Full Practice Authority for VA Registered Nurse Anesthetists (CRNAs) During the COVID-19 Pandemic

Full Practice Authority for VA Registered Nurse Anesthetists (CRNAs) During the COVID-19 Pandemic

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INSIGHTi

Full Practice Authority for VA Registered
Nurse Anesthetists (CRNAs) During the
COVID-19 Pandemic
May 27, 2020
On April 21, 2020, the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA)
issued guidance to VA medical facilities to allow Certified Registered Nurse Anesthetists (CRNAs) to
have full practice authority (maximum breadth of practice allowable for a provider) within the scope of
their license to provide anesthetic care. Specifically, it allows CRNAs to practice without physician
supervision when licensed in a state that allows such practice. CRNAs are advanced practice registered
nurses (APRNs) who have completed postgraduate education and training and have been certified in the
provision and managing of anesthesia. This temporary change in policy has once again brought into focus
the debate, mainly between the American Society of Anesthesiologists (ASA) and the American
Association of Nurse Anesthetists (AANA), about the scope of practice of CRNAs in the provision of
anesthesia services at VA medical facilities. Scope of practice refers to requirements for practicing a skill
or profession including types of patients or case load and practice guidelines that determine the
boundaries within which a physician or other health care professional practices. This Insight briefly
reviews the new directive during the COVID-19 pandemic and, to provide some context, briefly discusses
the previous policy debate surrounding CRNAs delivering anesthesia services to veterans.
New CRNA Full Practice Authority
The April 21 guidance allows VA medical facilities to amend bylaws and rules to permit CRNAs to
practice independently if their state license permits independent practice. This full practice authority
would be applicable at VA medical facilities located in 18 states that have permanently granted full
practice authority, and at least 9 states (as of April 21) that have granted temporary full practice authority
during the COVID-19 pandemic and were listed in the VA guidance. These states are listed in Table 1.
There are two states (Connecticut and Pennsylvania) that granted this practice authority but were not
included in the list of states in the VA guidance.
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Table 1. States with Full Practice Authority for CRNAs
Temporary Full Practice
Permanent Full Practice
Authority During the COVID-19
Authoritya
National Emergencyb
Alaska
Alabama
Arizona
Connecticut
California
Louisiana
Idaho
Maine
Iowa
Massachusetts
Kansas
Michigan
Kentucky
New Jersey
Maryland
New York
Minnesota
Pennsylvania
Montana
Tennessee
Nebraska
West Virginia
New Hampshire

New Mexico

North Dakota

Oregon

South Dakota

Washington

Wisconsin

Source: Richard Stone, Executive in Charge, Office of the Under Secretary for Health, to VHA Central Office Senior
Leaders, VISN Directors, and VA Medical Center Directors, “CRNA Practice During the COVID-19 National Emergency,”
Memorandum, April 21, 2020. American Association of Nurse Anesthetists, “Governors Executive Orders – CRNA Scope
of Practice.”
a. Some states with permanent authority to practice without supervision were granted additional temporary authority.
Kansas and Wisconsin CRNAs were granted authority to practice without written col aborative agreements, which is
normally required in the state. Kentucky CRNAs were granted the authority to prescribe control ed substances
without a col aborative agreement.
b. Connecticut and Pennsylvania were not listed in the VA guidance.
According to VA, this full practice authority will be in place for the duration of this public health
emergency, and it is expected that VA medical facilities will revert back to their standard bylaws, which
provided more limited practice authority for CRNAs, when it ends. In addition, according to VHA,
allowing CRNAs to practice to the full scope of their licenses would free up physicians from the
supervisory requirement and allow them to manage clinical care of COVID-19 patients, thereby
potentially expanding the VA’s capacity to provide COVID-19-related care. In its recent report, VA Office
of Inspector General (OIG), Determination of VHA’s Occupational Staffing Shortages, FY2019, found
that 28 VA medical facilities reported severe shortages of anesthesiologists. Providing full practice
authority for CRNAs is not without precedent; for example, the Centers for Medicare & Medicaid
Services (CMS), for the purposes of Medicare reimbursement, has also temporarily suspended physician
supervision requirements for CRNAs. Even outside the emergency period, Medicare will reimburse for
unsupervised CRNA services at certain rural hospitals.

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Background on VHA CRNA Scope of Practice Issues
Generally, there are four different types of master-level trained Advanced Practice Registered Nurses
(APRNs): Certified Nurse Practitioner (CNP), Clinical Nurse Specialists (CNSs), CRNAs, and Certified
Nurse Midwives (CNMs). APRN practice authority and the scope of practice that define the types of
services APRNs are permitted to provide are subject to state laws and regulations that vary among states.
A number of states have approved full practice authority for APRNs, including CRNAs. However, some
physician groups have advocated that supervision requirements are justified because they have completed
substantially longer education and training programs than APRNs have. Generally, practice as a CRNA at
a VA medical facility requires a current, full, active, and unrestricted registration as a graduate
professional nurse in a state, as well as completion of an accredited nurse anesthesia educational program
approved by the American Association of Nurse Anesthetists (AANA), among other basic qualifications
and requirements.
Beginning around 2009, VHA began discussing changes to the VA Nursing Handbook that would grant
APRNs full practice authority for independent APRN practice in VHA. In 2010, the Institute of Medicine
(IOM) published a report, The Future of Nursing: Leading Change, Advancing Health, that recommended
removal of scope-of-practice barriers to allow APRNs to practice to the full extent of their training and
certification, which provided further impetus to this change. Furthermore, VHA planned to provide full
practice authority for CRNAs across the VA health care system. The American Society of
Anesthesiologists (ASA) opposed this policy change. In May 2016, VA proposed regulations to allow
“APRNs to practice to the full extent of their education, training, and certification, regardless of
individual State restrictions that limit such full practice authority, except for applicable State restrictions
on the authority to prescribe and administer controlled substances, when such APRNs are acting within
the scope of their VA employment. The proposed rule would use the term ‘full practice authority’ to refer
to the APRN’s authority to provide advanced nursing services without the clinical oversight of a
physician when that APRN is working within the scope of their VA employment.” The rationale for this
proposed change was to “increase veterans’ access to VA health care by expanding the pool of qualified
health care professionals who are fully authorized to provide comprehensive primary health care and
other related health care services to veterans.” In December 2016, VA published final regulations and
provided CNPs CNSs, and CNMs throughout the VA health care system full practice authority “to provide
advanced nursing services to the full extent of their professional competence.” However, it excluded full
practice authority for CRNAs under this final rule.
The current role of CRNAs in patient care is delineated in VHA Directive 1123 and is governed
by each VA medical facilities’ bylaws. Except for the temporary expansion of CRNA full practice
authority announced on April 21, 2020, no other policy changes have taken place pertaining to
CRNAs practice at VA medical facilities.

Author Information

Sidath Viranga Panangala
Jared S. Sussman
Specialist in Veterans Policy
Analyst in Health Policy

Congressional Research Service
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Disclaimer
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