Missouri Enacts AA Licensure Law, Alters Anesthesia Nurse Scope of Practice

S. Diane Turpin, J.D., Assistant Director
Office of Governmental Affairs


In Missouri, legislation to license the practice of anesthesiologist assistants (AAs) passed the Senate by a vote of 29-2 and the House by a vote of 145-6. The bill was signed into law by the governor on June 20, 2003.

The law allows AAs to assist supervising anesthesiologists in formulating and executing an anesthesia care plan. AAs may obtain the patient’s history, perform relevant physical examinations, pretest and calibrate anesthesia delivery systems, interpret information while in consultation with an anesthesiologist, establish airway intervention, administer vasoactive and other anesthetic drugs, adjust vasoactive infusions and other tasks not prohibited by law. AAs must be under the supervision of an anesthesiologist at all times. Anesthesiologists are allowed to supervise up to four AAs at one time. The State Board of Registration for Healing Arts is charged with writing regulations for the practice of AAs.

This law also made an important change with respect to the scope of practice of nurse anesthetists. The new law requires nurse anesthetists to practice under the direct supervision of a physician, podiatrist or dentist instead of pursuant to a collaborative practice agreement as was previously required.

The State Medical Board of Ohio adopted regulations on May 14, 2003, effective May 30, 2003, to regulate the practice of AAs. The regulations require the “direct supervision” of an AA by the supervising anesthesiologist. “Direct supervision and in the immediate presence of” is defined as:

1. The supervising anesthesiologist shall remain physically present and available for immediate diagnosis and treatment of emergencies;

2. The supervising anesthesiologist shall be physically present in the anesthetizing area or operating suite, as defined by the hospital or ambulatory surgical facility, and accessible by beeper, telephone or overhead page, such that he or she is immediately available to participate directly in the care of the patient with whom the anesthesiologist assistant and the supervising anesthesiologist are jointly involved;

3. The supervising anesthesiologist shall personally participate in the most demanding procedures in the anesthesia plan, which shall include induction and emergence; and

4. “Direct supervision and in the immediate presence of” shall not be interpreted to:

a. Require the supervising anesthesiologist’s presence in the same room as the anesthesiologist assistant for the duration of anesthetic management; or

b. Prohibit the supervising anesthesiologist from addressing an emergency of short duration, administering labor analgesia or performing duties of short duration as required of a perioperative specialist in another location in the hospital or ambulatory surgical facility.

AAs are prohibited from performing epidural and spinal anesthetic procedures and invasive medically accepted 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.

An Ohio AA has filed a lawsuit against the medical board challenging the prohibition on epidural and spinal anesthetic procedures and invasive monitoring techniques. The court has granted a temporary restraining order suspending this regulation, and further hearings are scheduled for September 11, 2003.

Legislation was signed into law on May 23, 2003, to certify AAs to practice in Vermont. AAs are to practice under the direction and supervision of anesthesiologists; the AA’s scope of practice is that delegated to the AA by the anesthesiologist.

The Florida AA licensure bill failed to reach the full House and Senate before the legislature adjourned. The issue has been thwarted in Florida in large part due to erroneous information provided by opponents of the bill.

While Colorado Governor Bill Owens has yet to send a letter to the Center for Medicare & Medicaid Services opting out of the requirement for physician supervision of nurse anesthetists, the Board of Health has taken steps to pave the way for the governor’s action. On May 21, the Board of Health adopted a proposed rule eliminating the state law requirements whereby nurse anesthetists must be supervised by a physician when administering anesthesia in the hospital. Other provisions of state law provide for physician supervision of nurse anesthetists, but the hospital regulations contained the most express language. The Colorado Society of Anesthesiologists (CSA) presented oral and written testimony to the board, but it was clear that the board’s intention was to eliminate the requirement. CSA’s litigation over the pending opt-out continues.