By Emma Yasinski
A battle is brewing in Illinois over proposed legislation that would allow Certified Registered Nurse Anesthetists (CRNAs) to administer anesthesia without the physical presence of a dentist or physician. A coalition of medical groups, including dentists, physicians, and anesthesiologists, has formed to oppose the change.
Whatever the outcome, it is likely to influence regulations nationwide.
According to the Nurse Practice Act, a nurse anesthetist can administer anesthesia as long as “an anesthesiologist, physician, or operating dentist shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical conditions.”
However, the Illinois Association of Nurse Anesthetists (IANA) has proposed legislation to change this by removing the portion requiring the anesthesiologist, physician, or operating dentist to be physically present.
Utilization of CRNAs
“The law allows dentists to rely on nurse anesthetists as anesthesia experts,” Micah Roderick BA, MPA, IANA’s Executive Director told Incisor. He said he hopes the bill will clarify the role of physicians and dentists and help increase utilization of CRNAs.
But members of several professional groups including the American College of Surgeons (Metro Chicago Chapter), American Society of Anesthesiologists, Illinois Dermatological Society, Illinois Society of Anesthesiologists, Illinois State Dental Society, Illinois Society of Eye Physicians and Surgeons, and the Illinois State Medical Society have come together to oppose the legislation. They’ve formed a group called Preserve the Anesthesia Care Team (PACT) and launched a website.
According to the PACT site, five states (Alaska, Montana, Utah, New Hampshire, and Oregon) currently allow CRNAs to practice without the physical presence of a physician.
Dr. Adamina Podraza, an anesthesiologist in Illinois, was surprised to hear about the potential legislation. “As a physician anesthesiologist, we have significantly more education and training,” she told Incisor. “I always feel safety is the amount of training you have.”
The PACT website highlights the difference in years of secondary education and training between anesthesiologist assistants, nurse anesthetists, and physician anesthesiologists in a bar graph showing that physicians require about six more years of training than the other two professions.
The site also states, “Unfortunately, some CRNAs want to break the Anesthesia Care Team model.”
But Roderick says the website’s statement reflects a misconception.
Currently, “Illinois law does not require supervision of CRNAs by a doctor, but it does require dentists and physicians to remain physically present during the delivery of anesthesia. [The update] would still include that a dentist and a physician would remain available for consultation,” he said. “By removing the ‘physical presence’ language, it becomes more clear that the role of the CRNA is to work with dentists and physicians on the anesthesia plan.”
Worrying About Patients
Additionally, Roderick explained, “The Illinois Association of Nurse Anesthetists proposed the new legislation to clear up the confusion for dentists and physicians that they are responsible for supervising nurse anesthetists (CRNAs).”
Dr. Podraza worries most about patients who receive anesthesia in a dental office or a setting outside the hospital. The patients receiving anesthesia, especially at a dental office, tend to have more complex medical histories, she notes. They are patients who are uncooperative, have a cognitive impairment, and a higher risk of morbidity and mortality.
“It's not like you're in a hospital setting,” she said. “If something [a medical complication] happens, waiting and calling 9-1-1 does take time and nobody is immediately available in case of an emergency.”
J. Kathleen “Kate” Marcus, J.D., Regulatory Counsel for DOCS Education, comments:
It is critically important that one actually read House Bill 2813. It is explicit that CRNAs can only act in accordance with a written collaborative agreement over which the dentist or anesthesiologist has control. If physicians believe CRNAs are not sufficiently trained to administer anesthesia, the remedy is changing the education requirement for CRNAs or changing the written collaborative plan.
Ultimately the physician/dentist/anesthesiologist is responsible for that collaborative agreement. The written collaborative agreement can include provision of anesthesia by the CRNA or exclude it. The oversight necessary to ensure patient safety is still there.
This bill offers the possibility of reducing health care outlays in some cases where fewer professionals need to be in the room, thus lowering the cost of the procedure. It is not surprising that more expensive practitioners would object to being replaced by less expensive practitioners.
Allan Schwartz, DDS, CRNA, a DOCS Education instructor and veteran anesthesia teacher, responds:
As both a licensed Missouri Dentist, with a permit to perform Deep Sedation/General Anesthesia, and a board-certified licensed Certified Registered Nurse Anesthetist in Illinois, I have monitored this debate since becoming a student in 1992--and I have seen large numbers of hands-on patient cases requiring anesthesia.
Studies show that the Anesthesia Care Team Model has been deemed the least cost-effective due to the medical fee claimed by the anesthesiologist.!,2 There is no evidence proven by many studies that anesthesiologist medical direction is any safer than the CRNA model or the Consultative model for anesthesia delivery.3
There are currently 17 states that allow CRNAs to practice without a physician.
A CRNA’s training is currently four years for a Bachelor’s Degree in Nursing, at least one year of work experience in a critical care/intensive care unit, leading to a Master’s Degree in Nurse Anesthesia. All CRNAs will be required to attain a Doctoral Degree in Nurse Anesthesia starting in 2025. Southern Illinois University in Edwardsville, Illinois requires 80 hours of graduate-level courses, along with a doctoral thesis to attain a Doctorate in Nurse Anesthesia.
Anesthesia delivery requires intense education, along with broad clinical experience and judgment. It is a combination of both art and science, along with quick thinking and attention to many details during a patient dental case.
To say that one anesthesia provider is superior to another anesthesia provider based solely on their type of education is untruthful.
- Dulisse B, Cromwell J. "No harm found when nurse anesthetists work without supervision by physicians." Health Aff. Aug 2010;29(8):1469-1475.
- 5. Hogan P. et. al, “Cost Effectiveness Analysis of Anesthesia Providers.” Nurs Econ. 2010; 28:159-169.
- Negrusa B, Hogan PF, Warner JT, Schroeder CH, Pang B. "Scope of Practice Laws and Anesthesia Complications: No Measurable Impact of Certified Registered Nurse Anesthetist Expanded Scope of Practice on Anesthesia-related Complications." Med Care. May 20 2016.
Author: Contributing writer, Emma Yasinski received her Master of Science (MS) in science and medical journalism from Boston University. Her articles have also appeared at TheAtlantic.com, Kaiser Health News, NPR Shots, and Genetic Engineering and Biotechnology News.
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