Earlier this year, the California Department of Public Health (CDPH) cited two hospitals for actions it said involved Certified Registered Nurse Anesthetists (CRNAs) acting beyond the scope of their certification. The CDPH recently issued guidance on this matter that has gained national attention.
Advanced Practice Providers (APPs) are specialized healthcare providers who have attained a master’s degree or higher relevant to their area of practice. APPs work throughout the medical industry and function similarly to physicians in many ways. APPs include Nurse Practitioners (NPs), Physician Assistants (Pas), and CRNAs. That said, APPs are currently not able to function as physicians and some healthcare providers, and regulatory agencies such as the CDPH, take issue with hospitals and facilities who allow APPs, like CRNAS, to practice without the supervision of an actual doctor.
Gradual scope creep of the role of CRNAs and other APPs has led to a national discussion on the advisability of expanded authority for providers who have not had the rigorous medical training of physicians—and led to the regulatory action by the CDPH against two California hospitals this summer.
At two facilities in Modesto, California, the CDPH issued “Immediate Jeopardy” violations. One was related to a CRNA who altered an order for general anesthesia for a surgical patient. The CRNA switched the patient to spinal anesthesia, which is considered higher risk than that of general anesthesia. The patient was unresponsive following the surgery. The violations related to treatment by CRNAs that impacted the health of several patients, who were then transferred to facilities offering higher levels of care.
The citations underscore the danger of unqualified providers making or remaking decisions that should be left to fully qualified physicians. Patients assume their NP, PA, or CRNA is providing the same or similar treatment as their doctor without understanding the importance of physician oversight. As demonstrated in these California facilities, medical error can and does occur when APPs overstep.
Not surprisingly, the California Association of Nurse Anesthesiology and the California Society of Anesthesiologists had competing opinions regarding the necessity of physician supervision of CRNAs. As a result, the CDPH issued an All Facilities letter to California General Acute Care Hospitals. The letter makes clear that CRNAs can administer anesthesia services only when ordered by a doctor, dentist, podiatrist, or clinical psychologist. The letter goes on to affirm that CRNAs are not doctors, and are not allowed to practice medicine.
The clarification will quiet the conversation until it arises in another state. On the upside, patients in California can expect that CRNAs are duly supervised and fully understand their role within a care team.
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