Guidelines for Core Clinical Privileges for Certified Registered Nurse Anesthetists

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Clinical privileging is the process through which individuals are credentialed within institutions to provide specific patient-care services. Credentialing may be defined as the recognition of professional and technical competence and well defined criteria-based mechanisms to verify information and evaluate the applicant requesting privileges. Core privileges define the scope of the procedures and activities within a specialty that each practitioner has the education, experience and competence to perform.

Nurse anesthesia is an advanced clinical nursing specialty based on a graduate-level curriculum focused on development of clinical judgment and critical thinking. Certified Registered Nurse Anesthetists (CRNAs) are qualified to render patients insensible to pain and emotional stress during surgical, obstetrical, diagnostic and invasive procedures using general and regional anesthesia and all levels of sedation techniques.

Core clinical privileging is an institutional or agency credentialing process, usually administered by the medical staff or other equivalent process of the institution. CRNAs should be granted core clinical privileges consistent with other healthcare professional staff members who are permitted by law and the facility to provide patient care services. The credentialing and privileging process should provide an objective mechanism for initial application and renewal of clinical privileges based on education, experience, legal qualifications, and an assessment of the individual practitioner's competence and ability to render quality care.

CRNA scope of practice is dynamic and evolving. Privileges should be appropriate to the scope and complexity of care provided by CRNAs. Clinical privileging should be so defined as to permit the CRNA to provide core procedures and selected activities under specific conditions with or without supervision. The clinical privileging process includes: 1) the qualifications of the provider, 2) the actual practice privileges requested and granted, 3) the conditions or limits of practice, and 4) the process for assessment of quality of work and renewal of privileges.

Qualifications
Basic qualifications for clinical privileges shall include:

  1. State licensure as a registered professional nurse. Compliance with state and federal requirements for the advanced practice of nurse anesthesia.
  2. Graduation from a program of nurse anesthesia education accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs or its predecessor.
  3. Certification by the Council on Certification of Nurse Anesthetists or recertification by the Council on Recertification of Nurse Anesthetists or their respective predecessors or, if pending initial certification, evidence of graduation from a program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs
  4. Compliance with relevant requirements for continuing education, competence in advanced life support (adults, children and neonates as applicable), and pertinent education, training or expertise in specialty areas (e.g., fiberoptic intubation).
  5. Disclosure of information as to whether certification, licensure, or clinical privileges have ever been denied, revoked, or suspended.
  6. Attestation of physical and mental abilities to perform requested privileges.
  7. Proof of medical malpractice insurance appropriate for limits required by the institution or state.
  8. Evidence of National Practitioner Data Bank query.

Recommended Core Clinical Privileges
CRNA privileges and responsibilities must be consistent with law and may, without limitation, include the following:

Preanesthetic Preparation and Evaluation of the Patient

  • Obtaining an appropriate health history.
  • Conducting an appropriate physical screening assessment.
  • Recommending or requesting pertinent diagnostic studies and evaluating the results.
  • Selecting, obtaining, ordering, and administering preanesthetic medications.
  • Documenting the preanesthetic evaluation and obtaining a comprehensive informed consent for anesthesia and related services.

lntraoperative Care

  • Obtaining, preparing, and using all equipment, monitors, supplies and drugs used for the administration of anesthesia and sedation techniques; performing and ordering safety checks as needed.
  • Selecting, obtaining or administering the anesthetics, adjuvant drugs, accessory drugs, fluids and blood products necessary to manage the anesthetic.
  • Performing all aspects of airway management, including fiberoptic intubation.
  • Performing and managing regional anesthetic techniques including, but not limited to, subarachnoid, epidural and caudal blocks; plexus, major and peripheral nerve blocks; intravenous regional anesthesia; transtracheal, topical and local infiltration blocks; intracapsular, intercostal and ocular blocks.
  • Providing appropriate invasive and noninvasive monitoring modalities using current standards and techniques.
  • Recognizing abnormal patient response during anesthesia; selecting and implementing corrective action and requesting consultation whenever necessary.
  • Evaluating patient response during emergence from anesthesia and instituting pharmacological or supportive treatment to insure patient stability during transfer.

Postanesthesia Care

  • Providing postanesthesia follow-up and evaluation of the patient’s response to the anesthesia and surgical experience, taking appropriate corrective actions and requesting consultation when indicated.
  • Initiating and administering respiratory support to ensure adequate ventilation and oxygenation in the postanesthesia period.
  • Initiating and administering pharmacological or fluid support of the cardiovascular system during the postanesthesia period to prevent morbidity and mortality.
  • Initiating acute postanesthesia pain management techniques.
  • Discharging patients from a postanesthesia care unit (PACU) according to facility policy.

Clinical Support Functions

  • Inserting peripheral and central intravenous catheters.
  • Inserting pulmonary artery catheters.
  • Inserting arterial catheters and performing arterial puncture to obtain arterial blood samples.
  • Managing emergency situations, including initiating or participating in cardiopulmonary resuscitation.
  • Providing consultation and implementation of respiratory and ventilatory care.
  • Management of interventional pain therapy using drugs, regional anesthetic techniques, or other accepted pain-relief modalities.
  • Selecting, obtaining, ordering and/or administering medications or treatments related to the care of the patient, using consultation when appropriate.
  • Accepting additional responsibilities which are within the expertise of the individual CRNA and appropriate to the practice setting.

Special Requests

  • Diagnostic and therapeutic injections with or without fluoroscopic guidance including epidural, caudal , spinal, facet joint, selective nerve, and sympathetic blocks.
  • Transesophageal echocardiogram.

Nonclinical Responsibilities
The following list describes additional CRNA responsibilities:

Administrative/Management
Scheduling; material and supply management; supervision of staff, students or ancillary personnel; development of policies and procedures; fiscal management; performance evaluations; preventative maintenance; billing and data management.

Quality Assessment
Data collection, reporting mechanism, trending, compliance, committee meetings, departmental review, problem-focused studies, problem solving, interventions, documentation and process oversight.

Educational
Clinical and didactic teaching, BCLS/ACLS instruction, inservice commitment, EMT training, supervision of residents and facility continuing education.

Research
Conducting and/or participating in departmental, hospital-wide or university-sponsored research projects.

Committee Appointments
Assignment to committees, fulfillment of committee responsibilities, coordination of committee activities.

Interdepartmental Liaison
Interface with other departments such as nursing, surgery, obstetrics, PACU, outpatient surgery, admissions, administration, laboratory, pharmacy, etc.

Clinical/Administrative Oversight of Other Departments
Respiratory therapy, PACU, operating room, surgery intensive care units, pain clinics, etc.

CRNAs are responsible for seeking clinical privileges that reflect their educational preparation, clinical experience and level of professional competence. It is incumbent upon CRNAs to maintain knowledge of current scientific theories, principles and techniques related to the field of anesthesia and their current practice situation.

Individual clinical privileges should be delineated regardless of the contractual or employment relationship that exists within the practice setting. This can take a variety of forms, e.g., individual clinical privileges approved by medical staff or other bodies, or authorized through individualized position descriptions. The privilege-granting process should incorporate results of quality assurance and risk management activities. These recommended clinical privileges are not intended to be all-encompassing. They should serve only as examples since all institutions will, out of necessity, modify such procedures and documents to meet their individual circumstances, accreditation requirements, and state and federal law. The listed privileges should reflect the full scope of CRNA practice and should not be overly specific or restrictive. CRNAs should review their clinical privileges on a regular basis.

As part of the application process for clinical privileges, healthcare entities ask a variety of questions concerning personal and professional data relating to the suitability of a practitioner to provide anesthesia services. There are several federal laws relating to discrimination which may affect the institution or network's ability to inquire into an individual’s personal and professional data. It is advised to consult with an attorney if there are concerns related to clinical privileging applications or network provider participation applications.

 

The Guidelines for Granting Privileges to Certified Registered Nurse Anesthetists was previously published in the 1980, 1983, 1989 and 1992. Predecessors of this document,  were respectively titled: The American Association of Nurse Anesthetists Guidelines for the Practice of the Certified Registered Nurse Anesthetist (1980, 1983), Guidelines for Nurse Anesthesia Practice (1989), Guidelines and Standards for Nurse Anesthesia Practice (1992), and Guidelines for Clinical Privileges (1996).
Adopted by AANA Board of Directors November 2005.