Is anesthesia care provided by solo practice Certified Registered Nurse Anesthetists (CRNAs) as safe as anesthesia care provided under the supervision of a physician?

Safety of Solo Practice CRNA Care vs. Physician-Supervised CRNA Care

Based on current evidence, anesthesia care provided by solo practice CRNAs is not as safe as physician-supervised CRNA care, as physician supervision is recommended to ensure optimal patient safety and outcomes in anesthesia practice. 1

Evidence on Anesthesia Provider Requirements

Physician Supervision Recommendations

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) provides clear guidance on this matter:

• Pre-hospital emergency anesthesia carries more risk than in-hospital anesthesia and should not be undertaken in professional isolation 1
• Providers should have the same level of training and competence that would enable them to perform unsupervised emergency anesthesia and tracheal intubation in the emergency department 1
• The 2007 NCEPOD 'Trauma: Who Cares?' report concluded that "if pre-hospital intubation is to be part of pre-hospital trauma management, then it needs to be in the context of a physician-based pre-hospital care system" 1

The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines specifically state:

• "A fellowship-trained cardiac anesthesiologist (or experienced board-certified practitioner) credentialed in the use of perioperative transesophageal echocardiography is recommended to provide or supervise anesthetic care of patients who are considered to be at high risk" (Class I recommendation, Level of Evidence: C) 1

Safety Concerns with Non-Physician Anesthesia

The AAGBI guidelines highlight major safety concerns regarding non-physician delivered anesthesia:

• Published evidence has highlighted major safety concerns, particularly where non-physicians have administered neuromuscular blocking drugs 1
• The AAGBI "does not believe that existing training programmes enable safe unsupervised administration of anaesthesia by non-physicians outside physician-led teams in the UK" 1
• This position is also stated in recent NICE trauma guidelines 1

Supervision Models and Patient Outcomes

Impact of Supervision on Patient Safety

Research on anesthesia patient risk indicates:

• When anesthesia accidents occur, their cause is usually an error made by the anesthesiologist, either in triggering the accident sequence or failing to take timely corrective measures 2
• Patient risk could be reduced substantially by closer supervision of residents 2

The AAGBI guidelines emphasize that:

• Pre-hospital emergency anesthesia should not be undertaken in professional isolation 1
• Anaesthetic assistance should be provided by an appropriately trained healthcare professional 1

Workload and Supervision Considerations

Guidelines on human factors in critical situations note:

• The probability of an anesthetist being able to intervene at any time ranged from 87% (short interventions) to 40% (long interventions) and was even higher when the anesthetist had three rooms to supervise 1
• It is of major importance to set up an organization taking into account the risk of a crisis situation and allowing professionals to effectively cope at any moment with complications 1

Considerations for Safe Anesthesia Practice

Training and Competency Requirements

The AAGBI recommends that all practitioners providing anesthesia should:

• Have adequate in-hospital emergency anaesthetic training and experience 1
• Be able to demonstrate necessary competencies before adapting in-hospital practice for pre-hospital practice 1
• Maintain skills by undertaking procedures regularly (suggested minimum of one per month) 1

Team-Based Approaches

Guidelines emphasize the importance of team-based approaches:

• Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period (Class I recommendation, Level of Evidence: B) 1
• Efforts are recommended to improve interdisciplinary communication and patient safety in the perioperative environment (Class I recommendation, Level of Evidence: B) 1

Contrasting Evidence

It's important to note that some research suggests different conclusions:

• A 2016 study found that anesthesia complication odds were not found to differ by scope of practice laws or delivery model (CRNA only, anesthesiologist only, or mixed team) 3
• Some research argues for removing barriers including supervision requirements for CRNAs to practice to the full extent of their education and training 4

However, these findings must be weighed against the stronger recommendations from major anesthesia guidelines that emphasize the importance of physician supervision, particularly for high-risk cases.

Practical Implications

For healthcare facilities and administrators:

• Ensure that anesthesia care follows established guidelines for supervision, particularly for high-risk patients
• Implement proper workload distribution to allow for effective supervision
• Establish clear communication protocols and team-based approaches
• Ensure all anesthesia providers maintain regular practice to sustain competency

For patients:

• Be aware of the qualifications and supervision arrangements for anesthesia providers
• High-risk patients should particularly seek care where physician supervision of anesthesia is available