Interpretation Anesthesia practices are characterized by the administration of anesthetic agents to a patient to achieve a desired physiological result. Therefore, a knowledge of anatomy and physiology, of the body reactions to various types of anesthetic agents as well as a familiarity with the symptoms and treatment for untoward effects are essential. The CRNA must have a basic understanding of the science of chemistry, physics, physiology, as well as pharmacology. Pharmacology is defined as a science of natural phenomena dealing with measurable, predictable, and therefore, reproducible effects of drugs on the functions and cellular structures of animals and humans. Pharmacological considerations in anesthesia practice include the inherent characteristics of the drug, the dosage to be administered, and the characteristics of the patient. (The intent of this provision is to include a technical statement on the interrelation of the various disciplines which must be utilized for competent administration of anesthesia.) STANDARD II Because of the inherent nature of anesthesia, certain risks to the patient are always present when an anesthetic agent is administered. Therefore, only those nurse anesthetists who are competent and well trained should be permitted to administer anesthesia. Interpretation The purpose of anesthesia is to reversibly depress bodily functions, or otherwise desensitize a patient to permit the performance of medical or surgical procedures. Whenever the bodily functions are reversibly depressed or desensitized, there are certain inherent risks to the patient which must be recognized. Therefore, an anesthetic agent should be induced and maintained only by well-trained personnel who are capable of recognizing and managing untoward reactions which may develop. CRNA's are trained professionals who have had specialized training in anesthesia and have demonstrated competency in this area. They are licensed by the state as registered nurses and further have graduated from an accredited school of nurse anesthesia and have successfully completed a requisite examination for certification. Their course of study, and certification are effective indicators regarding their competency to administer anesthesia. STANDARD III Nurse anesthesia practice is characterized by continually questioning assumptions and techniques upon which the practice is based and retaining those which are valid and adopting and using new techniques and knowledge to continue upgrading the practice. Interpretation The study of anesthesia is a science in which constant innovation and improvements are being made. It is the obligation of the CRNA to participate in the improvement of the science by questioning the appropriateness or accuracy of current assumptions and techniques being employed within the practice. Furthermore, a nurse anesthetist continually should improve skills and knowledge by reading journals and pursuing continuing education to assure excellent anesthesia care. A bimonthly journal of the American Association of Nurse Anesthetists is one source from which practicing nurse anesthetists can obtain knowledge of new developments and techniques employed within their practice. In addition, the AANA continually sponsors educational programs by which practicing nurse anesthetists can remain current on new developments and techniques. CRNA's, who within a five-year period, meet the Standards as established by the Education Committee of the AANA, may earn a Certificate of Continuing Professional Excellence. STANDARD IV All patients shall receive a thorough and complete preanesthesia inspection. Interpretation The responsibility of a CRNA begins before the actual administration of the anesthetic. It is the duty of the attending physician to make a preanesthetic examination in every case, not the duty of the nurse anesthetist. The nurse anesthetist does have an obligation to ascertain that an appropriate preanesthesia exami nation has been made by a physician. An examination of the patient's chart will indicate whether the necessary routine examinations and tests have been made. A thorough and complete inspection of the patient prior to anesthesia is imperative to ascertain certain physiological and psychological factors which influence the selection of the anesthetic agent and the formulation of the plan of anesthetic management. This examination will help determine not only whether the patient should be subjected to anesthesia, but the suitability of the agent or method for both minor and major surgery. The nurse anesthetist should know the nature of the anesthetic agent, its effects, and the proper agent to use in case of a typical cardiovascular, renal, respiratory, or other pertinent conditions. The mental attitude of the patient has a profound influence on the course of the procedure. Therefore, the psychological condition of the patient must be determined in advance and efforts made to ease any fears. In making a preoperative visit, the psychological powers of the nurse anesthetist can be exerted. A preoperative visit, by the nurse anesthetist who will administer the anesthesia is recommended on the day before elective surgery. The preanesthetic visit serves several purposes. It enables the patient to become acquainted with and talk to the person who will administer the anesthesia. This meeting, combined with a proper psychological approach that includes sympathetic understanding and considertion for the natural anxiety and apprehension on the part of the patient, serves to facilitate the entire anesthetic procedure. A preanesthetic examination can ascertain additional details concerning the patient's medical history which may have a direct influence on the selection and management of anesthesia for the patient. Previous anesthetic experiences, the patient's personal preferences, the specific details concerning the types and dosages of medication which recently have been taken by the patient, along with other pertinent points should be covered. The history of unusual sensitivity to drugs and the presence of allergic conditions are also of special concern. The nurse anesthetist should ascertain that the laboratory procedures which are routinely performed prior to surgical procedures have been performed and duly noted on the patient's chart. Furthermore, the nurse anesthetist should ascertain whether studies of the respiratory, cardiovascular, metabolic, digestive, genitourinary, and nervous systems have been made for purposes of evaluating the performance of the major physiological component, with particular regard for the conditions and deficiencies which have anesthesia implications. In addition, the preanethesia evaluation should reflect the choice of premedication to be prescribed as well as the selection and utilization of equipment available. Pertinent information relative to the choice of anesthesia should be recorded. STANDARD V Anesthetic management includes the administration of the anesthetic agent as well as the professional observance of vital signs and the providing of resuscitative care to maintain or stabilize the patient's physical condition. Interpretation A CRNA should be competent to induce and maintain anesthesia at required levels as well as to manage any untoward reactions which may develop. The anesthetist practitioner must monitor, chart, and report the patient's vital signs and other appropriate indicators as well as provide resuscitative care that includes fluid therapy, maintenance of an airway which may necessitate intubating the trachea and providing assisted or controlled ventilation. The nurse anesthetist is responsible for the proper care and inspection of the selected anesthetic equipment. Modern anesthesia machines are precise instruments. The finest details of the machine and engineering are incorporated to insure that the nurse anesthetist will have accurately measured amounts of gas according to the prescription at the moment. The nurse anesthetist selects not only the proper agent but the amount desired. It is therefore necessary that the nurse anesthetist fully understands the particular machine being used. Safety regulations concerning the handling of flammable agents and the labeling of gas cylinders should be strictly followed. It is the function of the nurse anesthetist to monitor the patient in the overating room and to evaluate the physiological condition of the patient. This monitoring is not confined to clinical observation of vital functions alone, although this is a fundamental requirement and well serves the overall purpose. The scope of the actual monitoring and the varieties of methods available may be utilized as the circumstances require. STANDARD VI The nurse anesthetist is responsible for the prompt, complete, and accurate recording of anesthetic information on the anesthesia chart. Interpretation The observation and charting of the vital signs and other pertinent anesthesia data is the direct responsibility of the attending anesthesia practitioner. The course of the anesthetic management must be charted to afford a permanent record both as an aid to the retrospective review of the quality of the patient care rendered and further as a data basis from which analysis and innovation can be formulated. Recording of all events taking place during the induction of, maintenance and the patient's emergence from anesthesia, including the dosage and duration of all anesthetic agents, other drugs, intravenous fluids, and blood or blood fraction must be made. Accurate and relevant records are essential to the development of any science. This principle particularly applies to anesthesia practice. The primary step in the evaluation of a situation and in assessment of the patient is a record of the events. Hence, the anesthesia record is an integral part of the patient's clinical hospital chart. All vital function measurements, all procedures, all drugs should be charted in time sequences. The quality and sufficiency of these recorded observations will influence the accuracy of clinical anesthesia diagnosis. Among the purposes for which anesthesia records are kept are: 1. To facilitate the care of patients: (a) By insuring the frequent attention to the patient's condition. (b) By providing information regarding the patient's general condition. (c) By establishing the sequence of events leading to reactions and complications. 2. To provide material for teaching, for study, and for statistical information. 3. To establish a medical-legal record. The anesthesia records should be vital, available, and accurate. To be vital and representative of the actual progress of a particular anesthesia and surgical operation, a record must display several characteristics. It must be complete. It must be a stark observation picture of the situation. Every physiological parameter possible should be measured continuously and recorded. Change in technique, in agents, in position, in surgical procedure should be noted. All complications should be identified and the final condition assessed. To be available, the records should be kept from moment-to-moment to serve as a possible diagnostic and prognostic element in the operative course. Delays between observation and recording lead to errors; immediate notation is desired. The records must be neat and legible. To be accurate the data should be obtained from observation of the patient and should be recorded immediately. STANDARD VII Nurse anesthetists must be competent to terminate anesthesia and must report the patient's condition and other essential information to the personnel responsible for post-anesthesia care. Interpretation The CRNA in attendance must be competent to terminate the anesthesia and report all essential data regarding the emergence from anesthesia to the personnel in charge of the post-anesthesia care. STANDARD VIII The anesthetized patient should receive competent and continuous postanesthesia care by designated personnel. Interpretation Complete recovery from surgical anesthesia is dependent upon an essential property possessed by all anesthetic drugs, namely reversibility of the pharmscological action. As the concentration of an anesthetic drug within the blood stream and brain tissues or nerve fibers dwindles from the levels required to maintain anesthesia down to levels approaching zero, the normal reactivity of the nerve tissue is resumed. Partially-conscious patients must be cared for until full consciousness has returned and protective reflexes have been regained. The ultimate objective of a well-planned and carried-out anesthesia procedure is to interfere as little as possible with the essential bodily processes, thus insuring an uneventful recovery of the patient from the combined surgical and anesthetic undertaking. A nurse anesthetist, if so designated, shall remain with the patient as long as necessary to stabilize his condition. The recording of post-anesthetic visits that include notes describing the presence or absence of anesthetic-related complications must be made. STANDARD IX Appropriate safety precautions shall be taken to insure the safe administration of anesthetic agents. Interpretation Safety precautions and controls, as established within the institution, should be strictly adhered to, so as to minimize the hazards of fire and explosion in areas where flammable anesthetic agents are used. Anesthetic apparatus should be inspected and tested by the anesthetist before use. If a leak or other defect is observed, the equipment should not be used until it is repaired. The CRNA shall check the readiness, availability, cleanliness, and working conditions of all equipment to be utilized in the administration of the anesthetic agent. Proper clothing and footwear should be utilized in accordance with the established rules and regulations at the health care institution in which the anesthesia is administered. STANDARD X The practices employed in the delivery of anesthesia care must be consistent with the policies, rules and regulations of the medical staff of the institution in which the anesthesia care is rendered. Interpretation The conduct of the CRNA is governed by the policies, rules, and regulations as established in the health care institution in which the anesthesia care is being provided. These policies, as well as the extent of the responsibility delegated, should be closely adhered to. STANDARD XI Compensation for the rendering of anesthesia care must be made within the norms established by the code of ethics of the American Association of Nurse Anesthetists and the general rules and standards adopted by the profession within each locale. Interpretation The CRNA must assiduously guard against exploitation of the patient of any participation in practices which would be contrary to the best interest of the public. General rules and standards regarding remuneration may be adopted by the profession within each locale which are to be governed by policies and laws of that locale. The right to be adequately remunerated for the services rendered is recognized as well as the counterbalancing obligation to protection the patient from economic exploitation. Nurse anesthetists are free to render gratuitous services. Senator TALMADGE. Thank you very much, Ms. Ecklund for your helpful and constructive suggestions. We will review them carefully, the recommendations you have made, and urge you and your associates to continue to work with the staff of the committee and members of the committee in trying to develop this legislation as constructively as possible. Next and the final witness for the day is Dr. John W. Ditzler, president, American Society of Anesthesiologists, and Michael Scott, counsel. Doctor, I want to thank you and the organization you represent for your very helpful and constructive suggestions that you have made in trying to develop this legislation and urge you and your society to continue to work with the staff and members of the committee in developing it as it goes through the legislative process. STATEMENT OF DR. JOHN W. DITZLER, PRESIDENT, AMERICAN SOCIETY OF ANESTHESIOLOGISTS, ACCOMPANIED BY MICHAEL SCOTT, LEGAL COUNSEL Dr. DITZLER, Mr. Chairman, I am Dr. John Ditzler, an anesthesiologist from Chicago, Ill. I am a professor of anesthesiology, Northwestern University School of Medicine, and am, in addition, the Chief of Staff of the Veterans' Administration, Lakeside Hospital, Chicago, from which I am on annual leave to make this presentation. I speak today as the president of the American Society of Anesthesiologists, a physicians' organization. Senator TALMADGE. I am the ranking member of the Veterans' Affairs Committee. I hope it is not necessary for you to take annual leave to testify before a committee of the Congress. As I understand the Constitution of the United States, every citizen in America has an inalienable constitutional right to petition his Government for redress of grievances. You may proceed. Dr. DITZLER. I am accompanied by Mr. Michael Scott of the firm of Cox, Langford & Brown, the society's legal counsel in Washington. I would make it clear at the outset that our testimony addresses itself solely to the portions of the bill which specifically relate to anesthesiology and the delivery of anesthesia care for the American people. The primary goal of the members of our society is the delivery of superior anesthesia care. We believe that such care is optimally provided by a well-trained physician working with one patient, a ratio of one to one. We have believed in that concept and have implemented many of our policies with this in mind ever since the inception of the American Society of Anesthesiologists nearly 40 years ago. We have had problems with sufficient qualified anesthesia manpower, and would, only incidentally, call to your attention the need for special consideration for specialties such as anesthesiology when considering the overall United States manpower needs for physicians. The American Society of Anesthesiologists realizes that it has an obligation to all of the American people, and, that with well over 16 million anesthetics given per year, our current society strength of approximately 10,000 active members cannot provide the optimal oneto-one care, especially since anesthesiologists are now increasingly also engaged in intensive care units, pain centers, and pulmonary therapy support. In many areas of the country there are a variety of methods of delivery of anesthesia care, some of them historical, some of them new and innovative, and others bringing with them some concerns. We believe, therefore, that Senate bill S. 3205 is commendable in that it recognizes that in order to provide superior care to the American public, one must not only continue to recognize the optimal one |