About Nurse Anesthesiologists (CRNA)

Certified Registered Nurse Anesthetist (CRNAs) are anesthesia specialists who safely administer approximately 32 million anesthetics to patients in the United States each year. The nurse anesthesia specialty has a history of nearly 150 years. Today, more than 44,000 nurse anesthesiologists provide cost-effective, high-quality patient care that is essential to America’s healthcare system. In today’s changing healthcare environment, patients want healthcare delivered with personal care, at a lower cost, with a high degree of confidence.  For more information about CRNA's, please visit aana.com

Certified Nurse Anesthetist fact sheet:

Introduction: 

Certified Registered Nurse Anesthetists (CRNAs) practice in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms; critical access hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists; and U.S. military, Public Health Services, and Department of Veterans Affairs healthcare facilities.  In accordance with state law and facility privileges, CRNAs provide anesthesia care for dentists in the office, hospital or surgery center setting.

CRNA Educational and Practice requirements

o Current license to practice as a Registered Nurse/ Advanced Practice Registered Nurse

o CRNAs have a minimum of 7-8.5 years of nursing and anesthesia training before they are licensed to practice anesthesia.  Their education is broken down as follows:

1) Baccalaureate prepared registered nurse

2) Average of 2.9 years of critical care nursing experience before applying to CRNA program

3) 24-51 months of classroom and clinical education and training

4) Masters or Doctoral degree from an accredited nurse anesthesia educational program 

o Graduates of nurse anesthesia educational programsperform an average of 8,636 clinical hours prior to becoming a CRNA.  

o Must pass National Board Certification Exam as entry to practice and must recertify every 4 years.

o Must also pass a Continued Professional Certification Exam every 8 years

o CME requirements are minimum of 60 approved hours of continuing education and 40 hours of professional development activities every 4 years

o For more detail on courses and clinical experiences, see the Standards For Accreditation Of Nurse Anesthesia Educational Programs of the Council on Accreditation of Nurse Anesthesia Educational Programs at

0for%20Accreditation%20of%20Nurse%20Anesthesia%20Educational%20Programs,%20revised%20January%202018.pdf

 https://www.coacrna.org/accreditation/Documents/2004%20Standards%2

CRNA Independent Practice in NH

 - The New Hampshire Nurse Practice Act and Board of Nursing rules allow CRNAs to practice with physicians/surgeons, dentists and podiatrists without supervision or other restrictions on practice.  See https://www.oplc.nh.gov/nursing/laws-rules.htm.  

 New Hampshire “Opted-Out” of the federal supervision requirement for CRNAs in 2002 under then-Governor (now US Senator) Jeanne Shaheen (see attached).  Below are the conditions necessary to opt out:

Requirements for “Opt-Out” Of Federal Supervision Requirement 

• The federal requirement has been that CRNAs must be supervised by a physician. The November 13, 2001 rule allows states to "opt-out" or be "exempted" (the terms are used synonymously in the November 13 rule) from the federal supervision requirement. 

• For a state to "opt-out" of the federal supervision requirement, the state's governor must send a letter of attestation to CMS. The letter must attest that: 

1. The state's governor has consulted with the state's boards of medicine and nursing about issues related to access to and the quality of anesthesia services in the state; and 

2. That it is in the best interests of the state's citizens to opt-out of the current federal physician supervision requirement; and 

3. That the opt-out is consistent with state law.

The CMS November 13, 2001 rule comments cite a 1998 Journal of the American Medical Association (JAMA) article, and call it an “objective interpretation” of the supervision issue. The JAMA article, while not naming specific states, said that 18 states permit CRNAs to practice “independently.” [Cooper, Richard A., Henderson, Tim, Dietrich, Craig L., “Roles of Nonphysician Clinicians as Autonomous Providers of Patient Care.” JAMA. 1998; 280:795-802, at page 797 in Table 2.] The authors reasserted (in a letter published at page 511 of the February 10, 1999 issue of JAMA) that their findings are correct. The authors stated in their letter that: 

[W]e want to reiterate that our data collection included not only NPC [nonphysician clinician] organizations but also the Health Policy Tracking Service at the National Conference of State Legislatures and the Internet Web sites of individual states. From these sources we concluded that CRNAs have the authority to practice independent of physician supervision in 18 states. 

The NH Board of Dentistry rules clearly state that CRNAs are able to attend to cases in the dental office setting: 

Den 304.02  Administration of General Anesthesia or Sedation Exclusively by a New Hampshire Licensed Anesthesiologist or Certified Registered Nurse Anesthetist.Dentists shall not be obligated to obtain a permit pursuant to this part if general anesthesia or sedation is being administered exclusively by a New Hampshire licensed anesthesiologist or certified registered nurse anesthetist, so long as:

      (a)  The dentist first provides to the board:

(1)  The name of the licensed anesthesiologist or certified registered nurse anesthetist that the licensee intends will be administering anesthesia or sedation; and

(2)  The level of sedation being administered; and

          (b)  The dentist intending to use an anesthesiologist or certified registered nurse anesthetist for administration under this section passes an initial facility inspection of the facility or office as described in Den 304.05(c)(1) plus subsequent evaluations every 5 years thereafter, provided that anesthesiologists or certified registered nurse anesthetists who pass an initial facility inspection at one facility or office shall not be required to pass additional inspections at other facilities.

The New Hampshire Board of Dentistry’s position on CRNAs is further supported by the ADA

 The American Dental Association’s (ADA) “Guidelines for the Use of Sedation and General Anesthesia by Dentists” explicitly reference the use by dentists of “independently practicing qualified anesthesia healthcare providers,” such as CRNAs, to provide sedation and anesthesia in the dental office setting. See http://www.ada.org/en/~/media/ADA/Advocacy/Files/anesthesia_use_guidelines.

American Association of Nurse Anesthetist’s 

Position paper on CRNA care in the dental office setting 

Link: https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/dental-office-sedation-and-anesthesia-care.pdf?sfvrsn=ab0049b1_6

Position Statement

Dental Office Sedation and Anesthesia Care

Position Statement: Dental sedation safe outcomes, as with all procedural sedation, are best achieved when provided by a healthcare professional, whose only responsibility is the sedation and monitoring of the patient, and a proceduralist whose specific focus is on the procedure.1 Deep sedation and general anesthesia for dental procedures is safest when provided by a qualified, licensed anesthesia professional, who is not simultaneously engaged in the dental procedure.1-3 When sedation or anesthesia services are required, the use of anesthesia professionals, with delineated responsibilities, allows each team member to focus on his or her role for best outcomes and patient safety.1,4-7

Background

As an increasing number of patients of all ages and complexity seek sedation and anesthesia for dental procedures in office-based settings, it is important to keep patient safety central to the delivery of sedation and anesthesia services.3 Sedation and anesthesia for dental procedures may be administered to children, individuals with special needs, or adults due to fear, anxiety, or procedural pain.8-10 Sedation and anesthesia safety in an office-based setting is dependent on patient selection, sedation and anesthesia goals, techniques, vigilant patient monitoring, as well as the skills and competencies of the patient-centered care team.11

Quantifying the number of procedures that involve dental sedation or anesthesia, either with or without an anesthesia professional who is not the dentist, is difficult. When safety and monitoring guidelines are followed, office-based dental sedation and anesthesia has a record of safe outcomes although the facility should have appropriate equipment end medications, supporting clinicians to be adequately prepared to address adverse events, should they occur.9,12-14 Challenges to the provision of safe sedation and anesthesia may increase with special populations, including but not limited to, pediatric patients, senior patients, obese patients with related airway issues, and patients with increasing health complexity. The complexity of care required emphasizes the importance of sedation and anesthesia provided by a qualified, licensed anesthesia professional, who is focused only on patient safety, monitoring, and vigilance.15,16

Monitoring and Patient Safety

Sedation is a continuum that includes minimal sedation to general anesthesia.17 Each patient has a unique response to medications utilized for sedation and anesthesia. Therefore, moderate sedation may quickly transition to deep sedation and general anesthesia, affecting spontaneous ventilation and oxygenation requiring immediate intervention.3,11,17 When an anesthesia professional is available to continuously monitor the patient, he or she can focus on changes in the patient’s condition and intervene as necessary in emergent situations. Equipment used to monitor the patient during sedation and anesthesia should be consistent with AANA Standards for Office Based Anesthesia Practice and other nationally recognized standards and guidelines.2,4,5,7

Dental offices providing sedation and/or anesthesia services should be prepared with appropriately trained staff and have requisite equipment to manage adverse events and emergencies.4,9,14,18,19 Many state dental laws contain substantial, important requirements regarding monitoring and equipment necessary for providing safe dental office sedation and anesthesia. All healthcare professionals who provide sedation or anesthesia services must be aware of the statutes, regulations, and standards (including accreditation standards, if applicable) that govern their licensure, facility and clinical practice.

Throughout the dental procedure, communication about patient status and airway management is of paramount importance as the dentist and anesthesia professional share the airway.18 Techniques and drugs used for procedural sedation and anesthesia should promote rapid recovery. Clear discharge criteria and instructions should be in place to support the patient’s safe transition home.18,20

CRNAs Working in Dental Settings

CRNAs possess the education, training, and skills to provide safe, high-quality, and cost- effective care as members of the multidisciplinary patient-centered dental care team in all settings, including dental offices. CRNAs practice in accordance with their professional scope and standards of practice, federal, state, and local law, and facility policy to provide dental sedation and anesthesia services.21

Dentists and oral surgeons often work with CRNAs in hospitals and ambulatory surgical centers to provide dental procedures. CRNAs are safe and effective anesthesia professionals who can also improve patient safety in office-based dental practices. In many states, there are currently barriers for CRNAs to work in office-based dental practices. As the need for access to safe, cost-effective dental services is increasing, dentists, oral surgeons and CRNAs have opportunity to advocate for CRNA full scope of practice to provide dental sedation and anesthesia.

References:

1. The Role of the CRNA on the Procedure Team. Park Ridge, IL: American Association of Nurse Anesthetists; 2015.

2. Standards for Office Based Anesthesia Practice. Park Ridge, IL: American Association of Nurse Anesthetists; 2013.

3. Non-anesthesia Provider Procedural Sedation and Analgesia. Park Ridge, IL: American Association of Nurse Anesthetists; 2016

4. American Academy of Pediatric Dentistry. Clinical Affairs Committee - Sedation General Anesthesia Subcommittee. Guideline on use of anesthesia personnel in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent. Sep-Oct 2012;34(5):170-172

5. American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. 2016;