If the Veterans Affairs Department expands the scope of practice of its advanced practice nurses, VA hospitals could become “regulatory islands.”
Congress and the VA has for some time debated whether the department should allow advanced practice nurses to independently practice to the full extent of their training. Pending legislation would allow expanded practice authority to VA nurse midwives, clinical nurse specialists, nurse practitioners and potentially certified registered nurse anesthetists, even in states with laws that restrict their capabilities.
House bill H.R. 1247, introduced in March and currently in the hands of the Subcommittee on Health of the House Committee on Veterans' Affairs, includes all four specialties of advanced practice nurses, while the Senate bill, S. 297, introduced in January and currently with the VA Committee, does not include certified registered nurse anesthetists.
The authority of CRNAs has been a hot-button issue between the American Association of Nurse Anesthetists and the American Society of Anesthesiologists.
“The VA has authority to recognize APRNs to their full practice authority, and the VA should exercise that authority,” said Frank Purcell, senior director of federal government affairs for the nurse anesthetists' group.
At the moment, the VA recognizes APRNs based on the laws of the state they're licensed in, Purcell said. Although most states recognize the full authority of nurse anesthetists, some require them to be supervised by a physician.
“We believe that's a burden because it increases cost,” Purcell said.
By and large, VA nurse anesthetists can practice without the supervision of a physician, Purcell said, but his organization found that, in practice, anesthesiologists at 24 out of 32 VA facilities were supervising only one or two CRNAs, a ratio that the organization finds costly and inconsistent with practice outside of the VA.
But the American Society of Anesthesiologists feels strongly that CRNAs must work in teams, usually including two to four CRNAs supervised by an anesthesiologist, said Dr. J.P. Abenstein, president of the group. Given the particularly poor health status of veterans, it's “imperative” that they receive care that is supervised by a physician, he said.
“The nurse-only model is a fairly rare model and our concern and what we've conveyed to the VA and Congress is not the right model for patient population as found in the VA,” Abenstein said.
The society recognizes the importance of CRNAs in the technical delivery of anesthesia, but maintains that anesthesiologists still need to be close by for complex cases. Dr. Jane Fitch, immediate past president of the the American Society of Anesthesiologists and a former CRNA, said she went to medical school because she found herself unprepared to properly treat high-risk patients with complex underlying conditions.
“We all know when something (bad) happens in an operating room it's a medical or surgical underlying problem,” Fitch said. “The surgeon knows a lot more medicine and surgery than that nurse, and that's why we need the physician oversight.”
Although nurse practitioners more commonly work in primary-care settings, a nurse anesthetist is working in a much more acute situation, where time is of the essence and medical knowledge is crucial when something goes wrong, Fitch said. “That's the essence of why this issue is so dangerous, because there is so little time to prevent patients from dying when things go wrong,” she said.
Both inside and outside of the VA, the issue is a lack of understanding of what nurse anesthetists can do for a healthcare organization, nurse anesthetists say.
“It's reasonable to assume that not every hospital administrator knows the most safe and cost effective anesthesia delivery model,” Purcell said. “It's important for them to know that information, because the demand for the service anesthesia professionals offer is growing, and nurse anesthetists can solve a lot of problems in the VA through the full practice authority that the agency is considering.”
Purcell and the AANA believe the VA may have a proposed rule in the works regarding scope of practice, which would make legislation unnecessary. The VA wouldn't comment on whether that rule is happening, but said it is reviewing proposed legislation.
The American Association of Nurse Practitioners has voiced support for both bills, but encourages Senate bill sponsor Mark Kirk (R-Ill.) to include all advanced practice nurses in his proposal, said Mary Anne Sapio, the organization's vice president of federal government affairs.
Nurse practitioners follow full scope-of-practice laws in 21 states and D.C. NPs in particular can help the VA extend services by treating a backlog of veterans seeking care, Sapio said.
“We see it as a great service that we can provide to our veterans by allowing them unencumbered access to our NP services,” Sapio said. “We believe we can be extremely helpful to alleviate that backlog.”
