nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Wednesday, August 11, 2010

Should Nurse Anesthetists Work Unsupervised By Doctors

The nurse anesthetists want to "get out from under" physician supervision, which is currently the requirement.

A study appeared in Health Affairs (Aug 3) that alleges that anesthesia provided by nurses results in the same quality and safety whether they are supervised or not.

While one camp (nurse anesthetists, officially called Certified Registered Nurse Anesthetists-CRNA's) wants to revoke the supervision requirement, the other (anesthiologists) wants to maintain tight control of anesthesia practice.

The study was poorly designed and claims more than it proves, but I'll get to that.

I suggest there may be a middle way.  There is a clear difference in depth of training and range of experience between the two groups.  In medicine, when that occurs, there is usually some method of oversight that ensures that the less experienced group doesn't exceed the scope of what they are trained to do.

But that doesn't mean that within that scope of practice there isn't room for increased independence.  As a matter of practice, many nurse anesthetists are only loosely supervised.  It depends upon the complexity of the case.  Nurses tend to do the simpler, shorter, and safer cases on healthier persons, where there is less likelihood of a complication, or at least a complication that involves many organ systems, balancing benefit and risk to optimize the response.

There are even some cases which are so complicated that more than one anesthesiologists is needed.  There are many procedures on the other hand, where the skillset is less demanding, and it should be possible to define those operations and criteria for which independent care is safe and high-quality.

So, rather than throw stones at each other, how about sitting down and defining those criteria?  I know it's a difficult thing to accomplish in our "post-partisan," virulently polarized society.  But, the bottom line is we need to maximize everyone's potential to care for 30 million more insured and do it in a way that puts the patients' needs and safety first.

As far as the Health Affairs study, here's for the Onion Peelers:
They analyzed 481,440 hospitalizations covered by Medicare. They found that the frequency of nurse anesthetists’ providing anesthesia without anesthesiologist supervision grew from 1999 to 2005. As of 2005, 21 percent of surgeries in opt-out states and 10 percent in non-opt-out states used nurse anesthetists without anesthesiologists, as opposed to 17.6 percent and 7.0 percent in 1999.  The researchers also found that although nurse anesthetists are trained to handle very complex cases, anesthesiologists, on average, work on more of these cases, which involve greater risk of death. The authors hypothesize that anesthesiologists, who can choose their cases more often than can certified registered nurse anesthetists, prefer more complex, better-paying, cases. Anesthesiologists also are more prevalent in teaching hospitals that perform more complex surgery.

The thing about doctors prefering the "better paying" cases, is the typical slam that advocacy groups try to use to vilify others.  So we can disregard that, we're interested in data.

Although the study looks at almost 500K hospitalizations, they don't emphasize enough that the rate of mortality from anesthesia is very low (about 1:200K in some studies) so they still don't have much statistical power  to claim a difference.  A less important limitation on the research is they used insurance claims rather than clinical outcomes as their data source.

Also, I doubt that CRNA's are trained for complex cases.  Note the authors contradicted themselves; the docs do the more complex cases, so how is it that the nurses are trained in them?  In fact they aren't, except from the textbook perspective.  In practice, they have little experience of complexity.  Ask yourself if you want your appendix taken out by a surgeon who went through specialty training, but never did one.

I've seen CRNA's holler for help many times.

There is also value in having a general medical degree that involves the whole body and its integrated systems.  Nursing schools don't train to that level or depth.

Finally one of the authors said “Nurse anesthetists get essentially the same training in anesthesia as anesthesiologists. So in this case, a nurse is just about a perfect substitute for the doctor.”

As John Turturro said in O Brother, Where Art Thou?, "That don't make no sense."

Doc D

PS:  I have more training in management, governing, and leadership than the President.  Maybe I'm a perfect substitute.


Anonymous said...

You have my vote

Doc D said...

I couldn't take the grip-and-grin.

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