Compendium Table of Contents

California Association of Nurse Anesthetists, Inc A Compendium Documenting the Scope of Practice of Certified Registered Nurse Anesthetists in California

Section A: Legal basis of Nurse Anesthesia Practice in California

A 1. Scope of Practice Guidelines for California Certified Registered Nurse Anesthetists.

A 2. Nursing Practice Act, California Business and Professions Code, Section 2725 to Section 2727.5

A 3. Nurse Anesthetist Act, California Business and Professions Code, Section 2825 to Section 2833.6

A 4. Board of Registered Nursing Opinions and Correspondence

4.1 (11/15/1985) Copy of motion adopting legal opinion that the practice of registered nursing includes the ordering of laboratory tests, the results of which may be used in performing nursing functions.

4.2 (4/14/1986) CRNAs may perform the pre and post anesthesia evaluation, authorize the release of the patient from the PACU and may implement emergency procedures

4.3 (9/12/1988) CRNAs may authorize the discharge of a patient from outpatient surgery or an ambulatory care surgery center. CRNAs are independent practitioners and do not require supervision by a physician.

4.4 (11/11/1988) CRNAs may administer anesthesia ordered by a physician, dentist or podiatrist. Anesthesia services include regional or local anesthesia by injection and general anesthesia. May initiate orders to RNs, may perform a preanesthesia and post anesthesia evaluation. 4.5 (July 1990) CRNA is responsible for selecting and administering the anesthetic agent, monitoring the patient’s response thereto, and selecting and administering drugs required to maintain the patient’s stability during the operative period.

4.6 (1/15/1992) It is within the scope of practice of the CRNA to provide pain management services and emergency procedures both inside and outside the operating room suite.

4.7 (2/18/1993) CRNAs are responsible for their own professional conduct and may be held liable for those professional acts. CRNAs practice under his or her license and not that of a physician.

4.8 (9/16/1994) there is nothing in the statute that would preclude a CRNA from providing anesthesia services in Level I, II, or III trauma centers.

4.9 (7/11/2002) Letter to the California Department of Health Services; “It is the position of the Board of Registered Nursing that physician supervision is not required for certified registered nurse anesthetist practice.”

4.10 (11/20/2002) California Department of Health Services letter to Board of Registered Nursing stating that the Department defers to the Board of Registered Nursing concerning the scope of practice of nurse anesthetists.

4.11 (11/20/2009) California Department of Health Services letter to California Society of Anesthesiologists stating that the Department defers to the Board of Registered Nursing concerning the scope of practice of nurse anesthetists.

4.12 (1/24/2003) Letter to the California Society of Anesthesiologists stating that the BRN has determined that CRNAs may administer all types of anesthesia for surgery performed by podiatrists. 4.13 (11/23/2004) Letter to Department of Health Services “The BRN has long held that CRNAs are licensed independent practitioners and do not require the supervision of a surgeon or anesthesiologist”.

4.14 (1/20/2005) Letter to Harold Bressler, General Counsel, Joint Commission on Accreditation of Healthcare Organizations stating that California CRNAs do not require supervision.

4.15 (2/4/2005) Letter from DHS to BRN in part states that CRNAs are considered licensed independent practitioners under state law.

A 5. California Attorney General opinion number 83-1007 issued April 5, 1984 concluded that it is within the scope of practice of a certified registered nurse anesthetist to administer general or regional anesthesia.

Section B: California Administrative Code, Title 22

B 1. Title 22, Section 70231 to 70239, Anesthesia Services.

B 2. Title 22, Section 70223 Surgical Services, see part (d) for the anesthesia requirements for the surgical section.

B 3. Title 22 Regulatory Package R-34-85, December 22, 1986, changes eliminated the physician CRNA supervision requirement and restrictions on CRNAs administering regional anesthesia.

B 4. Title 22 Regulatory Package R 41-91, April 15, 1993, changes eliminated the requirement that only a physician may perform the preanesthesia evaluation and authorize the discharge of the patient from the PACU or the outpatient section. The wording changes permit CRNAs to perform those functions. Section C: Medicare Conditions of Participation for Hospitals and Conditions for Coverage for ambulatory surgery centers

C 1. Letter from Governor Schwarzenegger to CMS opting out of the Medicare supervision requirement for anesthesia services provided by a certified registered nurse anesthetist.

C 2. Medicare Conditions of Participation for Hospitals and Survey Guidelines, section 482.52: Anesthesia Services.

C 3. Medicare Conditions for Coverage for Ambulatory Surgical Centers and Survey Guidelines, section 416.42: Surgical service and section 416.52: Patient admission, assessment and discharge.

C 4. CRNA Medicare payment policies and anesthesia claims modifiers.

Section D: The Joint Commission Standards

D 1. Anesthesia Standards for Hospitals

D 2. The Joint Commission letter to AANA outlining the process of The Joint Commission survey procedure for determining licensed independent practitioner status for CRNAs (November 12, 2003).

D 3. The Joint Commission General Counsel letter to CANA attorney Patrick Shannon stating that CA CRNAs are eligible to be credentialed as licensed independent practitioners (November 12, 2004).

D 4. The Joint Commission General Counsel letter to CANA attorney Phillip Recht providing the definition of licensed independent practitioner and the process to determine licensed independent practitioner status (April 7, 1989).

Section E: California Outpatient Surgery Center Laws

E 1. California Health and Safety Code Sections 1248 to 1248.85. Section F: California Dental Anesthesia Laws and Regulations

F 1. California Business and Professions Code 1646 to 1646.9

F 2. California Code of Regulations Section 1043

F 3. CANA analysis of the dental office anesthesia laws and regulations

Section G: Podiatry

G 1. Memo from the attorney for the Department of Consumer Affairs concluding that nurse anesthetists may provide the full range of their services in an inpatient or outpatient setting for surgery performed by a podiatrist (9/2/1988).

G 2. Letter from the Board of Registered Nursing stating that CRNAs may administer all types of anesthesia as ordered by a podiatrist (1/24/2003).

G 3. Letter from the Board of Podiatric Medicine to California Society of Anesthesiologist stating that the restrictions on podiatrists administering anesthesia does not apply to the type of anesthesia a podiatrist may order (2/10/2003).

Section H: Education and Practice Standards

H 1. Education Standards of the Council on Accreditation of Nurse Anesthesia Education Programs

H 2. Scope and Standards for Nurse Anesthesia Practice, American Association of Nurse Anesthetists

H 3. Guidelines for Core Clinical Privileges, Certified Registered Nurse Anesthetists, American Association of Nurse Anesthetists

Section I: Resources I 1. American Association of Nurse Anesthetists at aana.com - go to Resources on the home page. The site contains practice documents, legal briefs and publications.

I 2. California Codes (laws) and legislation information http://www.leginfo.ca.gov

I 3. The Joint Commission http://www.jointcommission.org for questions concerning The Joint Commission and CRNAs contact John Herringer [email protected] or by phone 630-792-5900

I 4. California Board of Registered Nursing http://www.rn.ca.gov

I 5. Dental Board of California http://www.dbc.ca.gov

I 6. Centers for Medicare and Medicaid (CMS) - contains links to reimbursement, regulations and manuals concerning Medicare http://www.cms.hhs.gov.