States May Set Anesthesia Standards

Melanie R. Margolis

States may now allow certified registered nurse anesthetists (CRNAs) to administer anesthesia without direct physician supervision. The Centers for Medicare & Medicaid Services (CMS) issued a new rule that gives states the flexibility to regulate the administration of anesthesia in hospitals and ambulatory surgical centers. The new rule was published in the November 13, 2001 Federal Register, vol. 66, no. 219, 56762-56769. The rule is Web-accessible at The rule, which was originally published in the Federal Register on January 18, 2001, was withdrawn. It had been delayed on March 19, 2001 and further delayed on May 18, 2001.

This final rule maintains the current physician supervision requirement for CRNAs unless the governor of a state, in consultation with the state’s boards of medicine and nursing, creates an exemption from this requirement in a manner consistent with state law. The new rule permits a governor to attest that it is in the best interests of the state’s citizens to permit CRNAs to administer anesthesia without direct physician supervision. It allows CRNAs to practice without physician supervision when permitted by state law. It is important to note that the rule requires that CRNAs be supervised by a physician when required by state law or hospital policy.

The rule was enacted to help counter the increasing challenges in providing access to anesthesia services for everyone, particularly in rural areas or other areas with few anesthesiologists. The new rule is not without controversy. Those who oppose the change in policy argue that nurse anesthetists are far less educated and experienced than physicians and that surgery patients will be exposed to increased risk in the absence of physician supervision. The Agency for Health Research and Quality is concerned about the increased risk as well and plans to conduct a study to evaluate and improve the quality of care in states that opt out of the federal supervision requirement.

Currently, under Texas law, CRNAs may administer anesthesia or anesthesia-related services pursuant to a physician’s order, and the order need not be drug-specific, dosage-specific, or administration-technique specific. This delegation by the physician must be consistent with facility policy or medical staff bylaws. Texas law does not specifically address physician supervision of CRNAs. In Texas, advanced practice nurses, including nurse anesthetists, are governed by the Texas Board of Nursing Examiners ("Board"). According to the Board, 2,353 nurse anesthetists are currently licensed in Texas. See (Sept. 1, 2001).