Court rules nurse anesthetists don't need physician supervision

Certified registered nurse anesthetists may administer anesthesia to patients without physician supervision, a Colorado appeals court has ruled.

It’s the second such ruling in recent months. In June, the Supreme Court of California refused to block a lower court’s ruling allowing CRNAs to deliver anesthesia independently.

Doctors say the two rulings are harmful to patient care.

Dr. Clark

“This is first — and last — a patient safety issue,” said Randall Clark, MD, a Colorado anesthesiologist and regional director of the Colorado Society of Anesthesiologists, a plaintiff in the Colorado lawsuit. He also is a member of the American Society of Anesthesiologists board of directors. “Does this improve the quality of care that a patient receives, or does it diminish it? Any reasonable person would agree that it diminishes it. It removes physician oversight from the delivery of a very complex aspect of medical care.”

The Colorado Assn. of Nurse Anesthetists applauded the Colorado ruling, saying it is beneficial to patients. Research shows no differences in patient morbidity or mortality rates whether or not CRNAs are supervised by doctors, said Scott Shaffer, DNAP, CRNA, president of the Colorado Assn. of Nurse Anesthetists.

The California and Colorado cases stem from a decision by governors to opt out of requiring CRNAs to be supervised by a physician. Federal law says ambulatory surgical centers, hospitals and critical access hospitals must provide doctor supervision to CRNAs to receive Medicare payment.

States can opt out if governors consult with appropriate medical boards and conclude that an exemption is in citizens’ best interests. In 2010, then-Colorado Gov. Bill Ritter Jr. exercised an opt-out to all critical access hospitals and 14 rural hospitals in the state.

The Colorado Medical Society and the Colorado Society of Anesthesiologists sued. They contended that the opt-out was inconsistent with state law and requested the court to block the governor’s decision. In 2011, a district court upheld the exemption, and the doctors appealed. The Litigation Center of the American Medical Association and the State Medical Societies, along with the American Society of Anesthesiologists, filed a friend-of-the-court brief to the Colorado Court of Appeals in support of the Colorado Medical Society.

The appeals court on July 19 ruled in favor of CRNAs. In its opinion, the court said CRNAs who administer anesthesia are conducting independent nursing functions within the scope of nursing standards, and the state had the authority to opt out of the federal supervision requirement.

The doctors probably will appeal, Dr. Clark said.

Raising liability concerns

The Colorado Medical Society expressed disappointment at the ruling but noted that the court ruled only on whether state law allowed CRNAs to administer anesthesia independently and not on the wisdom behind the practice.

“There is no dispute that nurse anesthetists are highly trained professionals,” said Kari Hershey, an attorney for the Colorado Medical Society. However, “as an organization, we believe that patients receive the best care when care is delivered by highly trained, physician-led teams.”

The ruling means greater access to care for patients, said Shaffer, a Salida, Colo.-based CRNA. In the past, surgeons were hesitant to relocate to Salida after learning that they must supervise CRNAs, Shaffer said.

“It’s a huge access-to-care issue without a doubt,” he said. “Prior to the opt-out, there was a perception of [increased] liability from surgeons, and it [inhibited] providers from coming this way.”

Dr. Clark said the appeals decision raises new liability dilemmas for physicians and patients. A Colorado doctrine has long held that an operating surgeon is liable for the actions of those in the operating room, stemming from the doctor’s presumed ability to control all operating room staff.

The ruling “completely muddles who the surgeon is responsible for and when they are responsible,” Dr. Clark said. This “will create a gigantic burden on injured patients who will have to decide whose conduct” contributed to their injuries.

California doctors face similar issues after the state in 2009 chose to exempt California from requiring physician supervision of nurse anesthetists in Medicare-participating hospitals. The California Medical Assn. and the California Society of Anesthesiologists had sued to block the opt-out.

A March decision by the 1st District Court of Appeals affirmed a lower court’s decision to allow the exemption. The CMA sought a review by the state Supreme Court, which refused to examine the case. The AMA Litigation Center filed a friend-of-the court brief in support of California doctors.

In a statement, the CMA expressed disappointment at the state high court’s decision.

“Although nurse anesthetists can and do administer anesthesia, physicians are the most qualified to monitor the effects of the anesthesia and to react immediately when medically necessary,” the CMA said. “CMA is disappointed with the court’s decision but remains undeterred and committed to protecting the quality and safety of all medical care provided to Californians.”