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A 'turf battle' or a matter of patient safety?
City council considers new rules for anesthesia in D.C. operating rooms
(Published May 31, 2004)

By G. STEPHEN THURSTON
Staff Writer

One fact medical professionals in Washington can agree on is this: There are not enough anesthesiologists to cover the need for them in hospital operating rooms throughout the city.

As a result, non-emergency surgery has been rescheduled and emergency room hours have been cut.

To alleviate the shortage of professionals who are qualified to administer anesthesia to hospital patients, the D.C. City Council’s Committee on Human Services is working on a bill that would license "anesthesiologist assistants." The debate about licensure is pitting groups such as the D.C. Association of Nurse Anesthetists against local associations of hospitals and of doctors of anesthesiology.

"I don’t think it’s worth the risk," said Jane McCarthy, president of the D.C. Association of Nurse Anesthetists, referring to licensing of anesthesiologist assistants (AAs) under the bill’s current provisions.

Representatives from McCarthy’s group said the bill makes licensure too easy, that the anesthesiologist assistants might not have enough background to work safely in an operating room.

"We’re not saying not to have AAs licensed," she said in a telephone interview.

Her group would like to make the anesthesiologist assistants first become physician assistants, a training program that produces people who, in some states, can perform minor surgery and prescribe drugs. It’s a requirement that some other states include in their licensing. Only 16 states are believed to currently license anesthesiologist assistants.

"What we’re saying is that these AAs should be PAs [physician assistants] also, so I’m coming at it from a patient safety point of view," McCarthy said.

The bill originally was introduced in January by Councilwoman Sandra Allen, D-Ward 8, with the physician assistant requirement in the legislation, said Eric Goulet, a member of Allen’s staff. The language was stricken when doctors and hospitals said the requirement would exacerbate the current shortage of personnel, Goulet said. He added that the nurses "never said that an AA is not qualified" but that the nurses were better qualified.

One concern McCarthy expressed, though, is that anesthesiologist assistants haven’t been scientifically studied for their effectiveness, so "it makes more sense to go with the known entity" in certified registered nurse anesthetists, she said.

A major concern for the nurse anesthetists is the level of medical experience and education the anesthesiologist assistants have before they enter the program to become assistants. The two anesthesiologist assistants programs currently operating in the nation — at Emory University in Atlanta and at Case Western Reserve University in Cleveland — will consider applicants with any bachelor’s degree, so long as those applicants have taken the traditional pre-medical school courses. These include biology, chemistry and organic chemistry, physics, calculus and statistics. Neither requires a health, nursing or medical background.

By comparison, eligibility for the Certified Registered Nurse Anesthesia (CRNA) Program at Georgetown University (one of about 85 programs in the country) requires that the nurse already be a licensed registered nurse and has spent at least a year in critical care nursing experience (emergency rooms or other high-pressure settings).

"A CRNA has, one, gone to nursing school...[and] has several years of clinical care experience, and then goes through a CRNA program. You’re really talking about people at a graduate level," said Henry Banta, an attorney representing the nurses.

He also claimed the anesthesiologist assistants programs are "not even nursing school level."

But this does not appear to be the case, according to the executive director of the D.C. Board of Medicine. The course work for both the nurses and the assistants is graduate level and similar. Both require extensive clinical training in anesthesiology.

"They [AAs] have as much or more training [in anesthesiology] as the nurse anesthetists," said Jim Granger, executive director of the D.C. Board of Medicine.

Supporters of the licensing bill think people are blowing the threat out of proportion, since anesthesiologist assistants already work in D.C. hospitals.

In November 2002, the D.C. Board of Medicine issued guidelines for the use of anesthesiologist assistants in the District. Those regulations do not require that the anesthesiologists assistants be physician assistants.

Banta, the attorney for the nurses, said he thinks the regulations were improperly enacted, but instead of suing the Board of Medicine over it, his group went right to the city council with legislation of their own -- including the now-removed requirement that the anesthesiologist assistants be physician assistants as well.

As currently written, the bill is similar to the Board of Medicine’s guidelines. But the people fighting the legislation see one potential problem that was written into the bill. It says doctors of anesthesiology would be able to oversee as many as four anesthesiologist assistants at one time. It states the doctor need be "physically present or immediately available," meaning "in the same physical location or facility in which the services are provided."

This could mean being many minutes away in some of the District’s larger facilities, Banta said, with the potential for endangering patients.

The regulation originally said that the anesthesiologists overseeing their assistants would not have to remain in the operating room with their assistants, but "must be present in the operating suite."

"Are we once again lowering the standards for god knows whatever reason? Why should we be doing it in the District?" Banta asked in a telephone interview.

According to many people interviewed, the anesthetists are organized into teams, with a doctor overseeing both anesthesiologist assistants and certified registered nurse anesthetists in an operating "suite" or "theater."

"It’s a tightly regulated and monitored situation" in the operating room, said Paula Faria, a spokeswoman for Washington Hospital Center, which has been using anesthesiologist assistants since the regulations took effect. "CRNAs and AAs are always under the supervision of an anesthesiologist" at her hospital, Faria said.

Goulet, in Councilwoman Allen’s office, said that the "immediately available" language of the bill conforms to federal regulations and was inserted for that reason.

"I feel comfortable with the bill," he said. "If we need to reevaluate the 'immediately available' regulation, that’s fine."

No one interviewed for this story could provide evidence that the anesthesiologist assistants working at D.C. hospitals have caused patient-related problems. However, there was a lawsuit involving an anesthesiologist assistant in Ohio that resulted in a $22.5 million loss for the hospital, doctor and the anesthesiologist assistant. According to Anesthesia Malpractice Prevention, the 36-year-old patient ended up in a nursing home, unable to communicate because of problems caused by improper epidural drug administration and because of improper emergency procedures on the part of the anesthesiology assistant.

Not all certified registered nurse anesthetists share the same opinion on the issue. Stephen Gifford, who testified at a public hearing on the issue last January, said in written testimony that he has worked for a year with anesthesiologist assistants and feels confident "that at no time was patient safety compromised nor was the cohesiveness of the entire anesthesia care team model at risk."

Goulet said he believes the controversy is more about maintaining turf than about patient safety.

"Frankly, part of it is a turf battle. … They [CRNAs] right now get $120,000 for their job, and they have a stranglehold on the market. They don’t want to have competition," he said.

Goulet said he "would feel differently about this legislation if there were an abundance of CRNAs" in the District, but given how few anesthetists there are and how grueling work in the emergency room can be, something has to be done to attract more. Licensing will help attract qualified anesthesiologist assistants, he said.

For her part, McCarthy said that she does not feel threatened by more anesthesiologist assistants since they are being offered the same wage and benefits package as the nurse anesthetists, and the number of spaces the District needs to fill is so high there are plenty of jobs for everyone.

At a public hearing before the D.C. City Council’s Committee on Human Services in January, Dr. Eileen Begin, director of the Clinical Administration Department of Anesthesiology at Washington Hospital Center, testified that 20 certified registered nurse anesthetist positions have sat vacant at any one time since 2001. She said the shortage has made the hospital shut down three operating rooms, a hit of about 180 surgeries per month.

Given that shortage, one of McCarthy’s arguments against using the anesthesiologist assistants is the low number of people available to fill positions. With only two programs producing about 40 assistants per year, relying on them to fill the gap really won’t help, McCarthy said. She said her group’s concern is with public safety.

Under general anesthesia, patients no longer are controlling some basic life functions such as breathing. The anesthetist has to know what to do if there’s a heart arrhythmia or if the patient isn’t getting adequate oxygen, McCarthy said.

"You can have brain death in three minutes," she said, if the person isn’t getting oxygen because the breathing tube is improperly inserted.

With general anesthesia, "some people say you’re taking someone close to death and then bringing them back to life," McCarthy said.