California nurse anesthetists can practice independently, judge rules

The decision puts patients at risk by allowing CRNAs to administer anesthesia unsupervised by doctors, physician organizations say.

By — Posted Nov. 1, 2010

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A California judge has ruled that certified registered nurse anesthetists can work without physician supervision.

The ruling stems from a lawsuit filed by the California Medical Assn. and the California Society of Anesthesiologists against California Gov. Arnold Schwarzenegger. The suit sought to block the governor's decision to opt out of a Medicare provision that requires physician supervision of nurses administering anesthesia. California is among 16 states that opted out of the federal rule.

At issue is whether California law requires physician supervision of nurses administering anesthesia. State physician organizations say it does, but state nursing groups say it doesn't.

In his Oct. 8 ruling, San Francisco County Superior Court Judge Peter Busch said there is no state statute that specifically says physician supervision is required of certified registered nurse anesthetists. He said it is up to the California Legislature -- and not the court -- to institute such a rule.

The American Medical Association, CMA and CSA said the ruling jeopardizes patient safety. While nurse anesthetists are a valuable part of a medical team, they don't have the training to diagnose and respond to a medical emergency if a patient has an adverse reaction to strong anesthesia medications or another problem arises, the organizations said.

"For the governor and superior court to decide for the people of California that it is perfectly safe to remove the medical and physician component from anesthesia care is absolutely irresponsible," CSA President Narendra Trivedi, MD, said in a statement. "The governor's plan goes against the belief of most practicing physicians and jeopardizes the quality of care that citizens of California will receive."

An anesthesiologist has eight years of training after college, must complete a four-year clinical residency, and must pass several written and oral exams for certification, while a nurse anesthetist has about three years of training and must pass one three-hour certification exam, said Rebecca J. Patchin, MD, immediate past chair of the AMA Board of Trustees and an anesthesiologist and pain management specialist in Loma Linda, Calif.

"The AMA values the work of nurse anesthetists, but there are vast differences in the education and training of a physician and a nurse anesthetist which can impact patient care," she said.

A question of access

The governor's office and California Assn. of Nurse Anesthetists said requiring physician supervision would limit access to care in areas that have a hard time attracting and retaining anesthesiologists. Taking the exemption from the Medicare rule was "in the interests of the people of California," Schwarzenegger wrote in a June 2009 letter to the Centers for Medicare & Medicaid Services.

"We are pleased with the ruling, which will continue to allow greater access to important medical services throughout the state," said Rachel Arrezola, a spokeswoman for the governor.

Allowing the Medicare rule opt-out is particularly crucial for rural California, where anesthesiologists are often unavailable or too expensive for limited hospital budgets and many surgeons are unwilling to take on a supervisory role, said Phil Recht, an attorney for CANA.

Recht said there has been "no safety impact whatsoever" since the opt-out provision took effect.

"It's good finally to get the issue settled," he said of the ruling. "It eliminates confusion in the health care market and, in doing so, ensures that California can continue to provide access to critical anesthesia services, particularly in rural areas. That is what this case really is all about."

The CMA and CSA are considering whether to appeal the judge's decision or sponsor legislation to clarify state law.

"It has always been about patient safety," said Long Do, the CMA's director of litigation. "We don't want nurses to put patients under without having a physician supervise it. People react differently to anesthesia, so it's important that a physician be there to react to any unexpected consequences."

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