Physician organizations in Colorado expressed disappointment with a state appellate court ruling allowing certified registered nurse anesthetists to administer anesthesia
without physician supervision in the state's rural and critical-access hospitals.
“Contrary to the court's opinion, anesthesia care is more than just a medication,” Dr. Kristin Woodward, president of the Colorado Society of Anesthesiologists (PDF)
, said in a news release. “It is a complex and potentially life-threatening medical service. To abandon 150 years of physician supervision of this vital aspect of medical care unnecessarily lowers the standard of care in those hospitals affected by the governor's order and increases the likelihood of patient harm during surgery and other procedures.”
Federal law requires physician supervision unless states submit signed letters from the governor to the CMS opting out of this requirement stating that doing so is “in the best interest of state citizens and consistent with state law.” Former Colorado Gov. Bill Ritter had submitted such a letter on Sept. 27, 2010. The next day, the Colorado Medical Society requested an injunction ordering the governor to opt back in. Ritter's successor John Hickenlooper filed a motion to dismiss the society's suit, which was granted by the district court on April 8, 2011.
In its opinion, the court noted that it was ruling narrowly (PDF)
on the issues before it: Whether the governor had the authority to opt out and if doing so was consistent with state law, and was not weighing in on the qualifications of CRNAs vs. anesthesiologists.
While disappointed in the ruling, Kari Hershey, attorney for the Colorado Medical Society, said this point was appreciated.
“The society appreciates the court's acknowledgement that its role was limited to considering whether the law permits CRNAs to administer anesthesia without physician supervision and that it was not opining on the wisdom of doing so,” Hershey said in an e-mail. “In particular, the court pointed to the arguments made that anesthesiologists receive considerably more education and training than nurse anesthetists, and therefore are much better equipped to respond to emergencies and unexpected difficulties during surgery.”
Hershey added that the medical society's objection to ruling did not mean that CRNAs were not recognized as valuable members of the surgical team.
“There is no dispute that nurse anesthetists are highly trained professionals,” Hershey said. “As an organization, we believe that patients receive the best care when care is delivered by highly trained, interdependent, physician-led teams. In a surgery, the surgeon is able to lead the operative team.”
There was also concern that, under the “Captain of the Ship Doctrine” which places responsibility for all operating room personnel on the surgeon, operating surgeons will now be held legally liable for the actions of others outside their control.
The governor's decision to opt out of the federal supervision requirement was supported by the Colorado Hospital Association (PDF)
, which said that allowing CRNAs to work unsupervised was “needed to help fill a substantial gap in healthcare access in underserved regions” of the state.
But in the CSA statement, Dr. Randall Clark, director of the American Society of Anesthesiologists, disagreed, and said that “leadership in the Colorado Hospital Association and a few rural hospital administrators, have placed expediency above patient safety, and unnecessarily so.”
Clark added patients should be told whether a physician is supervising their anesthesia so they can decide whether to accept the risk.
“These hospitals must not impose that risk on patients without their knowledge,” he said.
Woodward said the CSA may either appeal the decision to the state Supreme Court or seek legislative action “to correct this flawed and pernicious setback for patient safety.”
Last week, the California state Supreme Court ruled in the nurses' favor in a similar case. The Colorado Appellate Court opinion noted that 14 other states have also opted out of the federal physician-supervision requirement: Alaska, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington and Wisconsin.