Certified Registered Nurse Anesthetist (CRNA)

According to the American Association of Nurse Anesthetists (on-line, 1999):

• Certified Registered Nurse Anesthetists (CRNA) are licensed registered nurses who undergo extensive educational and clinical training, become nationally certified by testing (which is required), and then provide anesthesia related services which are in similarity to anesthesiologists
• CRNAs have been delivering anesthesia and anesthesia related services for over one hundred years
• CRNAs have the capacity to serve as clinician, educator, administrator, manager and researcher
• Anesthesia is administered by CRNAs in many settings, including

• Today, more than 27,000 CRNAs provide anesthesia care in the United States
• CRNAs are the sole provider of anesthetics in almost 85% of rural hospitals
• The American Nurses Association reports that CRNAs administer more than 65% of all anesthetics given to patients each year
• The average salary of CRNAs, reported by the American Association of Nurse Anesthetists, was $87,000 in 1997
• The American Association of Nurse Anesthetists, founded in 1931, is the professional organization for CRNAs

History of the CRNA profession

     The first group of professionals in the United States to deliver anesthesia services to patients were nurses. Nurse anesthesia, which has also been referred to as "the first clinical nursing specialty", was developed in the late 1800’s at the request of surgeons who were looking for a solution to the high morbidity and mortality rates associated with anesthesia.(AANA, On-line, 1999)
     Surgeons felt that nurses would be able to give the patients undivided attention throughout surgical procedures, and thus became the professional discipline of nurse anesthesia. A few years later, in 1909 the first educational program to prepare nurse anesthetists was established.  (www.aana.com/library/history.asp)

Educational Requirements of CRNAs

According to the American Association of Nurse Anesthetists (On-line, 1999), the educational admission requirements to a nurse anesthetist program includes:

• There are approximately 90 accredited CRNA graduate level programs in the United States and Puerto Rico
• CRNA education ranges from 24 to 36 months, including both clinical and academic work
• Graduates of CRNA programs are required to complete at least 450 cases throughout their 24 to 36 month program. (This amounts to around 1000 hours of clinical experience)
• After graduation, students must sit for a national certification exam to be certified as a CRNA
• Every two years after being certified, CRNAs must become recertified through completing both practice and Continuing Educational requirements

Quality of CRNA Care

• The American Association of Nurse Anesthetist reports "recent studies have shown a dramatic reduction in anesthesia mortality rates to approximately one per 250,000 anesthetics" (AANA On-line, 1999)
• The Center for Disease Control attempted a study in 1990, to research mortality and morbidity in anesthesia. After an initial review of the data, the CDC concluded that mortality and morbidity rates were too low to conduct an expensive study. (AANA On-line, 1999)
• This fact is supported by a study done by the Minnesota Department of Health (no author identified, 1995), which found that "there have been no studies, either national in scope or Minnesota specific, which conclusively show a difference in patient outcomes based on the type of provider"
• To improve quality of care, CRNAs are required to complete continuing education requirements before recertification which can includes topics related to quality of care, patient safety research, patient satisfaction and technology development. (AANA on-line, 1999)
• According to the AANA (On-line, 1999), the largest writer of malpractice insurance which is located in Minnesota, reports that "there is no evidence that physicians (surgeons) working with CRNAs have a higher rate of claims made against insurance companies than physicians working with anesthesiologists
• In 1980, a study was conducted to compare anesthesia related patient outcomes between 16 randomly selected hospitals. The hospitals were classified as being either primarily staffed with anesthesiologists, or primarily staffed with nurse anesthetists (CRNAs). The outcome of the study showed that there were no significant differences between anesthesia outcomes between the hospitals. (Forrest, 1980)
• Conclusions                                                                                                                                                           - From the data and the findings from the studies listed above, CRNAs provide quality care to patients requiring anesthesia services and no findings to date have shown any significant differences in patient outcomes related to the level of education of the provider (CRNA vs. Anesthesiologist).

Cost Effectiveness of CRNA Care

• The average length of education for CRNAs is 7-8 years at $11,741 per year on average. Compared to an average length of education for anesthesiologists of 12 years at an average of $84,837 per year. (AANA on-line, 1999)
• The average salary in 1997 for CRNAs was $87,000 compared to the average salary of $244,600 in 1994 for anesthesiologists. (AANA on-line, 1999)
• Anesthesiologist salaries continue to be on the rise unlike the salaries of CRNAs (AANA on-line, 1999)
• Unfortunately, barriers exist in the practice of CRNAs. Due to current state regulations, CRNAs must be supervised by an anesthesiologist (who is also reimbursed for the procedure), a surgeon, a physician or another authorized health care professional. (AANA on-line, 1999)
• State law requirements that CRNAs must be supervised, lead to unnecessary increases in the cost of anesthesia to patients and to the health care system in general (AANA on-line, 1999)
• Conclusions                                                                                                                                                          - One must take into consideration several things about the cost-effectiveness of CRNAs. CRNAs are less costly as individuals, when considering educational costs and salary. However, considering current regulatory constraints on the practice of CRNAs, they are more costly because they require anesthesiologist/physician supervision in their practice.

• The HCFA (1998) has proposed a change, to withdraw the requirement for physician supervision of CRNAs to allow the CRNAs to receive Medicare reimbursement. If this proposed change is followed through, it would allow more flexibility in the practice of CRNAs and would reduce the costs of using CRNAs in practice. (www.hcfa.gov/pubforms/transmit/b98260.htm)
• Currently, there is a shortage of CRNAs. According to the AANA (on-line, 1999), The National Center of  Nursing Research reports that by the year 2000 there will be a need for 30,000 additional CRNAs and more than 35,000 by the year 2015.
• Further research needs to be done on whether or not the supervision of CRNAs has an effect on patient outcome. One could not compare supervised CRNAs to unsupervised CRNAs however, but using the information from the history of CRNAs, nurses were predominately the ones who administered anesthesia from the late 1800's to the middle of this century and during that time, the mortality and death rates were not high. Therefore nurse anesthetists are very much capable of delivering quality care to patients requiring anesthesia.

References
                                                            References
         American Association of Nurse Anesthetists. (1999). Cost Effectiveness of Nurse Anesthesia Practice.
     [On-line].  Available: http://www.aana.com/library/costeffect.asp

          American Association of Nurse Anesthetists. (1999). History of Nurse Anesthetists. [On-line]. Available:
     http://www.aana.com/library/history.asp

          American Association of Nurse Anesthetists. (1999). Nurse Anesthesia Education. [On-line]. Available:
     http://www.aana.com/library/naeducation.asp

          American Association of Nurse Anesthetists. (1999). Quality of Care in Anesthesia. [On-line]. Available:
     http://www.aana.com/library/qualityofcare.asp

          American Association of Nurse Anesthetists. (1999). Quality of Nurse Anesthesia Practice. [On-line].
     Available: http://www.aana.com/library/quality.asp

          Bankert, M. (1989). Watchful Care: A History of America's Nurse Anesthetists. New York: Continuum.

          Forrest, WH. (1980). Outcome - The Effect of the Provider. Health Care Delivery in Anesthesia. (Chapter 15,
     pp.137-142). Philadelphia: George F. Stickley Company.

          Health Care Financing Administration. B-98-2. (1998)

          Minnesota Department of Health. ( Jan 1995). Anesthesia Practices Study. St. Paul Minnesota: Minnesota
     Department of Health.

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Further Sites of Interest

            http://www.anesthesia-nursing.com/

            http://www.aana.com/

            http://www.ncana.com/

            http://www.kpsan.org/

            http://www.nurseweek.com/features/99-1/crna.html

            http://www.nurseweek.com/features/98-6/turf.html

            http://www.xact.org/letters/012698qy-mod-letter.html

            http://www.pana.org/nurseanesthesia.htm

            http://www.npg.com/npg/crna.htm

            http://www.nursingnet.org/

            http://www.nursingworld.org/
 

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