Veterans Health

Administration Nursing
Handbook Update

Angelique Davis
NRSG 808

Define the Problem
Affordable Care Act, 2010
Allows 32 million Americans to gain health care
insurance
To date 7 million Americans have gained
health care insurance
The Institute of Medicine did a report in 2011
on The Future of Nursing: Leading change,
advancing health care.
This report recommended a solution to the
growing number of Americans gaining
insurance


Define the Problem
Institute of Medicine Recommends:
The Future of Nursing: Leading Change,
Advancing Health Care, 2011
4 recommendations:
ensure that nurses can practice to the full extent of
their education and training
improve nursing education
provide opportunities for nurses to assume leadership
positions and to serve as full partners in health care
redesign and improvement efforts
improve data collection for workplace planning and
policy making
Define the Problem
Veterans Health Administration
VHA, largest health care provider in the United
States
Employs 667 CRNAs in the U.S., D.C., and the
Philippines
Proposing to change Nursing Handbook,
1180.03, to state that all APRNs can practice
without physician supervision
APRNs at the VHA include: Nurse Practitioners,
Nurse Midwives, Clinical Nurse Manager, and
Nurse Anesthetists
Assemble the Evidence,
with a nurse anesthesia focus
Nurse Anesthesia History
Nurses have provided anesthesia since the
1800s and in every war to date
The AANA was founded in 1931
First certification for nurse anesthesia in 1945
and recertification in 1975
First accredited school of nurse anesthesia was
established in 1952.
To date CRNAs provide 65% of all anesthetics
in the U.S.
The AANA represent 47,000 CRNAs
Assemble the Evidence,
with a nurse anesthesia focus
VHA history and facts
Department overall budget for 2014 is $140
million, this has risen 40% since 2009
Increasing number of veterans needing health
care
51,829 men and women wounded in action
since the beginning of the War on Terrorism
The VHA heeded the recommendations of the
IOM and has proposed to let its 6,135 APRNs
to practice as Licensed Independent
Practitioners; without physician supervision



Assemble the Evidence,
with a nurse anesthesia focus
CRNA scope of practice
Varies from state to state
Current VHA nursing handbook states that
CRNAs do not need physician supervision, but
rather a team based approach to anesthesia
CMS federal physician supervision opt rule
established in 2001
17 states to date have opted out of the CMS
rule

Assemble the Evidence,
with a nurse anesthesia focus
CRNA education
Requirements to become a CRNA
Bachelors in Nursing, 1 year minimum in acute care,
24-36 month accredited masters or doctoral nurse
anesthesia program.
Pass the NBCRNA to become certified
Total time to become a CRNA: 7-8 years

Recertify every two years
Minimum of 40 CEs
850 hours of substantial anesthesia practice
Construct the Alternatives
Alternative 1..
Anesthesiologists:
Average salary:
$336,000
Average amount to
educate: $1,083,795
No Change to VHA
nursing Handbook
CRNA
Average salary:
$170,000
Average amount to
educate:$161,809
Construct the Alternatives, Alt 1
The difference in the amount of money
spent and money earned between an
anesthesiologist and a CRNA equates to
6.7 CRNAs can be educated for every one
anesthesiologist.

Those 6.7 CRNAs provide 26.8 years of
anesthesia care before one
anesthesiologist graduates.
Construct the Alternatives
Alternative 2
Change the VHA nursing handbook to state
only CRNAs will become LIPs.
SRNAs are required by the Council of Accreditation to
have a minimum of 550 cases.
Average number of cases at KU: 881
Average number of clinical hours: 2500

Number of clinical hours required for nurse
practitioners is 500 without requirements in
subspecialties
Construct the Alternatives, Alt 2
Patient safety and mortality rates are not
compromised with solo CRNAs
A study done by Dulisse & Cromwell, 2010, stated

In opt-out states, complication rates for the nurse anesthetist solo group
were essentially identical to those for the anesthesiologist solo group.
The difference between complication rates for the nurse anesthetist solo
team anesthesia was also not statistically different in opt out states. We
recommend that CMS return to its original intention of allowing nurse
anesthetists to work independently of surgeon or anesthesiologist
supervision without requiring state governments to formally petition for
an exemption p. 1475).
Construct the Alternatives
Alternative 3
Change the VHA nursing Handbook to
allow all APRNs to work as LIPs.
This will decrease the amount of variability
that exists in VA facilities
May forge the way for all facilities at a federal
level
APRNs will still be in collaboration with other
health care providers No provider in the VA
system is an island (Lowes, 2013, p. n.d.)
Select the Criteria
Efficiency


Community


Political
Acceptability
Select the Criteria, Efficiency
Total yearly revenue
Yearly revenue
generated by a CRNA
and an
anesthesiologist is the
same at $5,317,945.

Total yearly revenue
minus total cost
Solo Anesthesiologist:
$1,285,945
Solo CRNA:
$3,277,945



CRNAs are more cost effective and could
provide the VHA with more revenue for our
nations veterans
Select the Criteria
Community
Defined as a feeling
of fellowship with
others, as a result
of sharing common
attitudes, interests,
and goals
Supporters of the
VHA nursing
handbook change
AVANA
AANA
Congressmen
AARP
Veterans
Select the Criteria
Political
Acceptability
Defined by Bardach,
2012, A feasible policy
must be politically
acceptable, or at least
not unacceptable.
Political unacceptability
is a combination of two
conditions: too much
opposition and/or too
little support (p. 41).
Main Opposition
ASA
The ASA states that LIP
CRNAs will jeopardize
the care of the nations
veterans
ASA quotes a study
done in Anesthesiology,
2000, that states
mortality and failure-to-
rescue rates were highest for
patients who underwent
operations without an
anesthesiologist providing
direction
Select the Criteria, Political Acceptability
Rebuttal to ASA
In recent literature summarized by Dulisse &
Cromwell, 2010, there was no difference in
mortality or anesthesia complications when
comparing provider type; anesthesiologist
versus CRNA.
This study did an analysis of Medicare data
from 1999-2005 in fourteen different states
that had enacted to opt out of the federal
supervision rule for CRNAs.

Project the Outcomes
Alternative 1
Does no justice to
any APRN provider
Prevents more
revenue from being
created
Decreases the
amount of veterans
being treated.
Project the Outcomes
Alternative 2
Best option for the VHA nursing handbook
CMS opt out rules serves as a viable example
of success with solo CRNAs
Quality and patient safety are not
compromised with CRNAs providing anesthesia
Significant difference in the amount of clinical
hours required for NPs and CRNAs
This proves CRNAs have a larger foundation of
patient care.


Project the Outcomes
Alternative 3
Would curtail the increasing number of
veterans seeking health care
6,135 APRNs will still use the team based
approach to health care
Would allow the VHA facilities greater support
in rural areas

Confront the Trade Offs
No trade offs with
allowing CRNAs
only to become
LIPs.
Annual savings of
$1,991,990
CRNAs predominate
in the military
No decline in
patient safety or
quality
Decide
After review of the current literature, I believe there should be a
revision to the VHA nursing handbook to change CRNAs only to
LIPs.
There are several studies that state there is no difference in
outcomes when looking anesthesia provided by CRNA vs.
anesthesiologists.
CRNAs are more cost effective
This change to the VHA nursing handbook could forge the way for
CRNAs to become LIPs at the federal level
Continuation of AVANA PAC to advocate for CRNAs
Promotion of education to the community
Lastly, "CRNA practice," 2011, sums up CRNA practice stating For
any service location, CRNAs are highly cost effective, quality
anesthesia providers on the basis of educational costs, cost of
service, productivity, and substitutability for more expensive
provider (p. n.d.).


References
2014 Criteria for recertification certified registered nurse anesthetist. (2014). Retrieved from
http://www.nbcrna.com/recertification/Documents/20140303%20Criteria%20for%20Recertification.pdf
American Association of Nurse Anesthestists. (2012). Fact sheet concerning state opt-outs and November 13, 2001 CMS rule [Fact
Sheet]. Retrieved from http://www.aana.com/advocacy/stategovernmentaffairs/Pages/Fact-Sheet-Concerning-State-Opt-Outs.aspx
Anesthesia: The practice of nursing or the practice of medicine. (2011). Retrieved from
http://www.kana.org/information/anesthesiapractice/
Bardach, E. (2012). A practical guide for policy analysis: the eightfold path to more effective problem solving (4th ed.). Washington,
DC: SAGE.
Beck, M. (2014, January 26). At VHA, doctors, nurses clash on oversight. Wall Street Journal. Retrieved from
http://online.wsj.com/news/articles/SB10001424052702304856504579340603947983912
Become a VA certified registered nurse anesthetist [Brochure]. (2012). Retrieved from
http://www.vacareers.va.gov/assets/common/print/CRNA_Brochure1.pdf
Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs,
1469-1475.
Education of nurse anesthetists in the United States - At a glance. (2014). Retrieved from
http://www.aana.com/ceandeducation/becomeacrna/Pages/Education-of-Nurse-Anesthetists-in-the-United-States.aspx
Hogan, P. F., Seifert, R. F., Moore, C. S., & Simonson, B. E. (2010). Cost effectiveness analysis of anesthesia providers. Nurse
Economics, 28, 159-169.
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academic
Press.
Kansas CRNA practice. (2011). Retrieved from http://www.kana.org/Information/CRNAPractice/
Kussman, M. J. (2007). Anesthesia service [VHA Handbook 1123]. Washington, DC: Department of Veterans Affairs.
Lowes, R. (2013, September 13). VA proposes independent status for all advanced practice RNs. Medscape Medical News.
National Task Force on Quality Nurse Practitioner Education. (2012). Criteria for evaluation of nurse practitioner programs. Retrieved
from American Association of Colleges of Nursing website: http://www.aacn.nche.edu/education-resources/evalcriteria2012.pdf
RAND. (2010). Is there a shortage of anesthesia providers in the United States? Research Highlights, 1-3. Retrieved from
http://www.rand.org/content/dam/rand/pubs/research_briefs/2010/RAND_RB9541.pdf
Talking point certified registered nurse anesthetist. (2010). Retrieved from
c.ymedn.com/sites/www.cnaptexas.org/resource/resmgr/imported/pdf_Talking_Points_CRNA.pdf
U.S. military casualties. (2014). Retrieved from https://www.dmdc.osd.mil/dcas/pages/report_oef_type.xhtml
Who are we. (2014). Retrieved from http://www.aana.com/aboutus/Pages/Who-We-Are.aspx