Nevada Advanced Practice Nurses Association

Nevada Advanced Practice Nurses Association

March 7, 2017

RE: NAPNA OPPOSED TO SB 210 (ANESTHESIOLOGY ASSISTANT BILL)

Dear Esteemed Nevada Legislators:

NAPNA is an organization representing more than 1,500 autonomous advanced practice registered nurses (APRNs) focused on improving access to health care for all Nevadans. This access includes the caveat that the health care provided be high quality, safe, cost-effective, and evidence-based. The use of anesthesiology assistants (AAs) has not been proven to be safe, does not reduce health care costs, and does not improve access to anesthesia services in the rural or urban underserved areas where physician anesthesiologists do not practice.

NAPNA has submitted PowerPoint slides for the record and this testimony is meant to complement the compelling data they contain. Certified registered nurse anesthetists (CRNAs) are found in 9 out of 17 Nevada counties, and 5 of those counties rely solely on CRNAs as their anesthesia provider (Office of Statewide Initiatives, 2016). While there are about 5 times more physician anesthesiologists than CRNAs in Nevada, they are found predominantly in the urban areas and in fact, urban per capita anesthesiologists exceed the national average (Office of Statewide Initiatives, 2016). Unlike most other types of health care providers, there is no shortage of physician anesthesiologists in Nevada or the western portion of the United States.

Other than the fact that CRNAs are already found in the rural areas, why should Nevada look to CRNAs rather than AAs to improve access to anesthesia care? CRNAs are the most cost-effective model for anesthesia delivery (Hogan et al, 2016). Data shows no conclusive difference in outcomes between physician anesthesiologists and CRNAs working individually or together as a team (Dulisse & Cromwell, 2010). CRNAs practice safely and autonomously with the same case mix as anesthesiologists (Hogan et al, 2010). CRNAs are full scope anesthesia providers who are equivalent in function, scope, and outcomes as physician anesthesiologists.

There is no comparison between CRNAs and AAs. AAs are trained only to assist physician anesthesiologists in technical functions. By proposing to allow AAs to administer spinals and epidurals, including the placement of regional blocks, SB 210 exceeds the scope of practice typically associated with AAs unless the physician anesthesiologist is physically present in the room, in which case the proven anesthesia provider, the physician anesthesiologist, should perform the procedure and negates the need for an AA to do so. As the AA is limited by setting and geography due to the requirement for immediate anesthesia supervision availability, they cannot address access issues in rural and underserved areas.

There is no data to show the use of AAs is cost effective. AA supervision lapses are known to be common with first case starts even with 1:2 supervision ratio (Epstein & Dexter, 2010) and SB 210 calls for 1:4 supervision ratio. Safety of Nevadans is of utmost importance, and although AAs have been around almost as long as nurse practitioners, there are NO published, peer-reviewed, evidence-based safety and outcomes data. Do we want to

EXHIBIT P Senate Committee on Commerce Labor and Energy Date:3-8-2017 Total pages: 15 Exhibit begins with: P1thru P15

experiment on Nevadans with unproven, unsafe providers under a physician "supervision" model that consistently has lapses?

NAPNA believes Nevadans deserve the best anesthesia care, which means the 1:1 interaction and attention of a CRNA or physician anesthesiologist who can provide autonomous, full scope anesthesia care. Using AAs with no proven safety or track record will create a two-tiered system for the underserved and underprivileged population. CRNAs and physician anesthesiologists are the best choice for Nevada, not AAs.

NAPNA would like to collaborate with the Nevada legislature in developing sustainable evidence-based solutions to health care issues. In regards to improving access to anesthesia services in the rural and urban underserved portions of the state, NAPNA recommends against utilizing an unproven, unsafe, dependent provider and to instead increase the utilization of CRNAs and create a favorable practice environment through policies supporting the hiring of CRNAs and CMA opt-out for hospitals. By encouraging out-of-state CRNAs to train in Nevada and increasing CRNA recruitment from states with a surplus, Nevada can simultaneously address the autonomous anesthesia provider pipeline issue and build up the rural workforce.

Thank you for your time and consideration.

Respectfully yours,

/./ //

\ Dr. ean-ne S yg

NlarA NP-BC, CCRN-CMC, PHN

NAPNA President



References

? Amburgey, B., Kentucky. General Assembly. Legislative Research Commission., . (2007). A study of anesthesiologist assistants. Frankfort, Ky.: Legislative Research Commission.

? Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8), 1469-1475.

? Epstein, R. H., & Dexter, F. (2012). Influence of supervision ratios by anesthesiologists on first-case starts and critical portions of anesthetics. Anesthesiology, 116(3), 683-691.

? Hogan, P. F., Seifert, R. F., Moore, C. S., & Simonson, B. E. (2010). Cost effective analysis of anesthesia providers. Nursing Economics, 28(3), 159-169. Retrieved from mi 10 hogan.pdf

? Office of Statewide Initiatives. (2016). Nevada Instant Atlas [County-level health workforce and population health database]. Retrieved from

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Nevada' Advanced Practice Nurses Association

CRNAs: Anesthesia Provider Access Solution for Nevada

Dr. Jeanine Swygman DNP, ACNP-BC, CCRN-CMC, PHN NAPNA President

Exhibit in Opposition to SB 210 March 8, 2017

Where CRNAs Practice in NV

CRNAs in 9 of 17 counties

-- Carson City (1) -- Churchill (5) -- Clark (71) -- Douglas (1) -- Elko (6) -- Humboldt (2) -- Nye (1) -- Washoe (6) -- White Pine (1) -- TOTAL: 94

5 CRNA only counties

-- Churchill -- Elko -- Humboldt -- Nye -- White Pine

TOTAL: 15 (16% of CRNAs)

(Office of Statewide Intbatives, 2016)

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Where Anesthesiologists Practice in NV

? Anesthesiologists practice in 4 counties --Carson City (17) --Clark (337) --Douglas (3) -- Washoe (107)

? Urban per capita anesthesiologists exceeds national average

? Out of 464 anesthesiologists in the state, only 3 are in the rural & frontier areas

? Anesthesiologist only counties -- NONE

(Office of Statewide Initiatives, 2016)

CRNA Numbers

100

90

80

70

60

50

State

40

? Rural & Frontier

30

20

10

2006 2008 2010 2012 2014 2016

(Office of Statewide Initiotive, 2016)

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CRNAs per 100,000 Population

Chart Title

14

12

10

8

6

4

2

0

I t

2006

2008

2010

- i 2012

2014

State Rural & Frontier sia Urban ? U.S.

2016

(Office of Statewide Initiatives, 2016)

Anesthesiologists per 100,000 Population

2015

20

18

16

14

12

10

8

6

4

2

0

State

Rural & Frontier

Urban

? 2015

U.S.

(Office of Statewide Initiatives, 2016)

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Why CRNAs?

? CRNAs as sole anesthesia provider is most costeffective model for anesthesia delivery (Hogan et al, 2016)

-- No difference in complications from anesthesiologists

(Dulisse & Cromwell, 2010)

? CRNAs practice safely and autonomously with same case mix as anesthesiologists

--Can perform the same set of anesthesia services including open heart surgeries, organ transplantations and pediatric procedures (Hogan et al, 2010)

Why CRNAs?

? Qualified to make independent judgements regarding all aspects of anesthesia care based on education, licensure, and certification

? Can work in diverse settings throughout state

-- Urban, underserved, rural and frontier -- Every setting: hospital surgical suites; obstetrical

delivery rooms; critical access hospitals; ambulatory surgical centers; offices of dentists, podiatrists, ophthalmologists, plastic surgeons; DOD & VA healthcare facilities

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CRNAs are equivalent in function, scope, and outcomes to anesthesiologists.

There is no comparison between CRNAs and AAs.

AAs Will Not Benefit NV

? Not a full service anesthesia provider. ? SB 210 exceeds the scope of practice typically associated

with AAs re: epidural & spinal anesthetic procedures, including placement of regional blocks unless the anesthesiologist is physically in the room

-- Limited value in obstetrics, pain management, orthopedics, and on-call

? Trained only to assist anesthesiologists in technical functions.

? Limited to certain settings and geographic areas dependent on anesthesiologist supervision availability.

? Cannot meaningfully address access issues in rural and underserved areas.

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AAs Will Not Benefit NV

? Not cost effective

-- Requires two healthcare providers to provide anesthesia care to one patient

-- OR start times need to be staggered

? AA supervision lapses common during first case starts even with 1:2 supervision ratio (Epstein & Dexter, 2012)

? Fails to adequately meet the needs of patients and healthcare providers

? No published, peer reviewed, evidence-based safety and outcomes data

Lack of Data on AA Safety

? No published, peer reviewed, evidence-based safety and outcomes data

? 2007: Kentucky Legislative Research Commission published "A Study of Anesthesiologist Assistants" --Lack of data "limits the conclusions that can be made about patient safety outcomes for AAs"

(Amburgey, et al, 2007)

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