U.S. ruling expected in bitter anesthesia battle

A fight over who should administer anesthesia is pitting anesthesiologists against nurse anesthetists

From Rhonda Rowland
CNN Medical Unit

ATLANTA, Georgia (CNN) -- When you are put to sleep for an operation, who should administer your anesthesia? An anesthesiologist -- a doctor, that is -- or a certified nurse anesthetist who makes one third as much?

It's a bitter turf battle that's been waged in the operating room and taken to the steps of Capitol Hill. Doctors say it's all about patient safety. Nurses say it's quality care at a cost-effective price

On his last day in office, President Bill Clinton approved a change in government regulations allowing specially trained nurses to provide anesthesia -- without a doctor's supervision -- to Medicare and Medicaid patients.

The Bush administration put a temporary hold on the ruling, and Health and Human Services Secretary Tommy Thompson is expected to make a final decision on the issue by Friday.

MORE Get more information about where each side stands on the issue:  • American Society of Anesthesiologists  • American Association of Nurse Anesthetists   RESOURCES Read the Health Care Financing Administration's fact sheet on the anesthesia rule   QUICKVOTE Should nurse anesthetists be allowed to administer anesthesia without supervision from an anesthesiologist? Yes No View Results

"The standard of care is the same regardless of who the provider is, whether that be a physician anesthesiologist, or whether that be a nurse anesthetist," said Larry Hornsby, president of the American Association of Nurse Anesthetists.

Anesthesiologists disagree.

"They may look like they're doing the same things with their hands, but the question is are they able to make the right judgments?" said Dr. John Neeld, former president of the American Society of Anesthesiologists.

Change wouldn't save U.S. money

Three years ago the federal government proposed doing away with a decades-old rule requiring doctors to supervise the work of nurse anesthetists when surgery is performed on Medicare and Medicaid patients.

The change would not save the government any money. It would still pay hospitals the same amount no matter who administers the anesthesia.

The American Hospital Association supports the change, as do nurse anesthetists, who say they're already doing the work.

"When I work, they're not standing over me choosing the drugs, telling me what to do or telling me how to do the anesthetic," Hornsby said. "They're out there, they may be directing four rooms that are taking place where surgeries are going on simultaneously."

In many cases, physician anesthesiologists are only in the operating room at two critical points, putting patients under and waking them. Nurse anesthetists stay with patients during the entire operation.

Doctors say safety's a concern

But if complications arise, doctors say they're most qualified to intervene -- they oppose the change, saying it's a matter of patient safety.

"We do not think independent practice is safe. It's purely a safety issue and changing the conditions of participation, changing the safety rule would mean that our Medicare population, our senior citizens, would in effect become guinea pigs for an experiment of safety," Neeld said.

Even though anesthesia is extremely safe today, complications can occur.

When CNN observed a nurse anesthetist waking up a patient after cosmetic surgery in a doctor's office, the anesthetist said the patient had a laryngospasm -- trouble getting air moved into the lungs. The nurse dealt with it according to standard medical procedure.

"The problem arises when the situation continues to deteriorate and becomes more and more life threatening. At that point in time, I think you'd like to have an MD anesthesiologist immediately available to assist the nurse anesthetist," said Dr. John Garino, an anesthesiologist.

Government study requested

So why can't the surgeon step in if needed?

"While the plastic surgeon may be very skilled at what he does, he probably isn't going to be much help to the nurse anesthetist if this situation continued to deteriorate," Garino said.

Troubleshooting also was needed during a knee operation in a hospital -- a leaky breathing tube had to be replaced -- but in this case the anesthesia was supervised by an anesthesiologist.

"Clearly it was a problem. I recognized it," Neeld said. "He and I solved it."

Studies, including a recent Institute of Medicine report on medical errors, show anesthesia is largely safe as it's delivered today.

Anesthesiologists have asked the government to do a study to see if allowing nurse anesthetists to practice unsupervised would jeopardize safety.

Dr. Carol Bannister, an anesthesiologist, is certain going it alone is not as safe. She first trained as a nurse anesthetist, which requires a nursing degree and two years of graduate anesthesia training.

"Many times I felt very much on thin ice," she said.

So she went through eight years of medical school.

"Knowing what I know now, it frightens me actually to think about that," she said.