News in brief

VA releases final rule, grants full practice rights to APRNs

The osteopathic profession commented in opposition to the proposal rule and plans to do the same during the comment period on the final rule.

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The US Department of Veterans Affairs (VA) published a final rule this week that will provide certain advanced practice registered nurses (APRNs) with full practice authority within VA facilities.

The rule pre-empts state scope of practice laws regulating medical care for services provided as part of an individual’s scope of employment within the VA system. The proposed rule would have allowed full independent practice for certified registered nurse anesthetists; they were removed from the final rule and their practice will remain under physician oversight.

The AOA supports team-based care that utilizes the complete medical education and training of a fully licensed physician as part of a collaborative effort with other health care providers. The AOA strongly believes that this is the only way to meet the comprehensive health care needs of each patient. The AOA also continues to support the right of states to regulate the delivery of health care within their borders.

As such, the osteopathic profession commented in opposition to the proposal rule earlier this year, and plans to do the same during the 30-day open comment period on the final rule.

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2 comments

  1. Audrey gauthe

    I am respectfully submitting a comment in response to the Department of Veterans Affairs RIN 2900-AP44 Advanced Practice Registered Nurses. The final rule published on December 14th, 2016 grants Full Practice authority to three of the four APRN groups, which is highly commendable, but specifically excludes CRNAs, which makes no sense and reflects obvious catering to a special interest group namely anesthesiologists.

    The extended comment period provides a unique opportunity for your agency to create a positive precedent of doing the right thing, by putting scientific evidence above politics and granting Full Practice Authority to ALL APRNs, instead of perpetuating the longstanding trend of corruption in government! The Office of the Federal Register clearly states in its Guide to the Rulemaking Process that an agency is not permitted to base its final rule on the number of comments received in support of the rule over those in opposition to it or vice versa. An agency must base its reasoning and conclusions on the rulemaking record, which consists of the comments received, scientific data, expert opinions, and facts accumulated during the pre-rule and proposed rule stages.

    Your own (VHA) document states: The safety of CRNA service has long been recognized by the VHA and underscored by peer-reviewed scientific studies including a major study published in Health Affairs which found that anesthesia care by CRNAs was equally safe with or without physician supervision. It is clear the VHA acknowledges that the anesthesiologists claim about CRNAs being unsafe is unsubstantiated and completely false!

    The only reason the VHA gives for excluding CRNAs in the rule is VHA believes that VA does not have immediate and broad access problems in the area of anesthesia care across the full VA health care system. Where is the proof of this belief? The anesthesiologists who provided comments in opposition to including CRNAs did not provide any proof. The Congressionally mandated Independent Assessment of the VA did not provide any proof either. The VHA statement actually alludes to the fact that there ARE shortages in certain VA facilities and areas. The VHA document obviously provides the answer to its own question: VA also requests comment on potential future anesthesia care issues, particularly in light of projected increases in demand for VA care, including surgical care, in coming years. Therefore, in light of the VAs acknowledgement that there will be increased future demand for anesthesia care services, it only makes sense to include CRNAs in the Full Practice Authority rule. Even if there were not any shortages currently, wouldn’t you agree that it is short-sighted to block the solution to future anesthesia shortage problems by excluding CRNAs from the rule?

    Another reason to include CRNAs in the rule is the fact that the utilization of CRNAs to the full extent of their education, training, and certification, will save crucial health care dollars that can be reallocated for the benefit of our deserving veterans. Currently, the VA uses the anesthesia team care model in most of its facilities. Here is what actually takes place in the team care model: The CRNA interviews the patient, reviews lab results, pertinent studies and health history, and prepares the anesthesia medications and equipment. The anesthesiologist is present for the first five to ten minutes of the case and may or may not administer the medications the CRNA has prepared (individualized). Then the anesthesiologist leaves the operating room (usually returning to their office) while the CRNA stays with the patient, making the second-to-second decisions that keep the patient stable and safe, for the remainder of the case. The anesthesiologist is available for emergencies, but when seconds count, their office may be quite a few seconds away. Of course, in facilities where there are not anesthesiologists, CRNAs skillfully and safely manage all the anesthesia care services.

    The study Cost Effectiveness Analysis of Anesthesia Providers? published in Nursing Economics in 2010 demonstrated that CRNAs working alone is the most cost effective model. Even though this model would be the most cost effective, I am not suggesting that the VA anesthesiologists be replaced with CRNAs. There are many excellent anesthesiologists that I personally worked with while in training at the Oklahoma City VA Hospital, and certainly there are many more throughout the VA system. There is no reason CRNAs and anesthesiologists cannot work together in the most efficient and safe manner possible to care for our most deserving Americans our veterans! However, anesthesiologists could be much more productive and better utilized by taking care of their own patients instead of earning their high salaries by sitting in an office. It is only a handful of anesthesiologists who create the ?squeaky wheel on the bandwagon to discredit CRNAs, and who also practically threaten their colleagues to jump on the bandwagon with them. (I have seen e-mails sent to anesthesiologists in my own facility with this type of message.) These anesthesiologists do not have our veterans? best interests in mind by lobbying against including CRNAs in the Full Practice Authority rule, they have their own interest of maintaining control over CRNAs in mind.

    Veterans are definitely facing delays to anesthesia care, and thus facing subsequent delays to vital procedures at the VA. I have personally observed these delays at the Oklahoma City VA Hospital for care related to my ex-husbands recent colon cancer surgery and treatment. I have had other family members and friends who also experienced delays in surgery and care. In a recent Congressionally mandated Independent Assessment of the VA, VA medical facility Chiefs of Staff reported challenges with lack of anesthesia services and support as a barrier to providing care. I am concerned as to why these objective findings are insufficient in your decision to deny CRNAs the ability to treat these patients to the full scope of our abilities.

    Additionally, anesthesia care is among the services that the VA seeks from non-VA providers through programs such as VA Patient Centered Community Care (PC3) and Choice Program contractors. And, as the VA seeks to revamp its community care programs through the “Community Care Network” contract, anesthesia is among the allowable services. Because the VA has a referral hierarchy, where internal resources are always considered first before turning to its partners in the private sector, it is clear that the VA’s current internal anesthesia care capacity is limited and could be improved with the use of CRNAs.

    CRNA Full Practice Authority is supported by the evidence-based recommendations advanced by the National Academy of Medicine, the Independent Assessment of the VA, and the blue-ribbon Commission on Care. It is also current policy in the Army, Navy, Air Force, Combat Support Hospitals, and Forward Surgical Teams, and is supported by the AARP, American Hospital Association, and several Veterans Service Organizations, including the Iraq and Afghanistan Veterans of America, AMVETS, Military Officers Association of America, Air Force Sergeants Association, Reserve Officers Association, and the Naval Enlisted Reserve Association.

    With the current public outrage regarding corruption in government, this would be a perfect opportunity for a government agency to actually do the right thing, especially since it involves the care of our American Veterans, who have done the right thing for all of us by serving our country. I highly encourage you to reconsider your final rule and change it to grant Full Practice Authority to ALL Advanced Practice Registered Nurses as an important step toward achieving our shared goals of improving timely access to the highest quality anesthesia care, and all health care services within the VHA.

    Thank you in advance for your decision to include CRNAs in the Department of Veterans Affairs RIN 2900-AP44 Advanced Practice Registered Nurses final rule.

    Respectfully,
    Audrey Gauthe, APRN-CRNA Oklahoma Association of Nurse Anesthetists

  2. James J. Roth

    Ms. Gauthe’s observations and evidence based discussion points are well presented. Physician led push back re: prescriptive privileges and independent practice authority for CRNAs has been and always will be unfounded and should be recognized as such. This is more about patient access to safe anesthesia care within the VA care system and nothing else. Any physician can give anesthesia to a patient. But only a nationally, board certified RN can give anesthesia to that same patient.

    I’ve enjoyed an honest, cooperative and meaningful working relationship with the Anesthesiologists I have worked with during my 20 year career as a CRNA. Patient safety is maintained and stressed above all else with the awareness that we (the CRNA and MDA) are partners in a team approach providing the best care we can deliver to our patients…together. This does not mean that we cannot do our work separately and unsupervised. If the CRNA or MDA needs assistance with a case, it should be reassuring that a well trained CRNA or MDA is available to lend a hand. Unfortunately, this paradigm is not being encouraged consistently to all anesthesia practitioners.

    Anesthesia as a science and an art continues to grow along with technology and the practice modalities we use to deliver care. Our thinking, regarding the issue of CRNAs as independent practitioners must change as well. There is no growth without change.

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