No Cochrane Meta-Analysis Exists Suggesting Unsupervised CRNA Care is Inferior
There is no Cochrane meta-analysis that suggests unsupervised CRNA (Certified Registered Nurse Anesthetist) care is inferior to supervised care.
Guidelines on Supervision in Anesthesia Practice
The available evidence from professional guidelines provides insights into supervision requirements for different practitioners:
Physician vs. Non-Physician Providers
- The Association of Anaesthetists of Great Britain and Ireland (AAGBI) explicitly states they "do not believe that existing training programmes enable safe unsupervised administration of anaesthesia by non-physicians outside physician-led teams" 1.
- The AAGBI guidelines highlight "major safety concerns, particularly where non-physicians have administered neuromuscular blocking drugs" 1.
- The 2017 AAGBI guidelines reference published evidence that raised safety concerns about non-physician delivered drug-assisted intubation 1.
Training and Competency Requirements
- Guidelines emphasize that practitioners providing anesthesia should have "adequate in-hospital emergency anaesthetic training and experience" 1.
- Regular practice is essential for maintaining competence, with a suggested minimum of one procedure per month 2.
- The AAGBI recommends that assessment of competence should involve direct observation by experienced senior clinicians 1.
Supervision Models
- The American Society of Anesthesiologists (ASA) guidelines state that "general medical supervision and coordination of patient care in the postanesthesia care unit should be the responsibility of an anesthesiologist" 1.
- For trainees, appropriate supervision is required at all times, sometimes necessitating direct supervision by a consultant or suitably trained and experienced doctor 1.
Practice Variations in the United States
- In the US, CRNAs practice with varying degrees of supervision by physicians or anesthesiologists 3.
- Before 2001, Centers for Medicare & Medicaid Services (CMS) required CRNAs to be supervised by a physician, but later implemented an opt-out policy giving states greater autonomy 3.
- Currently, CRNAs perform various kinds of anesthesia care either under medical supervision of anesthesiologists in most states, or independently without medical supervision in 16 states 4.
Factors Influencing Staffing Models
Research indicates that anesthesia staffing models differ based on:
- Geographic location (rural vs. urban settings)
- Facility type (hospitals vs. ambulatory surgical centers)
- Surgeon preference
- Organizational inertia
- Cost considerations 3
Notably, a 2020 study found that "differences in quality and safety between models were not contributing factors for most facilities" in their staffing decisions 3.
Limitations of Current Evidence
- There is no Cochrane meta-analysis specifically comparing supervised versus unsupervised CRNA care.
- The debate between anesthesiologists and CRNAs regarding independent practice remains "an on-going source of conflict" 4.
- While some research supports removing CRNA supervision requirements 5, authoritative guidelines from anesthesiology organizations continue to recommend physician supervision or leadership 1.
Conclusion
While there is no Cochrane meta-analysis suggesting unsupervised CRNA care is inferior, professional guidelines from organizations like the AAGBI express concerns about unsupervised non-physician anesthesia practice. The decision to use supervised or unsupervised CRNA models in the US appears to be influenced more by geographic, economic, and organizational factors than by definitive evidence of quality or safety differences.