Should Certified Registered Nurse Anesthetists (CRNAs) be able to practice independently?

Independent Practice for Certified Registered Nurse Anesthetists (CRNAs)

CRNAs should be permitted to practice independently in appropriate settings, as there is no evidence that CRNA-only anesthesia delivery results in higher complication rates compared to physician anesthesiologist-only or mixed team models.

Evidence on Safety and Outcomes

The highest quality evidence available indicates that patient safety is maintained regardless of the anesthesia provider model:

• Research demonstrates that anesthesia complication rates do not differ significantly based on whether care is provided by CRNAs independently, anesthesiologists independently, or mixed care teams 1.
• In both inpatient and outpatient settings, the odds of anesthesia-related complications are primarily influenced by patient characteristics, comorbidities, and procedure complexity—not by the type of provider or scope of practice laws 1.

Current Practice Patterns and Competencies

CRNAs have extensive training and demonstrated competence in various clinical settings:

• CRNAs are particularly valuable in rural and semi-rural settings, where they frequently manage airways and stabilize trauma patients 2.
• CRNAs currently provide more than 40 million anesthetics annually in the United States 3.
• CRNAs have been providing anesthesia care in the US for nearly 150 years, with all 50 states utilizing their services in some capacity 4.

Safety Considerations and Quality Assurance

For optimal patient safety, the following should be implemented regardless of provider type:

• Appropriate workload management is critical, as higher workload has been significantly associated with adverse anesthesia-related events 3.
• Years of experience correlates inversely with adverse events, suggesting the importance of continued professional development and experience 3.
• A strong patient safety culture within healthcare organizations is essential for reducing adverse events 3.

Practice Models and Settings

Different practice models may be appropriate in different settings:

• In pre-hospital emergency medicine, physicians with specialized training provide advanced airway management including rapid sequence induction and tracheal intubation 5.
• For complex procedures like pediatric deep sedation in dental facilities, specific provider requirements exist, including the presence of an independent observer with advanced training 6.
• In specialized settings like MRI units, appropriate training and competency verification are required regardless of provider type 6.

Key Considerations for Independent CRNA Practice

When implementing independent CRNA practice:

1. Ensure appropriate case selection based on patient complexity and risk factors
2. Establish clear protocols for consultation and escalation when needed
3. Maintain rigorous continuing education requirements
4. Implement robust quality assurance programs
5. Consider geographic and access factors, particularly in underserved areas

Potential Pitfalls and Caveats

• Provider experience matters—less experienced practitioners of any type may have higher complication rates 3.
• Workload must be carefully managed to prevent safety issues 3.
• Organizational culture significantly impacts safety outcomes regardless of provider type 3.
• Historical tensions between anesthesiologists and CRNAs have sometimes influenced policy decisions more than evidence 4.

The evidence supports that CRNAs can practice independently without compromising patient safety when appropriate systems are in place to ensure quality care and proper case selection.