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Proposed state bill has doctors, nurses at odds over who can give anesthesia

LANSING — Once a week, Mike Dosch typically works out of an operating room at Dearborn’s Beaumont Hospital, formerly Oakwood Hospital, delivering anesthesia to his patients.

Dosch, who has been a certified registered nurse anesthetist for 25 years, works as part of what’s known as an anesthesia care team. A physician who supervises as many as four registered nurses will order an anesthetic, he said, and the nurse anesthetist will decide the best way to give it.

“(Physicians) help start cases; they are there available for consultation,” said Dosch, also chairman of, and an associate professor in, the nurse anesthesiology department at the University of Detroit Mercy.

“Generally speaking, particularly with cases that are sort of routine, we don’t see them much during the day.”

More than 30 miles away, in Ann Arbor, Kevin Tremper, M.D., manages a team of 150 faculty anesthesiologists, 140 anesthesiology residents and roughly 120 nurse anesthetists as chairman of the anesthesiology department at the University of Michigan.

Doctors and nurses who give anesthesia care are battling over an important part of the treatment — which member of the healthcare team should be delivering the medicine to the patient.

A bill pending in the state Senate would remove Michigan’s requirement that physicians supervise nurse anesthetists, effectively allowing registered nurses to order and administer anesthesia on their own before, during and after surgery. The bill also would allow nurse anesthetists to practice independently during obstetrics and diagnostic procedures.

The bill remains in the Senate’s Health Policy Committee; it has not come up for a vote since testimony was heard in May.

The issue is framed in questions about access versus safety, especially in rural areas. Doctors say their more extensive training makes them the most-qualified providers of anesthesia care. Nurses say they’re crucial to delivering care to regions where there are not many doctors while also lowering medical costs at a time when health care systems face pressure to do so.

Physician anesthesiologists like Tremper review patients’ medical histories, work up anesthesia plans for the surgical procedure the patients will receive, and supervise nurse anesthetists as they start and finish administering an anesthetic.

Sometimes, he said, the CRNA will insert a breathing tube to manage the patient’s airway while a U-M faculty member gives the drugs, while at other times they switch roles.

“We work as an integrated team,” Tremper said. “It’s two people, four hands, there for the takeoff and the landing. You might have the pilot and co-pilot go back and forth during the flight, but they’re both behind the controls.”

A longstanding debate

This is not the first time the issue has been raised in Michigan, nor is it the only state to have entertained the debate. Expanding the authority of such advanced practice nurses, though, is a political football without clear-cut evidence on either side.

Depending on whom you ask, Michigan is either one of a few or one of many states with a supervision requirement. And several academic studies circulating as part of the debate were partially funded or supported by groups with a vested interest in the outcome.

Advocates, including nurse anesthetists and the Michigan Health and Hospital Association, say the law change would modernize Michigan’s health care delivery — particularly in rural towns, which they say have a harder time attracting or affording physician anesthesiologists and often rely on nurses to deliver anesthesia.

Anesthesiologists, who are leading the opposition charge, favor the use of teams, which include nurse anesthetists but are led by doctors with deeper medical training. Some even have gone so far to say that allowing nurse anesthetists to operate without doctor supervision will lead to more people who can prescribe opiates for postoperative pain management, which could lead to more prescription drug abuse — although little proof has been presented to back up the claim.

“Anybody that even brings up the opiate issue, that’s borderline ludicrous,” said Sen. Mike Kowall, R-White Lake Township, who sponsored the bill. “They’re only allowed to practice in the immediate area in the OR. It’s not like, ‘Here’s a handful of whatever, have a nice day.’”

Instead, Kowall said, his bill intends to allow nurse anesthetists to work to the full extent of their training, which includes a master’s degree and thousands of hours of study.

Requirement ‘on paper’?

Nurse anesthetists are registered nurses who have gone through advanced training in anesthesia care. They are licensed under Michigan’s public health code.

A 1989 decision by then-Michigan Attorney General Frank Kelley further outlined the requirement that nurse anesthetists can give anesthesia under the delegation and supervision of a physician. That isn’t limited to anesthesiologists; surgeons or other doctors on staff are able to sign off on the treatment plan.

“It’s really just a supervision requirement on paper,” said Anna Polyak, senior director of state government affairs for the American Association of Nurse Anesthetists. “Surgeons, they don’t like to be a supervising physician if they don’t have to be because, again, it’s not their area of expertise.”

The Michigan Association of Nurse Anesthetists says it has 2,300 members, with another 150 students and 400 more registered nurse anesthetists in Michigan who don’t belong to the association. The U.S. Bureau of Labor Statistics, however, estimated 1,780 were working in Michigan as of May 2014, the most recent data available.

Under Kowall’s bill, Senate Bill 320, nurse anesthetists would be allowed to develop a patient’s treatment plan; perform all tests and procedures related to treatment; order, prescribe and administer anesthesia, including prescription drugs or other controlled substances; and handle any patient emergencies that might arise during the procedure.

Nurse anesthetists only would be allowed to give anesthesia in a licensed health facility or other medical setting during surgery, obstetrical or interventional procedures or for diagnostic imaging purposes. Those services would not include chronic pain management, although nurses could give anesthesia to manage pain if delegated the authority by a physician.

Kowall said he plans to revise the bill to specifically exclude dental clinics from the list of facilities in which nurse anesthetists could practice without supervision.

“They’re helping to keep the cost of healthcare down,” he said. “Quite frankly, there are areas in the state that (have) a shortage of doctors and a shortage of anesthetists, and the nurse anesthetists can fill that void.”

Pushing cost savings

Supporters, including the Michigan Association of Nurse Anesthetists, says that’s one of the main reasons its pushing the bill. Anesthetists are less expensive.

The annual average salary in Michigan for a nurse anesthetist is $171,520, according to BLS figures. It’s a little higher in the Detroit metropolitan area, at $174,290.

Conversely, the average annual salary for a physician anesthesiologist in Michigan, $263,320, is slightly more than one and a half times that of a nurse anesthetist, BLS data show. The same goes for Detroit, where anesthesiologists earn an average of $269,890.

“Limited access to anesthesia services in rural areas has been an ongoing issue for many hospitals across the state,” the Michigan Health and Hospital Association wrote in submitted testimony on the bill. “The cause of this is twofold — a shortage of anesthesiologists and, in some cases, surgeons practicing in rural areas are concerned about supervising nurses whose anesthesia practice is outside of their physician specialty.

“It is clear,” the association wrote, “that the cost associated with having an anesthesiologist on call 24 hours a day may contribute to the shortage in rural areas.”

Proponents say the law change would benefit not only rural areas, but also smaller private surgical centers and clinics.

They say Michigan is an outlier, that 40 states and Washington, D.C., don’t have a requirement on the books that physicians supervise nurse anesthetists. That figure drops to 33 states when including the requirement in hospital licensing statutes or regulations.

Anesthesiologists, however, claim that 46 states and Washington, D.C., have a requirement that physicians not only supervise, but collaborate, direct, consult or otherwise assist nurse anesthetists in practice.

The National Conference of State Legislatures said it does not track individual state requirements specific to nurse anesthetists.

No opt-out

One number readily available is 17 — the number of states that have opted out of a Medicare physician supervision requirement since 2001, when a federal rule change first gave states the choice. Minnesota and Wisconsin are the only neighboring states to have done so.

Michigan can’t opt out of the Medicare requirement because the state’s definition of nursing practice doesn’t include nurses giving anesthesia independently, the state’s hospital association said in testimony. That would change if the bill becomes law, it said, although hospitals will continue to be able to adopt supervision requirements if they wish.

Trend toward giving nurses more latitude

In 2010, the Institute of Medicine, a unit of the National Academies of Sciences, Engineering, and Medicine, issued a report that called for nurses to play a larger role in the delivery of health care as the U.S. looks to lower costs and increase efficiency — all while its population grays. Requirements under the Affordable Care Act also mean more Americans now have health insurance, which adds to the potential patient load.

A study that year in the journal Nursing Economics found that nurse anesthetists practicing without a doctor’s supervision was the most cost-effective form of care and “the only model likely to have positive net revenue in venues of low demand.” That study was paid for by the national nurse anesthetists’ association.

Since they are capable of giving the same anesthesia services, including on complicated cardiac or pediatric cases, its authors wrote, “anesthesiologists and CRNAs are interchangeable.”

Doctors caution about complications

The supervision requirement isn’t so much to dictate how (and by whom) the anesthesia is given, but to address other medical issues that may arise, said Tom George, M.D., a physician anesthesiologist who practices in Kalamazoo and a past president of the Michigan Society of Anesthesiologists.

What happens, George said, if a patient wakes up from surgery and his left arm is numb? The medical issues, he said, are outside the realm of the nurse anesthetist.

“We would ask: What problem are we fixing?” he said. “There is not a problem.”

Whether anesthesia is safer when given by a nurse anesthetist or an anesthesiologist also depends on whom you ask — and who is funding the study.

A 2010 study in the journal Health Affairs found no significant increase in patient risk when anesthesia was given by a nurse anesthetist working without supervision, using data from states that had opted out of the Medicare rule. That study was funded by the national nurse anesthetists’ group.

Separately, a 2000 study found that both the 30-day mortality rate among patients and the mortality rate after complications arise were less when anesthesiologists led the treatment. That study was mostly funded by the researchers, they wrote, with grants from the Agency for Healthcare Research and Quality and the American Board of Anesthesiology in Raleigh, N.C.
It was published in Anesthesiology, the official journal of the American Society of Anesthesiologists.

The Cochrane Library, a collection of databases specializing in health care research, concluded in a 2014 review of available research that no definitive answer is possible when it comes to which method of anesthesia delivery is best.

It cited the complexity of procedures requiring anesthesia, the low risk of complications from the use of anesthetics and the fact that the studies reviewed were not randomly conducted.

Nurse anesthetists, said Tremper, are “the — by far — best-trained, most-skilled nurses, period.”
“They do a great job,” he added. “We think working with us has been very effective in providing very safe care, and we think we have a lot of room to improve in improving postoperative outcomes, but just to avoid having a physician involved seems like not a good idea.”

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