Opt-Outs

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Iowa, Nebraska, Idaho, Minnesota, New Hampshire and New Mexico have opted out of the Medicare rule requiring physician supervision of nurse anesthetists. New Hampshire, however, is the only state that allows the independent practice of nurse anesthetists, although only five hospitals in that state use nurse anesthetists exclusively.

Wyoming has considered the issue and decided NOT to opt out, thereby retaining the Medicare supervision standard. The governors of Texas and Missouri have both written letters stating their opposition to an opt-out. The opt-out issue has not been considered by the boards of medicine or nursing in either state. The opt-out was under consideration in Montana, but Governor Martz has indicated she will not opt out at this time. She has asked the medical and nursing boards to establish a joint committee to “better define the lines of authority and responsibility” between physicians and nurse anesthetists.

The issue is under consideration in Alaska, Kansas, Kentucky, North Dakota, Oregon, Washington and Wisconsin.

In Hawaii, a resolution was introduced to establish a task force to consider the opt-out, but it failed to pass the legislature.


Scope of Practice

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Hawaii — The governor signed H.B. 2065 eliminating the role of the medical board in determining prescriptive authority for nurse practitioners and in developing the formulary. This law places total authority within the control of the nursing board. The current formulary excludes general anesthetics and controlled substances.

Michigan — H.B. 4591 would require that a physician who delegates an act, task or function that involves the administration of general anesthesia have privileges at the health facility and be physically available in the health facility at the time the surgery is being performed. The legislation seeks to close a loophole in existing law that conceivably would allow a physician to supervise the administration of anesthesia by telephone. The bill was carried over from last year.

Montana — The Board of Nursing proposed regulations that would have expanded the scope of practice of nurse anesthetists. Under the proposed regulations, nurse anesthetists would have been “independent and/or interdependent” practitioners. The proposed regulations also would have required nurse anesthetists to have prescriptive authority and to practice in accordance with the American Association of Nurse Anesthetists (AANA) guidelines.

The Montana Society of Anesthesiologists vigorously opposed the proposed regulations and argued that the Board of Nursing did not have the statutory authority to expand the scope of practice of nurse anesthetists. The Society also brought this matter to the attention of state legislators. The Board of Nursing ultimately withdrew the proposed regulations, and an interim study committee of legislators is holding hearings on the Nurse Practice Act and the authority of the Board of Nursing to promulgate regulations. The governor has asked the boards of medicine and nursing to form a joint committee to “better define the lines of authority and responsibility” between physicians and nurse anesthetists.

Nebraska — L.B. 396/L.R. 332 proposes an interim study of the scope of practice of advanced registered nurse practitioners, including nurse anesthetists. An interim committee hearing has not been scheduled.

New Mexico — The Board of Nursing adopted regulations to implement the changes in prescriptive authority for nurse anesthetists provided for in the law passed last year. The boards of nursing and medicine are to develop a formulary for nurse anesthetists with prescriptive authority.

New York — S.B. 4923 and A.B. 8749, carried over from last session, would require nurse anesthetists to practice under the supervision of and in the presence of an anesthesiologist who is personally participating and immediately available or under the supervision of a dentist, oral surgeon or podiatrist who is performing the procedure and who is authorized by law to administer anesthesia. An anesthesiologist who is “personally participating” has responsibility for preanesthetic medical evaluation of the patient, prescription and implementation of the anesthesia plan, personally participates in the most demanding procedures in the plan, follows the course of anesthesia administration at frequent intervals, remains physically available for the immediate treatment of emergencies and provides indicated postoperative care. S.B. 4653 and A.B. 8537, introduced on behalf of the nurse anesthetists, define the practice of nurse anesthesia as the “administration of anesthesia, perianesthetic and clinical support functions and pain management, at the order of and in conjunction with a procedure performed by a physician, dentist, podiatrist or other health care professional authorized by law to determine the need for and order the administration of anesthesia.” These bills would give nurse anesthetists the authority to select, order, possess and administer drugs. None of the bills has passed.

Pennsylvania — H.B. 823, carried over from last session, requires that a nurse anesthetist must work under the supervision of a physician who is present in the health care facility when the anesthesia is administered. “Supervision” is defined as medical direction provided by a qualified physician who is responsible for the anesthesia care provided by the nurse anesthetist. The bill states that nurse anesthetists’ services do not include the prescription of medication or the performance of medical diagnosis or therapeutics. The bill passed the House unanimously last year and is pending in the Senate.

South Carolina — Advanced practice nurses, including nurse anesthetists, are seeking to amend existing regulations to eliminate the physician supervision requirement and replace it with physician collaboration. The nurses are seeking prescriptive authority and compliance with guidelines promulgated by national organizations. The South Carolina Society of Anesthesiologists is working to ensure that the nurse anesthetists are carved out of the proposed regulations.

Tennessee — H.B. 1794 and S.B. 1823 would have allowed advanced-practice registered nurses, including nurse anesthetists, to prescribe controlled substances in Schedules II through V. The bill failed.

Texas — The Department of Health proposed regulations to amend anesthesia requirements in ambulatory surgical centers. Among other things, the proposed regulations would have expanded the role of nurse anesthetists by allowing them to evaluate the patient prior to surgery and prior to discharge. The Texas Society of Anesthesiologists (TSA) provided comments to the Department of Health, and the final rule concurs with TSA’s comments. The new rule maintains the requirement that the operating surgeon or anesthesiologist evaluate the patient prior to surgery and prior to discharge. Nurse anesthetists continue to practice under the supervision of the operating physician or anesthesiologist who is immediately available if needed.

Washington — S.B. 5796 and H.B. 1621 would have expanded the prescriptive authority of advanced registered nurse practitioners (including nurse anesthetists) by allowing them to prescribe controlled substances in Schedules II through IV. The bills died at the end of this session.


Anesthesiologist Assistants (AAs)

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District of Columbia — The medical board has adopted guidelines to permit AAs to practice under the delegatory authority of anesthesiologists. The guidelines, as finalized by the board, have yet to be published.

Florida — Florida H.B. 599, providing for the licensure of AAs, passed the House but failed to be considered by the full Senate prior to the end of the session. The House-passed bill would have allowed an anesthesiologist to supervise two AAs, although the Board of Medicine would have been permitted by rule to allow an anesthesiologist to supervise up to four AAs after July 1, 2006. “Direct supervision” was defined as supervision by an anesthesiologist who is present in the same room as the AA or in an immediately adjacent room or hallway, such that the supervising anesthesiologist is able to monitor the ongoing anesthetic and be immediately available to provide assistance and direction while anesthesia services are being performed. The supervising anesthesiologist would have been required to personally begin the patient’s preanesthetic assessment.

Indiana — S.B. 370 would have prevented a physician assistant (PA) from prescribing, administering or monitoring general anesthesia, regional block anesthesia or deep sedation unless 1) a physician is physically present in the area and is immediately available to assist in the management of the patient, and 2) the PA is qualified to rescue patients from deep sedation and is competent to manage a compromised airway and provide adequate oxygenation and ventilation. The bill failed to pass.

Kentucky — H.B. 617 was signed into law to provide for the continued practice of PAs who have been practicing as AAs. The law requires the individual to have completed a four-year PA program followed by a two-year program that consists of academic and clinical training in anesthesiology. Under the law, a PA practicing as an AA may administer or monitor general or regional anesthesia if the supervising anesthesiologist is physically present in the room during induction and emergence, is not concurrently performing any other anesthesia procedure and is available to be immediately present in the room.

Louisiana — The governor has extended the time frame for the AA commission to develop legislation to license AAs until March 1, 2003.

Maryland — The governor signed H.B. 533 to establish a commission to propose regulations or legislation regarding the approval of delegation agreements for the administration of anesthesia by PAs. The commission was to report to the legislature by December 1, 2002.

New Jersey — A.B. 655 was introduced to license AAs. The bill states that an AA shall be under the direct supervision and medical direction of an anesthesiologist at all times. An AA may assist an anesthesiologist in developing and implementing an anesthesia care plan for a patient pursuant to a written practice protocol developed by the supervising anesthesiologist. The written protocol is to delineate all the services that the AA is authorized to provide and the manner in which the anesthesiologist will supervise and medically direct the AA. A supervising anesthesiologist shall not have more than two AAs under his or her supervision and medical direction or employment at any one time.

Ohio — The Anesthesiologist Assistant Advisory Committee (AAAC), a group formed by the Board of Medicine to draft regulations for AAs, has issued its final report to the board. The board has finalized the proposed regulations and has begun the formal rules process. The proposed regulations 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 will be reviewed by a supervising anesthesiologist, who will then 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.

Oklahoma — The Board of Medical Licensure and Supervision adopted regulations to allow PAs to perform preanesthetic and postanesthetic assessment of patients and administer topical, local or regional anesthesia. PAs are prohibited from administering general anesthetics without the express approval of the Board.

Pennsylvania — The Board of Medicine proposed regulations to codify criteria under which a physician may delegate the performance of medical services. While this regulation would apply to all physicians, anesthesiologists would be able to delegate authority to AAs.

Texas — The Board of Medical Examiners amended the AA guidelines to allow an anesthesiologist to supervise up to four AAs at one time. Previously the guidelines allowed for a ratio of 1:2.

This year-end summary will continue in January summarizing other activities in the states related to office-based anesthesia and tort reform.

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