To help ensure that all obstetric patients receive high-quality, safe analgesia and anesthesia care during labor and delivery, the American Association of Nurse Anesthesiology (AANA) has published its updated Analgesia and Anesthesia for the Obstetric Patient practice guidelines. This comprehensive revision provides evidence-based practice recommendations and closes equity gaps in obstetric pain management and anesthesia care.
According to the Commonwealth Fund, U.S. women have the highest rate of maternal deaths among high-income countries, with Black women being nearly three times more likely to die from pregnancy-related complications than white women.
“Many of the complications related to maternal care are preventable,” says Beth Ann Clayton, DNP, CRNA, FAANA, FAAN, lead revision subject matter expert. “We know that there is a significant equity gap in maternal care between races and that one of the best ways to close that gap is to have standardized, evidence-based care. AANA’s new guidelines offer obstetric anesthesia providers current practice recommendations to support optimal maternal care and improve the delivery of care, patient safety, and patient outcomes.”
Research confirms racial and ethnic disparities in pain control for maternal care. Therefore, standardization of care supported by these guidelines is important in addressing these disparities. The updated guidelines cover topics such as physiologic changes during pregnancy, pre-anesthesia assessment and evaluation, patient education, preparing a plan of care, analgesia and anesthesia options during labor, delivery, and postpartum care, as well as complications and emergency care. In addition, recommendations highlight care for high-risk patients, including those with hypertensive disorders such as preeclampsia and obstetric complications and emergencies such as obstetric hemorrhage and amniotic fluid embolism.
“These guidelines and their protocols promote equity of care. For example, when a patient has preeclampsia, direct steps for hypertension management can be taken,” Clayton says. “In an emergency, if clinicians do not have a protocol available, they may miss a step. These guidelines are in place to increase communication between the anesthesia, obstetric, and pediatric professionals regarding labor status and patient-specific considerations to create an optimal environment for safe maternal and neonatal care. The document also highlights how CRNAs help drive change to reduce maternal-related deaths and implement prevention strategies to reduce racial and ethnic disparities in pregnancy-related mortality.
CRNAs are highly educated, trained, and qualified anesthesia experts. They provide 50 million anesthetics annually in the U.S., working in every setting where anesthesia is delivered. CRNAs are the primary providers of anesthesia care in rural locations, enabling facilities in these medically underserved areas to offer obstetrical, surgical, pain management, and trauma stabilization services.
Practice authority for advanced practitioner nurses took another stride forward on May 10 when Michigan became the 20th state to opt out of federal regulations that require physician supervision of Certified Registered Nurse Anesthetists (CRNAs).
Gov. Gretchen Whitmer’s action in signing the opt-out ensures Michigan’s patients have access to value-based, high-quality care and optimizes healthcare teams across the state, according to Adam Kuz, MS, CRNA, president of the Michigan Association of Nurse Anesthetists (MANA).
In March 2020, to maximize healthcare resources during the outbreak of the COVID-19 pandemic, Gov. Whitmer enacted an executive order removing physician supervision for CRNAs. In July 2021, she signed HB4359 to remove supervision requirements for CRNAs in the state nurse practice act, and HB4359 is now permanent.
Highlights of the law include:
All of the following apply to a registered professional nurse who holds a specialty certification as a nurse anesthetist:
(a) In addition to performing duties within the scope of the practice of nursing, his or her scope of practice includes any of the following anesthesia and analgesia services:
(i) Development of a plan of care.
(ii) Performance of all patient assessments, procedures, and monitoring to implement the plan of care or to address patient emergencies that arise during implementation of the plan of care.
(iii) Selection, ordering, or prescribing and the administration of anesthesia and analgesic agents, including pharmacological agents that are prescription drugs as defined in section 17708 or controlled substances. For purposes of this subparagraph, the authority of a registered professional nurse who holds a specialty certification as a nurse anesthetist to prescribe pharmacological agents is limited to pharmacological agents for administration to patients as described in subdivision (b), (c), or (d), and his or her authority does not include any activity that would permit a patient to self-administer, obtain, or receive pharmacological agents, including prescription drugs or controlled substances, outside of the facility in which the anesthetic or analgesic service is performed or beyond the perioperative, periobstetrical, or periprocedural period.
(b) He or she may provide the anesthesia and analgesia services described in subdivision (a) without supervision and as the sole and independent anesthesia provider while he or she is collaboratively participating in a patient-centered care team.
“Removing barriers to CRNA practice allows Michigan hospitals to select the anesthesia delivery model that maximizes their workforce and increases access to safe, affordable care for all patients,” said former MANA president Toni Schmittling, DNAP, MBA, CRNA. “By signing this important legislation, Michigan recognizes that CRNAs are qualified to make decisions regarding all aspects of anesthesia care based on their education, licensure, and certification.”
Anesthesia services are provided predominantly by CRNAs in Michigan’s critical access hospitals, which offer surgical services in 99% of its rural hospitals. They comprise 68% of the state’s anesthesia care providers.
“The AANA applauds Gov. Whitmer for recognizing the important role CRNAs have in the delivery of safe anesthesia care in Michigan,” said AANA President Dina Velocci, DNP, CRNA, APRN. “Increased demand, limited resources, and a state with diverse populations, both rural and urban, dictate that a system capable of meeting the needs of all Michigan residents be maintained. By signing the opt-out letter, this has been achieved.”
Throughout the COVID-19 pandemic, nurse anesthetists across the country have, in addition to providing top-of-the-line anesthesia care, served as experts in airway management, hemodynamic monitoring, management of patients on ventilators, and overall management of critically ill patients. Instrumental in addressing the deadliest part of COVID-19, CRNAs have become highly sought-after anesthesia care providers.
Alabama patients now have increased access to safe, affordable care with the signing today of HB 268 by Governor Kay Ivey. The law provides that, in addition to physicians and dentists, Certified Registered Nurse Anesthetists (CRNAs) may provide anesthesia care under the direction of or in coordination with a physician, podiatrist, or dentist.
The law further clarifies that the CRNA scope of practice includes ordering of medications and tests before, during, and after analgesia or anesthesia in accordance with the anesthesia plan.
“Removing barriers to CRNA practice will allow Alabama healthcare facilities to maximize their workforce and increase access to safe, affordable care for our patients,” said Wesley Canerday, CRNA, president of Alabama Association of Nurse Anesthetists (ALANA). “By signing this important legislation, Alabama recognizes that CRNAs are qualified to make decisions regarding all aspects of anesthesia care based on their education, licensure, and certification.”
Anesthesia services are provided solely by CRNAs in many of Alabama’s critical access hospitals offering surgical services, and in a majority of its rural hospitals.
The law also specifies that anesthesia care, when an anesthesiologist is not present, is provided by CRNAs “in coordination with” a physician, podiatrist, or dentist, defined as a working relationship in which “each contributes his or her respective expertise in the provision of patient care, which includes the discussion of patient treatment, diagnosis, and consultation.”
“The American Association of Nurse Anesthesiology (AANA) applauds Gov. Ivey for recognizing the important role CRNAs have in delivery of safe anesthesia care to the residents of Alabama,” said AANA President Dina Velocci, DNP, CRNA, APRN. “Increased demand, limited resources, and the rural nature of the state dictate that a system capable of meeting the needs of all Alabama residents be maintained and this law provides that.”
As advanced practice nurses, CRNAs are members of one of the most trusted professions according to Gallup. CRNAs provide anesthesia care across all settings and in all patient populations and are the primary anesthesia providers in rural and underserved areas and on the battlefield in forward surgical teams. Because of their expertise in anesthesia delivery and management of critically ill patients, CRNAs have been a highly sought-after healthcare provider during the COVID-19 pandemic.
The American Association of Nurse Anesthesiology (AANA) is presenting the Pennsylvania Association of Nurse Anesthetists (PANA) with the Excellence in State Government Relations Advocacy Award at its Mid-Year Assembly in Washington, D.C. this week.
The Excellence in State Government Relations Advocacy Award, established in 2016, is presented annually to a state association based on the quality of its efforts in the state legislative or regulatory arena for the nurse anesthesiology profession. The recipient is chosen by the AANA Government Relations Committee.
In 2021, the PANA successfully lobbied for a law that includes formal title recognition for Certified Registered Nurse Anesthetists (CRNAs) in statute for the first time, clarifies the CRNA relationship with physicians and dentists, and allows for CRNAs to work with podiatrists.
“The pandemic raised awareness of the critical roles that CRNAs play in healthcare settings and how some state policies prevented CRNAs from practicing to the fullest extent of their education and training at precisely the time they were most needed,” PANA President Lew Bennett, DNP, CRNA, said. “We are honored to be recognized by the AANA for our achievements.”
To increase the flexibility of healthcare resources, Pennsylvania Governor Tom Wolf waived physician supervision during the pandemic. PANA used this opportunity to build relationships with legislators to support title recognition legislation.
“The relationships PANA developed with the governor and legislators will benefit CRNAs for years to come,” Bennett said. “Thank you to the many Pennsylvania CRNAs who laid the foundation for this effort, and those who will continue to fight to protect CRNA practice in the future.”
In addition, PANA developed relationships with a coalition of nursing, rural health, and other groups, including Americans for Prosperity, the Pennsylvania Farm Bureau, and the National Guard, all of which validated and reinforced PANA’s message to legislators.
As advanced practice nurses, CRNAs are members of one of the most trusted professions according to Gallup. CRNAs provide anesthesia care across all settings and in all patient populations and are the primary anesthesia providers in rural and underserved areas and on the battlefield in forward surgical teams.
During the COVID-19 pandemic, nurse anesthetists across the country have been essential in addressing the deadliest part of the disease in addition to providing top-of-the-line anesthesia care. They have served as experts in airway management, hemodynamic monitoring, management of patients on ventilators, and overall management of critically ill patients.
The president of the American Association of Nurse Anesthesiology (AANA) issued the following statement in response to a bill designed to prevent Certified Registered Nurse Anesthetists (CRNAs) from practicing to the full extent of their licensure in the Veterans Health Administration (VHA). AANA President Dina Velocci, DNP, CRNA, APRN, is calling on Congress to reject this “dangerous legislation and support our veterans’ access to the highest quality care.” Full statement:
“Today, allies of the American Society of Anesthesiologists introduced a bill to deny, delay, and disrupt veterans’ access to care in the middle of a public health emergency. In a direct attack on CRNAs, who have been serving on the front lines of the COVID-19 pandemic, the bill would limit the ability of the Veterans Administration (VA) to allow CRNAs to provide care to veterans. The bill would benefit physician anesthesiologists at the expense of our veterans and in denial of all available evidence and data. Reports from the VA Office of the Inspector General have shown dozens of facilities citing shortages of anesthesia staff, and on the ground evidence shows that overly onerous supervision requirements have caused delays and denials of care for veterans.
AANA strongly opposes this misguided legislation that would only serve to hurt veterans’ access to care. All available evidence shows that CRNAs working independently are the most cost-effective method of anesthesia delivery and the safest, which is why CRNAs are able to practice independently in every branch of the military and why 49 states do not require the involvement of physician anesthesiologists in CRNA practice. This is why multiple Veterans Service Organizations (VSOs) supported CRNA full practice authority in 2016 and why several VSOs have testified in support of national standards of practice that would allow CRNAs and other providers to practice to the top of their scope.
The move to eliminate CRNA full practice authority within the VA is being done without the health and wellbeing of our nation’s veterans in mind. While CRNAs provide the most cost-effective and timely access to highest quality care, we do recognize the need to have both physician and nurse anesthesiologists providing anesthesia collaboratively to our veterans, moving away from antiquated delivery models that have one qualified provider overseeing another qualified provider. Any model that unnecessarily restricts CRNA practice will only increase costs, delay care, and adversely affect veterans. At a time when the healthcare system is seeing overwhelming levels of retirements and burnout, stressing the workforce, and limiting care, the ASA and their allies are seeking to further limit care and put veterans at risk for their own benefit.
This is an unconscionable bill meant to slander nurses and hurt veterans.”
More than 1,100 CRNAs currently work in the VA. CRNAs have historically provided much of the anesthesia delivery to active-duty military in combat arenas since World War I and predominate in veterans’ hospitals and the U.S. Armed Services, where they enjoy full practice authority in every branch of the military. CRNAs have been in high demand during the pandemic, due to their skill in ventilator and airway management, as well as anesthesia and pain management. Information on CRNA safety and cost efficiency is available at anesthesiafacts.com/the-research.
In 2021, the PANA successfully lobbied for a law that includes 