MEMBER UPDATE on Changes to CRNA Regulations

June 25, 2008

Issue:

The New Jersey State Board of Nursing has recently adopted new regulations (the "Regulations") that change the classification of certified registered nurse anesthetists ("CRNAs"). As of June 16, 2008, CRNAs are now classified as Advanced Practice Nurses ("APNs") in the State of New Jersey.

It’s important to remember, however, that despite changes to the nursing regulations, the regulations governing the provision of anesthesia have not changed.

Background:

The Board of Nursing (or the "Board") has been working on these Regulations for some time now. Although the Regulations were proposed for comment on May 21, 2007, NJSSA was aware that the Board was developing the Regulations for several years prior to their proposal.

The Board of Nursing has the authority to regulate its nursing licensees. Effective June 16, 2008, CRNAs will need to comply with these regulatory changes:

1. The term “CRNA” or “certified registered nurse anesthetists” will cease to exist. CRNAs will now become Advanced Practice Nurses (APNs) with a specialty in anesthesia;
    

2. All APNs are required to have a master’s degree. However, those APNs with a specialty in anesthesia without a master’s degree will be grandfathered on or before June 16, 2009, if they meet certain requirements, including

a. the requirement that the applicant has worked a minimum of 1600 hours as a nurse anesthetist over the previous twenty-four months; and

b. the applicant has completed at least 39 hours of pharmacology during his or her educational program or at least three credits of graduate level course work in pharmacology and at least six hours in pharmacology relating to controlled dangerous substances.

These new Regulations do not supersede anesthesia supervision requirements.

Even though APNs may prescribe drugs if they enter into collaborative agreements with physicians, the Board of Nursing has acknowledged that these Regulations do not alter the supervision requirements that require nurse anesthetists to be supervised by a physician during the administration of anesthesia.

If the APN intends to prescribe drugs, the APN must practice under a collaborative agreement with a licensed New Jersey physician.

However, the current New Jersey regulations governing the administration of anesthesia require nurse anesthetists to work under the direct supervision of an anesthesiologist, or an appropriately trained and credentialed physician. Therefore, regardless of the new Board of Nursing changes, the current supervisory requirements are still in effect and physicians must comply with them.

Current Physician/Anesthesia Regulations

To refresh your memory:

The Department of Health and Senior Services ("DHSS") regulates the provision of anesthesia in hospitals and licensed ambulatory surgical centers ("ASCs"). Pursuant to DHSS regulations, physician supervision of nurse anesthetists is required in both hospital and licensed ASC settings.

The following is a summation of the wording of the existing regulations governing hospitals and licensed ASCs as they pertain to the administration of anesthesia by nurse anesthetists; these regulations remain in effect and have not changed:

General or major regional anesthesia provided in a hospital or ambulatory surgery facility shall be administered and monitored only by:

1. an anesthesiologist; or
    

2. a certified registered nurse anesthetist or registered nurse anesthetist under the supervision of an anesthesiologist or a physician who is privileged to administer or supervise the administration of anesthesia services, who in either case shall be immediately available during the surgery. N.J.A.C. 8:43G-6.3; 8:43A-12.5.

Anesthetic agent used for conscious sedation in a hospital or ambulatory surgery facility shall be administered only by:

1. a physician who has privileges in accordance with the medical staff bylaws to administer or supervise the administration of anesthesia; or
    

2. a certified registered nurse anesthetist or registered nurse anesthetist under the supervision of an anesthesiologist or a physician who is privileged to administer or supervise the administration of anesthesia services, who in either case shall be immediately available during the surgery.

A registered professional nurse may administer supplemental doses, after the initial dose is given by a privileged or supervising physician, who shall remain present.

The New Jersey State Board of Medical Examiners ("BME") regulates anesthesia provided in physician office settings. The BME regulations require supervision of anesthesia providers (including nurse anesthetists) in an office setting; these regulations remain in effect and have not changed:

The following is a summation of the wording of the existing regulations for administration of anesthesia in an office setting by a nurse anesthetist:

General anesthesia or regional anesthesia shall be administered and monitored in a physician's office only by:

1. a physician privileged by a hospital or the BME to provide general anesthesia services; or
    

2. a certified registered nurse anesthetist under the supervision of a physician privileged by a hospital or the BME to administer or supervise the administration of anesthesia services, who shall be physically present during the surgery. N.J.A.C. 13:35-4A.8; 4A.9.

Conscious sedation shall be administered in an office setting only by:

1. a physician privileged by a hospital or the BME to provide conscious sedation;
    

2. a certified registered nurse anesthetist under the supervision of a physician privileged by a hospital or the BME to administer or supervise the administration of anesthesia services, who shall be physically present during the surgery; or
    

3. a registered professional nurse or physician assistant who is trained and has experience in the use and monitoring of anesthetic agents, at the specific direction of a physician privileged by a hospital or the BME to administer or supervise the administration of anesthesia services, who shall be physically present during the surgery. N.J.A.C. 13:35-4A.10.

What’s Next?

At NJSSA’s request, Assemblyman Neil Cohen (D-Union) has introduced legislation (A2299) into the New Jersey State Assembly that will, if passed, codify existing New Jersey regulations that govern the administration of anesthesia in hospital, ASC, and office settings. Codifying the regulations into a statute would strengthen the supervision requirements. Thereafter, only subsequent legislation could “undo” or change them.

IN SUMMARY:

New Jersey is recognized nationally and internationally for its stringent regulations that address anesthesia patient safety.

NJSSA has met with representatives from both the DHSS and the BME who have carefully considered the appropriate role of nurse anesthetists in the delivery of anesthesia services, and have found that nurse anesthetists do not have requisite training to diagnose patients or prescribe anesthesia. Furthermore, the New Jersey Supreme Court has ruled that anesthesiology is the practice of medicine.

The new Board of Nursing Regulations do not change any of the strong patient safety regulations that are currently in effect.

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