CDPH Releases Official Guidance on Use of CRNAs in Anesthesia Care

SACRAMENTO, Calif.- The California Department of Public Health (CDPH) released new guidance for general acute care hospitals providing a "Reminder of Certified Registered Nurse Anesthetist Requirements." The All Facilities Letter(AFL) clarifies the credentialing and privileging requirements for nurse anesthetists (CRNAs), and outlines the state and federal laws and regulations that form the foundation for these requirements and guide the scope of practice for CRNAs.

An AFL is a formal communication from the California Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities licensed or certified by L&C.

There have been suggestions by CRNA advocates that the Medicare "opt-out" provisions in California allow CRNAs to replace anesthesiologists, who are physicians with advanced education and training in the delivery of anesthesia. However, the AFL confirms that CRNAs are not physicians, are not permitted to practice medicine, and must practice under the order of a physician, dentist or podiatrist.

"CRNAs play a vital role in the anesthesia care team in California, but it's important to recognize that physician leadership remains essential to ensure patient safety and compliance with state and federal regulations," said Todd Primack, D.O., FASA, chair of the Legislative & Practice Affairs Division of the California Society of Anesthesiologists.

Earlier this year, CDPH conducted investigations in several health care facilities in the Central Valley, and issued notices of violation regarding how CRNAs were being utilized for anesthesia care.

"There was a lot of recent attention on the role of CRNAs in California, including misinformation about the scope of practice for nurse anesthetists. The AFL clarifies that CRNAs are not anesthesiologists and must practice under the order of a physician," said American Society of Anesthesiologists President Ronald L. Harter, M.D., FASA.

The AFL issued on September 6, 2024 confirms the requirements for general acute care hospitals using CRNAs to provide anesthesia services, such as:

• Except as provided in California's Business and Professions Code (BPC) section 2725, a CRNA is not authorized to practice medicine or surgery. (BPC section 2833.5)
• Use of CRNAs to provide anesthesia services in an acute care facility must be approved by the hospital administration and the appropriate committee and must be at the discretion of a physician, dentist, or podiatrist. (BPC section 2827)
• A CRNA may only administer anesthesia and anesthesia related medications ordered by a physician, dentist, podiatrist, or clinical psychologist. (BPC section 2725)
• A CRNA must be responsible for their own professional conduct and may be held liable for those professional acts. (BPC section 2828)

Patient safety regulations under the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for the Medicare program, require physician supervision of CRNAs as a condition of receiving Medicare reimbursement. However, there is a provision in federal regulation allowing a state to "opt out" or exempt itself from that requirement, which Governor Arnold Schwarzenegger implemented via executive order in 2009. The California "opt-out" means that CRNAs are no longer subject to Medicare "supervision" requirements. However, the "opt-out" does not supersede longstanding California state law and regulation of CRNA practice that require the involvement of a physician or other clinician to order anesthesia care.

"We want to ensure that all health care facilities in California understand the rules regarding the use of anesthesia practitioners so they can provide compliant, safe patient care," said Dr. Primack. "The physician-led anesthesia care team model is the recognized best practice, and what all patients deserve. This AFL reminds health care facilities of the laws and regulations in place to protect patient safety, so that there can be improved transparency about the different anesthesia team members and responsible deployment of those professionals in the right roles."

For additional information on scope and standards of practice for CRNAs, CDPH pointed to the Board of Registered Nursing's Summary of Select Nursing Practice Act Provisions Relating to CRNA Practice, and directed facilities to the CDPH District Officesfor further questions on hospital requirements.

About the California Society of Anesthesiologists
The California Society of Anesthesiologists is a physician organization dedicated to promoting the highest standards of the profession of anesthesiology, to fostering excellence through continuing medical education, and to serving as an advocate for anesthesiologists and their patients. The CSA was founded in 1948 and incorporated in 1953 as a voluntary, non-profit association, and now includes more than 3,000 members. For more information visit www.safeanesthesiacare.com.

About the American Society of Anesthesiologists
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with nearly 58,000 members organized to advance the medical practice of anesthesiology and secure its future. ASA is committed to ensuring anesthesiologists evaluate and supervise the medical care of all patients before, during and after surgery. ASA members also lead the care of critically ill patients in intensive care units, as well as treat pain in both acute and chronic settings. For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about how anesthesiologists help ensure patient safety, visit asahq.org/madeforthismoment.

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