Over a year ago we paid brief attention to a topic that deserves much more. The Standard of Care in Anesthesia is a somewhat elusive concept depending, as we noted, on whom is asking the question and in what setting. We said at the time:

The basic issues regarding monitoring, procedures and various technical aspects of the delivery of anesthesia are much agreed upon when it comes to a “standard” within the community of anesthesia providers. Fiercely disputed however, is who should practice that standard and when. No where else in medicine does state law determine a standard of care more than in the practice of anesthesia. And nowhere else in medicine is state law ignored as much as possible in a fight aimed at creating separate standards of care for the same health care. As shown in the documents linked above, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA)  have very different ideas regarding who may execute the fundamentally agreed upon treatment standards. This has created a battle not over the right or wrong way anesthesia procedures should technically be done, but rather over who may do them. This in spite of a 100 year history of Nurse Anesthetists and Physician Anesthesiologists safely administering anesthesia, and even creating a model of safety that is the envy of every medical and nursing specialty.

Now we delve further into this conundrum. It should first be noted that a medical or nursing Standard of Care is one of at least two concepts, again depending on who is asking the question and in what setting. If you ask a health care professional what the Standard of Care is regarding treatment of a specific patient’s malady, they will answer with their current understanding of the latest recommended therapy. Doctors and nurses  determine the standard of care for their patients almost without having to think in many situations. A physician diagnosis a patient first by applying what the physician believe to be the standard of care for the diagnosis. Maybe a CT scan, some lab work, an x-ray..what have you. Then, once diagnosed, orders for treatment are written, nursing diagnosis are made, and care is provided appropriately…or rather the standard care is applied.

Despite our recent article about physicians practicing defensive medicine, defensive medicine is NOT a way to improve or guarantee the Standard of Care nor is it likely to make much difference in the rate of malpractice lawsuits. It certainly will increase the cost of health care exponentially. “‘Cover your ass” with tests because you fear a lawsuit COULD become the standard of care if all other similarly situated physicians  accepted that a head CT was necessary for every patient with a simple headache. Unlikely since physicians by nature prefer practicing evidenced based medicine. The health care professional is seldom thinking of the legal side of the Standard of Care (at least not properly) which rears its head in the court room during a medical malpractice trial, yet their version and the version determined in court should generally be the same.

In court expert witnesses who are health care professionals deemed expert in the care in question opine as to the Standard of Care in the treatment of the patient/plaintiff, whether that Standard was met and what harm may have been caused if it was not. In this setting the Standard of Care is the care a similar health care provider of basic competence, similarly situated, would have have provided to the patient. This takes into consideration that the health care provider is not expected to be a world class surgeon with the resources of the Mayo Clinic at his fingertips if the patient was treated at a rural 20 bed hospital with no MRI or 24 hour laboratory.

For our purposes, we will concern ourselves with the Standard of Care which is decided by expert witness testimony in a court room, since THAT version of the Standard of Care has the greatest effect on health care practitioners yet does not diminish the importance such standards play in ensuring quality patient care. Now, one might conclude with seeming logical reasoning that the Standard of Care in Anesthesia should easily be described by any anesthesia professional. After all, they ought to know their stuff as experts in their field. It seems impossible to imagine allowing an anesthesia provider to practice their craft on you or a loved one if they did not know the Standard of Care for treating you. The extraordinary reality is that 4 different anesthesia providers could give you four different versions of the Standard of Care, some in direct contrast to the others, and all could be correct…..depending on who is asking the question and for what purpose.

There are two independent providers of anesthesia in the United States: Certified Registered Nurse Anesthetists (CRNA) and physician Anesthesiologists (MDA). CRNAs may practice independent of a MDA in all 50 states and are trained to administer all manner of anesthetics including general, spinal, epidural and various peripheral nerve blocks, for all manner of surgeries including pediatrics, open heart, organ transplantation, etc. The majority of rural hospitals are serviced by CRNAs alone. In most larger hospitals and academic medical centers CRNAs and MDAs work side by side under the ASA Anesthesia Care Team (ACT) model, with the MDA supervising the care provided by the CRNAs often at a ratio of up to 1:4. No state laws dictate that the ACT approach is to be employed. The AANA has their own version of CRNAs and MDAs working together.  Often a variation of the ACT  is used where very little supervision is involved and collaboration is a better term. In still other variants MDAs and CRNAs work side by side but as equal colleagues with none supervising the other. And finally there are MDAs who work alone.

As we have pointed out, the actual nuts and bolts of  delivering an anesthetic or performing various procedures in anesthesia, are well agreed upon and are uniformly practiced for all intents and purposes. For this reason patients can rest easy since the confusion and debate does not alter their basic care. The Standard of Care in Anesthesia begins to fall apart only when one tries to determine which anesthesia professionals can provide what services which is entirely dependent on location (right down to the very street address), and likely influenced by a membership biased professional association who has published their version of  ‘standards’ or ‘guidelines’ which, while nice for a private club of members, are meaningless to the anesthesia community at large unless the community at large adopts them. In fact, they may merely cause undue professional hardship to the association members when they are based more on politics than science as we shall see.

For example, the American Society of Anesthesiologists has published Standards for Post Anesthesia Care which state quite clearly that patients in a Post Anesthesia Care Unit (PACU) should be cared for by a MDA and that only a physician may discharge a patient from the PACU. At the same time the American Association of Nurse Anesthetists (AANA) has published Postanesthesia Care Standards for the Certified Registered Nurse Anesthetist which require that a “qualified health care provider” care for the patient and that discharge of the patient also be accomplished by a qualified provider according to institutional policy and medical staff criteria. Now imagine the battle of the expert witnesses who attempt to rely on either of these ‘standards’ in court as the basis for their argument. What if no MDAs are employed by the hospital? What if MDAs and CRNAs both work at the hospital but in independent capacities, each caring for their own patients? What if some days there are MDAs and some days there are CRNAs? What is the standard of care? Now you see the problem.

Consider that there are two hospitals on opposite street corners. One hospital utilizes the anesthesia care team and follows the ASA PACU ‘standard’ as an institutional policy. The other hospital employs and all CRNA group which patterns their PACU policy after the AANA’s ‘standard’. Institutional policies and procedures can create a local standard of care….so local that it exists only inside that building! In the first hospital a CRNA who discharged a patient from the PACU would violate the standard of care, while a CRNA at the second would not….and the first CRNA could be sued, fired or even disciplined by the Board of Nursing. Yet if they had worked 100 yards across the street, all would be well. There are countless examples of such discrepancies between the two associations ‘standards’, ‘guidelines’ and ‘recommendations’ including administration of spinal and epidural anesthesia, use of the anesthesia care team approach, provision of anesthesia in the office setting, pain management, organization of an anesthesia department, pre-operative patient evaluation and on and on. One of the safest specialties in nursing and medicine has the most contentious diametrically opposed view of how the specialty should be practiced. All the evidence regarding quality of care and outcomes indicates that there should be no disagreement at all.

Part 2: Dr. Bernstein is screwed by his own ASA and the Maryland Board of Physicians loses its mind.

Related Posts

1. Anesthesia Standard of Care: Dr. Bernstein, the ASA, Maryland Board of Physicians, and Random GPS Locations: Part 4
2. Anesthesia Standard of Care: Dr. Bernstein, the ASA, Maryland Board of Physicians, and Random GPS Locations: Part 3
3. Anesthesia Standard of Care: Dr. Bernstein, the ASA, Maryland Board of Physicians, and Random GPS Locations: Part 2
4. READ: Maryland Board of Physicians Charges Against Dr. Midei.
5. The Standard of Care in Anesthesia….not what you think