bill that would allow nurse anesthetists to perform interventional pain management procedures died in committee before the Louisiana Legislature adjourned for the year. S.B 322 would have expanded nurse anesthetist scope of practice to perform procedures, including but not limited to those involving the injection of local anesthetics, steroids and analgesics for pain management purposes under the direction and supervision of a physician. The procedures for pain management purposes include, but are not limited to, peripheral nerve blocks, epidural injections and spinal facet joint injections when the registered nurse anesthetist can document education, training and experience in performing such procedures. S.B. 322 conflicted with the advisory opinion adopted by the Louisiana State Board of Medical Examiners in 2006, which authorizes nurse anesthetists to provide anesthetics for acute pain associated with surgery, but defines procedures for interventional pain management as the practice of medicine and can only be performed by a physician.

The pain bill (S.B. 322) passed the Senate, but it was never voted upon by the full House. This legislation was in response to efforts by the nursing board over the past two years to authorize nurse anesthetists to practice pain medicine. As reported in previous articles, a lawsuit was filed after the nursing board adopted an “opinion” that allowed nurse anesthetists to perform interventional pain management procedures under the direction and supervision of a physician. The petitioner argued that the “opinion” in effect constitutes a rule and that the nursing board circumvented the rule-making process by establishing scope of practice via an advisory opinion. The Louisiana Court of Appeal agreed and held that the statement issued by the nursing board was a rule, subject to the Louisiana Administrative Procedures Act. The Louisiana Supreme Court denied the nursing board’s petition to review the lower court’s decision. ASA and the Louisiana Society of Anesthesiologists filed amicus briefs in support of the petitioner. Several unresolved issues still remain at the trial level.

Support Erodes for Pennsylvania Nurse Scope-of-Practice Expansion Legislation
Legislators pulled from the agenda of the Pennsylvania House Professional Licensure Committee a bill (H.B. 1256) that would have allowed nurse anesthetists to administer anesthesia in collaboration with a physician or dentist. This bill would have been the first step toward an opt-out of the federal physician supervision requirement. Similar legislation has been introduced for the past six years, but there was a stronger push this year due to Governor Edward G. Rendell’s plan to create universal health care. Members of the Pennsylvania Society of Anesthesiologists testified before House committee hearings earlier in the year. While the possibility remains that the House committee could vote on the bill this year, it appears that H.B. 1256 has died this session.

Anesthesiologist Assistants
After three years, the North Carolina General Assembly passed legislation that would provide for licensure of anesthesiologist assistants (AAs). AAs would administer anesthesia under the supervision of an anesthesiologist. H.B. 1492 is awaiting the governor’s signature. North Carolina will become the 11th state (including the District of Columbia) to license AAs. North Carolina will join Alabama, the District of Columbia, Florida, Georgia, Kentucky, Missouri, New Mexico, Ohio, South Carolina and Vermont.

In accordance with this legislation, the supervising anesthesiologist would be actively engaged in clinical practice and immediately available on site to provide assistance to the AA. Anesthesiologists would supervise no more than two AAs at one time; however, such limitation would not restrict the number of other qualified anesthesia service providers an anesthesiologist may concurrently supervise. The same supervision ratio would apply to student AAs. After January 1, 2010, the board of medicine could amend the supervision ratio to allow an anesthesiologist to supervise up to four licensed AAs concurrently. The board at that time could also amend the supervision limitations of student AAs so that requirements for student AAs and student nurse anesthetists would be similar. Finally, student AAs would be prohibited from using the terms “intern,” “resident” or “fellow.”

In addition to North Carolina, AA licensure legislation was introduced in Texas. Although the legislation died in committee, the bill had gained strong support during its first legislative session. The session reconvenes in 2009.

H.B. 3313 would have authorized AAs to assist the supervising anesthesiologist in developing and implementing an anesthesia care plan for a patient. AAs would have practiced only under the direct supervision of a board-certified anesthesiologist who is physically present or immediately available. The supervising anesthesiologist would have supervised no more than four AAs; an AA could have more than one supervising anesthesiologist. AAs would have been prohibited from referring to their license as “board-certified” or any other terminology that implies that the AA is a physician. Similar to North Carolina legislation, student AAs would have been prohibited from using the terms “intern,” “resident” or “fellow.”

Reversing the lower court’s decision, the Ohio Supreme Court held that while Ohio statutes permit AAs to carry out epidural and spinal anesthetic procedures, such procedures must be requested by and performed under the direction of a supervising anesthesiologist who is physically present in the room. The issue before the court was the definition of “assist.” The court ultimately rejected the medical board’s argument that the Ohio Legislature intended “assist” to have its dictionary meaning of “to help” or “to aid” and applied its technical meaning in the field of anesthesiology: “to carry out.” The case is Hoffman v. State Medical Board of Ohio, 113 St.3d376, 2007-Ohio-2201.

Lisa Percy, J.D., manages state affairs for ASA’s Office of Governmental and Legal Affairs in Washington, D.C.