Many may have seen the article by Anesthesiologist Dr Sibert entitled "Unsupervised anesthesia care by a nurse anesthetist is a threat to patient safety". As one would expect this article had a number of replies from both sides of the debate. Most recently however was a reply from current AANA president Debra Pecka Malina, DNSc, MBA, CRNA. It is posted below.

Apparently accurate information and published research don’t fit into Dr. Sibert’s arguments about physician supervision of nurse anesthetists. Following are facts that can be checked simply by looking them up:

With regard to the recently issued new rules concerning conditions of participation, CMS left in place a rule that requires nurse anesthetists to be supervised by physicians, but that provides states a mechanism for opting out of this requirement. To date, 16 states have.


To be perfectly clear, federal laws and regulations do not require nurse anesthetists to be supervised by anesthesiologists. To assert otherwise is patently incorrect.


President Bill Clinton’s mother was, indeed, a CRNA. However, the opt-out rule was signed into law by President George W. Bush during his first term in office [66 FR 56762-56769]. President Bush’s mother was not a CRNA.


The anesthesia care team model is far from the most cost-effective anesthesia delivery model. According to a study conducted by Virginia-based The Lewin Group and published in the May/June 2010 issue of the Journal of Nursing Economic$, the most cost effective model of anesthesia delivery is a CRNA acting as the sole anesthesia provider. The study, titled “Cost Effectiveness Analysis of Anesthesia Providers,” considered the different anesthesia delivery models in use in the United States today, including CRNAs acting solo, physician anesthesiologists acting solo, and various models in which a single anesthesiologist directs or supervises one to six CRNAs. The results show that CRNAs acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model. On the other end of the cost scale, the model in which one anesthesiologist supervises one CRNA is the least cost efficient model. The study’s authors also completed a thorough review of the literature that compares the quality of anesthesia service by provider type or delivery model. This review of published studies shows that there are no measurable differences in quality of care between CRNAs and anesthesiologists or by delivery model. And, in the name of transparency, it is important to note that the study was supported by the AANA Foundation, but that was where the Foundation’s involvement in the research or publication of the results ended.


Two months later, in the August issue of Health Affairs, a national study conducted by RTI International confirmed that there are no differences in patient outcomes when anesthesia services are provided by Certified Registered Nurse Anesthetists (CRNAs), physician anesthesiologists, or CRNAs supervised by physicians. The study, titled “No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians,” compared patient outcomes in states where the supervision requirement is in place with patient outcomes in the 14 states that had opted out of the requirement between 2001 and 2005, and found that patient outcomes did not differ. The researchers concluded that “Based on these findings we recommend that CMS repeal the supervision rule.” Again, it is important to note that the study was supported by the AANA Foundation, but that was where the Foundation’s involvement in the research or publication of the results ended.
Then, in October 2010, landmark findings from the Institute of Medicine (IOM) asserted that expanding the role of nurses in the U.S. healthcare system will help meet the growing demand for medical services. Titled “The Future of Nursing: Leading Change, Advancing Health,” the IOM report urged policymakers to remove policy barriers that hinder nurses—particularly advanced practice registered nurses such as CRNAs—from practicing to the full extent of their education and training. The IOM report was the work of the IOM’s committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, which consists of doctors, nurses, academicians, and other healthcare representatives.


With regard to anesthesia in the military, CRNAs have been the main provider of anesthesia care to men and women serving in the military since World War I. True stories: When U.S. Army Private Jessica Lynch was freed from her Iraqi captors in a daring rescue mission in 2003, it was a special ops nurse anesthetist carrying medical supplies and a weapon who accompanied the team, not an anesthesiologist. In 2006, when Bob Woodruff was critically wounded covering the war in Iraq, it was a CRNA, not an anesthesiologist, who flew into the combat zone and airlifted the reporter to safety. And when President George H.W. Bush attended a drug summit in Columbia in 1990, a ground medical team was present to support the president in case of a terrorist attack. That team was made up of two surgeons and a CRNA; an anesthesiologist stayed safely on board the U.S.S. Nassau off the coast, not exactly “immediately accessible” should something have happened. In all of these cases, either it was deemed unnecessary to have an anesthesiologist present, or an anesthesiologist couldn’t be found to volunteer for the mission, but the bottom line was an anesthesiologist wasn’t there. Dr. Sibert’s depiction of CRNAs in the military is not only offensive and inappropriate, it’s grossly inaccurate.

Finally, on the topic of pain management, procedures such as epidurals, nerve blocks, and other techniques are as much a part of a CRNA’s education and training as they are an anesthesiologist’s. In fact, the majority of obstetrical anesthesia, including epidurals, given in this country is administered by nurse anesthetists. Seriously, at 2 a.m. when a CRNA is on OB call and an epidural needs to be placed, how often does it occur that a physician of any kind is standing looking over the CRNA’s shoulder to make sure this “complex” procedure is done correctly?

The main focus of CRNAs is to ensure all patients access to safe, cost-effective anesthesia care, and it has been shown over and again—in daily practice and through research—that this is exactly what is happening year in and year out.


Debra Pecka Malina, DNSc, MBA, CRNA
President, American Association of Nurse Anesthetists
American Association of Nurse Anesthetists