In its Winter 2017
issue (see p. 8), the Association of the U.S. Navy (AUSN) published an article in Navy
magazine boasting how it had influenced the VA “to reverse its proposal to replace physician anesthesiologists with nurses in VA health care facilities," and calling the Dec. 13 publication of the final rule “an early Christmas gift” for the AUSN Legislative Department. The final rule, of course, granted full practice authority to all advanced practice registered nurses except CRNAs. Throughout the comment period, the AUSN opposed the VA granting full practice authority to CRNAs despite strong evidence that contradicted the naval association’s rationale. In March, AANA President Cheryl Nimmo, DNP, MSHSA, CRNA, responded to the Navy
magazine article with a letter to the editor addressing the AUSN’s arguments, reminding the AUSN of the facts surrounding the proposed rule and the numerous studies that confirm CRNAs’ record of ensuring patients', including veterans', access to safe, high-quality, cost-effective anesthesia care. AANA members, especially Navy veterans who are also members of the AUSN, are encouraged to read Nimmo’s letter in response to the AUSN article and consider writing their own letter to the editor to professionally express
displeasure with the article’s misinformation and unsupportable conclusions. Letters can be sent to Editor Heidi Lenzini, USN(ret), at firstname.lastname@example.org
. AANA remains committed to correcting biased reporting on CRNA full practice authority issues.
Letter from President Nimmo to Navy Editor
To the Editor:
As president of the 50,000-member American Association of Nurse Anesthetists, including active duty and retired Navy CRNAs who are also members of AUSN, I’m amazed at the dearth of facts in Michael Little’s Legislative Affairs column in theWinter AUSN newsletter
If one actually reads the final rule on full scope of practice for advanced practice registered nurses (APRNs) that excluded Certified Registered Nurse Anesthetists (CRNAs), one will quickly see the following:
The VA never proposed replacing anesthesiologists with CRNAs, not in the proposed rule
published in May 2016, and not in the final rule
published in December. To suggest this is simply and completely inaccurate, and easily fact-checked.
The proposed and final rule both supported and retained the care team for patient care, in which CRNAs would continue to work closely with surgeons, anesthesiologists, other nurse specialists, and other healthcare providers to ensure the best surgical and anesthetic outcomes for their patient. There would not have been a “fundamental change” in the delivery of anesthesia care for veterans, as Little surmises. Simply refer to the language in the rules.
With regard to Little’s assertion that 46 states and the District of Columbia require physician “involvement” for anesthesia care, this number is arbitrary and unsupportable. A state by state analysis reveals that, in reality, there are 40 states that have no supervision requirement in their nurse practice acts, board of nursing rules/regulations, medical practice acts, board of medicine rules/regulations, or their generic equivalents. In addition, 17 states have opted out of the Medicare physician supervision requirement for CRNAs. This is all easily researched with a little time and effort.
Therefore, the VA’s final rule actually is not in alignment with the vast majority of states and the District of Columbia; in fact, it’s not even in alignment with the Navy’s position on physician supervision for CRNAs. The Navy (along with the Army and Air Force) does not require physician supervision of CRNAs, which is why these anesthesia experts are the primary anesthesia providers for active duty personnel in battle. If CRNAs can care for a horribly wounded sailor at sea without a surgeon supervising them or an anesthesiologist anywhere to be found, surely they can provide the same standard of care for veteran sailors back home.
- Groups opposed to the VA granting full practice authority for CRNAs leaned heavily on the QUERI study cited by Little; however, the preponderance of evidence confirming CRNA safety trumps QUERI by a wide margin. In fact, in the final rule itself the VA lauds the safety record of CRNAs and refers to the research evidence upon which their sterling reputation has been built. Peer-reviewed studies published in Medical Care, Health Affairs, Nursing Economic$, Journal for Healthcare Quality, Nursing Research, Health Services Research, AANA Journal, and the acclaimed Cochrane Collaboration, plus the results of the VA’s own Independent Assessment mandated by Congress in 2015, beg to differ with QUERI and Little: CRNAs are extraordinarily safe whether they are the working as the sole anesthesia provider or as part of an anesthesia care team.
With all evidence and logic supporting inclusion of CRNAs in the final rule, and the final rule itself seemingly in support of their inclusion, the real reason they were not included is simple: The doctor in charge was opposed to it. We’ll see where this issue goes from here. In the meantime, I urge the AUSN to do a better job of presenting the facts on this important issue and to stop misleading the men and women—active duty and veterans alike—who protect our country at sea.
Cheryl Nimmo, DNP, MSHSA, CRNA
USAR, MAJ (Veteran)