Two sides to the quality care issue
A year ago, three categories of advanced practice registered nurses (APRN) were granted full practice authority within the Veterans Health Administration (VHA) system when acting within their scope of employment. This stepped up authority, the result of a final rule announced on December 14, 2016, extends to certified nurse practitioners, clinical nurse specialists, and certified nurse midwives. Left out, however, were certified registered nurse anesthetists (CRNA)—who had been part of the proposed rule.
Two groups, one on each side of the CRNA practice authority question, both say they want what is best for patients and the healthcare system in general.
“The American Society of Anesthesiologists [ASA] holds as its primary mission patient safety and quality of care. We work toward assuring the greatest number of patients, including veterans, get optimal perioperative care,” says Jeffrey Plagenhoef, MD, presdent of the American Society of Anesthesiologists (ASA).
Plagenhoef says the ASA is not trying to disrespect CRNAs or downplay their role in patient care; rather, the organization supports a team-based model that is physician-led.
The Amercain Association of Nurse Anesthitists (AANA) agrees with the team-based approach model, but it has a different definition of a team.
“The team approach is a good approach—one that is patient-centered and not physician-centered. I believe that in the future, if we can do that, we will be giving our patients the best of both worlds,” says Cheryl Nimmo, DNP, MSHSA, CRNA, president of AANA. “This ruling … increases the number of hands-on available providers in the VA system without costing the taxpayers any more dollars. So cost-wise it makes an awful lot of sense, safety-wise it makes an awful lot of sense, and for the patients it makes an awful lot of sense because it increases their access and it decreases their wait time significantly.
“[The VA] made a big mistake not including us in the final rule … with very little support and evidence for that decision. We are going to work to challenge that decision and provide evidence and additional information and data that will encourage them to change their minds,” says Nimmo.
The Cochrane Collaboration, an independent healthcare research collaborative, assembled an assessment to see whether non-physician anesthetists can provide anesthetic services equivalent to those of physician anesthetists. Cochrane searched databases for controlled trials, non-randomized studies, non-randomized cluster trials, and observational study designs related to assessing the safety and effectiveness of different anesthetic providers for patients undergoing surgical procedures under general, regional, or epidural anesthesia. The findings from the studies varied. For example, stated the assessment’s authors, “one study reported a lower mortality risk for non-physician anesthetists working independently compared with supervised or directed non-physician anesthetists. One reported a higher mortality risk for non-physician anesthetists working independently than in a supervised or directed non-physician anesthetists group, but no statistical testing was presented.”
The authors concluded that they could not provide an answer to the question under review.
“No definitive statement can be made about the possible superiority of one type of anesthesia care over another. The complexity of perioperative care, the low intrinsic rate of complications relating directly to anesthesia, and the potential confounding effects within the studies reviewed, all of which were non-randomized, make it impossible.”
Nimmo, who is a veteran, disagrees with the argument that CRNAs are not qualified to take care of veterans because they typically have more health issues than the average patient. “CRNAs typically deal with soldiers on the frontlines of battles, and there aren’t that many, if any, anesthesiologists at that time. I would say that we are qualified to take care of the veterans.
“Both groups are highly educated and very skilled at what they do, and in fact, a lot of our education is exactly the same as theirs. We take the same classes and we use the same textbooks. It is important that the public realize that both groups are highly trained, highly skilled, highly educated, so I would not put down one group over the other. But our priority is patients,” says Nimmo.
She adds that veterans are currently not getting the same level of care of other patients because they wait longer to get that care.
Plagenhoef argues that veterans deserve to have a physician-led anesthesia care team because most patients receive care from such teams.
“It should come across as counterintuitive and illogical to say we are going to improve quality and safety and not have physicians part of that equation at all,” says Plagenhoef. “That calls into question the entire medical education system in the USA, which is an undeserved question. It has evolved over time because it produces a high-quality product in physicians of all specialties.
“I won’t apologize for offending anybody when what I am offending them with is saying we should provide our nation’s veterans, those who provide our rights and freedom in this country, with the highest-quality and safest perioperative care that we can offer.”
Source: News and Anaylsis