Governor Rick Perry (R-TX) and Governor Bob Holden (D-MO) have indicated that they do not intend to opt out of the Medicare requirement for physician supervision of nurse anesthetists. The opt-out issue has not been considered by the Boards of Medicine and Nursing in Texas and Missouri. In a letter to the Texas Society of Anesthesiologists, Governor Perry stated, “Although federal policies currently allow states to opt out of certain supervision requirements for anesthesia, Texas presently has no plans to avail itself of this option.” Governor Holden stated in a letter to the Missouri State Medical Association, “My number-one concern is patient safety, and after meeting with both anesthesiologists and nurse anesthetists on this issue, I have determined it is in the best interest of our citizens that our supervision requirements are left in place. This rule has worked well protecting patients during the critical administration of anesthesia, and I am confident that it will continue to do so.”

The debate over the opt out continues in Alaska, Kansas, Kentucky, New Mexico, North Dakota, Oregon, Washington and Wisconsin.

Nurse Anesthetists
The District of Columbia Department of Health has proposed regulations to expand the scope of practice of nurse anesthetists by eliminating the existing requirement that nurse anesthetists practice in collaboration with an anesthesiologist, other physician or dentist and practice pursuant to a written protocol agreement. Under the proposed regulations, nurse anesthetists would interact collaboratively with “other health professionals.” The scope of practice defined in the proposed regulations includes ordering and administering general and regional anesthesia; inhalation agents and techniques, intravenous agents and techniques; and techniques of hypnosis. In addition, nurse anesthetists would be permitted to recognize and take appropriate corrective action for abnormal patient responses to anesthesia, adjunctive medications or other forms of therapy and to recognize and treat cardiac arrhythmia. The District of Columbia Society of Anesthesiologists and the Medical Society are opposing the proposed regulations.

Office-Based Anesthesia
The New Jersey Board of Medical Examiners has finally adopted regulations to establish a mechanism by which physicians who do not hold hospital privileges can become “privileged” by the board to administer and supervise anesthesia in the office setting. The regulations must be approved by the Division of Consumer Affairs and Department of Law and Public Safety by November 19. Upon final adoption, a physician who does not hold hospital privileges must apply for board privileges no later than one year after the effective date of the rule.

This alternative privileging process defines the requirements a physician must meet to be approved by the board. A physician who administers or supervises the administration of general anesthesia must, during every consecutive three-year period, complete at least 60 category 1 hours of continuing medical education (CME) in anesthesia. A physician privileged to administer or supervise regional anesthesia must, during every consecutive three-year period, complete at least eight category 1 hours of CME in anesthesia exclusively or as it relates to the physician’s field of practice. A physician privileged to administer or supervise conscious sedation must, during every consecutive three-year period, complete at least eight category 1 hours of CME in any anesthesia services, including conscious sedation exclusively, or in anesthesia as it relates to the physician’s field of practice. Nurse anesthetists must be supervised by qualified physicians.

Minor conduction blocks, with the exception of retrobulbar blocks, shall be administered only by a physician or podiatrist, a nurse anesthetist, a certified nurse midwife, advanced practice nurse or physician assistant who has training and experience in the administration of minor conduction blocks. Retrobulbar blocks shall be administered only by a physician.

The Ohio Board of Medicine has finalized the proposed language for office-based surgery regulations and voted to take the rules into the formal rule-making process. It is expected that the final rules will be approved by the end of the year. The rules provide for accreditation of office settings and reporting of adverse incidents. The proposal would require the supervising nonanesthesiologist physician to develop expertise based on CME or training. For moderate sedation/analgesia, a nurse anesthetist must be supervised by a physician who holds privileges to provide moderate sedation/analgesia in a local hospital or ambulatory surgical center or by a physician who has completed at least five hours of category 1 CME relating to the delivery of moderate sedation/analgesia during the current or most recent past biennial registration period. For general anesthesia, a nurse anesthetist must be supervised by a physician who holds privileges to provide general anesthesia in a local hospital or ambulatory surgical center or by a physician who has completed at least 20 hours of category 1 CME relating to the delivery of general anesthesia during the current or most recent past biennial registration period.

Anesthesiologist Assistants (AAs)
The Ohio Anesthesiologist Assistant Advisory Committee (AAAC), a group formed by the Ohio Board of Medicine to develop the initial proposed regulations, has issued its final report to the board. The board has finalized the proposed regulations and begun the formal rules process. The proposed rules require supervising anesthesiologists to establish a written practice protocol with AAs and to provide direct supervision in the immediate presence of the AA. During the first four years of an AA’s practice, the supervising anesthesiologist shall provide “enhanced supervision.” “Enhanced supervision” requires regular, documented, quality assurance interactions between the supervising anesthesiologist and the AA. An AA shall be required, during the first two years of practice, to file monthly a separate record of cases of anesthetic management in which he or she participated. The record shall be reviewed by a supervising anesthesiologist who shall file a report of each quality assurance interaction.

AAs are permitted to practice only in hospitals and ambulatory surgical facilities and are prohibited from performing epidural and spinal anesthetic procedures and invasive monitoring techniques such as pulmonary artery catheterization, central venous catheterization and all forms of arterial catheterization with the exception of brachial, radial and dorsalis pedis cannulation.

---