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VA Expands Practice Authority for Three High-Level Nurse Categories

by U.S. Medicine

January 16, 2017

Exclusion of Fourth, CRNAs, Fuels Controversy

By Brenda L. Mooney

Last spring, about 500 nurse anesthetists from around the country converged on the U.S. Capitol to support the plan proposed by the VA to expand veterans’ access to healthcare by allowing broader scope of practice for advanced practice registered nurses, including certified nurse anesthetists.
American Association of Nurse Anesthetist photo by John Wheeler Commercial Photography

WASHINGTON—The VA has granted full practice authority to three roles of advanced practice registered nurses (APRN) to practice to the full extent of their education, training and certification, regardless of state restrictions.

 

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Should Certified Registered Nurse Anesthetists have been included in the VA's expansion of nursing scope of practice?

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The change, which affects certified nurse practitioners, clinical nurse specialists and certified nurse midwives who are acting within the scope of their VA employment, was expected after an announcement earlier this year and months of Federal Register comment periods, attracting more than 100,000 responses.

What was less expected—and has produced substantial controversy—

is the VA’s decision to exclude Certified Registered Nurse Anesthetists (CRNA) from the expansion of practice.

“CRNAs provide an invaluable service to our veterans,” said Under Secretary for Health David J. Shulkin, MD. “Though CRNAs will not be included in VA’s full practice authority under this final rule, we are requesting comments on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rule-making. In the meantime, we owe it to veterans to increase access to care in areas where we know we have immediate and broad access challenges.”

The response was swift and sharp from the profession. “This is an example of the kind of potentially dangerous decision-making within the VA that has led to all-too-frequent media reports of terrible neglect and bad outcomes in VHA facilities,” emphasized Cheryl Nimmo, DNP, MSHSA, CRNA, president of the 50,000-member American Association of Nurse Anesthetists (AANA).

“Just imagine how many more veterans could be cared for if start times for surgical and other types of cases requiring anesthesia were no longer delayed unnecessarily while waiting for supervising anesthesiologists to become available,” Nimmo added.

The decision was applauded, however, by the American Society of Anesthesiologists (ASA), which had been in bitter opposition to expansion of practice for CRNAs.

“This was the right decision for our nation’s veterans and for safe patient care,” said Jeffrey Plagenhoef, MD, president of the physicians group. “We’re thrilled with the VA’s decision to remove anesthesia from the new Advanced Practice Registered Nurses rule. We commend VA’s leadership for their recognition that the operating room is a unique care setting and that surgery and anesthesia are inherently dangerous, requiring physician leadership. This is true for anyone, but especially for our nation’s veterans, given many of them have multiple medical conditions that put them at greater risk for complications during and after surgery and anesthesia.”

The VA explained that, while localized issues with providing anesthesia care exist, the healthcare system doesn’t have “immediate and broad access challenges in the area of anesthesia care” to require broader practice authority for CRNAs. The agency said it would request comment on whether there are current anesthesia care access issues for particular states or VA facilities and whether permitting CRNAs to practice to the full extent of their advanced authority would resolve these issues.

Timely Care

VA announced its intentions, through a proposed rule, to grant full practice authority to four APRN roles last May. “Advanced practice registered nurses are valuable members of VA’s health care system,” Shulkin said after adoption of the final rule. “Amending this regulation increases our capacity to provide timely, efficient effective and safe primary care, aids VA in making the most-efficient use of APRN staff capabilities and provides a degree of much-needed experience to alleviate the current access challenges that are affecting VA.”

The American Medical Association decried the move, saying the unprecedented proposal will significantly undermine the delivery of care within the VA.

The American Nurses Association (ANA), on the other hand, celebrated the change—as far as it went—but challenged VA’s basis for denying expanded practice for CRNAs.

“This rule puts veterans’ health first and will help improve access to the timely, effective and efficient care they have earned,” Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, responded. “However, ANA is concerned with the final rule’s exclusion of CRNAs, which is solely based on the VA’s belief that there is no evidence of a shortage of anesthesiologists impacting access to care. We join with our colleagues in continuing to advocate for CRNAs to have full practice authority within the VA health care system.

As the nation’s largest employer of nurses, VA employed about 5,769 APRNs, as of July 2016 among its workforce of more than 93,000 nurses.

The AANA argued that the VHA independent assessment ordered by Congress and published in 2015 contradicts the VA’s rationale, “identifying numerous access problems such as delays in cardiovascular surgery for lack of anesthesia support, rapidly-increasing demand for procedures requiring anesthesia outside of the operating room and slow production of colonoscopy services in comparison with the private sector.”

The group maintained that, by granting full practice authority to CRNAs, VHA would be able to make full use of more than 900 CRNAs already practicing in VHA facilities, increasing anesthesia services and veterans’ access to care without additional federal funding.

“It does seem that perhaps politics, personal agendas or favoritism may have gotten in the way of sound decision-making with regard to this important VA issue,” Nimmo posited. “Hopefully that’s not the case; the VA will review the evidence and reconsider its decision, and a final rule will be published that better serves our nation’s veterans.”

The VA, for its part, pointed out that 104,256 comments against granting full-practice authority to CRNAs had been received. It also noted that the ASA, which lobbied heavily against VA CRNAs having full-practice authority, established a website to facilitate comments against the CRNAs, which actually provided the language to use.

“These comments were not substantive in nature and were akin to votes in a ballot box,” the VA stated in a Federal Register summary. “The main argument against the VA CRNAs was that, by granting CRNAs full-practice authority, VA would be eliminating the team based concept of care in anesthesia, which is currently established in VA policy via VHA Handbook 1123, Anesthesia Service.”

The agency said it rejected that argument, instead making its decision on the basis “that evidence exists that there is not currently a shortage of anesthesiologists that critically impacts access to care, and therefore VA agrees with the sentiment of this argument.”


8 Comments

  • Mary Kastner says:

    The RNA was one of the first Advanced Practice Nurses. RNA are incredibly skilled and bring the nursing assessment process to the bedside giving them an edge over medicine. Please properly vet them and allow them the full extent of practice according to their licensure.

  • Mary Kastner says:

    The RNA was one of the first Advanced Practice Nurses. RNA are incredibly skilled and bring the nursing assessment process to the bedside giving them an edge over medicine. Please properly vet them and allow them the full extent of practice according to their licensure.

  • Randall James Dotts, PA-C, Doctor of Medical Science student says:

    As both a disabled veteran who will need surgery someday, and as a medical provider, I would not want an independent ARNP/AANA providing me solo care. The biggest reason is that anesthesia is a legal overdose of medication and I would be in a life or death situation if the not as well trained Anesthetist did not know what to do. That is why MD’s/DO’s go to school and residency as long as they do. When it comes to drug overdoses, which is what anesthesia is, I want the best trained and the number of hours of AANA just does NOT compare to those of MD’s/DO’s.

  • Michael John Knitter, MD says:

    Our Nation’s motto is In God We Trust. Then other scriptures would state a question and then gives answer : “Do you want to be unafraid of the authority? Do what is good…” It is our job (including the CRNAs) to question bad authority and bad policy and poor policy making per the Administrative Procedure ACT. To ignore and violate State Law is not a trivial VA statement.

    Physicians need to stay close and accept their responsibility for CRNA care and support. The surgeon needs to be present at anesthesia induction for back up cricothyrotomy air way and the Surgeon needs to be in house for Home Discharge physician order to rule out sending Veteran home with surgical complication. This has less to do with anesthesiologist physicians and more to do with Physician direct in room/in house involvement.
    An OB/GYN/General Surgeon physician can cut the cricothyroid membrane or relieve tension peritoneum/pneumothorax which is often iatrogenic to the medical care procedures. A nurse midwife is unsafe to supervise the CRNA. If Federal agency now willing to license instead of State/Commonwealth, then the Federal Government should follow through and clarify the muddy waters.
    I praise the strength of the CRNA group pictured and I also question the policy making of our leadership. Yet once I am satisfied the leadership gets clear report, I then consider ending my report as described in Ezekiel 33.
    The leadership in now to take responsibility for their actions and inactions.

  • John Kennedy MD says:

    The Decision to NOT grant full independent credentialing to CRNA’s was 100% correct. The only shame was that the rest of the Medical Profession , the Physicians, caved into this incursion on our Profession.
    An ARNP is not a Physician . It is really that simple, and the moment we allow ARNP’s , however you dress it up, to essentially have the same standing as independent Practitioners , you undermine the very structure of Medicine.
    Why would anyone now bother to go to Medical School and complete Residency and Board Certification, when an ARNP can essentially have the same Privileges. That is the absurdity of it. We are now being asked to privilege ARNP to have separate independent Practitioner rights. As a colleague asked , does that mean they do not have to be supervised by a Physician , and can make clinical decisions about our Patients without anyone ensuring that their decision is correct ? What does it mean that for example in primary care privileges they can assess and treat Cardiovascular disease, or if granted privileges can go into an operating room , or assess an acutely psychiatric ill patient.
    The irony of course is that PA-C’s , who are better trained than ARNP’s, will not have the same authority. I guess their lobby is less powerful.
    As a Family Physician, if there is one thing that galls me more than anything is when ARNP’s say well its only Primary Care. Only Primary care !! Family Medicine has been a constituent member of the American Board of Medical Specialties since 1969. To be a Board Certified Family Physician takes a minimum of 7 years training, and often more, and I have yet to meet an ARNP that could pass the Board Exam. It is no easier than being a Psychiatrist or internal medicine Physician or Dermatologist or an Anesthetist or yes a Surgeon. A confounding factor is ARNP’s with DNP’s insisting on being called Dr. When a patient hears Dr they expect to see an MD, why, because that’s what a Dr is.
    This is the thin wedge that will fracture Medicine and split the profession apart. The ‘Sub Specialists’ will rally round and sacrifice Family Medicine and other Primary Care Specialists ( yes that’s what we are) to protect themselves. At least the Anesthetists stood their ground, and rightly so.
    If you want to be a Doctor , go to Medical School, do a Residency /Fellowship, and pass the Board Exam.

  • John Kennedy MD says:

    The Decision to NOT grant full independent credentialing to CRNA’s was 100% correct. The only shame was that the rest of the Medical Profession , the Physicians, caved into this incursion on our Profession.
    An ARNP is not a Physician . It is really that simple, and the moment we allow ARNP’s , however you dress it up, to essentially have the same standing as independent Practitioners , you undermine the very structure of Medicine.
    Why would anyone now bother to go to Medical School and complete Residency and Board Certification, when an ARNP can essentially have the same Privileges. That is the absurdity of it. We are now being asked to privilege ARNP to have separate independent Practitioner rights. As a colleague asked , does that mean they do not have to be supervised by a Physician , and can make clinical decisions about our Patients without anyone ensuring that their decision is correct ? What does it mean that for example in primary care privileges they can assess and treat Cardiovascular disease, or if granted privileges can go into an operating room , or assess an acutely psychiatric ill patient.
    The irony of course is that PA-C’s , who are better trained than ARNP’s, will not have the same authority. I guess their lobby is less powerful.
    As a Family Physician, if there is one thing that galls me more than anything is when ARNP’s say well its only Primary Care. Only Primary care !! Family Medicine has been a constituent member of the American Board of Medical Specialties since 1969. To be a Board Certified Family Physician takes a minimum of 7 years training, and often more, and I have yet to meet an ARNP that could pass the Board Exam. It is no easier than being a Psychiatrist or internal medicine Physician or Dermatologist or an Anesthetist or yes a Surgeon. A confounding factor is ARNP’s with DNP’s insisting on being called Dr. When a patient hears Dr they expect to see an MD, why, because that’s what a Dr is.
    This is the thin wedge that will fracture Medicine and split the profession apart. The ‘Sub Specialists’ will rally round and sacrifice Family Medicine and other Primary Care Specialists ( yes that’s what we are) to protect themselves. At least the Anesthetists stood their ground, and rightly so.
    If you want to be a Doctor , go to Medical School, do a Residency /Fellowship, and pass the Board Exam.

  • Randall James Dotts, PA-C, Doc says:

    As both a disabled veteran who will need surgery someday, and as a medical provider, I would not want an independent ARNP/AANA providing me solo care. The biggest reason is that anesthesia is a legal overdose of medication and I would be in a life or death situation if the not as well trained Anesthetist did not know what to do. That is why MD’s/DO’s go to school and residency as long as they do. When it comes to drug overdoses, which is what anesthesia is, I want the best trained and the number of hours of AANA just does NOT compare to those of MD’s/DO’s.

  • Michael John Knitter, MD says:

    Our Nation’s motto is In God We Trust. Then other scriptures would state a question and then gives answer : “Do you want to be unafraid of the authority? Do what is good…” It is our job (including the CRNAs) to question bad authority and bad policy and poor policy making per the Administrative Procedure ACT. To ignore and violate State Law is not a trivial VA statement.

    Physicians need to stay close and accept their responsibility for CRNA care and support. The surgeon needs to be present at anesthesia induction for back up cricothyrotomy air way and the Surgeon needs to be in house for Home Discharge physician order to rule out sending Veteran home with surgical complication. This has less to do with anesthesiologist physicians and more to do with Physician direct in room/in house involvement.
    An OB/GYN/General Surgeon physician can cut the cricothyroid membrane or relieve tension peritoneum/pneumothorax which is often iatrogenic to the medical care procedures. A nurse midwife is unsafe to supervise the CRNA. If Federal agency now willing to license instead of State/Commonwealth, then the Federal Government should follow through and clarify the muddy waters.
    I praise the strength of the CRNA group pictured and I also question the policy making of our leadership. Yet once I am satisfied the leadership gets clear report, I then consider ending my report as described in Ezekiel 33.
    The leadership in now to take responsibility for their actions and inactions.


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