CRNA Practice Models: Scope, Cost, and Team-Based Care

Introduction: A Century and a Half of Nurse Anesthesia

Nurse anesthetists across the nation have administered anesthesia to patients for a century and a half — long before it became a physician specialty. Conventional training occurred in military or hospital-based programs ranging from several months to several years in length. Surgeons strongly supported Certified Registered Nurse Anesthetist (CRNA) practice rights and abilities, and continue to do so today.

Dr. George Crile, founder of the Cleveland Clinic Foundation and a general surgeon, was targeted in 1912 by physicians in Ohio through the state's Attorney General and Medical Board, owing to his advocacy of nurse anesthetists. Dr. Crile, together with Lakeside Hospital where he worked, was threatened with the withdrawal of physician payments and hospital appropriation funding in retaliation for his support of nurse anesthetist training and employment. Following a lengthy five-year struggle, the doctor and his hospital prevailed in their nurse anesthetist advocacy.

Crile's leading nurse anesthetist, Agatha Hodgins, who had held the position since 1908, went on to found the National Association of Nurse Anesthetists, which later became the American Association of Nurse Anesthetists (AANA). During this same period, other lawsuits and sanctions were brought against individuals who trained or employed nurse anesthetists in California, Kentucky, Pennsylvania, and New York (Malina & Izlar, 2014).

According to Massie (2014), the "tipping point" for the nation's healthcare delivery system — representing a moment of critical threshold — has arrived. The concept is straightforward: employ CRNAs as well as APRNs (advanced practice registered nurses) to the fullest extent of their practice scope, and provide cost-effective, superior-quality care with increased accessibility for patients, as mandated by the implementation of the Affordable Care Act (ACA). The Institute of Medicine's 2010 report, The Future of Nursing: Leading Change, Advancing Health, justifies precisely that recommendation, advising APRNs to practice to the full extent of their training and education.

Scope of CRNAs and APRNs

CRNAs administer over 32 million general and local anesthetics per year to patients in the United States. By collaborating with healthcare providers such as surgeons and physician anesthesiologists, they practice in all settings where anesthesia is administered: conventional hospital, obstetrical delivery, and surgical suites; critical access clinics; ambulatory surgical facilities; healthcare facilities affiliated with the Department of Veterans Affairs, the U.S. military, and Public Health Services; and the offices of podiatrists, dentists, plastic surgeons, pain management professionals, and ophthalmologists. Regardless of practice arrangement and setting, research has repeatedly confirmed these anesthetists' exceptional safety record.

In medically underserved parts of the country, such as rural communities, CRNAs serve as the primary anesthesia providers. Their presence enables healthcare facilities and hospitals to provide trauma stabilization, obstetrical, and surgical services to individuals who would otherwise have to travel long distances to access essential care. In some states, CRNAs are the sole anesthesia providers in virtually every rural hospital. Given their history of delivering high-quality, safe anesthesia and their status as the nation's most economical anesthesia providers, their contribution to the American healthcare system is of significant value (Hogan, Seifert, Moore, & Simonson, 2010).

Medicare Part B, as well as the majority of private and public health plans, reimburse CRNAs through various modalities, including both non-medically directed and medically directed services. Non-medically directed services represent significant value to the patient and guarantee high-quality anesthesia delivery that is indistinguishable from costlier practice modalities. This creates savings when compared to the medically directed model, despite both being identically reimbursed under Medicare Part B (Hogan, Seifert, Moore, & Simonson, 2010).

The educational costs of preparing CRNAs are considerably lower than those of preparing anesthesiologists. It typically takes at least 7–8 years to become a CRNA — including one year of acute care nursing experience — whereas it normally takes approximately 12 years to become an anesthesiologist. Moreover, CRNAs enter the medical workforce and begin service approximately four years earlier, which represents an additional advantage for the U.S. healthcare system (Cost Effectiveness of Nurse Anesthesia Practice, 2010).

Studies have found no appreciable differences in anesthesia complication or mortality rates between patients treated by anesthesiologists and those treated by CRNAs, or among different anesthesia delivery models involving anesthesiologists, CRNAs, or both, when other relevant factors are controlled. Research published in peer-reviewed health economics literature indicates that CRNAs who practice independently deliver anesthesia at the lowest cost, with net revenue typically remaining positive. The supervisory anesthesia services model ranks second in cost-effectiveness, though its profitability is constrained by reimbursement policies (Hogan, Seifert, Moore, & Simonson, 2010).

Cost Effectiveness of Nurse Anesthetists

CRNAs practicing in team-based patient care must employ the skills and expertise defined by their scope of practice when collaborating with team members to promote safe, patient-focused care. They are also required to adhere to core teamwork characteristics — including adaptability, shared goals, and collective decision-making — through the application of relationship-building principles when planning and delivering anesthesia care throughout the perioperative process.

Additionally, each team member is expected to incorporate the IOM's principles of timely, safe, equitable, efficient, effective, and patient-focused care. Finally, every anesthesia professional and trainee — including student registered nurse anesthetists, anesthesiologist assistants, and physician anesthesia residents and fellows — is duty-bound to identify themselves accurately to team members, patients, and their families, while also clearly defining the role they play in patient care, whether that involves direct care, training, or supervision (AANA, 2010).

CRNAs and anesthesiologists are interchangeable in terms of clinical capability. Both deliver identical anesthesia services, including relatively complex and infrequent procedures such as organ transplantations, open heart surgery, and pediatric procedures. CRNAs are typically salaried, though their compensation lags behind that of anesthesiologists, and they generally do not receive overtime pay.

With continually growing healthcare demand, the number of CRNAs is increasing, and they are being permitted to practice within highly efficient care delivery models. This expanded utilization will be essential to maintaining healthcare quality while controlling costs. The integration of CRNA practice across diverse settings and team-based care frameworks positions these professionals as critical contributors to the sustainability and accessibility of the American healthcare system (Hogan, Seifert, Moore, & Simonson, 2010).

Conclusion

Malina, D., & Izlar, J. (2014). Education and practice barriers for certified registered nurse anesthetists. The Online Journal of Issues in Nursing, 1–8.

Massie, M. L. (2014). The tipping point in health care: Using the full scope of practice of certified registered nurse anesthetists as advanced practice registered nurses. Springer Publishing Company, 7(1).