VA’s final rule leads to underutilization of CRNAs in VHA facilities

Despite documented evidence confirming that veterans are experiencing delays for essential healthcare services due to lack of anesthesia support in Veterans Health Administration (VHA) facilities, the Department of Veterans Affairs (VA) has published its final rule granting full practice authority to all advanced practice registered nurses except Certified Registered Nurse Anesthetists (CRNAs).

"This is an example of the kind of potentially dangerous decision making within the VA that has lead to all-too-frequent media reports of terrible neglect and bad outcomes in VHA facilities," said Cheryl Nimmo, DNP, MSHSA, CRNA, president of the 50,000-member American Association of Nurse Anesthetists (AANA).

In the rule, the VA indicates that CRNAs are highly qualified for full practice authority, but were not included with the other three APRN specialties because there currently is not a problem with access to anesthesia care in VHA facilities. However, evidence cited in the VHA Independent Assessment ordered by Congress and published in 2015 debunks the VA's rationale, identifying numerous access problems such as delays in cardiovascular surgery for lack of anesthesia support, rapidly increasing demand for procedures requiring anesthesia outside of the operating room, and slow production of colonoscopy services in comparison with the private sector.

"Without question, this speaks to the underutilization of CRNAs who are not allowed to practice to the full scope of their education, experience, and licensure in VHA facilities," said Nimmo. "It also raises the same concerns about anesthesiologists who spend their time supervising CRNAs rather than actually providing hands-on patient care, even though CRNA supervision is not required by the VA.

"Just imagine how many more veterans could be cared for if start times for surgical and other types of cases requiring anesthesia were no longer delayed unnecessarily while waiting for supervising anesthesiologists to become available," said Nimmo.

By granting full practice authority to CRNAs, the VHA would be able to make full use of more than 900 CRNAs already practicing in VHA facilities, increasing anesthesia services and veterans' access to care without additional funding from the federal government or American taxpayers.

Nimmo pointed out another peculiarity in the final rule: The VA's unusual step of adding a 30-day public comment period, through Jan. 13, 2017, to help determine "whether there are access issues or other unconsidered circumstances that might warrant [CRNAs'] inclusion in a future rulemaking." This is the second public comment period on the full practice authority issue, the first being a 60-day period last summer to collect comments on the rule as initially proposed. "It makes you wonder how confident the VA is in its own rule if they are asking for still more evidence to convince them they aren't making a huge mistake by not including CRNAs," said Nimmo.

Support for CRNAs being included in the final rule came from thousands of comment letters; numerous Veterans Service Organizations (VSOs), healthcare professional associations, policymakers, and other stakeholders; and scientific research evidence from no fewer than 10 research studies published in peer-reviewed journals since 2000. Not a single paper has been published in the same time period calling into question CRNA safety. The proposed rule was also supported by the VHA Independent Assessment and the final report of the bipartisan Commission on Care chaired by the CEOs of the Henry Ford Health System and Cleveland Clinic. Both the independent assessment and the commission report identified the use of all APRNs, including CRNAs, to their full scope of practice as a necessary step toward improving the VHA system.

"It does seem that perhaps politics, personal agendas, or favoritism may have gotten in the way of sound decision-making with regard to this important VA issue," said Nimmo. "Hopefully that's not the case, the VA will review the evidence and reconsider its decision, and a final rule will be published that better serves our nation's veterans."