A story in the April 6 edition of the Watertown Daily Times announced recent changes in the way anesthesia is administered at Watertown Regional Medical Center and the piece has generated considerable feedback from around the country.
Since the story ran, readers from the medical field, as well as former anesthesia patients who have had bad experiences, have said they are displeased with the hospital’s decision.
The president of the American Society of Anesthesiologists called the restructuring at WRMC, “a negative move and dangerous for patients.” Others have said they support the changes.
Earlier this month, after what WRMC leadership called, “careful consideration” and with the support of physician leaders and surgeons, the hospital shifted to a comprehensive certified registered nurse anesthetist structure in its anesthesia department. This was a switch away from anesthesiologists who are exclusively medical doctors.
“CRNAs have been providing high-quality anesthesia services at our hospital, and other hospitals across the country, for years,” Richard Keddington, CEO of the medical center said in early April as he announced the changes. “Following evidence-based best practices, these highly trained medical professionals bring essential skills and expertise to rural and medically underserved communities, allowing patients to access critical care when and where they need it.”
ASA President Dr. Beverly Philip, a professor of anesthesia at Harvard Medical School, said, however, that her organization was, “very disappointed to learn of this change in anesthesia practice” in Watertown.
“This is definitely a negative move and dangerous for patients,” Philip said. “Physician-led anesthesia care is the national standard and the care that is provided by the nation’s top hospitals. Patients in rural areas should expect and demand the same standards of care as urban and suburban patients receive.”
Philip said the change is not a common one in the United States in the current era of medicine.
“The nurse-only model of anesthesia is rare,” Philip said. “The vast majority of hospitals across the U.S. recognize the importance of physician-led anesthesia care and are not replacing physician anesthesiologists with nurse anesthetist teams. In fact, doing so in most states is not permissible. Laws in 45 states and the District of Columbia require physician involvement for anesthesia care to ensure the safety of patients. The ASA supports the anesthesiologist-led, team-based model and so does the public.”
Philip said the ASA is committed to ensuring all patients receive the safest, highest quality medical care.
“We will do everything possible to uphold patient-centered, physician-led anesthesia care,” she said. “We advocate that anesthesia be administered in physician-delivered and physician-led care team models.”
Philip added that the ASA supports nurse anesthetists in their work.
“Our members work with nurse anesthetists every day,” she said. “However, there is no independent evidence that patients are as safe under a nurse-only model as they are under an anesthesiologist or the team-based model of care. In fact, the independent research is clear patients have better outcomes with an anesthesiologist involved in their care. Independent research shows that physician anesthesiologists’ care decreases the risk of death and complications. The data also shows elimination of physician involvement does not improve access to care or save medical costs.”
Philip said the team-based model of anesthesia is well-established as a safe, cost-efficient model of care. Medicare and commercial insurers recognize the team-based model, she said.
“There is great flexibility in these team-models that can accommodate any facility,” she said. “But there must be a commitment by the hospital to provide their patients the highest standard of care.”
Philip said recent polls show that eight in 10 patients want a physician anesthesiologist by their side to keep them safe in surgery and nine in 10 surgeons believe physician anesthesiologists are the most qualified to respond to complications and emergencies in the operating room.
“As medical doctors, physician anesthesiologists specialize in anesthesia care, pain management and critical care medicine, bringing the knowledge required to treat the entire body,” she said. “Their education and training includes 12 to 14 years of post-secondary education, including medical school; 12,000 to 16,000 hours of clinical training; at least four months of concentrated work in intensive care units; training to develop expertise in a subspecialty, such as pediatric surgery, labor and delivery, pain management, critical care, neurosurgery or cardiac surgery.”
Philip said, by contrast, nurse anesthetists have five to seven years of education past high school and about 2,500 hours of training.
“We believe that only anesthesiologists have a complete and thorough education, skills and training in anesthesia care,” she said. “ASA has nearly 100 members who previously were educated, trained and practiced as nurse anesthetists. These nurses concluded that they wanted additional training and subsequently completed 4 years of medical school and a 4-year anesthesiology residency program to gain a thorough medical understanding of anesthesia.”
American Association of Nurse Anesthetists President Steven M. Sertich, a CRNA, countered Philip, saying she was “fear-mongering.”
“As healthcare systems become more accountable to the delivery of care, the CRNA approach will continue to drive a higher standard of care,” he said. “CRNAs have a sterling patient safety record and ability to provide high-quality, cost effective anesthesia care. Across Wisconsin, CRNAs spend more time with patients prior to, during and after surgical procedures, providing continuity, greater safety and an enhanced patient experience.”
Sertich said “physician special interest groups” argue that the supervision requirement of CRNAs is necessary, asserting that unsupervised practice lowers the standard of care and risks patients’ lives.
“This type of fear-mongering lacks substance and attempts to confuse the public, and it is not based on science or credible evidence,” Sertich said. “Studies show that anesthesia care is the safest it has ever been, regardless of whether the anesthesia is provided by a nurse anesthetist or a physician anesthesiologist. CRNAs are highly educated practitioners whose skills, leadership, and patient safety record stand for themselves. In fact, 42 states have removed the requirement for physician supervision of CRNAs from their state’s nurse practice acts.”
LaSandra Cooper, senior manager of public relations at the ASA, who works with Philip, said although there are states that do not use the term “supervision,” “ ... all but five use a term that is synonymous, or tantamount, to requiring physician involvement or oversight.”
She said, at present, 45 states and the District of Columbia require, “physician supervision, collaboration, direction, consultation, agreement, accountability, or discretion over nurse anesthetists providing anesthesia services either by law or regulation.”
“For example,” she said, “in Arizona, a physician’s presence and direction is required. So when the AANA’s president says ‘physician supervision,’ he’s omitting the fact that states use words other than ‘supervision’ in laws or regulations in all but five states in the U.S.”
Sertich said that, with a 150-year history of anesthesia delivery, nurse anesthetists practice in every state, in every branch of the military and the U.S. Department of Veterans Affairs system. He said CRNAs also provide the majority of anesthesia care to rural and medically underserved areas in the United States.
“A landmark study published in 2010, and updated in 2016, found that the most cost-effective anesthesia delivery model is a CRNA working as the sole anesthesia provider. Another study published in Nursing Economic$ found that a CRNA working alone is significantly more — 25% more — cost effective than the next most cost-effective anesthesia delivery model,” he said.
According to Sertich, the decision at WRMC is the correct one, particularly for patients and the communities it serves.
“CRNAs have risen to many challenges,” he said, “especially those presented by the pandemic, courageously caring and providing life-sustaining services to Wisconsin’s patients.
Another CRNA, Travis Sullivan, is president of the Wisconsin Association of Nurse Anesthetists. Sullivan said Philip failed to provide any scientific evidence to back up her “emotion-driven statements.”
“This is so often is the case when the medical community feels threatened by qualified providers who are equally safe and more cost-efficient,” Sullivan said.
Sullivan said that, in Wisconsin, CRNAs provide more than 850,000 anesthetics to patients annually.
“They are master’s- or doctoral-prepared anesthesia experts who provide every type of anesthesia, to patients in every age group, for every kind of procedure, and in every type of healthcare setting where anesthesia is required,” he said. “Approximately 60 hospitals and numerous surgery centers, physician offices and other facilities across our state rely on CRNAs practicing independently — in other words, CRNAs providing anesthesia without the involvement of an anesthesiologist. As the primary anesthesia professionals in Wisconsin’s rural and critical access hospitals, CRNAs enable these facilities to provide surgical, obstetrical, emergency and chronic pain management services to patients who otherwise would have to travel long distances for needed healthcare.”
Sullivan contradicted Philip’s statement that CRNA, nurse-only models are rare.
“The truth is, it has been common for the last two-plus decades,” he said. “So well-respected are the capabilities of CRNAs that Wisconsin state law does not require them to be supervised by physicians of any type, including anesthesiologists. There are 42 states in total that do not require physician supervision at the state level. Further, Wisconsin is one of 19 states that have also opted out of the federal Medicare physician supervision requirement for CRNAs since 2001.
Last year, Arizona and Oklahoma became the 18th and 19th states. Wisconsin opted out in 2005.”
Sullivan said that, even when CRNAs work with an anesthesiologist, it is typically the CRNA who provides the hands-on patient care — intubating the patient, staying with them throughout the procedure to monitor anesthesia, waking the patient up at the end of the procedure and delivering them to the recovery room.
“This is often without the anesthesiologist in, or even stopping by, the operating room,” Sullivan said. “It is also not uncommon for CRNAs to be the on-call providers — overnight — while the anesthesiologists are home in bed.”
In followup comments to the Daily Times’ initial article, Keddington clarified that WRMC will continue to have a physician anesthesiologist on staff, but that person will not be on-site at all times for the administration of anesthesia.
“This physician will provide clinical oversite and leadership for all anesthesia services,” Keddington said. “As previously shared, very little is changing here at Watertown and this model is proven to be as safe as others, with no difference in quality, risk of complications, or patient outcomes.”
Philip, however, remained steadfast in her belief WRMC should rethink its new model.
“If you or your family member was having a procedure or surgery, who would you want administering his or her anesthesia care?” She said. “The change in the anesthesia practice model at this facility represents a step back from the safe, physician-delivered and physician-led models of anesthesia care our patients expect. The nurse-only model of anesthesia care is rare and for good reason — it is inconsistent with the highest standards of patient safety. The independent research is clear — physician involvement in anesthesia care provides better outcomes.”