HB 52: Ohio CRNA Law – Shift to Consultation

Subject: Proposed amendments to Ohio law governing the practice of Certified Registered Nurse Anesthetists (CRNAs).

Executive Summary:

Ohio House Bill 52 proposes significant revisions to the state laws governing the practice of Certified Registered Nurse Anesthetists (CRNAs). The bill aims to modernize and clarify the scope of practice for CRNAs, primarily by shifting from a model of “supervision” to one of “consultation” with physicians, podiatrists, or dentists. It also introduces new regulations and repeals existing sections related to CRNA practice. The bill modifies definitions related to advanced practice registered nurses and their collaborative relationships and impacts related sections concerning pharmacy, medicine, and respiratory care.

Main Themes and Important Ideas/Facts:

1. Shift from “Supervision” to “Consultation” for CRNAs:

• The bill redefines the oversight of CRNAs from “supervision” and “immediate presence” to “consultation.”
• Under the amended Section 4723.43(D), a CRNA, “in consultation with a physician, podiatrist, or dentist actively engaged in practice in this state, may perform for a patient any of the following nursing care activities…” This signifies a move towards greater autonomy for CRNAs.
• The previous language in Section 4723.43(B)(1) stated that CRNAs could “With supervision and in the immediate presence of a physician, podiatrist, or dentist, administer anesthesia…” This requirement of immediate presence is removed under the consultation model for the listed activities in the new division (D).

1. Expanded Scope of Practice Under Consultation:

• Section 4723.43(D) outlines specific nursing care activities a CRNA can perform under consultation, including:
• Obtaining informed consent for anesthesia care and performing preanesthetic preparation and evaluation.
• Administering anesthesia (induction, maintenance, and emergence).
• Performing epidural or spinal anesthetic procedures.
• Performing postanesthetic preparation and evaluation and providing postanesthesia care.
• Performing clinical support functions.
• Selecting, ordering, and administering treatments, drugs, and intravenous fluids for conditions related to anesthesia administration or clinical support functions.
• Ordering and evaluating diagnostic tests for conditions related to anesthesia administration or clinical support functions.
• Directing registered nurses, licensed practical nurses, or respiratory therapists in supportive care and the administration of treatments, drugs, and IV fluids related to anesthesia.

1. Limitations and Restrictions:

• Despite the shift to consultation, certain limitations remain:
• A consulting dentist’s authority limits the CRNA’s scope to anesthesia procedures the dentist is permitted to perform under their conscious sedation or general anesthesia permit (Section 4723.43(D)).
• CRNAs are still prohibited from prescribing drugs for use outside the setting where they practice (Section 4723.43(D)).

1. Introduction of New Section 4723.433:

• This new section introduces provisions allowing consulting physicians, podiatrists, dentists, or the practice setting to determine if a CRNA performing specific activities under Section 4723.43(D) is not in the patient’s best interest.
• If such a determination is made, it must be documented in the patient’s medical record, prohibiting the CRNA from performing those specific activities (Section 4723.433(A)).
• CRNAs are also required to indicate in the patient’s record when they perform activities under Section 4723.43(D) (Section 4723.433(B)).
• The section clarifies that it does not prevent CRNAs from implementing verbal orders from a consulting physician, podiatrist, or dentist (Section 4723.433(C)).

1. Impact on Definition of “Supervision”:

• The definition of “Supervision” in Section 4723.01(M) is revised to exclusively pertain to CRNAs and now means the CRNA is “under the direction of a podiatrist acting within the podiatrist’s scope of practice… a dentist acting within the dentist’s scope of practice… or a physician…” The requirement of “immediate presence” is tied to when “administering anesthesia” under this definition, but this definition is largely superseded by the new consultation model in Section 4723.43(D).

1. Collaboration vs. Consultation:

• The bill maintains the concept of “collaboration” for Clinical Nurse Specialists (CNSs), Certified Nurse-Midwives (CNMs), and Certified Nurse Practitioners (CNPs) with physicians or podiatrists, requiring standard care arrangements (Section 4723.01(L)).
• “Consultation” is specifically defined for CRNAs, signifying a different level of oversight compared to the collaboration required for other APRN roles.

1. Amendments to Related Sections:

• Section 4723.01 (Definitions): Updates definitions of Registered Nurse, Licensed Practical Nurse, all categories of Advanced Practice Registered Nurses (APRNs), “Supervision,” and “Collaboration.”
• Section 4723.432 (Cooperation in Investigations): Modifies language to reflect the shift to consultation for CRNAs. CRNAs now cooperate with the board of nursing, state medical board, or state dental board in investigations related to consulting physicians, podiatrists, or dentists.
• Section 4729.01 (Pharmacy Definitions): Amends the definition of “licensed health professional authorized to prescribe drugs” to include CRNAs, but explicitly limits this authority to the extent defined in “section 4723.43 and 4723.434 of the Revised Code.” Notably, 4723.434 is being repealed, suggesting a potential oversight or a future amendment might clarify this.
• Section 4731.27 (Standard Care Arrangements): Clarifies that standard care arrangements are for collaborating physicians/podiatrists and CNSs, CNMs, and CNPs, implicitly excluding CRNAs who operate under consultation. It also updates language regarding cooperation in investigations to align with the changes for CRNAs.
• Section 4731.35 (Exemptions from Medical Practice Act): Amends this section to state that the chapter does not prohibit an individual from practicing as a CRNA “in accordance with Chapter 4723 of the Revised Code,” reflecting the updated legal framework for CRNA practice.
• New Section 4731.513: Explicitly states that the state medical board shall not prohibit podiatrists practicing outside of the specific setting described in 4731.51 from “consulting with a certified registered nurse anesthetist.”
• Section 4761.17 (Respiratory Care Practice): Updates references to CRNA practice, allowing respiratory care to be provided pursuant to an order from a CRNA acting in compliance with “section 4723.43, 4723.433, and 4723.434 of the Revised Code.” Again, the reference to the repealed 4723.434 may need further attention.

1. Repeal of Existing Sections:

• The bill proposes to repeal existing sections 4723.433, 4723.434, and 4723.435 of the Revised Code, which currently address aspects of CRNA supervision and collaborative practice. The introduction of a new section 4723.433 suggests a complete replacement and restructuring of these regulations.

Potential Implications:

• Increased Autonomy for CRNAs: The shift to a consultation model is likely to grant CRNAs greater professional autonomy in their practice.
• Clarification of Scope of Practice: The detailed listing of activities under consultation aims to provide clearer guidelines for CRNA practice.
• Impact on Healthcare Settings: Hospitals, surgical centers, and other facilities will need to adapt their policies and procedures to reflect the new consultation framework.
• Collaboration and Communication: While supervision is removed, the emphasis on consultation implies an ongoing need for communication and collaboration between CRNAs and physicians, podiatrists, or dentists.
• Potential for Debate: Changes to the scope of practice for advanced practice nurses often generate discussion and debate among various healthcare stakeholders.

Key Quotes:

• Sec. 4723.43(D): “A nurse authorized to practice as a certified registered nurse anesthetist, in consultation with a physician, podiatrist, or dentist actively engaged in practice in this state, may perform for a patient any of the following nursing care activities…” (Emphasis added)
• Sec. 4723.01(M) (as amended): “‘Supervision,’ ‘Consultation’ or ‘consulting,’ as it pertains to a certified registered nurse anesthetist, means that the certified registered nurse anesthetist is under the direction of a podiatrist… a dentist… or a physician…” (Emphasis added)
• Sec. 4723.433(A): “A certified registered nurse anesthetist shall not engage in one or more of the nursing care activities described in division (D) of section 4723.43 of the Revised Code if either of the following determines that it is not in the patient’s best interest for the nurse to perform such an activity or activities: (1) The nurse’s consulting physician, podiatrist, or dentist; (2) The setting where the nurse and physician, podiatrist, or dentist practice.”

Further Considerations:

• The implications of repealing existing sections 4723.433, 4723.434, and 4723.435 and replacing only one with a new section numbered 4723.433 warrant careful review to understand the complete restructuring of regulations.
• The continued reference to the repealed Section 4723.434 in Sections 4729.01 and 4761.17 suggests a need for technical correction or further legislative action.

This briefing document provides an overview of the main aspects of Ohio House Bill 52. A thorough understanding of the full text and its potential impact requires further analysis and consideration of stakeholder perspectives.