great idea!

Sounds like a lot more clicks though :hilarious:
 
ZzzPlz said:
That's a great idea!

Sounds like a lot more clicks though :hilarious:
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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.

It would be great especially for frequent procedures. No room for "he said/she said" if the CRNA does not follow the plan to a T.
 
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FFP said:
Only if the state allows independent CRNA practice, right?
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No, I think you are referring to the opt-out issue. This doesn't have anything to do with that. CRNA's, to my knowledge, are legally authorized to practice in every state (assuming they applied for a license). The opt-out, and independent practice, is a Medicare part A issue. Billing anesthesia for medical direction, supervision or QZ (not medically directed) is a Medicare part B issue. The two aren't related. A CRNA can bill QZ regardless of the states opt-out status.
 
FFP said:
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.
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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.
 
FFP said:
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.
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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.

Our computerized pre-op evaluation and order program uses a number of checkboxes to note requirements for specific patients, whether that be for type of anesthesia, invasive lines required, specific drugs to be used (ketamine/lidocaine infusions for example) or anything else of note. Desired intervals for vitals? Seriously? More often than q3-5 minutes means an A-line. Our EMR tracks it every piece of data q30 sec but our display and printout are q5 min, so regardless of what is tracked, that's all we see unless we change the display interval, which makes for a really long anesthesia record.

Maybe your CRNA's are inept - or maybe they're not team players. We make it clear during the interview process how our practice functions and what is expected. CRNA's who have drunk the independent-practice "I don't need a doc" koolaid generally weed themselves out of the hiring picture and wouldn't be extended an offer anyway. The anesthesiologist is in charge of, and actively participates in, every single case in our practice, whether MAC, general, or regional. There is never a time 24/7/365 that there is not an anesthesiologist in-house. (Those of you who abdicate all the OB 24/7 and the OR's at 3pm to the CRNA's and on nights, holidays, and weekends are part of the problem IMHO) We hire competent AA's and CRNA's who, regardless of experience, are going to get a couple months of close orientation to the way we do things. The docs know us, we know them - all 200+ of us. I know who wants what and when. I know who likes this and that and who doesn't. Micro-management is counter-productive and time-wasting. I know practices that want their anesthetists to call at the first hint of bradycardia and hypotension BEFORE they treat it. That's pretty absurd. Do you really want me to call you when the heart rate drops to 59 from 60, or the systolic BP from 90 to 89? I can do that - but it's a waste of time and talent.

ACT practices work and work well - if they're well managed. It's perfectly do-able - and there's even time available for drinking coffee.
 
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Mman said:
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.
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That sounds ideal to me!
 
jwk, when I said desired intervals for vitals, I meant the intervals (limits) for acceptable values, not how frequently they are checked. For some patients, or procedures they are really important (see the debate about MAP in sitting shoulders). Same goes for certain important medication doses: what, when, how much, and what not to give (such as versed). Not a micromanaged down to every single little detail plan, but one that would spell out the major milestones and targets for that specific procedure and/or patient.

Why would I like anesthesia plan templates? Not just for medico-legal purposes, but because it would allow me to save time (especially when it's a longer or important list). 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?
 
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Planktonmd said:
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.
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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
 
FFP said:
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?
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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.
 
drmwvr said:
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.
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It's still not clear to me whether you are a CRNA or an anesthesiologist, but I'll humor you this once.

The CRNAs are not "my" proxies, they are my employer's. I don't get to hire them, I don't get to fire them, I don't even get to review them. I am only responsible for their screw-ups. I don't see their CVs, their personnel files, I have no idea what they (don't) know, unless from some friendly and reliable colleagues.

TEFRA's second requirement is for the anesthesiologist to "prescribe" the anesthesia plan. It doesn't say in what detail; the type of anesthesia (GA vs MAC etc.) usually suffices. I am a doctor; my role is to think and decide, not just to rubberstamp. There should be a clear and detailed plan, showing my thinking. Or at least a departmental protocol for that particular procedure, if applicable.

Regardless of TEFRA, in case of a bad outcome, the buck stops with the attending anyway. What can one do with people who don't follow one's anesthesia plan to a T? It has happened to me more than once. What does one do in places where one knows (from experience) that reporting them would get only oneself in trouble? (more and more of them) In places where if anything bad happens, it's "he said, she said"?

If in a sitting shoulder case (let's use Blade's favorite), the anesthesia plan clearly documents "maintain MAP at heart level over 90 at all times", and then a stroke happens, because the "proxy" kept the BP at 65, at least there is proof. If I document "no nitrous" or "no propofol" in a retina patient, and s/he uses it and the patient goes blind, it's again clear who did what. If it says call attending stat at least when the O2 sat decreases to 80, there is no excuse for calling at 40, or not calling at all. Etc. These are common-sense stuff, and yes, everybody should know them, and they should be at least in some departmental rules or protocols. But they are not, so we don't hurt the proxies' feelings.

I am wondering at what point should anesthesiologists also consider documenting these details, the same way any other non-anesthesiologist physician writes or signs off on a detailed assessment and plan? Whenever an internist works with a bunch of midlevels, or residents, even if the entire note was written by the NP/PA, there is that sign-off from the attending, at the end. Why can't we do the same? "GA with standard ASA monitors, A-line" is not an anesthesia plan, it's a mockery.

Why is it such a big deal? Why document mostly things that are important for billing, instead of documenting things are important to patient care, and to us? Just because we are lazy, or we are afraid to hurt some feelings? How about my family's "feelings"? It should be no more than a few lines, and customizing it should take only a few minutes per patient. I would love a malpractice lawyer's opinion on this.

In the era where anesthesiologists are mostly employees, not partners, this is food for thought. Do we need written, relatively detailed, anesthesia plans to protect us, if our group does not?

Employed surgeons would not accept signing off on just any hospital PA's work in the OR, unless they were present and directed them at all times (I am not talking about "proxies" they work with on a daily basis, probably even selected by the surgeons). Why do we, on a daily basis?
 
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Planktonmd said:
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!
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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.
 
PreAA said:
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
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I am a supporter of AAs but unfortunately they are no where close to being a serious player in this game.
This is mainly the fault of the ASA for not recognizing the importance of these professionals early enough and not providing them the support they need.
If the ASA really represented anesthesiologists it should have poured unconditional support into creating and supporting more AA programs decades ago.
 
FFP said:
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 you put a detailed anesthesia plan in your note, and the CRNA decides to ignore it, at least it's clear who did what.
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They will not let you put a detailed anesthesia plan on the chart, it will not happen my friend
 
Who are "they"?

And since when can't a doctor write whatever s/he wants in his/her own medical note, especially if pertinent?
 
Give it a try. 🙂

Think about it. Any midlevel that works under supervision in any other specialty has his/her note (meaning assessment and plan) reviewed and signed by the attending, with modifications if needed.
 
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Of course, there is always the version with running around with a big tablet, with all supervised patients opened simultaneously, watching the screen pretty much all the time, calling the CRNAs every time one sees something not OK, many times post hoc, this while doing everything else one is supposed to do at work. And if it happens, and we can't fix it, we'll play "he said, she said". ("But the doctor never told me...")
 
FFP said:
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.
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If limiting your malpractice liability is your objective, I don't see how writing a detailed plan or 'preference card' would help. At the end of the day, catastrophes in the OR are rare, and by general definition, not anticipated. This disaster you seek to avoid wouldn't be the one that happens and wouldn't be addressed in your plan. But there would sit your detailed plan. Plaintiff's attorney would simply ask why.
 
My objective is avoiding the avoidable. The inappropriately low MAP is a classic. I cannot keep my eyes on 3 rooms all the time.

Of course I could just tell the person but, in my experience, that doesn't always help (in one ear and out the other). Also, when there are multiple intraop objectives, it's nice to have a written plan. This is not a situation for the typical quality PP group, more for the typical rat race group or AMC.

I doubt a malpractice attorney would question my reason for having a written plan, especially if I had one for every patient with the same procedure. It would point to quality of care, going the extra mile, not negligence.

As we transition from partners to employees, with less and less impact on the hiring and firing of the midlevels we work with (and implicitly their quality), I would not be surprised if this kind of more extensive anesthesia plan becomes the rule, not the exception. All it takes is one malpractice case where only the CRNA would be held responsible (for not respecting the attending's written instructions), like any other nurse would.

There is a pretty good chance the ERAS movement will take care of this, without the need for individual anesthesiologists to risk group opprobrium. I'd never thought I'd become a supporter of Gawande's checklist and flight plan system.
 
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I agree with FFP there should be detailed written plans in the anesthetic plan.

Strict parameters. LImit 5 cc of fentanyl, maintain 2 twitches at all times, extubate AWAKE after full reversal keep sbp >140 . etc etc

Crnas hate this because they want to do what they want they dont want no stinkin physician "restricting their practice"and they dont want to be directed.

My retort to the CRNAs .... IF YOU DID NOT WANT TO BE DIRECTED YOU SHOULD HAVE GONE TO DIRECTOR SCHOOL.
 
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criticalelement said:
LImit 5 cc of fentanyl, maintain 2 twitches at all times, extubate AWAKE after full reversal keep sbp >140 . etc etc
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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?
 
deansrv72 said:
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?
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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.

Two twitches might not be always necessary, but it's a great way to provide good muscle relaxation while decreasing the chances of post-reversal weakness, especially when coupled with full reversal. You only need to see one patient with cogwheel type movements or severe weakness, after the nice CRNA reversed her too early and/or incompletely, at just one twitch. Again, a nice unforgettable bond between patient and provider. Oh, and the pleasure of babysitting the patient who doesn't have even one twitch, because somebody found it easier to just push another vial of roc and then smartphone away...

Actually, your opposition is the one that needs explanation, not criticalelement's pretty decent guideline examples for dealing with uneducated or irresponsible providers. 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?
 
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FFP said:
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?
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Actually it takes on average two to three application cycles to gain admission. The average GPA for my class was 3.85. There were two seasoned NPs in my class one in neonatology and the other in cardiology. CRNAs are the best of the best when it comes to nurses. When you underestimate their intelligence and skill, that's when they fight back by taking over the specialty.

I like your idea of protocols. But as a written document that they sign at employment. Give some room for them to use the critical thinking skills that they mastered as RNs and in training. For example: The CRNA will call the anesthesiologist with vital signs out of X and Y parameters. The CRNA will discuss with the anesthesiologist the anesthetic plan and will abide by it unless otherwise approved and documented by the anesthesiologist.
Something that gives some independent thinking while still holding on to the reins.
 
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