Nurse anesthetist battle shatters illusion of unity

Although most public pronouncements from healthcare organizations these days sound like they're prepared from the same we're-all-in-this-together template, the latest scope-of-practice court fight showed that all sides still seem ready to drop the gloves at any moment.

A Colorado state appellate court affirmed a decision from the state's former governor permitting certified registered nurse anesthetists to administer anesthesia without a physician's supervision in the state's critical-access and rural hospitals.

Doctors then squared off against nurses and hospitals, and national organizations representing all sides joined in. The court acknowledged it was ruling narrowly on the issues of whether the governor had the authority to make his decision and whether the decision was consistent with state law. It said yes to both, but its opinion (PDF) also included this note:

"Our role is limited to determining whether Colorado law permits CRNAs to administer anesthesia without physician supervision. We may not pass on the wisdom of the decision to allow CRNAs to do so."

The doctors' case may have been doomed from the start. Maybe I just need to get out more, but I found other statements in the opinion interesting as well:

"The doctors urge us to conclude the act allows CRNAs to administer anesthesia only with physician supervision. However, we perceive several problems with the doctors' interpretation.

"First, a CRNA would never administer treatment, including anesthesia, unless he or she was implementing a medical plan or acting in a manner that was consistent with a physician's medical plan. Thus, under the doctors' interpretation, virtually every function performed by a CRNA could be characterized as 'a delegated medical function' requiring supervision by a physician. For this reason, the district court concluded the doctors' interpretation 'cuts way too broadly.' We agree.

"The doctors' interpretation also renders other portions of the act meaningless. For example, section 12-38-111.5(6) requires that each advanced-practice nurse 'have a safe mechanism for consultation and collaboration with a physician, or, when appropriate, referral to a physician.' However, this subsection the act would be superfluous if a CRNA were permitted to administer anesthesia only under a physician's supervision."

The court addressed doctors' concerns that, under the "captain of the ship" doctrine, surgeons are vicariously liable for the actions of others in the operating room, and now they'd be responsible for someone not under their supervision. According to the court, the legislature addressed this by requiring CRNAs to have liability insurance—even if it's a fraction of doctors' insurance requirements.

"We acknowledge the doctors' argument that the amount of professional liability insurance for CRNAs is only half the amount required of physicians. Nevertheless, the General Assembly has apparently determined that individuals injured by CRNAs have reasonable options available to them."

This fight has now been played out in 16 states and—who knows—may be repeated 34 more times. With everyone trying to stretch scarce resources, it might pay to settle these issues before the lawsuit stage.

Follow Andis Robeznieks on Twitter: @MHARobeznieks.



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