84 ■ I: HISTORICAL AND THEORETICAL FOUNDATIONS FOR ROLE DELINEATION
Nationally, 18 states have enacted the “opt out,” where physician anesthesiolo-
gist supervision is no longer required for Medicare and Medicaid patients. This was
intended to increase access to care for those patients who resided in primarily rural areas
(Agres, 2010). According to 2004 data by the AANA, approximately 39% of CRNAs were
employed by hospitals; 36% were employed by physician anesthesia groups; 15% were
employed by nurse anesthesia groups; and 10% were employed by a physician office
(dentist, podiatrist), were self- employed, or were employed by a university (AANA,
2013). Military CRNAs have had a distinguished history of autonomous practice. On
Navy ships, smaller military and Veterans Administration (VA) hospitals, and on the
battlefield they have provided and continue to practice without anesthesiologist super-
vision as the sole provider to the U.S. military (Jenkins, Elliott, & Harris, 2006).
The current scope of practice according to the practice guidelines, published by
the AANA, includes:
- Preoperative assessment
- Development and implementation of an anesthetic plan
- Anesthesia delivery (sedation, general anesthesia, regional and neuraxial anes-
thesia) - Selection and implementation of noninvasive and invasive monitoring (arterial
lines, pulmonary artery [PA] catheters, and central lines) - Airway management (natural airway, endotracheal intubations, laryngeal
mask airway [LMA] placement and implementation of alternative airway tech-
niques, fiber- optic intubations [FOI], needle cricothytotomy) - Facilitation of emergence from anesthesia; transfer to the post- anesthesia care
unit (PACU) and PACU management - Chronic and acute pain management
- The ability to function as a member of emergency response teams (providing
cardiopulmonary support) (AANA, 2010)
It is important to note that the scope of practice for CRNAs is determined by indi-
vidual state nursing boards and by each facility where the CRNA practices, as deter-
mined by their bylaws.
Nurse anesthesia has, from its nascence, had to continuously and diligently prove
its important contribution to the delivery of anesthetic care within the matrix of the U.S.
health care system. Two important, recent studies examined the effect of the anesthe-
sia provider on mortality rates (Canadian Coordinating Office for Health Technology
Assessment, 2004). First, Pine, Holt, and Lou (2003) examined risk- adjusted mortality
rates for the following provider models: anesthesiologist as sole provider, CRNAs as sole
provider, and the ACT model. Medicare patients undergoing eight surgical procedures
were the focus of the study. Results indicate that there was no statistically significant
difference between provider types. Similar results were found among the sole CRNA
provider, anesthesiologists, and ACT personnel (Pine et al., 2003), meaning anesthesia
care outcomes were equivalent regardless of provider type. Second, Jordan, Kremer,
Crawforth, and Shott (2001) found no statistical difference in adverse outcomes between
type of provider and preoperative physical status, patient age, surgical procedure, or
method of anesthesia in a study that reviewed 223 closed claims studies from 1989 to
- In 2010, Dulisse and Cromwell’s retrospective study of Medicare data from 1999
to 2005 reported no adverse outcomes when CRNAs are not supervised by a physician.
This study, published in Health Affairs , was important in that it was not biased and the
authors recommended that the Centers for Medicare & Medicaid allow CRNAs to prac-
tice without physician supervision in every state. Although only two studies have been
cited, it is important to note that CRNAs, who now almost universally have a master’s