"Supporting Our Members
Protecting Our Patients"
California CRNA Practice - Compendium
One of the hallmark activities of professional associations is the ability
to clearly articulate the scope of practice of its constituent members.
For more than 65 years, CANA has been the champion of nurse anesthesia
practice not only in California, but has served as a model of excellence
for CRNA associations across the country. An important component of CANA's
many activities is the dissemination of accurate information about CRNA
scope of practice to its members, other health professionals, health care
institutions, payer groups, representatives of governmental agencies,
state and federal legislators, and the public. CRNA practice in California
is governed by statutes, regulations, and rules enacted by the state
legislature in the Nurse Practice Act and the Nurse Anesthetist Act.
In 1996, with the advice and consent of CANA's Board of Directors, a
compendium was produced and published that succinctly outlines the legal
scope of practice of CRNAs and provides the documents that discuss the
specific rules, regulations, and opinions which govern California nurse
anesthesia practice. This document, titled "Certified Registered Nurse
Anesthetists' Scope of Practice in California: A Compendium" or simply,
the "Compendium."
The book compiles the legal documents a hospital or surgery center might need in order to answer questions about CRNA scope of practice. CRNA scope of practice is often challenged by groups and individuals that seek to narrow CRNA practice rights. It is therefore helpful for hospitals and surgery centers to have a ready source of reliable information about what CRNAs may legally do in California.
A Compendium Documenting the Scope of Practice
of Certified Registered Nurse Anesthetists in California
Compendium Table of Contents:
This document is extremely large in file size. To read the document,
you will need to click the Section you want to read to keep it manageable
for all users
Section A: Legal basis of Nurse Anesthesia Practice in California
A1. Scope of Practice Guidelines for California
Certified Registered Nurse Anesthetists.
A2. Nursing Practice Act, California Business and
Professions Code, Section 2725 to Section 2727.5
A3. Nurse Anesthetist Act, California Business and
Professions Code, Section 2825 to Section 2833.6
A4. Board of Registered Nursing Opinions and Correspondence
4.1 (11/15/1985) Copy of motion adopting legal
opinion that the practice of registered nursing includes the ordering of
laboratory tests, the results of which may be used in performing nursing
functions.
4.2 (4/14/1986) CRNAs may perform the pre and post
anesthesia evaluation, authorize the release of the patient from the PACU
and may implement emergency procedures
4.3 (9/12/1988) CRNAs may authorize the discharge of
a patient from outpatient surgery or an ambulatory care surgery center.
CRNAs are independent practitioners and do not require supervision by a
physician.
4.4 (11/11/1988) CRNAs may administer anesthesia ordered by a
physician, dentist or podiatrist. Anesthesia services include regional or
local anesthesia by injection and general anesthesia. May initiate orders
to RNs, may perform a preanesthesia and post anesthesia evaluation
4.5 (July 1990) CRNA is responsible for selecting and administering the
anesthetic agent, monitoring the patient’s response thereto, and selecting
and administering drugs required to maintain the patient’s stability
during the operative period.
4.6 (1/15/1992) It is within the scope of practice of the CRNA to provide
pain management services and emergency procedures both inside and outside
the operating room suite.
4.7 (2/18/1993) CRNAs are responsible for their own professional conduct
and may be held liable for those professional acts. CRNAs practice under
his or her license and not that of a physician.
4.8 (9/16/1994) there is nothing in the statute that would preclude a CRNA
from providing anesthesia services in Level I, II, or III trauma centers.
4.9 (7/11/2002) Letter to the California Department of Health Services;
“It is the position of the Board of Registered Nursing that physician
supervision is not required for certified registered nurse anesthetist
practice.”
4.10 (11/20/2002) California Department of Health Services letter to Board
of Registered Nursing stating that the Department defers to the Board of
Registered Nursing concerning the scope of practice of nurse anesthetists.
4.11 (11/20/2009) California Department of Health Services letter to
California Society of Anesthesiologists stating that the Department defers
to the Board of Registered Nursing concerning the scope of practice of
nurse anesthetists.
4.12 (1/24/2003) Letter to the California Society of Anesthesiologists
stating that the BRN has determined that CRNAs may administer all types of
anesthesia for surgery performed by podiatrists.
4.13 (11/23/2004) Letter to Department of Health Services “The BRN has
long held that CRNAs are licensed independent practitioners and do not
require the supervision of a surgeon or anesthesiologist”.
4.14 (1/20/2005) Letter to Harold Bressler, General Counsel, Joint
Commission on Accreditation of Healthcare Organizations stating that
California CRNAs do not require supervision.
4.15 (2/4/2005) Letter from DHS to BRN in part states that CRNAs are
considered licensed independent practitioners under state law.
A5. California Attorney General opinion number 83-1007 issued April 5,
1984 concluded that it is within the scope of practice of a certified
registered nurse anesthetist to administer general or regional anesthesia.
Section B: California Administrative Code, Title 22
B1. Title 22, Section 70231 to 70239, Anesthesia Services.
B2. Title 22, Section 70223 Surgical Services, see part (d) for the
anesthesia requirements for the surgical section.
B3. Title 22 Regulatory Package R-34-85, December 22, 1986, changes
eliminated the physician CRNA supervision requirement and restrictions on
CRNAs administering regional anesthesia.
B4. Title 22 Regulatory Package R 41-91, April 15, 1993, changes
eliminated the requirement that only a physician may perform the pre-anesthesia evaluation and authorize the discharge of the patient from
the PACU or the outpatient section. The wording changes permit CRNAs to
perform those functions.
Section C: Medicare Conditions of Participation for Hospitals and
Conditions for Coverage for ambulatory surgery centers
C1. Letter from Governor Schwarzenegger to CMS opting out of the Medicare
supervision requirement for anesthesia services provided by a certified
registered nurse anesthetist.
C2. Medicare Conditions of Participation for Hospitals and Survey
Guidelines, section 482.52: Anesthesia Services.
C3. Medicare Conditions for Coverage for Ambulatory Surgical Centers and
Survey Guidelines, section 416.42: Surgical service and section 416.52:
Patient admission, assessment and discharge.
C4. CRNA Medicare payment policies and anesthesia claims modifiers.
Section D: The Joint Commission Standards
D1. Anesthesia Standards for Hospitals
D2. The Joint Commission letter to AANA outlining the process of The
Joint Commission survey procedure for determining licensed independent
practitioner status for CRNAs (November 12, 2003).
D3. The Joint Commission General Counsel letter to CANA attorney Patrick
Shannon stating that CA CRNAs are eligible to be credentialed as licensed
independent practitioners (November 12, 2004).
D4. The Joint Commission General Counsel letter to CANA attorney Phillip Recht providing the definition of licensed independent practitioner and
the process to determine licensed independent practitioner status (April
7, 1989).
Section E: California Outpatient Surgery Center Laws
E1. California Health and Safety Code Sections 1248 to 1248.85.
Section F: California Dental Anesthesia Laws and Regulations
F1. California Business and Professions Code 1646 to 1646.9
F2. California Code of Regulations Section 1043
F3. CANA analysis of the dental office anesthesia laws and regulations
Section G: Podiatry
G1. Memo from the attorney for the Department of Consumer Affairs
concluding that nurse anesthetists may provide the full range of their
services in an inpatient or outpatient setting for surgery performed by a
podiatrist (9/2/1988).
G2. Letter from the Board of Registered Nursing stating that CRNAs may
administer all types of anesthesia as ordered by a podiatrist (1/24/2003).
G3. Letter from the Board of Podiatric Medicine to California Society of
Anesthesiologist stating that the restrictions on podiatrists
administering anesthesia does not apply to the type of anesthesia a
podiatrist may order (2/10/2003).
Section H: Education and Practice Standards
H1. Education Standards of the Council on Accreditation of Nurse
Anesthesia Education Programs
H2. Scope and Standards for Nurse Anesthesia Practice, American
Association of Nurse Anesthetists
H3. Guidelines for Core Clinical Privileges, Certified Registered Nurse
Anesthetists, American Association of Nurse Anesthetists
Section I: Resources
I1. American Association of Nurse Anesthetists at
http://www.aana.com - go to
Resources on the home page. The site contains practice documents, legal
briefs and publications.
I2. California Codes (laws) and legislation information
http://www.leginfo.ca.gov
I3. The Joint Commission
http://www.jointcommission.org for questions
concerning The Joint Commission and CRNAs contact John Herringer
jherringer@jointcommission.org or by phone 630-792-5900
I4. California Board of Registered Nursing
http://www.rn.ca.gov
I5. Dental Board of California
http://www.dbc.ca.gov
I6. Centers for Medicare and Medicaid (CMS) - contains links to
reimbursement, regulations and manuals concerning Medicare
http://www.cms.hhs.gov