Pa. should utilize nurse anesthetists in COVID-19 response | Opinion

Published in the Pennsylvania Capital-Star

By Jessica Poole, Capital-Star Op-Ed Contributor

As the COVID-19 pandemic continues to increase exponentially in Pennsylvania, certified registered nurse anesthetists (CRNAs) are uniquely prepared to provide care for the surge of critically ill patients. Unfortunately, the full contribution of CRNAs is being limited.

There are approximately 3,700 CRNAs and students in Pennsylvania, making us one of the largest contingencies of CRNAs in the nation.

In fact, anyone having a surgery or procedure requiring anesthesia was likely under the direct care of a CRNA. However, due to widespread cancellations of elective surgery throughout Pennsylvania, many CRNAs are off the job, creating an untapped resource for fulfilling critical roles outside of the operating room during this crisis.

CRNAs possess a skillset uniquely suited to aid in management of this crisis. Most have cared for patients as sick as, or even more acutely ill than, the COVID-19 patient. In the operating room, the nurse anesthetist serves as the frontline, critical care intensivist; surveilling, assessing and implementing appropriate interventions.

Much has been said about the importance of ventilators during this crisis, and CRNAs not only routinely use them, but they tailor their complex settings to each patient. Due to a nurse anesthetist’s science-based education and clinical experience, CRNAs understand the why and how of their equipment, allowing them to manage complex patients.

The CRNA possesses hands-on skills extending far beyond their already vast critical care experiences. CRNAs perform rapid physical assessments, airway and ventilatory management, volume resuscitation and hemodynamic management, patient triage, emergency preparedness, and procedural skills that include central and arterial invasive line placement.

Furthermore, a skill unique to the nurse anesthetist is our ability to lead and manage the care of a critical patient. Health care is experiential, and CRNAs have the experience of critical care nursing with further graduate level education in the application of medical skills beyond that of a critical care nurse. This level of expertise places the CRNA in a position of leadership and management extending beyond the operating room.

As frontline health-care professionals, we play a crucial role in the state’s response to this pandemic, especially one related specifically to respiratory failures. Facing unprecedented challenges in our medical communities, health-care systems must prepare to fully utilize the unique skill set of CRNAs.

Pennsylvania remains a state that still requires supervision of a CRNA by a physician. However, under the directive of President Donald Trump, the Centers for Medicare and Medicaid Services removed the national physician supervision requirement for CRNAs and encouraged states to allow CRNAs to practice to the fullest extent of their education and training to best care for patients during this crisis.

States like New York, West Virginia, Maine, Michigan, New Jersey and Arizona have already acted to remove barriers, allowing them to better utilize all available health-care providers without risking patient safety. It is imperative for Pennsylvania to do the same.

Gov. Tom Wolf and his administration should lift the requirement that Pennsylvania CRNAs be supervised by a physician to ensure that CRNAs can respond immediately to the COVID-19 health-care crisis using their advanced education and training to provide expert anesthesia and emergency airway management.

In Pennsylvania, education and clinical training for CRNAs is extensive. Unlike physicians, national board certification is required for CRNAs to practice. In total, CRNAs complete approximately 9,000 clinical hours.

Numerous scientific research studies have shown no statistical difference in patient outcomes when a CRNA provides anesthesia care compared to a physician anesthesiologist, even for rare and difficult procedures. In fact, the Federal Trade Commission cautioned states against policies that restrict the scope of advanced practice nurses. Direction from the President supports this.

More importantly, this crisis requires an all-hands-on-deck approach, and removing the supervision requirement of CRNAs in Pennsylvania will avail more physicians to provide hands-on care, expand the capacity of both CRNA and physician providers, and augment our system to meet the growing demands of this pandemic.

Our health-care systems are challenged to function above capacity, and untethering Pennsylvania CRNAs from unnecessary statutory and regulatory requirements will allow CRNAs to contribute more efficiently to the rapid response needed.

Wolf and his administration should follow the lead of our federal government and several other states by finally permitting CRNAs to serve to the full capacity of their education and training. CRNAs are prepared and eager to help keep Pennsylvania residents healthy and safe.

Jessica Poole is the director of State Government Affairs for the Pennsylvania Association of Nurse Anesthetists.

State asked to allow nurse anesthetists to do more to help in crisis

By Paul J. Gough – Reporter, Pittsburgh Business Times

Apr 7, 2020, 1:47pm EDT Updated Apr 7, 2020, 2:35pm EDT

Pennsylvania's certified registered nurse anesthetists are urging the Pennsylvania Department of Health to waive a supervision requirement to allow them to fully help patients to the level of their training.

Nurse anesthetists are advanced practice nurses that deliver medications including anesthesia during surgery, medical procedures like colonoscopies and dental procedures. They normally work under the supervision of an MD anesthesiologist but have a substantial course of training in their own right: Not just an RN degree but also generally two or three years of advanced practice training beyond it and thousands of clinical hours.

But even though they play a critical role, Pennsylvania's nurse anesthetists aren't given by law what is called a title designation: They can't practice except under the supervision of an anesthesiologist. That, said its trade association the Pennsylvania Association of Nurse Anesthetists, is a critical distinction and an area of opportunity in the commonwealth if health officials allow it.

Pennsylvania is the only state that doesn't allow nurse anesthetists to practice their full scope, which is critically important during the COVID-19 pandemic. New York, the only other state in the country that has the same strictures, last month relaxed them to allow nurse anesthetists to practice to the full level of their training.

That's what Pennsylvania Association of Nurse Anesthetists (PANA) is advocating with the Pennsylvania Department of Health. It's also what the Trump administration, through the Centers for Medicare and Medicaid Services, has done on the national level.

"We are highly educated and trained professionals," said Jess Poole, a Westmoreland County nurse anesthetist and government relations director of PANA. "Our skill sets should be utilized."

That's because in the COVID-19 emergency, some of the skill sets that nurse anesthetists have — the proper intubation and use of ventilators — are really needed. There's already a nationwide shortage of ventilators and more are going to be needed, as well as the skilled medical professionals who know how to use them.

Poole said that it's crucial for nurse anesthetists to be able to help out. Previous attempts to allow it, before a crisis, have not been successful in the Pennsylvania Legislature. But Poole said the Wolf administration has the power to allow them to do it on a temporary, emergency basis.

PANA has requested a waiver from the supervision requirement but it's not yet been granted.

PANA Letter to Gov. Wolf RE: Authorizing Professional Designation to Facilitate Crisis Response

Pennsylvania Association of Nurse Anesthetists

March 25, 2020

Re: Certified Registered Nurse Anesthetists in Pennsylvania

Hon. Tom Wolf, Governor

Commonwealth of Pennsylvania

Office of the Governor

508 Main Capitol Building

Harrisburg, PA 17120

Dear Gov. Wolf:

On behalf of the Pennsylvania Association of Nurse Anesthetists (PANA), which represents more than 3,700 certified registered nurse anesthetists (CRNAs) and students in Pennsylvania, we want to commend you and your administration for the aggressive actions to slow the spread of the coronavirus (COVID-19) and respond to this pandemic. We fully recognize that this unfolding situation has everyone anxious, and we appreciate your leadership on this issue.

As you know, certified registered nurse anesthetists are the hands-on providers of anesthesia care, operating safely in every setting where anesthesia is administered, including hospital operating and delivery rooms; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons; pain management centers and more. As frontline health-care professionals, we play a crucial role in the state’s response to this pandemic. Unfortunately, the full contribution of CRNAs is being limited.

Putting the Full Extent of CRNA Education and Training to Work

As our health-care system strains to address the demands created by the current crisis, one way to increase the number of health-care providers that can address patient needs is to grant advanced practice nurses, including CRNAs, the ability to practice to the full extent of their education and training. Many of the limits on CRNA practice are not based on any data or research, and CRNAs can safely practice beyond these limits (and often do safely practice in other states). States like New York, West Virginia, Maine and Arizona already have acted to remove barriers, allowing them to better utilize all available health-care providers without risking patient safety.

In Pennsylvania, education and clinical training for certified registered nurse anesthetists is extensive, requiring national board certification. In total, CRNAs ultimately complete approximately 9,000 clinical hours including their intensive care unit clinical experience, anesthesia clinical training and undergraduate nursing clinical experience before board certification as a CRNA. Patient safety data from these states do not differ compared to national statistics. In fact, numerous medical studies show there is no statistical difference in patient outcomes when a nurse anesthetist provides treatment, compared to an anesthesiologist, even for rare and difficult procedures.

We don’t know what demands will be placed on our health-care system in the near future, but freeing providers from unnecessary statutory and regulatory burdens will allow CRNAs to contribute more efficiently to the response.

Authorizing Professional Designation to Facilitate Crisis Response

Pennsylvania remains one of only two states that fails to recognize CRNA professional designation in some form. Because there is no formal definition for “certified registered nurse anesthetist” under the state’s Professional Nursing Law, CRNAs are recognized only as registered nurses (RNs). This creates fiscal and logistical challenges that are magnified at times like this.

Pennsylvania ranks among the top draws nationally for CRNAs and students, with 13 highly rated nurse anesthetist programs serving every corner of the commonwealth and helping to sustain one of the largest contingencies of professionals in the country. In times of need, our professionals are in demand to help with crisis response. However, Pennsylvania-based CRNAs cannot be part of response teams in other states that are asking for help simply because our CRNAs lack formal credentials that nearly every other state already recognizes.

Neighboring states like Maryland, Ohio and Virginia, as well as Washington, D.C., all have declared states of emergencies. Because states of emergencies have been declared, Pennsylvania-based CRNAs and other medical licensees are able to work in these states, even if not licensed there. But, we have to practice according to Pennsylvania’s State Board of Nursing requirements, which again only define CRNAs as RNs, limiting our capacity to provide anesthesia as we are trained to do.

Professional designation legislation (S.B. 325) passed the Senate last year but has not yet been taken up by the House. The bill currently sits in the House Professional Licensure Committee. Additionally, a companion bill (H.B. 1064) by Rep. Tarah Toohil (R-Luzerne) has been introduced in the House and remains in committee. These simple professional designation measures would address the current issues that prevents CRNAs from acting in their fullest capacity to help out state and nation at this time of crises.

Other states already are allowing health-care providers to work across state lines. For example, New York Gov. Andrew Cuomo temporarily suspended state licensing laws “to the extent necessary to allow registered nurses, licensed practical nurses, and nurse practitioners licensed and in current good standing in any state in the United States to practice in New York State without civil or criminal penalty related to lack of licensure.” Not only does this allow health-care workers to move to areas that are hardest hit in order to provide care for the patients who need it most, it also greatly expands the possibility of using telehealth, as a nurse in one state would be able to address patient needs in any state. This helps to extend providers’ reach and efficiency, and alleviate demand on local practitioners.

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Our team continues to monitor the situation, relying on state and federal updates, while employing the most effective measures to keep our patients, providers and peers safe and well informed. Like the rest of the country, we are watching with deep concern as the COVID-19 pandemic continues to affect a world already brought to a standstill. Projections show the impact getting worse before things get better. We stand ready to do all we can in partnership with your administration to respond effectively to this crisis. We urge your support for these measures. Thank you.

SINCERELY,

Angelarosa DiDonato, DNP, CRNA

President

Pennsylvania Association of Nurse Anesthetists

Jessica Poole, DNAP, MHS, CRNA

Director, State Government Affairs

Pennsylvania Association of Nurse Anesthetists

cc: Pennsylvania Health Secretary Dr. Rachel Levine