Physician Supervision No Longer Required for Registered Nurse Anesthetists

SAN FRANCISCO — California law no longer requires a physician to supervise certified registered nurse anesthetists (CRNAs), a state appeal court ruled in March.

On March 15, the California Court of Appeal in San Francisco unanimously affirmed a trial court’s ruling that state law, unlike federal law, does not require physicians to supervise CRNAs.

In the ruling, presiding Justice Ignazio Ruvolo noted that while California CRNAs administer anesthesia once given a physician order, the order is not a requirement to do so under physician supervision.

The ruling is especially important to rural and medically underserved areas across the state, where CRNAs commonly administer anesthesia without supervision.

The debate began with a July 2009 letter to the Centers for Medicare & Medicaid Services, when then-Gov. Arnold Schwarzenegger wrote that after consulting with the California Boards of Medicine and of Registered Nursing, it was in the “interests of the people” to opt out of the federal requirement.

The California Medical Association and the California Society of Anesthesiologists then unsuccessfully sued to require the governor to comply with federal law and the court to declare under state law that a CRNA must administer anesthesia under a physician’s watch.

The groups said a lack of physician supervision would make it more difficult for patients needing surgery to receive safe, quality care from physicians.

“Nurses can be an integral part of a medical team if they work hand in hand and under the guidance of physicians, as they have for many decades,” said James Hinsdale, president of the California Medical Association. “But nurses are not trained to react to the myriad potential complications that can arise in the administration of anesthesia. Patients place thorough trust in their physicians when they must undergo surgery.”

Narendra Trivedi, president of the California Society of Anesthesiologists, said the governor’s plan goes against many practicing physicians’ belief that physicians ordering a treatment should supervise the nurses giving it. The plan, he said, potentially jeopardizes the quality of care that Californians will receive.

“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,” he said.

The appellate opinion ruled against the state medical association and anesthesiologist group, which in January 2011 appealed the trial court’s ruling that upheld the state’s right to opt out of the physician supervision requirement.

The California Medical Association has not decided whether to seek review of the appellate opinion in the California Supreme Court.

In his ruling, Ruvolo said there was insufficient evidence to show that an absent supervising physician poses safety risks.

Ruvolo sided with the California Association of Nurse Anesthetists, which presented two national studies that demonstrated in 2010 that nurse anesthetists were safe and cost-effective.

The group “is pleased that the California courts have agreed for the second time that California law authorizes nurse anesthetists to provide safe anesthesia care with no requirement for physician supervision,” said Philip Recht, an attorney for the association.

“The court’s opinion not only confirms the legality of decades-long custom and practice in the state, but recognizes the key role that CRNAs play in California’s and modern medicine’s efforts to expand access to high-quality, cost-effective anesthesia services.”
The association argued the federal supervision rule is not intended to ensure patient safety. Rather, it is a requirement hospitals must meet to receive Medicare reimbursement for anesthesia services — unless a state chooses to opt out of the rule, as California has done.

With the court’s ruling, California joins 15 other states that have opted out of the federal supervision rule.

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