CRNAs Practice Updates and Trends
For more than 150 years, nurse anesthetists have provided anesthesia care in the United States, and now certified registered nurse anesthetists (CRNAs), also known as nurse anesthesiologists, safely administer to patients more than 49 million anesthetics annually. So what trends are expected for CRNAs now?
It is a top priority for CRNAs to be able to practice at the full scope of our education and training to service the public and provide affordable and quality health care,” said Jose Castillo III, Ph.D., MS, CRNA, APRN, president of the Florida Association of Nurse Anesthetists
CRNA Scope of Practice and Supervision
Although 30 states, such as California, and the District of Columbia, allow CRNAs independent practice, many other states, including Florida and South Carolina, require physician supervision of CRNAs. But that is starting to change.
A significant activity gaining traction among U.S. lawmakers is allowing advanced practice registered nurses, such as CRNAs, to practice at the full scope of their education and training,” said Melissa Cooper, spokesperson for the American Association of Nurse Anesthetists (AANA).
Greg Crawford, MSN, CRNA, president of the California Association of Nurse Anesthetists, agreed, adding that with all of the supportive research, he is seeing movement in the direction of CRNAs being allowed to practice to the full extent of their training.”
Supervision can be a physician or a dentist, not necessarily an anesthesiologist. For example, a CRNA in a plastic surgery center can be supervised by a plastic surgeon.
The surgeons, MDs or DOs, are governed by their scope of practice, and I, being a CRNA, am governed by standards of practice, based on what the American Association of Nurse Anesthetists put forth as standards,” Castillo said.
In addition to administering general and spinal anesthesia, nurse anesthetists also can place arterial lines, pulmonary artery catheters, and other lines and administer nerve blocks.
CRNAs also may offer pain management. The University of South Florida in Tampa and Texas Christian University in Fort Worth offers CRNA pain management fellowship programs.
Expanded CRNA scope of practice becomes extremely important in rural settings, where nurse anesthetists may be the sole anesthesia providers.
In New York, nurse anesthetists are working toward being recognized and licensed as CRNA, instead of practicing under their RN license, said Stephanie Grolemund, BSN, MSN, CRNA, president of the New York State Association of Nurse Anesthetists.
Federal Changes for CRNAs
The Centers for Medicare & Medicaid Services (CMS), in the Physician Fee Schedule, recognized a CRNA's ability to perform pre-anesthetic assessments in ambulatory surgical centers. It also recognized Medicare Part B payments to CRNAs for evaluation and management services.
We are grateful and strongly support CMS’ action, which promotes key regulatory efficiencies and consistencies and adherence to standards in nursing practices,” said Kate Jansky, MHS, CRNA, APRN, USA, LTC (Ret), president of AANA, in a statement.
Executive order #13890, signed in October 2019, calls for reforms to the Medicare program, including eliminating supervision requirements. This will enable “CRNAs to provide patient care at the top of their advanced education and training,” Grolemund said.
CRNAs State Opt-Outs
CMS gave state governors the authority to opt-out of a hospital or ambulatory surgery center reimbursement requirement for physician supervision of nurse anesthetists, in 2001. Seventeen states opted out of the supervisory requirement. These states are Alaska, California, Colorado, Iowa, Idaho, Kansas, Kentucky, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin.
Opt-in is confusing,” Crawford said. “It is a billing issue, not a practice issue. The American Society of Anesthesiologists has issued a statement, stating it strongly opposes gubernatorial opt-outs, citing safety concerns. But multiple studies do not bear that out.
Published research shows no difference in outcomes of care with physician supervision, and the increase in cost for unnecessary supervision is borne by patients and facilities,” said Jansky, in a statement.
Educational Changes for CRNAs
Preparation for practicing as a CRNA is changing, and starting in 2025, all newly minted CRNAs will need a doctoral degree. The move is consistent with the educational preparation of other healthcare professionals, such as pharmacists and physical therapists.
"Opioid alternatives are a trend for CRNAs," Grolemund said. The State of Florida is one of a few states requiring an anesthesiology provider to discuss nonopioid options with the patient prior to a procedure. Those options may include nerve blocks or the use of gabapentin, acetaminophen, lidocaine, ketorolac, or other medications given intravenously for general anesthesia.
Patients can refuse opioids, and we, as anesthesia providers, can give alternatives during the procedure,” Castillo said. “Patients go home more alert, with no nausea and vomiting. At the same time, patients come out with better outcomes from anesthesia.”
Patients seem familiar with CRNAs, who will take time to talk with patients and tailor a plan to each individual’s needs.
“Most patients are more than happy to have a CRNA administer their anesthesia,” Crawford said. “They understand we are advanced practice nurses prepared to deliver anesthesia independently.”
Growing CRNA Opportunities
As the demand for anesthesia care has grown, so has the need for CRNAs to fill temporary assignments as locum tenens. These jobs can be full-time traveling jobs with supplied housing or part-time assignments in your own backyard. Locum CRNAs can choose when and where they work, and enjoy a number of career and lifestyle benefits.