Physician Supervision of Nurse Anesthetists Upheld in North Carolina

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


In North Carolina a trial court has dismissed the lawsuit filed by the Board of Nursing [see October 2003 ASA NEWSLETTER] seeking to overturn the Board of Medicine’s requirement for physician supervision of nurse anesthetists in the office setting. The “Guidelines for Office-Based Surgery,” effective January 2003, simply mirrored what the Board of Medicine believed to be existing law with respect to physician supervision of nurse anesthetists. As we have seen in other states that attempt to address patient safety in the office setting, litigation was filed to stop the effort.

The Board of Nursing alleged that the physician supervision requirement violated a 1994 Consent Order involving the Board of Nursing, the Board of Medicine, the North Carolina Society of Anesthesiologists and the North Carolina Medical Society regarding nurse anesthetists’ scope of practice. The basis of the complaint was that state law required nurse anesthetists to collaborate with a physician but did not require physician supervision and, as such, the Board of Medicine could not require supervision in the office setting. 

As a party to the lawsuit, the North Carolina Society of Anesthesiologists, the North Carolina Medical Society and the Board of Medicine filed a motion to dismiss the lawsuit on a variety of procedural and substantive grounds. ASA filed an amicus curiae brief in support of the motion to dismiss the nursing board’s action. The physicians were successful, and the trial court denied the Motion for Enforcement of the Consent Order in its entirety.

The court’s action clearly confirms the medical community’s view that North Carolina law requires physician supervision of nurse anesthetists, not merely physician collaboration. Furthermore the office-based surgery guidelines remain intact following the court’s decision. The Board of Nursing may appeal the decision, and we will report any further developments.

Prior to the disposition of this case, the North Carolina Society of Anesthesiologists, the North Carolina Medical Society and several individual physicians filed a complaint for declaratory judgment against the Board of Nursing. Plaintiffs are requesting the court to determine that the Board of Medicine acted within its authority in adopting office-based anesthesia guidelines that require physician supervision of nurse anesthetists. The Board of Nursing has filed a counterclaim essentially recycling the allegations from the lawsuit referenced above. We will continue to follow this litigation.

AMA Adopts Office-Based Surgery and Anesthesia Core Principles
In December the American Medical Association (AMA) announced the adoption of 10 core principles for office-based surgery. The core principles reflect the consensus of 35 organizations that considered the fundamental patient safety principles earlier last year. ASA was a key participant in this process.

The core principles are designed for application in offices that utilize moderate sedation/analgesia, deep sedation/analgesia or general anesthesia as defined by ASA’s “Continuum of Depth of Sedation.” A complete copy of the Core Principles may be found at <www.ASAhq.org/Washington/AMACorePrinciples.pdf>.

Core Principle 9 provides that “at least one physician who is credentialed or currently recognized as having successfully completed a course in advanced resuscitative techniques (e.g., ATLS, ACLS or PALS), must be present or immediately available with age- and size-appropriate resuscitative equipment until the patient has met the criteria for discharge from the facility.”

Of particular interest to anesthesiologists, Core Principle 10 states that “physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training.”

The interest in ensuring the safety of the office setting has grown over the past few years with as many as 17 states having adopted guidelines or regulations to address some aspects of surgery and anesthesia. AMA’s adoption of the Core Principles, with Core Principle 1 calling on states to adopt guidelines or regulations for office-based surgery, should help to advance the cause in other states.

ASA is now working with the American College of Surgeons to develop materials for patients undergoing procedures in the office setting. ASA has long advocated for increased attention to the office surgery setting and has devoted many resources to working with state officials to ensure that appropriate regulations are adopted.