Anesthesia provision in the United States

In the United States, anesthesia can be administered independently by anesthesiologists or by nurse anesthetists.

Anesthesia providers

Anesthesiologists

Anesthesiologists are physicians specializing in the practice of anesthesiology.

The training of an anesthesiologist typically consists of 4 years of college, 4 years of medical school, 1 year of internship, and 3 years of residency. Completion of the written and oral Board examinations by a Physician is insufficient to allow one to be called "Board Certified" or a "Diplomate" of the American Board of Anesthesiology as additional license, training, and professional standards must also be met. It is not required to be board certified in the USA in order to practice anesthesiology. According to an American Society of Anesthesiologists (ASA) press release Anesthesiologists provide or participate in more than 90 percent of the 40 million anesthetics delivered annually.^[1]

Other specialties within medicine are closely affiliated to anesthesiology. These include intensive care medicine and pain medicine. Specialists in these disciplines have usually done some training in anesthetics. Anesthesiology is not limited to the operation itself. Anesthesiologists are termed "peri-operative physicians", and involve themselves in optimizing the patient's health before surgery, performing the anesthetic, following up the patient in the post-anesthesia care unit and post-operative wards, and ensuring optimal analgesia throughout.

Nurse Anesthetists

As a long-standing profession in the United States, advanced practice registered nurses specializing in the provision of anesthesia are Certified Registered Nurse Anesthetists (CRNAs). As of 2007 CRNAs represent 50% of the anesthesia workforce in the United States, with 36,000 providers, according to the American Association of Nurse Anesthetists, and administer approximately 27 million anesthetics each year. Thirty-four percent of nurse anesthetists practice in communities of less than 50,000. CRNAs begin their education with a four-year Bachelor of Science degree and more than 1 year of critical care nursing experience. During 3 years of graduate school focusing on anesthesiology, they practice to complete a master's degree in nurse anesthesia and must pass the NBCRNA national certification exam.^[2] As of 2014 17 governors have opted out of the CRNA supervision requirement of the Centers of Medicare and Medicaid Services (CMS). The remaining states maintain that CRNAs must work with podiatrists, dentists, anesthesiologists, surgeons, obstetricians and other professionals with similar anesthesia training.^[3] CRNAs administer anesthesia in all types of surgical cases, and are able to apply all of the accepted anesthetic techniques—general, regional, local, or sedation. Nurse Anesthetists are able to practice anesthesia independently in some states, as well as in Anesthesia Care Teams.^[4]

Anesthesiologist Assistants

Anesthesiologist Assistants are another group who participate in anesthetic care. They earn a master's degree and can practice only under Anesthesiologist supervision in eighteen states through licensing, certification or physician delegation.^[5] Anesthesiologist Assistant's responsibilities in the ACT settings are similar to those of CRNAs.

Anesthesia Supervision

Effective November 13, 2001, CMS established an exemption for Certified Registered Nurse Anesthetists (CRNAs) from the physician supervision requirement. This exemption recognized a Governor's written request to CMS attesting that he or she is aware of the State's right to an exemption of the requirement and that is in the best interests of the State's citizens to exercise this option. As of September 2014, seventeen States have chosen to opt-out of the CRNA physician supervision regulation. The States are: California, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin, Montana, Colorado, and Kentucky. ^[6]

Anesthesia Care Teams

According to the ASA statement on the Anesthesia Care Team, anesthesia care personally performed or medically directed by an anesthesiologist constitutes the practice of medicine. According to the American Association of Nurse Anesthetists and state law in all fifty states, anesthesia care provided by a Certified Registered Nurse Anesthetist is considered the practice of nursing. Certain aspects of physician directed anesthesia care may be delegated to other properly trained and credentialed professionals.^[7]

Law regarding anesthesia provision

It has been established that, under US law, anesthesia is both the practice of medicine and nursing. Frank v. South,^[8] Chalmers-Francis v. Nelson^[9] and other court decisions determined that anesthesia was the practice of Nursing as well as Medicine.^[10] As such, the practice of anesthesia in the US may be delivered by either a nurse anesthetist or an anesthesiologist. The decisions have not been challenged since the Dagmar Nelson case.^[11] In addition to legal decisions, individual hospital and surgical facility policies also regulate the granting of anesthesia clinical privileges.

See also

• ASA physical status classification system

References