The California Department of Public Health (CDPH) issued a letter in September clarifying the role of Certified Registered Nurse Anesthetists (CRNAs) in the state’s health care system.
The letter came following surveys conducted at Stanislaus Surgical Hospital and Doctors Medical Center in Modesto, California, where CRNAs were found practicing independently without appropriate physician supervision.
These surveys, conducted by state and federal surveyors, led to “Immediate Jeopardy” citations at both facilities, which resulted in the cancellation of surgeries.
The surveyed hospitals had outdated policies that didn’t reflect the current legal requirements for anesthesia staffing, Rachel Carey, counsel at legal firm Whiteford, Taylor & Preston LLP told ASC News. The confusion around the CRNA scope of practice in California stems from the state’s 2009 opt-out of Medicare’s physician supervision requirement, Carey said.
“The CRNA supervision opt-out is in the conditions of participation for hospitals and ambulatory surgery centers (ASCs),” she said. “There’s a requirement for an overseeing and directing physician, but it doesn’t specifically state that the physician must be an anesthesiologist.”
As for who can provide anesthesia, CRNAs require supervision, but operators can opt out of that if it aligns with the state’s regulations for the CRNA scope of practice.
“California did opt out, and it was highly litigated for several years,” she said. “They kept the opt-out. What’s interesting is that while CRNAs don’t have independent prescribing authority, they weren’t required to rely on anesthesiologists to the extent that they would prescribe the plans.”
A nationwide impact
Although this guidance specifically targets California, it has broader implications, particularly in states where CRNA advocacy groups push for expanded autonomy.
CDPH also acted on behalf of the Centers for Medicare & Medicaid Services (CMS), whose regulations apply to hospitals across the U.S. that participate in Medicare and Medicaid programs, Carey said.
Hospitals and ASCs across the country should be paying attention, she added.
“If [CDPH] were just coming in on behalf of the state and only looking at those areas, it would be one thing, but they were also acting on behalf of CMS,” she said. “With this guidance in mind, ASCs are urged to revisit their policies, procedures and staffing models related to anesthesia services.”
Operators need to make sure CRNAs are appropriately credentialed for the procedures they’re performing, she added.
“For instance, if a facility is starting to offer outpatient procedures that traditionally required hospital-based care, like C-sections, it’s critical to confirm that the CRNA has the right experience and qualifications,” she said.
The nationwide shortage of anesthesiologists is one of the contributing factors to the increased reliance on CRNAs in many facilities. This case serves as a reminder of the delicate balance between cost-saving measures and maintaining high standards of care, Carey said.
“The goal should be to ensure that all patients receive safe, high-quality anesthesia care, whether it’s provided by a CRNA or an anesthesiologist,” she said. “But the reality is that cutting corners on staffing, particularly in anesthesia, can lead to serious compliance issues and, more importantly, adverse patient outcomes.”
Carey advised facilities looking to expand CRNA roles to closely examine state and federal guidelines, particularly given the ongoing debate about CRNA autonomy.
“We’re at an interesting point in anesthesia,” Carey said. “We want qualified people, whether they are CNAs, anesthesiologists, or anesthesiologist assistants, to be in the field. However, I think we need to take a broader look at what we want in terms of requirements.”
