SRNA supervision?

[Medstudent9]

Hey all, just wondering if anyone has this information. Are there actual rules on SRNA supervision ratios like how residents can only be 2:1 with an attending and CRNAs 4:1? If an SRNA is in a room, do they need an attending or CRNA 1:1 with them or are they treated as a resident (2:1 supervision)?

My google-fu is failing me at finding out if there are billings regulations in this regard.

Thanks mucho.

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[Pharmado]

Don’t teach SRNAs. Just don’t do it.

 

[Modanq]

Why would you supervise SRNAs or work with them? Under what context is this?

 

[IMGASMD]

I think it’s 1:2 at most, since they are consider as trainees?

We usually have only 1 SRNA at a time. So, they end up being paired up with a CRNA or one of the attending will supervise them, so 1:1.

 

[DrZzZz]

Not sure of the "rules", but where I'm at, they're paired up with a CRNA and it doesn't affect supervision ratios. The SRNA can't be in the room alone, so since there's always a CRNA with them, the docs can still supervise up to 4 rooms.

 

[jwk]

Not sure of the "rules", but where I'm at, they're paired up with a CRNA and it doesn't affect supervision ratios. The SRNA can't be in the room alone, so since there's always a CRNA with them, the docs can still supervise up to 4 rooms.

We teach a ton of AA students and a handful of SRNAs each year. All of them are ALWAYS paired with an AA or CRNA, and NEVER alone in the room. Period. We try to put an SRNA with a CRNA when possible - sometimes it isn't as we have far more AAs than CRNAs working for our group. Our AA students go with AAs and CRNAs. AA students are happy to learn anything from anyone. The SRNAs think they can only learn from a CRNA.

 

[AdmiralChz]

We teach a ton of AA students and a handful of SRNAs each year. All of them are ALWAYS paired with an AA or CRNA, and NEVER alone in the room. Period. We try to put an SRNA with a CRNA when possible - sometimes it isn't as we have far more AAs than CRNAs working for our group. Our AA students go with AAs and CRNAs. AA students are happy to learn anything from anyone. The SRNAs think they can only learn from a CRNA.

Exactly how my practice does it. It’s a huge no-no having them do their own cases like a resident in our group - this isn’t a licensed provider beyond RN and their training... not great. I guess there are places out there with severe staffing shortages that utilize them as such, but I have no direct knowledge of any specific places.

We have a local program at the university in town, it’s in our best interest to allow them rotations with us to maintain good faith with the hospital (there are NP students all around the hospital littered amongst the other departments so it’s not a huge deal). That being said they only do a general rotation with us and go elsewhere for all subspecialty training including halfway across the country for cardiac and peds.

Our student nurses have shown minimal to no interest in MD teaching so I don’t do much of anything.

 

[Mman]

while we do not do it, I have heard of places that will occasionally leave an SRNA in a room by themselves. In those situations, you must be no more than 1:2 similar to rules for residents.

 

[Medstudent9]

Its not my choice to supervise them. I don’t make my own assignments. As an attending this week I was tasked with covering an SRNA in the OR and an off floor CRNA. I objected strongly to this but I am hoping for some official billing or other policy to bring it up to my service chief who thinks it’s fine.

 

[2Fast2Des]

Exactly how my practice does it. It’s a huge no-no having them do their own cases like a resident in our group - this isn’t a licensed provider beyond RN and their training... not great. I guess there are places out there with severe staffing shortages that utilize them as such, but I have no direct knowledge of any specific places.

We have a local program at the university in town, it’s in our best interest to allow them rotations with us to maintain good faith with the hospital (there are NP students all around the hospital littered amongst the other departments so it’s not a huge deal). That being said they only do a general rotation with us and go elsewhere for all subspecialty training including halfway across the country for cardiac and peds.

Our student nurses have shown minimal to no interest in MD teaching so I don’t do much of anything.

I'm not sure what the point of supervising a room with a crna supervising the srna, the attending role is already diminished except to sign away their license, and the srna doesn't give a damn except to use that to their benefit, especially when they don't know jack

 

[DM27]

SRNAs for us are treated similar to someone doing an "anesthesia Sub-I". They are not allowed to be left alone in the room by themselves and are always under some degree of supervision by the CRNA assigned to the room. Essentially the goal for them is that they "do" the hands on part of the case, but they cannot be left alone as the only person in the room.

I don't have any animosity regarding teaching them, but I do think that any knowledge I impart on them will ultimately be washed out by their school whose main goal is to produce glorified robots. Due to this, I do not go out of my way to teach them unless I for some reason developed some rapport with them in their time here, however, if I am asked a question or requested to explain something I will gladly do so.

 

[Pharmado]

We recently started taking 1 SRNA at a time. They stay with the CRNAs, who work under the surgeons and spend 90% of their time doing endo. I’m constantly amazed that this is a training site because they do nothing but endo.

 

[AdmiralChz]

I'm not sure what the point of supervising a room with a crna supervising the srna, the attending role is already diminished except to sign away their license, and the srna doesn't give a damn except to use that to their benefit, especially when they don't know jack

Come again? I don’t agree with this at all. The CRNA never leaves the room and the SRNA is like an extra body. Sorry you feel this way, but at my shops an MD is involved in ALL anesthetics period and all decisions on my cases are funneled through me. Patient-centric, physician-led care. ACT is the ONLY way this is possible in my part of the country. It works well here and we have a thriving, equitable PP. Most of the vocal detractors to ACT practice don’t work in it themselves on here. Good for those of you that work MD only, but given that we employ 100 nurse anesthetists that isn’t a feasible reality here.

Rant time:

I’m over everyone losing their minds when “supervision” and “ACT” are mentioned. Me and my partners aren’t miserable overworked sheep like some would lead them to believe. I make above average, work about average and have a great, fulfilling home life. Can’t say that for most of the surgeons I work with, including my neighbor neurosurgeon who is 70 on his 5th wife and projects himself to be working another 10 years.

Ugh. Attitudes like this is why I’m real close to shutting down SDN visits. It’s always the same 5-7 people who are exceptionally negative shouting how crappy the job is, mocking those interested in the field and tearing down those brave enough to post job openings (which is why very few do so here). Sorry, been meaning to get this out for a while.

/ end rant

 

[2Fast2Des]

Come again? I don’t agree with this at all. The CRNA never leaves the room and the SRNA is like an extra body. Sorry you feel this way, but at my shops an MD is involved in ALL anesthetics period and all decisions on my cases are funneled through me. Patient-centric, physician-led care. ACT is the ONLY way this is possible in my part of the country. It works well here and we have a thriving, equitable PP. Most of the vocal detractors to ACT practice don’t work in it themselves on here. Good for those of you that work MD only, but given that we employ 100 nurse anesthetists that isn’t a feasible reality here.

Rant time:

I’m over everyone losing their minds when “supervision” and “ACT” are mentioned. Me and my partners aren’t miserable overworked sheep like some would leave them to believe.

Ugh. Attitudes like this is why I’m real close to shutting down SDN visits. It’s always the same 5-7 people who are exceptionally negative shouting how crappy the job is, mocking those interested in the field and tearing down those brave enough to post job openings (which is why very few do so here).

/ end rant

I'm glad you are able to be in a practice where you actually have a say in the plan or anesthetic, that's truly remarkable considering the current times. But from places I've rotated as a med student and resident where crna\srna are, especially in the community setting, the CRNAs despise the MD presence and want to push their own drugs and do everything while the MD is relegated to chart monkey or wall flower. Not sure if in your practice you can actually get hands on but, one peds hospital I was at the CRNA literally yelled at my attending for showing him how he was botching the art line, it was a new light I saw there. I'll take a pay cut to do my own thing than be a glorified breaker\preop monkey\firefighter

 

[chocomorsel]

Come again? I don’t agree with this at all. The CRNA never leaves the room and the SRNA is like an extra body. Sorry you feel this way, but at my shops an MD is involved in ALL anesthetics period and all decisions on my cases are funneled through me. Patient-centric, physician-led care. ACT is the ONLY way this is possible in my part of the country. It works well here and we have a thriving, equitable PP. Most of the vocal detractors to ACT practice don’t work in it themselves on here. Good for those of you that work MD only, but given that we employ 100 nurse anesthetists that isn’t a feasible reality here.

Rant time:

I’m over everyone losing their minds when “supervision” and “ACT” are mentioned. Me and my partners aren’t miserable overworked sheep like some would lead them to believe. I make above average, work about average and have a great, fulfilling home life. Can’t say that for most of the surgeons I work with, including my neighbor neurosurgeon who is 70 on his 5th wife and projects himself to be working another 10 years.

Ugh. Attitudes like this is why I’m real close to shutting down SDN visits. It’s always the same 5-7 people who are exceptionally negative shouting how crappy the job is, mocking those interested in the field and tearing down those brave enough to post job openings (which is why very few do so here). Sorry, been meaning to get this out for a while.

/ end rant

Take a break. I don’t think you have been online that long and if this rubs you the wrong way and pisses you off, then SDN ain’t your place. People will piss you off, you will piss people off, but it shouldn’t be a big deal. It’s an online forum for crying out loud, not your everyday life. Some of us have had bad experiences with CRNAs and prefer to work alone and not teach SRNAs.

No one says because you supervise you are miserable. If you are happy, good for you. I am currently working with CRNAs right now who are easy and respectful, where as in some places their counterparts make your life miserable. You never know. I am actually enjoying my current locums gig now compared to the last one. But I never know what kind of crazy CRNAs await me in my next gig you know.

Glad you are happy and not overworked. Let others’ opinions on here roll off you like water on a duck’s back. They aren’t living your life. No need to get butthurt about it.

 

[Pharmado]

I may be wrong about this, but it seems like the PPs that employ their own CRNAs (and can fire them) seem happy. Those who work for management companies or hospitals where they don’t control the employment status of the CRNAs are less likely to have a good relationship with them. Just my observation from what I’ve seen on SDN.

 

[Mman]

I may be wrong about this, but it seems like the PPs that employ their own CRNAs (and can fire them) seem happy. Those who work for management companies or hospitals where they don’t control the employment status of the CRNAs are less likely to have a good relationship with them. Just my observation from what I’ve seen on SDN.

as a generalization that is probably correct most of the time

 

[DM27]

I have personally not had any issues regarding my interactions with CRNAs or any sort of battle for dominance over the anesthetic plan. I have noticed however that the attendings who had issues tended to have them everywhere they worked including places I had also been without issue.

 

[deleted171991]

I have personally not had any issues regarding my interactions with CRNAs or any sort of battle for dominance over the anesthetic plan. I have noticed however that the attendings who had issues tended to have them everywhere they worked including places I had also been without issue.

That only means that you basically let them do mostly what they want. 🙂

 

[Mman]

That only means that you basically let them do mostly what they want. 🙂

there is an art to getting someone to do what you want while making them feel like they came up with the plan themselves or wanted to do it all along

 

[deleted171991]

there is an art to getting someone to do what you want while making them feel like they came up with the plan themselves or wanted to do it all along

Especially if it's beyond their knowledge. 😛

 

[Urzuz]

there is an art to getting someone to do what you want while making them feel like they came up with the plan themselves or wanted to do it all along

And why do you need to play these mind games? To not hurt the fragile egos of the nurses you “supervise?” Do you really feel like an attending directing subordinates if you’re scared to make them feel like they are taking orders from you? Genuinely curious.

I don't have any animosity regarding teaching them...

You need to pay more attention then. These are the same people that in a year will claim that you add zero value to a surgical team and they can do your job better than you can.

With all the **** that the AANA has pulled in the past year, with the creation of the “nurse anesthesiologist” title to their declaration that MDs are literally of no use, we still have these doctors that won’t stand up for their profession and fight to take it back. If all the stuff they have done doesn’t breed animosity towards them then I don’t know what will. They can literally **** on your doorstep and you will offer them toilet paper to clean themselves.

 

[dannyboy1]

And why do you need to play these mind games? To not hurt the fragile egos of the nurses you “supervise?” Do you really feel like an attending directing subordinates if you’re scared to make them feel like they are taking orders from you? Genuinely curious.

Why? Because I make over 400k/year working on average less than 50 hrs a week, and my job (for the most part) involves nothing more than signing the charts of reasonably competent CRNA’s and giving breaks. It’s a good job and I’d like to keep it. What the future holds, I don’t know, but I do know that it is pointless to fight the MD vs CRNA battle with individuals in the workplace.....

 

[norski]

there is an art to getting someone to do what you want while making them feel like they came up with the plan themselves or wanted to do it all along

Shh. Don't spill the beans! Said every bedside nurse worth their salt, ever.

 

[dhb]

Why? Because I make over 400k/year working on average less than 50 hrs a week, and my job (for the most part) involves nothing more than signing the charts of reasonably competent CRNA’s and giving breaks. It’s a good job and I’d like to keep it. What the future holds, I don’t know, but I do know that it is pointless to fight the MD vs CRNA battle with individuals in the workplace.....

Ouch!

 

[DM27]

Why? Because I make over 400k/year working on average less than 50 hrs a week, and my job (for the most part) involves nothing more than signing the charts of reasonably competent CRNA’s and giving breaks. It’s a good job and I’d like to keep it. What the future holds, I don’t know, but I do know that it is pointless to fight the MD vs CRNA battle with individuals in the workplace.....

I agree with this as well. I don't view it as constructive to be antagonistic to people I work with who are nothing but pleasant and do not cause any problems for me. The organization that represents their specialty may be a total piece of insecure garbage that is out to get us, but that does not mean I need to judge people I know based on the opinions of an organization I do not. It's the same as if someone knows my political inclinations I have no desire to be judged based on the overall action of the party that best represents these views.

My goal at work is not to show up and stand alone on an island and be the only one who actively antagonizes and puts down the CRNAs we work with and to be an overall ass to anyone who is seeking any form of education. Me being pleasant may play a part in the downfall of our specialty but I didn't get this job to show up every day and be someone nobody wants to work with.

 

[deleted171991]

I agree with this as well. I don't view it as constructive to be antagonistic to people I work with who are nothing but pleasant and do not cause any problems for me. The organization that represents their specialty may be a total piece of insecure garbage that is out to get us, but that does not mean I need to judge people I know based on the opinions of an organization I do not. It's the same as if someone knows my political inclinations I have no desire to be judged based on the overall action of the party that best represents these views.

My goal at work is not to show up and stand alone on an island and be the only one who actively antagonizes and puts down the CRNAs we work with and to be an overall ass to anyone who is seeking any form of education. Me being pleasant may play a part in the downfall of our specialty but I didn't get this job to show up every day and be someone nobody wants to work with.

I agree, as long as you understand perfectly what a wh-re you are. Me too. Just don't look down on the attendings who actually have the balls to stand up to them.

I have personally not had any issues regarding my interactions with CRNAs or any sort of battle for dominance over the anesthetic plan. I have noticed however that the attendings who had issues tended to have them everywhere they worked including places I had also been without issue.

 

[Mman]

And why do you need to play these mind games? To not hurt the fragile egos of the nurses you “supervise?” Do you really feel like an attending directing subordinates if you’re scared to make them feel like they are taking orders from you? Genuinely curious.

You seem terribly mistaken. I'm not playing mind games with people to avoid hurting fragile egos, nor am I scared to make them feel like they are taking orders from me. I'm coming up with an anesthetic plan for a patient and trying to make sure the person in the room is a part of that plan and on board with what I want/need them to do. Acting like General Patton and screaming out orders left and right is not going to make them want to talk to me or call me into the room when something questionable is happening. I need them to be comfortable asking for help, not terrified they might get yelled at. I need them to know I'm going to help them take the best care of the patient possible.

 

[Mman]

I agree, as long as you understand perfectly what a wh-re you are. Me too. Just don't look down on the attendings who actually have the balls to stand up to them.

There is a difference between standing up to the AANA and being an dingus to everyone you work with. Our CRNAs (and AAs) all work for us and as a group are just wonderful to work with. I see literally none of this angry militant stuff that people complain about constantly. I am aware it is out there and have seen it in other places, but not every CRNA is a terrible human being trying to put you out of a job and pretending they are as good or better than a doctor.

 

[Mman]

Especially if it's beyond their knowledge. 😛

nah, those instances are actually really straightforward, just takes a little more time for me to explain the science behind what we are doing (at least for the ones that care to learn what I'm explaining vs the ones that are happy to do what I ask but don't care to learn my rationale).

 

[IlDestriero]

We have SRNAs rotate through occasionally. We treat them like they’re a medical student and never leave the room. It’s easier to pair them up with a CRNA, then we can cover 2:1, etc.

 

[mdawarre]

You are opening yourselves for liability and compliance issues if you have SRNAs by themselves in a room. Check out page 5.

https://www.asahq.org/-/media/sites/asahq/files/public/resources/standards-guidelines/statement-on-the-anesthesia-care-team.pdf?la=en&hash=9674E540AB92E575C1FD8AB9B48159F7656B9AEB

 

[Endee]

I expect that statement to be revised again. It was extremely contentious in 2018 and I think ASA is going to walk back the language. But then again, anything could happen on the floor of the House of Delegates. Last year the HOD rejected what was approved by the ASA Board in August and strengthened the wording to include a reference to violating the ASA's ethical practice guidelines.

You are opening yourselves for liability and compliance issues if you have SRNAs by themselves in a room. Check out page 5.

https://www.asahq.org/-/media/sites/asahq/files/public/resources/standards-guidelines/statement-on-the-anesthesia-care-team.pdf?la=en&hash=9674E540AB92E575C1FD8AB9B48159F7656B9AEB

 

[mdawarre]

Endee, I don’t disagree. However this is a current ASA statement on ACT. Do you know who loves ASA guidelines? Plaintiff’s attorneys. Source: a plaintiff’s attorney. They don’t care if it’s a guideline, or recommendation, or statement. It looks great on a big PowerPoint slide in front of a jury.

 

[Endee]

Yep. It's the current statement. I'm just saying I think by the end of this month, at the ASA Annual Meeting, it will have been revised again.

Endee, I don’t disagree. However this is a current ASA statement on ACT. Do you know who loves ASA guidelines? Plaintiff’s attorneys. Source: a plaintiff’s attorney. They don’t care if it’s a guideline, or recommendation, or statement. It looks great on a big PowerPoint slide in front of a jury.

 

[ScarfTheVerb]

There is a difference between standing up to the AANA and being an dingus to everyone you work with. Our CRNAs (and AAs) all work for us and as a group are just wonderful to work with. I see literally none of this angry militant stuff that people complain about constantly. I am aware it is out there and have seen it in other places, but not every CRNA is a terrible human being trying to put you out of a job and pretending they are as good or better than a doctor.

This is my experience as well. We employ our CRNAs and they’re happy to do whatever I ask. They do a great job, get paid well, and seem to appreciate their limited responsibility and the lower stress that comes with it.

 

[mdawarre]

Yep. It's the current statement. I'm just saying I think by the end of this month, at the ASA Annual Meeting, it will have been revised again.

Statement revised at this past ASA meeting, however verbiage re: SRNAs is unchanged (Don't put them in rooms alone).

"Students are not qualified anesthesia personnel. Therefore, the use of students in place of qualified personnel is inappropriate as well as inconsistent with the ASA Guidelines for the Ethical Practice of Anesthesiology."

 

[Endee]

Yep, I was there at the HOD, I was surprised because at the caucus and reference committee level there seemed to be plenty of support for the revision (removing the reference to the Ethical Guidelines), but the HOD reverted to the unchanged version.

I love the strong statement, but as a compromise, I don't know why they didn't just do "...is inappropriate and unethical." since it seems that referencing the Ethical Guidelines was the sticky part for a lot of people.

Statement revised at this past ASA meeting, however verbiage re: SRNAs is unchanged (Don't put them in rooms alone).

"Students are not qualified anesthesia personnel. Therefore, the use of students in place of qualified personnel is inappropriate as well as inconsistent with the ASA Guidelines for the Ethical Practice of Anesthesiology."

 

[deleted126335]

This guideline is not legally binding, although it is certainly admissible in a medmal proceeding for a jury to consider. It is in conflict with AANA position statement. There are ways to supervise a SRNA as long as you bill appropriately.