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  • Determining Scope of Practice for CRNAs: A Complete Guide

    Certified Registered Nurse Anesthetists (CRNAs) are advanced practice registered nurses (APRNs) who provide anesthesia related care in a variety of healthcare settings before, during, and after therapeutic, diagnostic, surgical, and obstetrical procedures. CRNAs have many responsibilities for anesthesia care, and as such, follow a scope of practice. 

    The term “scope of practice” has long been used to describe the extent of a nurse’s ability to perform medical procedures. It also refers to the services that an allied health profession is allowed or not allowed by law or regulation to provide within a state, region, or other jurisdiction.  Scope of practice manuals are guides for Certified Registered Nurse Anesthetists (CRNAs) and other healthcare providers that describe the boundaries within which a nurse or other provider is allowed to practice. These manuals usually outline educational requirements, laws and regulations, standards of care, professional guidelines for malpractice insurance, and the process for reporting inappropriate conduct as well as malpractice issues.

    The Scope of Practice for CRNAs is determined by the state laws that govern the practice. The qualifications required to obtain a nurse anesthesia license are defined in each state’s nurse practice act. These requirements include advanced degree at masters or doctorate level either as an APRN or as a CRNA, and successful completion of certification exam by the Council for Accreditation of Nurse Anesthesia Educational Programs (COA). The process for obtaining a CRNA license is further defined in each state’s nurse practice act.

    CRNAs practice in a wide array of settings, including ambulatory surgical centers, non operating room anesthetic areas, hospitals, and office-based settings. CRNAs provide all types of anesthetic care for diagnostic, surgical, and therapeutic procedures. 

    In fact, CRNAs are the sole anesthesia providers in approximately one-third of all U.S. hospitals and in more than two-thirds of rural hospitals. CRNAs help to make healthcare more effective, accessible, and cost affordable. 

    CRNAs provide anesthetic care for all specialties, which include but aren’t limited to: 

    • General surgery and care 
    • Obstetrics 
    • Trauma 
    • Cardiac 
    • Orthopedic
    • Dental
    • Gastrointestinal
    • Plastic surgery

    Additionally, they provide care in all locations in the United States, and often are the sole anesthesia providers and professionals who deliver care to the military, medically underserved populations, and rural areas. 

    CRNAs are accountable for engaging in professional excellence through evidence-based practice, lifelong learning, certification, engagement in professional development and quality improvement, and complying with the Standards for Nurse Anesthesia Practice and Code of Ethics. 

    The Code of Ethics for CRNAs (2005) is intended as a guide to ethical behavior and provides information about confidentiality, patient rights, informed consent, malpractice insurance, the public’s health and welfare, and collaboration with other healthcare providers.

    CRNAs exercise professional judgment and are accountable for their actions, services, and clinical competence. The scope of an individual CRNAs practice is determined by experience, education, and local state and federal laws.

    CRNA scope of practice includes but is not limited to the following:

    Preoperative/Preprocedure

    • Provide counseling and education to the patient about the procedure and options
    • Perform a thorough and comprehensive physical examination and history.
    • Assess and evaluate patient to determine best course of action
    • Develop a patient-centered plan for analgesia, anesthesia, multi modal pain management, and recovery
    • Ensure patient understanding and obtain anesthetic-specific informed consent
    • Select, prescribe, order, and administer pre-anesthetic medications, including various necessary controlled substances.

    Intraoperative/IntraProcedure

    • The use of anesthesia and sedation to achieve the reversible loss of consciousness, amnesia, analgesia and/or muscle relaxation for diagnostic and therapeutic procedures with sufficient depth and duration as needed.
    • Implement a patient-specific plan of care, which may involve anesthetic techniques, such as general, regional and local anesthesia, sedation, and multi modal pain management
    • Select, order, prescribe and administer anesthetic medications, including controlled substances, adjutant drugs, accessory drugs, fluids, and blood products
    • Assessing airway, vital signs (pulse, blood pressure) with appropriate equipment
    • Interpretation and management of abnormal diagnostic data
    • Engage in safe perioperative patient care practices which includes but is not limited to safe use of anesthesia equipment for administration; oxygen therapy; central venous access devices including ultrasound guidance if performed within an approved education program.

    Post Operative/Post Procedure

    • Facilitate emergence and recovery from anesthesia
    • Select, order, prescribe and administer post anesthetic medications, including controlled substances
    • Conduct post anesthesia evaluation
    • Educate the patient related to recovery, regional analgesia and continued multi modal pain management
    • Discharge from the postanesthesia care area or facility

    Pain Management 

    • Provide comprehensive patient centered pain management to optimize recovery
    • Provide acute pain services, including multi modal pain management and opioid-sparing techniques
    • Provide anesthesia and analgesia using regional techniques for obstetric and other acute pain management
    • Provide advanced pain management, including acute, chronic, and interventional pain management

    Other Services 

    • Order or prescribe medications for pain management or medication assisted treatment, including controlled substances 
    • Provide critical care, emergency, and resuscitation/airway management services 
    • Perform testing for point of care
    • Order, evaluate, and diagnose based on radiological and laboratory studies 
    • Use and supervise technologies for both diagnostic and care delivery 
    • Provide ongoing pain management and sedation for palliative care 
    • Order treatments, services, and consults related to a patient’s care

    Considerations for Adding New Activities to Individual CRNA Scope of Practice 

    Following scope of practice is very important for CRNAs. 

    Regulatory agencies and legislators look to the American Association of Nurse Anesthesiology (AANA) for resources that represent the professional practice of CRNAs. 

    The AANA develops information and documents to support policy decisions and scope of practice to ensure effective and safe delivery of anesthesia services. The Scope of Practice refers to the broad continuum of best practices rather than a detailed list of services. 

    The scope of practice considerations are created and vetted through a process supported by: 

    • The accredited education that CRNAs obtain 
    • The formal assessment and evaluation of organizations that issue credentials 
    • The evolving nature and dynamic of practice 


    Throughout the course of their careers, CRNAs will undoubtedly incorporate new technologies and techniques into their practice based on patient safety needs, new technological innovations that improve outcomes, and peer-reviewed scientific evidence. 

    The decision to add a new activity to the Scope of Practice is both complex and based on considerations that are unique to the CRNA, facility, and state in which they practice. 

    CRNAs must carefully conduct an analysis and evaluate if a specific technique or procedure related to sedation, pain management, anesthesia, or related nursing services are within the CRNA’s scope of practice. 

    CRNAs are highly trained and this foundation in education, assessment, and training, along with the individual’s procedure specific education and clinical competencies allow CRNAs to incorporate new techniques and activities into practice. These activities may or may not be represented in traditional pain management, sedation, or anesthetic roles. 

    CRNAs should refer to the following scope, standards, and guidelines when determining if a new technique, technology, or procedure falls within the scope of acceptable practice.  The following, however, provides a framework for individual CRNAs so that they can make an evidence-based and informed decision regarding scope of practice. The CRNA should ensure that they are complying with applicable regulation, statutes, and guidelines and should consult their state nursing boards, colleagues, and other professionals to make a sound decision. 

    Nurse Anesthesia Professional Scope, Standards, Guidelines, and Ethics Considerations 

    The American Association of Nurse Anesthetists (AANA) is the professional organization representing more than 52,000 Certified Registered Nurse Anesthetists. The AANA Scope of Practice includes the provision of anesthesia care to patients across the lifespan in all healthcare settings. The AANA has a long history of promoting excellence in nurse anesthesia care and advancing the profession.

    • Is the act related to anesthesia? 

    If not, it may be within the RN scope of practice as determined by your state board of nursing (or applicable governing body). Consider consulting your state board of nursing

    • Is the act within your professional scope of practice?

    It’s important to determine if the act falls under the Scope of Nurse Anesthesia Practice and the Clinical Privileges and Other Responsibilities of Certified Registered Nurse Anesthetists. If it’s not, consider consulting with your licensure board or seeking additional clarification.

    • Will the act be performed in compliance with the Standards for Nurse Anesthesia Practice?

    The standards of practice are there for a reason. They are intended to support the delivery of high quality, consistent, patient-centered anesthesia care. Individual CRNAs are expected to comply with the standards to increase successful patient outcomes and safely deliver anesthetic healthcare. 

    •  Is the act consistent with the ethical standards in the Code of Ethics for the Certified Registered Nurse Anesthetist? 

    It’s important to consider and evaluate the ethical components of performing a given act or procedure. It’s necessary for the CRNA to ensure that all treatments are ethical and that they are legal and in accordance with state and federal regulations, statutes, and rules.

    • Do you hold the appropriate authorization and/or licensure or to practice in the state?

    It’s important to make sure that you are allowed to practice in the state, and to consider the act in question. Is the act expressly prohibited or protected by the state nursing practice guidelines, rules and regulations, or other state statutes?

    •  Has the state board of nursing issued a statement, policy, or opinion on whether the act is in accordance with the CRNA scope of practice? 

    If you’re unsure, it’s prudent to consider consulting the state licensing board, which is usually your state Board of Nursing. Doing so can give you guidance on whether or not the technique or procedure is within the CRNA scope of practice. 

    •  Is performance of the proposed act in compliance with applicable federal authorities?

    It is important to check in to determine the performance of the proposed practice in compliance with authorities such as the Centers for Medicare and Medicaid Services regulations. 

    • Would a reasonable and responsible CRNA perform this activity in this setting?

    It is critical that the CRNA’s actions are reasonable and that the benefits outweigh the risks. Consider if other CRNAs would perform a similar activity in a similarly given setting. The CRNA should consider if he or she is willing to accept the responsibility of the actions and choice that is made. 

    • Is your performance of the act consistent with evidence-based care? 

    Evidence-based care is critical to performance as an APRN. Consider if your performance is consistent with the accepted standards of care. Consider if you possess the relevant education, procedure-specific training, and clinical competencies. Consider if you have access to the resources and equipment to perform the act both effectively and safely. 

    • Have you demonstrated and maintained the competencies necessary to perform as a CRNA?

    AANA recommends that you maintain evidence of competencies, including education, assessments, training, peer review, and outcomes. Doing so will ensure that you are in compliance with your competencies that are necessary for providing care as an APRN.  

    •  Does the procedure meet applicable reimbursement criteria set by healthcare payers? 

    Consider if you will be reimbursed for the service. If you won’t be, it could be an indication that further research is warranted or that the act should not be performed because it has not been deemed an evidence-based procedure that other CRNAs have done.  Another important factor to consider is if your professional liability carrier provides coverage for performing such a procedure. 

    CRNAs enjoy a great deal of autonomy and collaborate with various healthcare professionals and patients to provide high quality, patient-centered evidence based and cost effective care. 

    CRNAs are held to the highest standards of clinical practice and are accountable for their own actions. Staying compliant, as well as holding malpractice insurance is a must for CRNAs. CRNA malpractice insurance protects the CRNA from allegations of malpractice while providing coverage in the event that malpractice does occur.

    Malpractice Issues Involving Certified Registered Nurse Anesthetists

    Because CRNAs practice autonomously, they are at a greater risk of being involved in a malpractice lawsuit. CRNA malpractice insurance is professional liability coverage. It is needed to protect CRNAs from allegations of error or neglect that result in the significant injury of a patient. 

    Liability requirements vary from state to state. However, malpractice insurance is required in all states and medical systems as a requirement of licensure and practice as a CRNA. 

    Malpractice insurance is available through many different sources, including professional organizations, larger institutions, insurance carriers, and medical risk groups. Both individual and group plans are available. 

    For employed CRNAs, malpractice insurance is typically offered by the health system, practice group, or hospital that employs the APRN. 

    However, CRNAs are recommended to have their own supplemental insurance so their best interests are represented. The amount and type of insurance you may need will vary according to your various needs, including the state’s malpractice minimum requirements and personal asset protection that will vary according to your individual circumstance. 

    Additionally, CRNAs are often named defendants along with anesthesiologists or surgeons who were also involved in rendering care for certain types of malpractice cases. When they are party to these malpractice lawsuits they are most often sued together because there was significant communication between them during surgery that led to injuries related to anesthesia services being rendered by both professionals.

    CRNAs should make sure that they have malpractice insurance in place to cover them in the event of a lawsuit. It’s not enough to assume that your workplace or healthcare facility will cover you.

    There are a number of different malpractice insurance policies available, so make sure you shop around and find the policy that best meets your needs. Some policies offer broad coverage, while others are more limited. You may also want to consider whether you want a policy that covers defense costs or one that pays out damages if you are found liable for malpractice. Not only will malpractice insurance protect you in the event of a lawsuit, but it can also help with legal expenses and damages. In some cases, malpractice insurance can even provide financial assistance if you are forced to take time off work.

    Consider supplemental insurance, as it offers more autonomy and can safeguard your career. When you have your own CRNA malpractice insurance, you’re in charge of your defense. You’ll get to decide when and if you settle, for how much, and your legal defense strategy. Unfortunately, when you only have hospital group malpractice insurance, your employers can settle without your consent. This can be harmful to your career and livelihood. 

    Make sure you represent your best interests by researching well respected supplemental malpractice insurance to help safeguard your reputation, career, and finances. 

    AANA Insurance Services is an industry leader in malpractice insurance coverage and has been trusted for over three decades by CRNAs. 

    Coverage benefits include: 

    • Consent to settle, which allows you to decide how a claim is handled 
    • Unlimited costs for your defense
    • A dedicated attorney to represent your interests 
    • Occurrence coverage, so you don’t have to purchase a tail. 

    Contact AANA Insurance Services today to learn more about malpractice insurance coverage for CRNAs.

    No matter what policy you choose, make sure you read the fine print so you know exactly what is and is not covered. And, most importantly, always act in the best interests of your patients. If you put their safety first, you’ll have more peace of mind when it comes to malpractice insurance and coverage.

    Conclusion 

    The Scope of Practice for CRNAs is determined by the state laws that govern the practice. The qualifications required to obtain a nurse anesthesia license are defined in each state’s nurse practice act. These requirements include advanced degree at masters or doctorate level either as an APRN or as a CRNA, and successful completion of certification exam by the Council for Accreditation of Nurse Anesthesia Educational Programs (COA). The process for obtaining a CRNA license is further defined in each state’s nurse practice act.

    CRNAs enjoy a great deal of autonomy and collaborate with various healthcare professionals and patients to provide high quality, patient-centered evidence based and cost effective care. CRNAs are held to the highest standards of clinical practice and are accountable for their own actions. Malpractice insurance is a must for CRNAs, and CRNA malpractice insurance through the AANA is an important part of protecting your career.

    The AANA’s malpractice insurance program is tailored specifically for CRNAs and offers protection from malpractice allegations while providing coverage in the event that malpractice does occur. CRNA malpractice insurance through the AANA is an important part of protecting your career and ensuring that you have the resources you need in the event of a malpractice claim. 

    A malpractice insurance policy can be a financial lifesaver if you are sued for malpractice. Make sure you have one in place before something happens. For more information on CRNA malpractice insurance, please visit our website.

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