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    States Debate CRNAs’ Scope of Practice

    By Jennifer Huddleston, staff writer     

    Several state legislatures are discussing the possibility of extending or redefining certified registered nurse anesthetists’ (CRNAs’) scope of practice to include performing pain interventions and having prescriptive authority that includes controlled substances. [1]

    A number of professional associations have joined in the debate as well.

    While anesthesiologists contend that neither need nor legislation grants ability, the American Association of Nurse Anesthetists (AANA) asserts that acute and chronic pain management without physician supervision is within CRNAs’ professional scope of practice.
    [2]

    The AANA’s position statement “Pain Management,” adopted in 1994 and revised most recently in 2005, states that: “By virtue of education and individual clinical experience, CRNAs possess the necessary knowledge and skills to employ therapeutic, physiological, pharmacological, interventional and psychological modalities in the management of acute and chronic pain.”
    [3]

    According to Barbara L. Anderson, J.D., the AANA’s assistant director of state government affairs, the AANA believes CRNAs can and should be able to perform these duties without physician supervision. While Mitchell H. Tobin, J.D., senior director of state government affairs at the AANA, notes that these statements do not imply that CRNAs are seeking to practice medicine, the American Society of Interventional Pain Management (ASIPP) disagrees. The ASIPP considers practicing interventional pain management to be practicing medicine.
    [4]

    “We do not train CRNAs and do not approve of CRNAs, or any other nonphysicians, performing interventional pain management procedures,” said David Schultz, M.D., president of ASIPP.
    [5]

    The debate over CRNAs’ scope of practice is not a new one. In a 2005 advisory opinion by the Louisiana State Nursing Board, CRNAs received power “to perform pain management procedures, including but not limited to, peripheral nerve blocks, epidural injections and spinal facet joint infections … based on a physician’s order,” with physician review. The Spine Diagnostic Center of Baton Rouge sued, claiming that these procedures were equivalent to the practice of medicine and therefore outside the scope of nursing. In 2007 the Louisiana Court of Appeal agreed and discontinued the practice.
    [6]

    The rules concerning CRNAs ordering and supervising fluoroscopy are also a topic of debate in Iowa, among other states.
    [7] The Iowa Board of Nursing maintains that CRNAs have legal power to supervise fluoroscopy, and the Department of Public Health aims to revise its policy in order to allow CRNAs to supervise such procedures. However, the Iowa Board of Medicine and the Iowa Medical Society (IMS) are in agreement that CRNAs should not be allowed such authority. [8]

    Exactly how much authority should be given to CRNAs in the area of pain management is the question a number of states have been debating in recent years.

    While no action is expected during the current legislative session, a proposed New York Senate bill would give CRNAs prescriptive power and the right to practice anesthesia independently, with review by any physician—including those not specializing in anesthesia or practicing within the state of New York.
    [9]

    In Oklahoma, Attorney General Drew Edmondson’s recent opinion on whether CRNAs may administer anesthesia in pain management clinics stated that CRNAs’ power is limited to selecting drugs and treatments during the time immediately before or after a surgery or delivery and to administering anesthesia in a pain management setting where a supervising physician has chosen the drugs and treatments and is available onsite.
    [10]

    The Nebraska state legislature is expected to pass a bill in 2009 allowing CRNAs to perform interventional pain procedures—specifically to use fluoroscopy to more accurately administer medication—without physician supervision.
    [11]

    As professional organizations across the country continue to grapple with these issues, it appears that the decision of what will happen next rests in the hands of each state’s lawmakers.


    [1] Douglas, Elizabeth. “State Initiatives Aim to Expand Role of Nurse Anesthetists.” Anesthesiology News, Anesthesiology News. Volume 34:09. September 2008.
    [2]  Ibid .
    [3] AANA Board of Directors. “Pain Management.” Position Statement 2.11. June 1994.
    [4] Douglas, Elizabeth. “State Initiatives Aim to Expand Role of Nurse Anesthetists.” Anesthesiology News, Anesthesiology News. Volume 34:09. September 2008.
    [5]  Ibid .
    [6]  Ibid .
    [7]  Ibid .
    [8]  Albany, Lisa Percy. “2008 State Activities.” ASA State Beat. American Society of Anesthesiologists NEWSLETTER. Volume 72, Number 8. August 2008.
    [9] Douglas, Elizabeth. “State Initiatives Aim to Expand Role of Nurse Anesthetists.” Anesthesiology News, Anesthesiology News. Volume 34:09. September 2008.
    [10]    “AG Opinion Cites Limits on CRNAs’ Role in Pain Management.” The Journal Record. Sept. 29, 2008.
    [11] Douglas, Elizabeth. “State Initiatives Aim to Expand Role of Nurse Anesthetists.” Anesthesiology News, Anesthesiology News. Volume 34:09. September 2008.



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