I am writing to provide you additional information related to VA’s release of the Advanced Practice Registered Nurses (APRN) final rule last week.
As you know, on December 14th, VA issued the final rule granting so-called “full practice authority (FPA)” or the ability to practice without the “clinical supervision or mandatory collaboration of a physician,” to certain categories of APRNs in all VA facilities, regardless of state law. The final rule includes nurse practitioners, nurse midwives, and clinical nurse specialists under its new FPA model. The rule specifically excludes nurse anesthetists from the FPA model.
Final Rule Concludes Rulemaking
VA’s rulemaking on the subject of nurse anesthetists in VA facilities is concluded. The final rule is not subject to change or revision for the foreseeable future. With an implementation date of January 13, 2017, by law, any change or revision to the final rule would require VA to initiate a separate, new formal rulemaking process, including a proposed rule, public comment period, and final rule issuance.
Thank you to VA: Decision Supported by VA’s Evidence
ASA is extremely gratified by VA’s decision to preserve physician-led, team-based anesthesia care for Veterans. It is the right decision for our nation’s Veterans. ASA thanks the VA leadership for placing the well-being of Veterans first. ASA is leading an effort to support VA’s decision.
During the department’s consideration of this issue, VA’s own internal research institute, the Quality Enhancement Research Initiative (QUERI) issued a report titled “Evidence Brief: The Quality of Care Provided by Advanced Practice Registered Nurses.” The report raised significant questions about the safety of the “solo CRNA” or nurse-only model of anesthesia. After reviewing existing studies, including even the AANA’s own self-funded advocacy study, VA’s QUERI concluded the evidence did not prove it would be safe to implement nurse-only models of anesthesia for VA, specifically questioning “whether more complex surgeries can be safely managed by CRNAs.”
Additional Comment Period Will Not Change Final Rule
The final rule includes a request for comments related to nurse anesthetists and “whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking.” As the provision states, these comments are being collected for potential “future rulemaking.” These comments, which will be accepted until January 13, 2017, will not change the content of the final APRN rule.
The information collected as part of this additional comment period could be used by VA to open a new rulemaking process in the future. However, because of the highly controversial nature of this issue which lasted for more than 6 years, and because of overwhelming public and Congressional opposition to including nurse anesthetists in FPA, we do not anticipate the rule being reopened in the foreseeable future. Nevertheless, be assured, ASA will closely monitor VA’s activities moving forward.
ASA to Engage in New Comment Period
ASA members will again be encouraged to participate in this new comment period. Unlike the previous public comment period which was more open-ended with regard to nurse anesthetists, this comment period is very focused and VA is seeking specific information related to access. ASA is conducting targeted outreach to individuals who may have information relevant to VA’s specific request. Other individuals interested in submitting comments may go to www.SafeVACare.org to submit comments to the Federal Register.
I want to conclude by expressing my gratitude for the support we have received for preserving the highest quality care in VA. I am extremely appreciative of the support of you, my colleagues. As the final rule notes, VA received more than 100,000 comments in support of retaining physician-led team-based anesthesia care in VA facilities. Although not referenced in the final rule, we know from our review of the comments that nearly 30,000 of those comments came from Veterans and Veterans families. In contrast, VA received less than 10,000 comments in support of abandoning the team-based model of care for anesthesia. I am also gratified by the support we received from Veteran organizations and over 140 Members of Congress, all of whom worked to put the health and safety of our Veteran patients first.
Please stay tuned for more details regarding the comment period. And please do not hesitate to contact me or any member of our Advocacy team if you have additional questions about the final rule and next steps.
Jeffrey Plagenhoef, M.D.
American Society of Anesthesiologists
Chair, Safe VA Care Initiative