In New Jersey, executive order expands access to care during COVID-19 crisis

  • Apr 30, 2020

By Julie Ciaramella
AANA Public Relations & Communications

With the expanding role of nurse anesthetists during the COVID-19 pandemic, governors across the country have recognized the need for access to care. Many have removed barriers to practice for nurse anesthetists and other advanced practice providers. 

In New Jersey—one of the states hit hardest by COVID-19—the removal of barriers to practice has allowed providers to cross state lines to help where they’re needed as healthcare workers deal with an overwhelming number of patients and the emotional toll of the crisis. 

“The first week as we were watching the number of cases rise, it was like a freight train coming at us here,” said Tracy Castleman, CRNA, a former president of the New Jersey Association of Nurse Anesthetists (NJANA) and current leader of NJANA’s task force on COVID-19. 

New Jersey has one of the most restrictive practices for nurse anesthetists in the country, Castleman said. The state requires nurse anesthetists to enter into a joint protocol with a physician anesthesiologist to provide care. On April 1, Gov. Phil Murphy issued an executive order that suspended the joint protocol and expanded access to care during the coronavirus pandemic.

“The big advantage in New Jersey is the executive order allowed advanced practice nurses to cross state lines,” Castleman said. “We could not bring in help with the joint protocol in place.” 

Certified Registered Nurse Anesthetists (CRNAs) have come from Arizona, Virginia, and other states to battle COVID-19 thanks to the temporary removal of the joint protocol, Castleman said. These CRNAs who have crossed state lines are helping New Jersey nurse anesthetists as they are managing airways, intubating and sedating patients, and managing ventilators. They are also proning patients—flipping them over onto their stomachs—which has been shown to help COVID-19 patients on mechanical ventilation.

“Nurse anesthetists are educated as nurses; we’ve worked in the ICU. Critical care nursing is our background, and working with this level of patient is normal,” Castleman said. “More often than not, as nurse anesthetists we’re providing anesthesia care to people with multiple comorbidities. We’re sedating them, and we’re managing their airways. We’re optimizing their blood pressure, their heart rate, their hemodynamics, their breathing, and we’re protecting their brain. That’s very similar to what these COVID patients are requiring now.”

Castleman, who works at a hospital in central New Jersey, said supporting the ICU and caring for these patients is a natural role for CRNAs.

“Our role is to optimize patients and gather information in real time to produce a better outcome for the patient,” she said, “and that’s what we’re doing in the ICUs. These patients need to be managed minute by minute, hour by hour, and that’s what we’re very comfortable doing as nurse anesthetists.”

At her hospital, CRNAs are also coming together to care for each other during a difficult time. Healthcare workers are experiencing sadness, disappointment, and fear while wanting to do the best for their patients—patients they know may never get better.

“The CRNAs have been emotionally supportive of each other. We’re on intubating teams and we’re putting tubes in people who are in a room by themselves. They’re calling their families to say, ‘I’m really sick now and they’re putting a breathing tube in’ while they’re watching the news in their room and seeing how people are dying on ventilators,” Castleman said. “It’s emotionally devastating because it’s not what we’re used to.”

Normally, CRNAs meet their patients, bring them to the operating room, put them to sleep, and everything turns out fine, Castleman said. She can speak to the family after surgery and tell them their loved one did great and the family can see them soon.

“In the new roles we have assumed, when we intubate a patient for COVID positive symptoms, their outcomes are far more uncertain. That’s much different than when we intubate patients in the OR for surgery,” she said. “That change is troubling for me as a CRNA.”

While CRNAs’ training, education, and backgrounds have prepared them to manage the most critically ill patients, so much about COVID-19 is still unknown, Castleman said.

“We have not figured out how to treat this disease. We have not found a cure for it, and we have not stopped this disease with social distancing. What we’ve done is we’ve slowed it down so we can spread out our resources,” she said. “It’s still very much lurking and waiting to get the next person. What we’ve done is we’ve slowed down the progression of the amount of people getting sick at once so we can have time to treat each patient.”

She said while CRNAs have “stepped up remarkably” during the crisis, she’s concerned about their mental well-being. As leader of NJANA’s COVID-19 task force, she’s been sharing wellness resources from the AANA and research journals with the NJANA membership twice a week.  She’s concerned about significant levels of post-traumatic stress disorder and other mental health issues once the crisis is over.

“I’m worried what we’ll all look like emotionally when this is done,” she said.