Working with Podiatrists or Dentists

1. Does the nursing statute and/or board of nursing regulations of the state permit CRNAs to work with podiatrists or dentists?
   
   In some states, the nursing statute or board of nursing regulations contain language specifying that CRNAs must be "supervised" or "directed" by, or "collaborate" with, a certain kind of provider or providers. For example, a state might specify in its nursing statute that a CRNA must be supervised by a physician, podiatrist or dentist. In such a state, in which "podiatrist" or "dentist" is explicitly named, there is no question that CRNAs may legally work with podiatrists or dentists. In states in which CRNAs are permitted to practice without reference to having to be supervised, directed or collaborate with a particular kind of provider, there is also no question regarding whether CRNAs may work with podiatrists or dentists.
   
   The more difficult question occurs in states in which CRNAs are required to be supervised by, be directed by, or collaborate with "physicians" or "surgeons" with no explicit reference to podiatrists or dentists. In some states, "physician" or "surgeon” is defined in the nursing statute or board of nursing regulations in a way that clearly precludes podiatrists or dentists from being considered a "physician" or "surgeon” who may work with CRNAs. In such states, CRNAs do not have legal authority to work with podiatrists or dentists. In other states, however, "physician" or "surgeon" is not defined in the nursing statute or rules. The question, then, is whether the legislature (in the case of the nursing statute) or board of nursing (in the case of regulations) intended "physician" or "surgeon" to include podiatrists or dentists. Links to nursing statutes and regulations are often included on board of nursing websites. In states where it is unclear whether the nursing statutes or regulations allow CRNAs to work with podiatrists or dentists, you may want to contact your state nurse anesthetist association to see if it has previously evaluated this issue.
   
   
2. If the nursing statute and regulations do not prevent CRNAs from working with podiatrists or dentists, what is the scope of practice for podiatrists or dentists in the state, and for what anesthetic activities are podiatrists or dentists permitted to utilize CRNAs?
   
   This question is only pertinent if the state's nursing statute or regulations (and, as discussed below, in the case of a facility such as a hospital or ASC, the state licensing statutes or rules for such a facility as well) do not prevent CRNAs from working with podiatrists or dentists. Assuming there is no such impediment, the question then becomes "what anesthetic activities are CRNAs permitted to perform when they work with podiatrists or dentists" in a particular state?
   
   To answer that question, you must consult the statutes and regulations that govern podiatric or dental practice for your state (in addition, of course, to whatever scope of practice for CRNAs, if any, explicitly appears in your state's nursing statute and rules).In some states, language concerning podiatric scope of practice appears in the same statute that governs physicians, or the regulations of the board of medicine.  In other states, podiatrists are governed by scope of practice language that appears in separate statutes or regulations. In some states, the scope of practice for podiatrists may not address the use of anesthesia. Sometimes, though, podiatrists are limited to utilizing "local" anesthetics in their practice. Depending on the specific state’s language, when podiatrists are limited to using "locals," the CRNAs who work with them may be similarly limited. In other instances, the language could be interpreted to allow CRNAs working with podiatrists to administer types of anesthetics that podiatrists are not personally qualified or authorized to perform. Links to podiatric statutes and regulations are often included on podiatric board websites.
   
   Dentists are governed by dental statutes and dental board regulations. Most state dental statutes or regulations explicitly address the use of sedation and anesthesia in the dental office setting. Dental statutes or regulations often address (a) requirements for dentists to personally administer sedation or anesthesia; (b) requirements when dentists utilize another provider (e.g., a CRNA or anesthesiologist) to provide sedation or anesthesia; (c) dental board permit requirements with which the dentist must comply; and (d) facility equipment and supply requirements. Links to dental statutes and regulations are often included on dental board websites.
   
   Useful information concerning office-based anesthesia, regardless of the type of provider with whom CRNAs are working, is available in the AANA’s Standards for Office Based Anesthesia Practice. In addition to standards, this document includes "Minimum Elements for Providing Anesthesia Services in the Office Based Practice Setting" and an "Anesthesia Equipment and Supplies Checklist."

The analysis in 1.) and 2.) above assumes that a CRNA wants to work in a podiatric or dental office. In such an instance, typically only the nursing statute regulations, and either the podiatric or dental statutes and regulations, need to be consulted to answer the question of whether CRNAs may work in a podiatric or dental office. If, however, a CRNA wants to work with a podiatrist or dentist in a hospital or ambulatory surgical center (ASC), there may be state licensing statutes or regulations for such facilities that also must be consulted. Regulations for such facilities are usually adopted by state departments of health, and should be reviewed to determine whether they include requirements that a certain kind of provider (e.g., a "physician") supervise, direct, or collaborate with CRNAs in that particular type of facility.

As always, please contact the State Government Affairs Division if you need assistance or have additional questions.