WASHINGTON — Nurse anesthetists will not be able to independently administer anesthesia — at least as of now — in Department of Veterans Affairs (VA) facilities under a that scaled back an earlier proposal.
“The Department of Veterans Affairs (VA) is amending its medical regulations to permit full practice authority of three roles of VA advanced practice registered nurses (APRN) when they are acting within the scope of their VA employment,” the agency said in the rule. “Certified Registered Nurse Anesthetists (CRNA) will not be included in VA’s full practice authority under this final rule, but comment is requested on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking.”
Although nurse anesthetists did not get the go-ahead, three other types of advanced practice nurses did: certified nurse-midwives, nurse practitioners, and clinical nurse specialists. “By permitting [these] three APRN roles … throughout the VHA [Veterans Health Administration] system with a way to achieve full practice authority in order to provide advanced nursing services to the full extent of their professional competence, VHA furthers its statutory mandate to provide quality health care to our nation’s veterans,” wrote the authors of the rule.
“This regulatory change to nursing policy permits three roles of APRNs to practice to the full extent of their education, training and certification, without the clinical supervision or mandatory collaboration of physicians.”
The rule has been the subject of some controversy. “We feel this proposal will significantly undermine the delivery of care within the VA,” , chair of the American Medical Association’s (AMA) board of trustees, this past spring when the proposed rule was first issued, adding that the association was “disappointed” by the VA’s “unprecedented proposal.”
“The AMA urges the VA to maintain the physician-led model within the VA health system to ensure greater integration and coordination of care for veterans and improve health outcomes,” Permut said then.
Responding to the final rule, the American Society of Anesthesiologists (ASA) praised the decision to withhold full authority from nurse anesthetists. “This was the right decision for our nation’s veterans and for safe patient care,” ASA President , said in a statement. “We’re thrilled with the VA’s decision to remove anesthesia from the new Advanced Practice Registered Nurses rule.
“We commend VA’s leadership for their recognition that the operating room is a unique care setting and that surgery and anesthesia are inherently dangerous, requiring physician leadership. This is true for anyone, but especially for our nation’s veterans, given many of them have multiple medical conditions that put them at greater risk for complications during and after surgery and anesthesia.”
The American Medical Association (AMA) also praised the decision. “The AMA is pleased that the VA final rule continues to recognize the critical need for collaboration among physicians and nurse anesthetists to ensure patient safety when delivering anesthesia care,” AMA president Andrew Gurman, MD, said in a statement.
However, he added, the association is not happy that other advanced practice nurses will be able to practice independently within the VA. “This part of the VA’s final rule will rewind the clock to an outdated model of care delivery that is not consistent with the current direction of the healthcare system.”
The American Association of Nurse Anesthetists (AANA) said it was disappointed by the final rule. “We think it was a terrible mistake for them not to include us,” AANA president , said in a phone interview. “The VA’s own Commission on Care recommended that all the advance practice nurses, including CRNAs, be granted full practice authority … So they’re not even following their own assessment recommendations.”
The group had backed the original proposal. “Our veterans are waiting too long to get the healthcare they have earned and they deserve,” , president of the American Association of Nurse Anesthetists, in Park Ridge, Ill., said at a June briefing. “We, as advance practice registered nurses (APRNs), all realize we’re ready and capable [of providing] the services that are necessary for our veterans today.”
The American Association of Nurse Practitioners (AANP) was mostly happy with the rule. “This final rule is a critical step for America’s veterans to be able to obtain timely, high quality care in the Veterans Health System,” AANP president , said in a statement. “We are pleased the VA will move forward with allowing veterans throughout the country to have direct access to nurse practitioner-provided health care.” She added, however, that she hoped the VA eventually would allow nurse anesthetists to practice independently.
An unprecedented number of Americans including veterans, their families and caregivers responded to the VA’s request for comments, and we are pleased that their voices were heard.”
The VA gave some background on its decision to leave the nurse anesthetists out of getting full practice authority. “We received 104,256 comments against granting full practice authority to VA CRNAs,” the authors noted. “The American Society of Anesthesiologists lobbied heavily against VA CRNAs having full practice authority. They established a website that would facilitate comments against the CRNAs, which went as far as providing the language for the comment. These comments were not substantive in nature and were akin to votes in a ballot box.”
“The main argument against the VA CRNAs was that by granting CRNAs full practice authority VA would be eliminating the team-based concept of care in anesthesia … Team-based care was not addressed in the proposed rule because we consider it to be an integral part in addressing all of a veteran’s health care needs. Establishing full practice authority to VA APRNs, including CRNAs, would not eliminate any well-established team-based care.”
On the other hand, “The second argument posed against granting full practice authority to VA CRNAs was that there is ‘no shortage of physician anesthesiologists in VA and the current system allows for sufficient flexibility to address the needs of all VA hospitals,’” the rule continued. “VA does believe that evidence exists that there is not currently a shortage of anesthesiologists that critically impacts access to care, and therefore VA agrees with the sentiment of this argument.”
As a result of the agency’s analysis, “We will, therefore, not finalize the provision including CRNAs in the rule as one of the APRN roles that may be granted full practice authority at this time. However, we request comment on this decision,” wrote the authors. “If we learn of access problems in the area of anesthesia care in specific facilities or more generally that would benefit from advanced practice authority, now or in the future, or if other relevant circumstances change, we will consider a follow-up rulemaking to address granting full practice authority to CRNAs.”
The public has 30 days from the final rule’s official publication on Wednesday to weigh in on it. Comments can be submitted beginning Wednesday.