How Proposed New Rules Could Change the Anesthesia Care Team

Karen Sullivan Sibert

I admit, I was taken aback at the headline in the Houston Press:

Going Under: What Can Happen if your anesthesiologist leaves the room during an operation.”

The curious reader is bound to wonder why the anesthesiologist would leave the operating room in the first place.

Of course, reporter Dianna Wray explains that in many hospitals, one physician anesthesiologist often supervises multiple cases staffed by nurse anesthetists. This model of care is called the “anesthesia care team“, and has a very long record of safe practice in nearly all major hospitals in the United States. Typically, the anesthesiologist makes rounds from one operating room to the next, checking on each case frequently, just as an internal medicine physician would round on patients in the hospital who are being monitored by their nurses.

Ms. Wray’s article narrates in detail what happened in several anesthesia cases where things went horribly wrong. She points out that the patients and families were not aware that the anesthesiologist would not be present during the entire case.

Complications can develop with patients on the ward, in the intensive care unit, or in the OR. In any medical setting, the nurse’s job is to recognize the problem in time to call for help, so that the physician can respond and the patient can be treated successfully. Sometimes, the call for help may not come in time for successful resuscitation. The results can be tragic — cardiac arrest, brain damage, even death. Hospitals track “Failure to Rescue” events that cause adverse patient outcomes as a Joint Commission and CMS standard for measuring quality in nursing care.

The fact is — anesthesia is dangerous. We have made huge strides in developing safer drugs and better monitoring techniques. But going under anesthesia — losing consciousness from the drugs we give — is really the same thing as inducing coma. Most anesthesia drugs have the potential to depress breathing, lower blood pressure, and decrease the function of the heart. Even regional anesthesia, using proven techniques such as spinal and epidural blocks, can cause major complications.

I can verify that even the most routine procedure — under sedation, regional block, or general anesthesia — has the potential to evolve into a crisis. Some days are completely routine, and some days I find I need every scrap of medical knowledge and experience I can bring to the problems my patients face.

No one should read Ms. Wray’s article and conclude that a physician anesthesiologist needs to be in the OR with every patient 100% of the time. Nurse anesthetists are highly qualified members of the anesthesia care team.

However, patients and families have a right to be informed about the plan of care. Will a physician anesthesiologist be present for the entire case, or supervising more than one case? Will a physician anesthesiologist be involved at all?  Many people would be surprised to learn that in a number of states, including California, there is no requirement for nurse anesthetists to be supervised by physicians, or even to consult with a physician about patient care.

Ms. Wray’s article explains that many nurse anesthetists feel that they should be able to practice in complete independence, without a physician anesthesiologist even on site. This is part of a concerted effort nationwide to grant independent practice to all advanced practice registered nurses (APRNs) — nurse practitioners, midwives, and anesthetists — in the name of cost-cutting.

Proposed changes to the VA Nursing Handbook would mandate that APRNs must practice in VA hospitals without physician supervision of any kind, whether or not the mandate conflicts with state law, and whether or not the nurse would prefer to have physician backup. Given how desperately ill and injured many of our veterans are, this seems like poor policy indeed.

The cases that Ms. Wray outlines in her article are tragic, and they prove how quickly a situation can deteriorate in the operating room. They highlight the folly of attempting to cut costs in our healthcare system by reducing the presence and availability of physicians. Once a patient has encountered a life-threatening complication, even the best attempts at resuscitation may fail. That’s why the key to success is having a high-functioning healthcare team that can avoid the complication in the first place.

To clarify one point in Ms. Wray’s article — certified anesthesiologist assistants, or CAAs, are qualified anesthesia practitioners on a par with nurse anesthetists. In the states where CAAs are licensed, they perform exactly the same functions in the operating room that nurse anesthetists do. The only major difference is that CAAs prefer to work under anesthesiologist supervision. Both CAAs and nurse anesthetists are certified healthcare practitioners who take direct care of patients, as distinct from anesthesia technicians who assist with anesthesia equipment and technical procedures.

I’ve written before about what a shame it is that animosity ever exists among healthcare professionals in any field, especially my own. Medicine is, or should be, a team sport. I rely on an entire surgical team of physicians, nurses, and technicians taking care of my patients every day. I’ll always value the wisdom, skill, and friendship of the many experienced nurse anesthetists I worked with at Duke University Medical Center when I was a young physician fresh out of residency.

My husband, a cardiac anesthesiologist, often gives his residents a favorite piece of advice:  “In anesthesia, it’s not necessarily what you know, it’s what you can think of in time.” Sometimes what you need to think of is to call for help. I’ve certainly done that on any number of occasions, when I needed someone with a different set of specialized anesthesia skills from my own, when I wanted to run an unusual problem by an experienced colleague, or when I just needed an extra pair of hands.

That’s the real advantage of the anesthesia care team. Help is around when you need it. You just need to think of it in time.

Karen Sibert is an anesthesiologist in Los Angeles.

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  1. A quick background question for the benefit of THCB readers. How many other states are considering passing legislation like this?