Strategies to Strengthen the Anesthesia Workforce in Virginia, Joint Commission on Health Care (2024)
Summary
Joint Commission on Health Care report to the Governor and the General Assembly of Virginia, Strategies to Strengthen the Anesthesia Workforce in Virginia (Report Document #939, 2024). It states that concerns about the anesthesia workforce received significant debate during the 2024 General Assembly session with the introduction of two bills, HB 1322 and SB 33. Its policy options in brief include directing BON to update regulations governing practice of CRNAs to remove references to any specific edition of the American Association of Nurse Anesthetists' Standards for Nurse Anesthesia Practice, and not recommending any policy that would make supervision of certified registered nurse anesthetists more restrictive. It states that stakeholders agreed more restrictive supervision requirements would greatly impact how anesthesia care is delivered in Virginia.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Cite this document
“Strategies to Strengthen the Anesthesia Workforce in Virginia, Joint Commission on Health Care (2024).”
Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/2024-rd939-b27898f177/
, SHA-256 25a36c32503856492b4482fabf371151bfb36af50859b9be786067e73c224a94.Full text
JOINT COMMISSION ON HEALTH CARE
STRATEGIES TO STRENGTHEN THE ANESTHESIA WORKFORCE IN VIRGINIA
REPORT TO THE GOVERNOR AND THE
GENERAL ASSEMBLY OF VIRGINIA
REPORT DOCUMENT #939
COMMONWEALTH OF VIRGINIA
RICHMOND
2024
Code of Virginia § 30-168. Joint Commission on Health Care
The Joint Commission on Health Members
Care (the Commission) is
Chair
established in the legislative branch
of state government. The purpose The Honorable Delegate Rodney T. Willett
of the Commission is to study, Vice Chair
report and make recommendations The Honorable Senator Ghazala F. Hashmi
on all areas of health care
provision, regulation, insurance,
liability, licensing, and delivery of
Delegate N. Baxter Ennis
services. In so doing, the Senator Barbara A. Favola
Commission shall endeavor to
Delegate C.E. (Cliff) Hayes, Jr.
ensure that the Commonwealth as
provider, financier, and regulator Senator Christopher T. Head
adopts the most cost-effective and Delegate M. Keith Hodges
efficacious means of delivery of
Delegate Patrick A. Hope
health care services so that the
greatest number of Virginians Senator Mamie E. Locke
receive quality health care. Further, Senator L. Louise Lucas
the Commission shall encourage
the development of uniform Delegate Robert D. Orrock, Sr.
policies and services to ensure the Senator Stella G. Pekarsky
availability of quality, affordable
Senator Todd E. Pillion
and accessible health services and
provide a forum for continuing the Delegate Marcia S. Price
review and study of programs and Delegate Atoosa R. Reaser
services.
Delegate Mark D. Sickles
The Commission may make
recommendations and coordinate
Senator David R. Suetterlein
the proposals and Delegate Howard Otto Wachsmann, Jr.
recommendations of all
commissions and agencies as to Staff
legislation affecting the provision Sarah Stanton, JD, MPA
and delivery of health care. For the
Executive Director
purposes of this chapter, “health
care” shall include behavioral Jen Piver-Renna, PhD
health care. Deputy Director
Estella Obi-Tabot, MSPH
Senior Health Policy Analyst
Emily Atkinson, MPH, CHES
Assistant Health Policy Analyst
Agnes Dymora
Executive Assistant/Office Manager
Strategies to Strengthen the
Anesthesia Workforce in Virginia
Contents
In-brief ................................................................................................................................ i
Health care professionals involved in the delivery of anesthesia ...................................... 1
Provider shortages are a barrier ........................................................................................ 6
Virginia General Assembly anesthesia legislation .............................................................. 8
Stakeholder input ............................................................................................................ 14
Approach to strengthening Virginia’s anesthesia workforce............................................ 17
Appendix 1a: House Bill 1322 .......................................................................................... 21
Appendix 1b: Senate Bill 33 ............................................................................................. 27
Appendix 2: Operative responsibilities by anesthesia provider ....................................... 30
Appendix 3: Anesthesia Models by Health District .......................................................... 31
Appendix 4: Sources and methods .................................................................................. 32
Appendix 5: State Statutes and Regulations .................................................................... 34
Strategies to Strengthen the
Anesthesia Workforce in
Virginia
POLICY OPTIONS IN BRIEF FINDINGS IN BRIEF
Option 1: Direct BON to update Multiple authorities are responsible for determining supervision
regulations governing practice of requirements of CRNAs
CRNAs to remove references to any There are at least three layers of rules that may impact the extent
specific edition of the American to which CRNAs are supervised, including federal rules, state laws,
Association of Nurse Anesthetists’ and hospital or facility bylaws. Due to the interplay between these
Standards for Nurse Anesthesia overlapping authorities, CRNA supervision requirements vary widely
Practice. in each state. In Virginia, CRNAs are currently subject to the federal
rule and Code of Virginia § 54.1-2957.
Option 2:
Not recommend any policy that Stakeholders agree that more restrictive supervision requirements
would make supervision of certified would be detrimental to efforts to address anesthesia workforce
registered nurse anesthetists more shortages
restrictive. Stakeholders agreed that implementing more restrictive supervision
requirements for CRNAs would greatly impact how anesthesia care
Option 3: is delivered in Virginia, particularly for remote or rural facilities in
Direct the DHP to develop a plan to Virginia which use proceduralists as CRNA supervisors and may not
transition CRNAs with sufficient have physician anesthesiologists on staff.
training and experience to
independent practice. Available evidence supports a measured approach to changes in
CRNA supervision requirements
Option 4: Evidence indicates that less restrictive CRNA supervision
Require DHP to re-analyze the state requirements present a low risk of harm to patients and a possible
of the anesthesia workforce in benefit to the anesthesia workforce. State models that step down
Virginia. from supervision into independent practice could be considered so
that possible impacts can be monitored over time.
Option 5:
Provide funding to VHWDA to study Strengthening Virginia’s anesthesia workforce requires a
the capacity and needs of current multifaceted approach
anesthesiology residency programs Stakeholders interviewed by the JCHC offered alternative strategies
and CRNA training programs in to address anesthesia provider workforce shortages beyond
Virginia and make changes to CRNA supervision, including the licensing of CAAs to
recommendations for further practice in Virginia and developing additional capacity for physician
expansion. anesthesiologist residency programs and CRNA training programs.
JCHC Analyst: Emily Atkinson
i
Strategies to Strengthen the
Anesthesia Workforce in Virginia
Concerns about the anesthesia workforce in Virginia received significant debate during the
2024 General Assembly session with the introduction of two bills, HB 1322 and SB 33,
pertaining to the supervision of Certified Registered Nurse Anesthetists (CRNA; APPENDIX
1a and 1b). CRNAs are advanced practice nurses who specialize in administering anesthesia
and, per Virginia law, are required to be supervised by a licensed doctor of medicine,
osteopathy, podiatry, or dentistry (Code of Virginia § 54.1-2957).
Lacking stakeholder consensus on the impact changes to CRNA supervision requirements
would have on the anesthesia workforce, HB 1322 and SB 33 were both tabled and referred
by letter to the Joint Commission on Health Care (JCHC) from the House Committee on
Health and Human Services and the Senate Committee on Education and Health. These
letters requested that the JCHC study “issues related to the supervision of CRNAs, and an
assessment of the anesthesia provider workforce including physician anesthesiologists,
CRNAs, and certified anesthesiologist assistants (CAAs).”
During the June 2024 Commission meeting, JCHC members directed staff to conduct a
targeted, narrowly scoped study on the anesthesia workforce in Virginia, with a focus on:
• Understanding and describing the anesthesia provider workforce to include the role
of anesthesiologists, CRNAs, and CAAs, and
• Assessing the impact of and noting considerations for state strategies to expand the
anesthesia provider workforce, including changes to CRNA supervision
requirements.
Multiple health care professionals are involved in the delivery
of anesthesia care to patients
Anesthesia is an important aspect of patient care and prevents
Types of anesthesia serve different
patients from feeling pain during surgery or other medical purposes and vary in intensity. Local
procedures (SIDEBAR). There are three types of health care anesthesia numbs a small part of
professionals who can deliver anesthesia care, two of which the body while regional anesthesia,
such as an epidural, blocks pain in
practice in Virginia. A physician anesthesiologist is a doctor of
large parts of the body. Sedation
medicine or osteopathy who administers anesthesia. A CRNA is puts a patient partially to sleep with
an advanced practice registered nurse who specializes in the ability to easily wake them and
administering anesthesia. CAAs practice as members of care is typically used for colonoscopies.
General anesthesia makes a patient
teams who work under the direction of a physician completely unconscious and
anesthesiologist to carry out the anesthesia care plan. CAAs are unaware of pain and is typically
used for major surgeries.
1
not permitted to practice in Virginia but do practice in 21 other states/localities. Each
provider has differing levels of education, training, and responsibilities as it pertains to a
patient’s anesthesia care.
Anesthesia providers vary in education, training, certification, and licensing
requirements
Anesthesia providers must meet varying educational and training requirements before they
can practice (TABLE 1). Anesthesiologists complete four years of pre-med undergraduate
education and four years of medical school followed by four years of a residency program in
anesthesiology, resulting in a minimum of 12 years of education. It is difficult to quantify
the number of clinical hours a physician anesthesiologist receives over the course of their
training; however, it is estimated that they receive close to 16,000 hours. This is calculated
based on anesthesia residency restrictions which state that residents cannot work more
than 80 hours per week. CRNAs pursue a nursing degree through four years of nursing
school and then must work for at least one year obtaining hands-on experience in an
intensive care unit (ICU). They can then apply to attend a three-year doctoral nurse
anesthesia program, during which they complete 2,000 clinical hours. Similar to
anesthesiologists, CAAs first complete pre-med training through an undergraduate
program. They then pursue a two-year master’s level Anesthesia Assistant program during
which they complete 2,000 clinical hours, resulting in a minimum of 6 years of educational
training.
TABLE 1. Anesthesia providers differ in their educational and training requirements
Education Comparison Anesthesiologist CRNA CAA
Degree Level MD or DO Doctor of Nursing Master’s Program
Months of Anesthesia 48 36 (Note 1) 24-28
Program
Patient Cases Unclear 650-700 600
Clinical Hours ~16,640 (4 years at 80 2000 2000
hours per week)
Minimum Total Number 12 7 6
of Years of Education
Certification Board Certification Exam and national Exam and national
certification certification
Licensing in Virginia Board of Medicine Board of Nursing & N/A (Note 2)
Medicine
MD = Doctor of Medicine; DO = Doctor of Osteopathy
NOTE 1: By 2025, all new CRNAs must have a doctorate degree from a nurse anesthesia program that is accredited
by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA).
NOTE 2: CAAs are not permitted to practice in Virginia.
SOURCE: JCHC staff analysis of program documentation, 2024.
2
While the length of the anesthesia programs represents minimum educational
requirements, stakeholders reported that in Virginia, many physician anesthesiologists and
CRNAs pursue additional years of training. For example, CRNA programs have such
competitive applicants that many seek additional years of experience in an ICU setting
before applying. In addition, physician anesthesiologists may move into a fellowship for
specialty anesthesia following their residency, instead of going directly into practice.
Anesthesiologists interviewed by JCHC staff highlighted their advanced skill set, either in
terms of the hours of clinical training in certain procedures, or exposure to complex cases
during residencies and fellowships, which they felt qualified them to address more difficult
cases and specialty cases, such as pediatric or cardiac patients.
In addition to education, all anesthesia providers can receive certification although the
processes and certification bodies differ. Anesthesiologists are medical doctors who can
obtain board certification; however, board certification is not required to practice.
Conversely, CRNAs and CAAs are both mandated to take certification exams through
national accrediting bodies. CRNAs receive certification through the National Board
Certification and Recertification for Nurse Anesthetists (NBCRNA) and CAAs receive
certification through the National Commission of Certification of Anesthesiologist
Assistants (NCCAA).
Responsibilities and tasks can vary depending on the type of anesthesia provider
Responsibilities for anesthesia providers can be divided into (1) preoperative, (2)
intraoperative, and (3) postoperative responsibilities. Preoperative responsibilities include
tasks such as obtaining patient health history, evaluating the patient, ordering tests,
prescribing preanesthetic medications, and developing the anesthesia care plan.
Intraoperative responsibilities occur during the procedure and include duties such as
prescribing anesthetic medications, administering anesthetic agents, establishing airway
interventions, monitoring the patient, and recording intraoperative events. Post operative
responsibilities include facilitating emergence and recovery from anesthesia, prescribing
post-anesthetic agents, conducting post-anesthesia evaluation, and discharging the patient.
Anesthesiologists and CRNAs can perform similar preoperative, intraoperative, and
postoperative responsibilities, while CAAs have less scope (APPENDIX 2). For example,
physician anesthesiologists and CRNAs are both capable of developing an anesthesia care
plan for a patient; however, CAAs must work under the supervision of a physician
anesthesiologist to assist in creating the plan. Also, physician anesthesiologists and CRNAs
can prescribe anesthetic medications, while CAAs cannot.
Anesthesia providers deliver services via two models of care
Anesthesia departments may choose to implement services through one of two delivery
models: (1) the Anesthesia Care Team (ACT) Model, or (2) the Efficiency Driven Anesthesia
Model.
3
The Anesthesia Care Team Model is directed by a physician anesthesiologist who supervises
non-physician anesthesia providers, such as CRNAs or CAAs. There is a clear hierarchy
within the model, with the physician anesthesiologist responsible for management of team
personnel, patient preanesthetic evaluation, prescription of the anesthetic plan,
management of the anesthetic, post anesthesia care, and anesthesia consultation. According
to the ACT model, the anesthesiologist may delegate tasks to other team members but
should, “participate in critical parts of the anesthetic, and remain immediately available for
management of emergencies. i”
The Efficiency Driven Anesthesia Model is non-hierarchal and identifies the optimal
distribution of anesthesia providers based on factors such as provider availability, provider
capabilities, patient acuity, and procedure type while maintaining quality and increasing
patient access. The model is flexible to match local demand and financial capacity with
three team structures (FIGURE 1):
• The consultative/collaboration model includes the use of both physician
anesthesiologists and CRNAs.
• The medical direction model uses one physician anesthesiologist who is
responsible for overseeing up to four CRNAs, or a 1:4 ratio.
• The solo CRNA or solo physician anesthesiologist model involves the selected
practitioner delivering anesthesia by themselves.
FIGURE 1. The Efficiency Driven Anesthesia Model offers flexible team structures
SOURCE: American Association of Nurse Anesthesiology. Efficiency Driven Model Toolkit, 2022.
i American Society of Anesthesiologists. Statement on the Anesthesia Care Team. 2023.
4
Anesthesia providers report multiple factors influence the type of anesthesia
delivery models available in Virginia facilities
Based on Virginia Medicare claims from 2022, the most recent year available, 55 percent of
anesthesia procedures were performed using the medical direction model. For
stakeholders practicing under this model, the most frequently mentioned ratio was 1:4,
meaning one anesthesiologist was responsible for supervising four CRNAs. Ratios were
even more stringent for specialty and higher acuity cases with providers reporting either a
ratio of 1:1 or 1:2 when treating pediatric patients or cardiac cases. Another 23 percent of
procedures were performed using the consultative/collaborative model, and 22 percent
were performed by a solo anesthesiologist. Stakeholders interviewed for this study indicate
that the model used to deliver anesthesia services in Virginia varies based on facility type,
geographic location, patient acuity, or the complexity of the surgical procedure.
CRNAs and physician anesthesiologists more often work separately in rural areas than in
urban ones. In one national sample of rural hospitals, nearly 55 percent of counties had no
anesthesia provider, and for those that did, on average more than 80 percent of anesthesia
providers in rural counties were CRNAs. Consistent with national literature, larger hospitals
and health systems in Virginia more often reported using the ACT model with a physician
anesthesiologist as lead, while smaller rural hospitals and ambulatory surgical centers
reported using the solo CRNA model where operating physicians work with CRNAs to
provide services. JCHC staff analysis of procedures among Virginia Medicare recipients in
rural and remote health districts indicates a smaller proportion of procedures are
performed by solo physician anesthesiologists compared to procedures using the medically
directed model or the consultative/collaborative model (APPENDIX 3). Given their
increased presence in rural areas, studies also indicate that CRNAs were more likely to be
the anesthesia providers for vulnerable populations, such as lower-income, uninsured,
unemployed, and Medicaid eligible patients, rather than anesthesiologist-provided care.
Specialty cases, such as pediatric or cardiac patients, and higher acuity cases are
better suited for anesthesiologists
In Virginia, anesthesiologists, CRNAs, proceduralists (e.g., operating physicians or dentists),
and health systems interviewed for this study agree that anesthesiologists are better
qualified to take on higher acuity and specialty cases. Interviewees indicated that
anesthesiologists were necessary in facilities that served patients with high acuity or
complex procedures, and within certain specialty areas, particularly pediatrics and
cardiology.
Stakeholders also acknowledged confidence in CRNAs’ ability to determine when it is
clinically necessary to transfer a case to a higher level of care or determine if a case is not
appropriate for the practice setting in which the patient is being treated. CRNAs recognized
their role in ensuring patients are being treated in the appropriate setting and described
several instances in which high acuity patients were stabilized and transferred to a facility
5
with an anesthesiologist. As one CRNA interviewed for this study explained, “it’s my role as
an anesthesia provider to say, hey, this is not a patient that is appropriate for this setting.”
Provider shortages are a barrier to timely anesthesia care for
patients in Virginia
Nationally, the number of anesthesia providers, including physician anesthesiologists,
CRNAs, and CAAs, has increased by 54 percent since 2012. Stakeholders in Virginia
however, cite the increasing demand for anesthesia services as the main reason why a
shortage of anesthesia providers is still the largest barrier to timely anesthesia care in
Virginia.
Supply of anesthesia providers is not keeping pace with demand
Research on the anesthesia workforce points to several factors impacting the demand for
anesthesia services, including a growing elderly population, an increasing number of
elective and outpatient procedures, and proliferation of non-operating room anesthesia
(NORA) sites. Stakeholders in Virginia point to an “explosion” of NORA sites, including
imaging centers and ambulatory surgical centers, leading to rationing of the anesthesia
provider workforce. At the same time, the supply of physician anesthesiologists is impacted
by limits on the number of residency slots, an aging workforce, and burnout. In addition,
hospitals expressed increasing financial pressures from rising salaries and competition
with private equity groups that offer significant benefits to anesthesiologists and CRNAs
not available through private practices or small hospitals.
The number of anesthesiologists practicing in Virginia has increased
Data from the Virginia Department of Health Professions (DHP) indicate that the number of
physicians who are board certified in anesthesiology has increased by 125 providers
between 2014 to 2020. ii Since the COVID-19 pandemic, stakeholders interviewed for this
study report significant shifts in the physician anesthesiologist workforce, including more
residents choosing to enter fellowships instead of entering into practice, an increase in
retirements, changes in specialties that require less intensive schedules, and a shift towards
positions with better work/life balance.
The National Center for Health Workforce Analysis estimates that Virginia’s physician
anesthesiologists are at 79 percent adequacy in 2024, meaning the current workforce can
ii
DHP reports a significant decrease in the number of board-certified anesthesiologists practicing in Virginia in
2022, the most recent year of data available. However, DHP staff indicate that the decrease may have resulted
from board certifications no longer being a required reporting element.
6
meet 79 percent of current demand. By 2034, they estimate that adequacy for physician
anesthesiologists will drop to 70 percent, attributed to a five percent decrease in the
workforce and a seven percent increase in demand (FIGURE 2). This suggests that Virginia
will require additional physician anesthesiologists to ensure patients have access to
anesthesia services.
FIGURE 2. The demand for anesthesiologists is predicted to increase faster than the supply
Projected Supply and Demand of Physican
Anesthesiologists in Virginia
1610
1500
1180 1120
2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034
Supply in Estimated FTEs Demand in Estimated FTEs
FTE = Full time equivalent
SOURCE: JCHC staff analysis of data from the National Center for Workforce Analysis, 2024.
The number of CRNAs licensed and practicing in Virginia has increased
The total number of CRNAs licensed in Virginia increased by 33 percent in the past five
years, from 2,070 in 2019 to 2,771 in 2023. JCHC staff analysis of available DHP data
indicates, on average, 80 percent of CRNAs licensed in Virginia also practice in Virginia
(FIGURE 3). In 2023, the most recent year available, DHP estimates that 2,162 of 2,771
CRNAs worked in Virginia in the past year. These estimates exclude CRNAs working in
Virginia for the federal government, the military, or Veterans Affairs facilities.
7
FIGURE 3. On average, eighty percent of CRNAs licensed in Virginia also practice in Virginia
21.8 17.9 19.7 17.1 22.0
78.2 82.1 80.3 82.9 78.0
2019 2020 2021 2022 2023
Working in Virginia in past year Not working in Virginia in past year
SOURCE: JCHC staff analysis of DHP profession report data, 2019-2023.
Between 2024 and 2036, the National Center for Health Workforce Analysis predicts a 24
percent increase in supply of CRNAs in Virginia, but only an 8 percent increase in demand.
While Virginia does not currently have enough CRNAs to meet demand, the rapid increase
in the number of CRNAs practicing in the state indicates a narrowing, rather than widening,
gap between supply and demand.
The Virginia General Assembly considered changing CRNA
supervision requirements to strengthen the anesthesia
workforce
Currently, Virginia law requires CRNAs to be supervised by a licensed doctor of medicine,
osteopathy, podiatry, or dentistry. Some stakeholders suggest that removing supervision
requirements would increase access to anesthesia services through the independent
practice of CRNAs, while others suggest that CRNAs practicing independently may
compromise patient safety and quality of care.
8
HB 1322 and SB 33 on CRNA Supervision
During Virginia’s 2024 legislative session, two bills were introduced regarding CRNA supervision
requirements. HB 1322 would have changed the requirement that a CRNA practice under the
supervision of a doctor of medicine, osteopathy, podiatry, or dentistry to a requirement that a CRNA
practice in consultation with a doctor of medicine, osteopathy, podiatry, or dentistry. In contrast, SB
33 would have defined supervision as “the licensed doctor of medicine, osteopathy, podiatry, or
dentistry is present during an operation or procedure or is immediately available to respond and
provide patient care as needed.” This sparked a debate within the Virginia General Assembly around
the merits of current CRNA supervision requirements. Those in favor of HB 1322 suggested that
removing CRNA supervision requirements would increase access to anesthesia care for patients and
assist with anesthesia workforce shortages, while those opposed believed removing supervision
requirements would be detrimental to the quality and safety of anesthesia care for patients. Those in
favor of SB 33 felt that supervision should be further defined to provide clarity around the practice of
CRNAs, while those opposed believed SB 33 to define supervision more restrictively than current law
requires, therefore potentially exacerbating anesthesia workforce shortages.
JCHC staff reviewed relevant documents and scientific literature and conducted interviews
with more than 50 stakeholders to determine factors influencing CRNA supervision and the
potential impacts of proposed changes (see APPENDIX 4 for a full description of methods).
CRNA supervision and scope of practice are separate, distinct concepts
Differing definitions and uses of terms describing CRNA practice, such as supervision and
scope of practice, have caused confusion during discussions of key issues on CRNA practice
in Virginia. According to the American Medical Association, scope of practice “refers to
those activities that a person licensed to practice as a health professional is permitted to
perform.” Scope of practice is best explained as the actual procedures a CRNA can perform
based on their education and license.
Scope of practice is a distinct and separate concept from supervision, which refers to the
type of oversight with which a CRNA may practice. The type and degree of supervision
required for CRNA practice can range from direct, in-person supervision by an
anesthesiologist to no supervision (FIGURE 4). The presence of supervision does not
innately limit CRNAs’ scope of practice. When a CRNA is practicing under supervision, they
may still practice the full scope of anesthesia procedures and services they have been
trained to perform. Virginia law currently requires CRNAs to practice under the supervision
of a licensed doctor of medicine, osteopathy, podiatry, or dentistry but does not require the
in-person presence of the supervising practitioner. Nothing in Virginia law currently
restricts CRNA scope of practice beyond the American Association of Nurse Anesthesiology
standards.
9
FIGURE 4. CRNAs practice under a spectrum of supervision models
Independent Supervision: Non- Supervision:
Practice Medically Directed Medical Direction
Physician
No requirements
anesthesiologist
The ability for a for the physician
must meet seven
provider to to provide hands-
documentation
practice without on care; instead,
requirements
supervision or the physician is
which includes
medical available to assist
more hands-on
direction. in any of the
involvement in
concurrent cases.
patient care.
SOURCE: JCHC staff analysis of relevant documentation, 2024.
Multiple authorities are responsible for determining supervision requirements
of CRNAs
Supervision requirements are not solely determined by state law or regulation. There are at
least three layers of rules that may impact the extent to which CRNAs are supervised,
including federal rules, state laws, and hospital or facility bylaws. Due to the interplay
between these overlapping authorities, CRNA supervision requirements vary widely in each
state. This makes interpreting CRNA supervision by state difficult, as it could vary
substantially across patient population and facility types.
States may choose to opt-out of the federal rule requiring CRNA supervision
Prior to 2001, the federal Centers for Medicare & Medicaid
Services (CMS) required, as a Condition of Participation
(SIDEBAR) for Medicare and Medicaid reimbursement, that CMS developed Conditions of
CRNAs in hospitals, critical access hospitals, and ambulatory Participation (CoPs) that health care
organizations must meet to begin and
surgery centers administer anesthesia only under the continue participating in the
supervision of an operating practitioner or of an Medicare and Medicaid programs.
anesthesiologist who is immediately available (42 C.F.R. pts. These standards are the foundation
for improving quality and protecting
416, 482, and 485). Beginning in 2001, CMS permitted states
the health and safety of beneficiaries.
to opt out of this rule if the state’s governor sent a letter to
CMS attesting consultation with the state’s Boards of
Medicine and Nursing, affirmed that the opt-out is consistent with state law, and concluded
that opting out would be in the best interest of the state.
10
As of May 2024, 24 states and Guam have opted out of the federal CRNA supervision rule
(FIGURE 5). For the remaining 26 states, including Virginia, the federal CRNA supervision
rule is still in effect for hospitals and facilities seeking reimbursement from Medicare and
Medicaid for CRNA services.
FIGURE 5. Twenty-four states and Guam have opted out of the federal CRNA supervision rule
SOURCE: JCHC staff analysis of documentation provided by CMS, 2024.
Opting out of the federal rule does not guarantee CRNA independent practice. The
federal CRNA supervision rule is relevant to reimbursement for CRNA services in hospitals,
including critical access hospitals and ambulatory surgical centers. In other scenarios, state
law applies, and in some opt out states, the applicable state statute or regulation is more
restrictive than the federal rule. In other words, it is possible for a state to opt out of the
federal rule and still have state statute or regulations which require CRNAs to practice
under supervision or medical direction. For example, Arizona opted out of the federal rule
in 2020; however, their state law requires CRNAs to practice under the direction of a
physician or surgeon and requires an in-person presence of this supervisor. This language
makes Arizona’s state law more restrictive than the federal rule. Similarly, Wisconsin opted
out of the federal rule in 2005 and has state statute which requires CRNAs to perform
anesthesia services “in the presence of a supervising anesthesiologist or performing
physician.” There are also states that have opted out of the federal rule but still require
supervision in particular care settings. For example, New Hampshire opted out of the
federal rule in 2002 but only allows CRNAs to deliver anesthesia services without
supervision in critical access hospitals. California opted out of the federal rule in 2009 but
requires CRNAs to be supervised in trauma centers. So, while these states are typically
11
counted as “opt-out states,” CRNAs are not permitted to practice independently in all
settings.
All states describe CRNA supervision in state law or regulation, but language
varies considerably
JCHC staff identified state statutes or regulations that describe CRNA supervision in all 50
states and the District of Columbia (see APPENDIX 5 for language from each state). While
there are consistencies across states in defining the role of CRNAs, JCHC did not identify a
single standard or model policy that multiple states use to describe supervision
requirements. In fact, fourteen different terms or phrases are used to describe how CRNAs
relate to other health care professionals, such as operating physicians or anesthesiologists,
with many states using multiple terms (TABLE 2). States most commonly described the
relationship between CRNAs and physicians as collaborative (18 states) or supervisory (11
states, including Virginia). Only 5 states specifically use the term “independent.” Fifteen
states use language that requires a health care professional other than the CRNA to be
immediately available (eight states) or physically present (ten states). Three states require
a physician to be immediately available and physically present.
TABLE 2. States use 14 terms to describe the relationship between CRNAs and other
health care professionals
Term Appearing in Statute or Regulation Number of States
In collaboration with 18
Under supervision 11
In consultation with 9
Under the direction of 7
Independent 5
Responsible to 2
Refer to 2
Interdependent 2
Without supervision 2
With the consent of 1
Accountable to 1
Delegate to 1
In coordination with 1
Upon request of 1
Total 63
NOTE: States can use more than one term.
SOURCE: JCHC staff analysis of state statutes and regulations, 2024.
12
In Virginia, CRNAs are currently subject to the federal rule and Code of Virginia §
54.1-2957. Virginia has not opted out of the federal ruling for CRNA supervision. In
addition, Code of Virginia § 54.1-2957 requires CRNAs to practice under the supervision of
a licensed doctor of medicine, osteopathy, podiatry, or dentistry; however, supervision is
not further defined. Virginia regulations in 18VAC90-30-121 further state that, “the practice
of a certified registered nurse anesthetist shall be based on specialty education preparation
as an advanced practice registered nurse in accordance with standards of the applicable
certifying organization and with the functions and standards defined by the American
Association of Nurse Anesthetists (Standards for Nurse Anesthesia Practice, Revised
2013).” However, the Standards for Nurse Anesthesia Practice were most recently updated
in 2019.
OPTION 1: The JCHC could introduce a Section 1 bill directing the Board of Nursing to
update regulations governing practice of advance practice registered nurses licensed as
certified registered nurse anesthetists (CRNAs) to remove references to any specific edition
of the American Association of Nurse Anesthetists’ Standards for Nurse Anesthesia
Practice, so that the practice of a CRNA shall be consistent with the most recent version of
the Standards for Nurse Anesthesia Practice available.
Hospital bylaws determine team structure and define roles for anesthesia
providers
In addition to the federal rule and state statute, hospitals and health systems implement
their own bylaws for CRNA supervision that can be more restrictive than the state law
limiting CRNA practice. For example, a facility could choose to use a more restrictive model
of practice, such as medical direction, which would mean that the procedures and services
a CRNA could perform could be limited by the supervisor to an extent that is more limited
than the CRNA’s scope of practice. Literature reviewed by JCHC staff indicates that
anesthesia team structure, supervision requirements, and the type of procedures and tasks
a CRNA is allowed to perform are more hospital-driven than federal rule or state statute-
driven. Even in states that opt out of the federal rule and have permissive supervision
requirements, some health care facilities still choose to engage in the Anesthesia Care Team
model. In Virginia, CRNAs interviewed by JCHC staff reported that the application of
hospital bylaws limits the type of procedures and tasks they are allowed to perform more
than the state supervision law.
Given the authority health systems have to implement their own bylaws, stakeholders
interviewed by JCHC staff expressed uncertainty about the impact of changes in the federal
rule or state law. Anesthesiologists hypothesized that hospital bylaws requiring CRNA
supervision would likely not change if Virginia opted out of the federal rule. However,
health systems said they would consider moving to an efficiency-driven model, where
CRNAs could practice independently at certain facilities or under certain circumstances.
One health system noted, “we would probably still keep [supervision] in place at our
13
hospitals because in the acute setting, those patients are sicker, and the anesthesia is more
complicated. But what we would also do is, in an ambulatory setting, we might loosen
[supervision restrictions].”
Stakeholders do not want more restrictive CRNA practice but
disagree on the impact of reducing CRNA supervision
requirements
While stakeholders interviewed by JCHC for this study had varying opinions on reducing
CRNA supervision requirements, they were unanimously opposed to implementing more
restrictive supervision requirements.
Stakeholders agree that more restrictive supervision requirements would be
detrimental to efforts to address anesthesia workforce shortages
In general, CRNAs and proceduralists indicated that Virginia statute, as currently written,
was flexible enough to allow anesthesia providers to practice as they preferred and to allow
proceduralists to deliver anesthesia care to their patients as they preferred, with CRNAs
under the supervision of an anesthesiologist or a proceduralist. Some anesthesiologists
expressed a preference for more restrictive supervision, where CRNAs always practiced
under their supervision, but they also recognized that such a structure would be
impractical given current workforce shortages. Most anesthesiologists believe that the
current state law is working for Virginia. One anesthesiologist stated, “good care is
happening under our current system” and another recognized that the current law is
flexible enough for hospitals to implement the supervision requirements that fit their
situation. Stakeholders universally agreed that implementing more restrictive supervision
requirements for CRNAs would greatly impact how anesthesia care is delivered in Virginia,
particularly for remote or rural facilities in Virginia which use proceduralists as CRNA
supervisors and may not have physician anesthesiologists on staff.
OPTION 2: The JCHC should not recommend any policy that would make supervision of
certified registered nurse anesthetists more restrictive than current state statute or federal
rule require.
There is no consensus among stakeholders regarding the impact of reducing
supervision requirements
Stakeholders had varying opinions on the impact that reducing CRNA supervision
requirements would have on the anesthesia provider workforce in Virginia.
Anesthesiologists generally oppose reducing supervision due to concerns about patient
safety. They hypothesized that, if CRNA supervision were removed, anesthesia care would
develop into a two-tiered model in Virginia, where certain populations would have access
to an anesthesiologist and certain populations would have access to a CRNA depending on
14
where they live and not the type of care they need. In terms of the impact on the workforce,
anesthesiologists typically believed that changing CRNA supervision requirements would
create additional workforce concerns as anesthesiologists would seek out practice
environments where they are “actually contributing to care rather than just signing pieces
of paper” and proceduralists who are uncomfortable in a CRNA-only environment would
choose to practice elsewhere.
CRNAs interviewed by JCHC staff supported reducing supervision requirements. CRNAs
reported that the current state law does not, in their opinion, reflect current practice with
its emphasis on supervision instead of collaboration. Anesthesiologists interviewed for this
study often used the word “collaborative” to describe their relationship with CRNAs. One
CRNA stated, “it's the anesthesiologist’s job to assess the risk of the patient, do the pre-
operative, and then be there for that extra set of hands if you ever need them, but then
we're performing 95% of the anesthesia that happens.” CRNAs felt that changing
supervision requirements could eliminate confusion about current practice and address
concerns about the relationship between supervision and liability that make some
proceduralists hesitant to work with CRNAs.
Many CRNAs expressed that in cases where a proceduralist is providing supervision, they
are providing supervision on paper, but not in practice. Proceduralists are not experts in
airways or anesthesia and therefore do not truly supervise CRNAs in the way that a
physician anesthesiologist would. CRNAs believe that loosening supervision requirements
in Virginia would not have a huge impact on how anesthesia care is being delivered but
would instead more accurately reflect what is already occurring in practice and possibly
reduce the administrative burdens supervision carries, leading to less costly care for
patients, and more CRNAs wanting to come to Virginia to practice.
Hospitals and health systems remained neutral in their opinions around the impact of
changing CRNA supervision requirements. While they would not oppose additional
flexibility around supervision rules and would welcome the opportunity to move to an
efficiency driven model, changes to supervision requirements at the state level would likely
not have significant impacts on how they operate, particularly for specialty cases and
higher acuity cases. One health system indicated that, if state law became less restrictive,
they would be willing to reconsider their bylaws to allow CRNAs to practice more
independently. In contrast, a specialty hospital indicated that they would not change their
bylaws regarding CRNA supervision, even if state law became less restrictive, given the
acuity of patients that come to their hospital.
There is little evidence to suggest that CRNAs decrease patient safety, patient
outcomes, or quality of care compared to anesthesiologists
Anesthesiologists opposed to changes in CRNA practice believed patient safety would be
compromised if supervision requirements were removed as CRNAs would not have back up
in the operating room if something went wrong. However, the literature reviewed by JCHC
15
staff does not support this concern. A number of studies provided quantitative evidence
that there is no difference in patient safety or patient outcomes with CRNAs compared to
anesthesiologists. Multiple stakeholders interviewed for this study agreed that both
anesthesiologists and CRNAs provide safe, effective, and high-quality anesthesia services to
patients. Several Virginia-based health systems also expressed that they did not see a
difference in care quality between the different anesthesia providers that were employed
by their health system.
Evidence is mixed on whether CRNAs increase access to care for patients
Proceduralists interviewed by JCHC staff noted that working with CRNAs had improved
access to care for their patients by allowing them to treat patients in an outpatient setting
who would otherwise have had to be hospitalized. However, evidence from the scientific
literature is mixed on the impact of CRNA supervision on access to anesthesia care. While
CRNAs have been shown to assist with workforce shortages and access to anesthesia
services more generally, it is unclear if changes in supervision requirements are the reason
patients’ access to anesthesia services increases. A handful of studies provided evidence
that CRNAs are more likely to practice in rural and underserved areas, but multiple studies
also showed that reducing supervision requirements had no impact on patient’s access to
anesthesia services. This suggests that the presence of CRNAs on a care team might
increase access to anesthesia services more generally, but changes in supervision
requirements do not necessarily equate to increased access for patients.
Available evidence supports a measured approach to changes in CRNA
supervision requirements
In summary, evidence reviewed by JCHC staff for this study indicates that less restrictive
CRNA supervision requirements present a low risk of harm to patients and a possible
benefit to the anesthesia workforce. If repealing or reducing CRNA supervision
requirements is of interest to the General Assembly, state models that step down from
supervision into independent practice could be considered so that possible impacts can be
monitored over time, including any unintended consequences.
Three states allow CRNAs to transition from supervised practice to independent practice
based on specific criteria. In Michigan, for example, CRNAs may practice without
supervision after 3 years of experience and a minimum of 4,000 hours as a nurse
anesthetist. In Vermont, a formal agreement with a collaborating provider is required until
CRNAs reach 12 months of experience or 1,600 hours. And in Connecticut, CRNAs must
practice under a physician for the first three years after receiving their initial licensure.
OPTION 3: JCHC could introduce a Section 1 bill directing the Department of Health
Professions, in consultation with the Board of Medicine and the Board of Nursing, to
develop a plan to transition CRNAs with sufficient training and experience to independent
practice. Development of the plan should include stakeholder engagement, considerations
16
for opting out of the federal rule, and methods to monitor the effects of implementation.
The plan should specify the training and experience necessary for transition to
independent practice, including (i) the appropriate number of clinical hours and years of
practice required for transition to independent practice and any requirements related to
clinical hours dedicated to specialty anesthesia services such as anesthesia services for
pediatric, cardiac, or higher acuity patients, if appropriate, and (ii) the process by which a
CRNA may apply for and obtain permission to practice without supervision. DHP would
submit the plan and suggested language for legislation to the Joint Commission on Health
Care by October 1, 2025.
Strengthening Virginia’s anesthesia workforce requires a
multifaceted approach
Stakeholders interviewed by the JCHC offered alternative strategies to address anesthesia
provider workforce shortages beyond changes to CRNA supervision, including the licensing
of CAAs to practice in Virginia and developing additional capacity for physician
anesthesiologist residency programs and CRNA training programs.
CAAs practice in 21 states and Washington, D.C. but supply is limited
CAAs practice in 21 states and Washington, D.C. Currently, Virginia does not allow CAAs to
practice and there are no CAA training programs in the state. Most states that license CAAs
have explicit licensure through the state medical board, but four states (Kansas, Michigan,
Pennsylvania, Texas) require CAAs to practice under delegatory authority of an
anesthesiologist’s license, and one state (Kentucky) requires CAAs to also have a physician
assistant license to practice. There are 20 CAA training programs across the United States,
with the closest to Virginia being in Washington, D.C., and as of 2024, there were
approximately 4,000 CAAs in total across the entire country. For CAAs to be a health care
extender in Virginia, additional training capacity would be required. As such, CAAs would
not necessarily address short-term workforce issues.
CAAs are limited in the tasks they can perform and, unlike CRNAs, must always be under
the direction of an anesthesiologist. Although the tasks that CAAs can carry out vary from
state to state, most commonly CAAs can administer controlled substances, establish airway
interventions, and perform epidurals. Anesthesiologists and health systems who provided
perspective on the CAAs felt that even with their limited scope, CAAs could assist with
workforce shortages in areas where anesthesiologists are practicing by reducing strain on
the current anesthesia workforce and providing hospitals additional staffing flexibility. For
example, one health system indicated that they would use CAAs consistent with their skill
set, adding, “we can control the safety and make sure we have the same level of care, not
because of anything the Commonwealth would do, but because of our own regulations and
bylaws.”
17
In 2017, DHP conducted a study on the feasibility of licensing CAAs at the request of the
Virginia General Assembly. At that time, the DHP report concluded that licensing CAAs was
not recommended due, in part, to a lack of proof of a statewide shortage of anesthesia
providers. However, workforce projections used in DHP’s analysis have changed
significantly since that time given the impacts of the COVID-19 pandemic and the slow pace
at which the health care workforce generally, and the anesthesia provider workforce
specifically, has been able to recover.
OPTION 4: JCHC could submit a Section 1 bill requiring the Department of Health
Professions to re-analyze the state of the anesthesia workforce in Virginia with the most
current data available to determine whether there is sufficient proof of an anesthesia
workforce shortage that would justify licensure of certified anesthesiologist assistants. The
Department would submit a report to the Joint Commission on Health Care by October 1,
2025.
Stakeholders support increasing the pipeline of anesthesiologists and CRNAs in
Virginia
Stakeholders interviewed for this study nearly unanimously supported increasing the
capacity of Virginia’s physician anesthesiology residency programs and CRNA doctoral
training programs as a strategy to address provider shortages. National research also
supports the value of increasing the anesthesia provider pipeline, with one study indicating
that an annual increase of two percentage points in the entry rate of anesthesia providers
would eliminate nearly all excess demand within seven years.
Virginia’s anesthesiology residency programs and CRNA training programs are
operating at capacity
Education and training program leaders indicate significant interest in pursuing careers in
anesthesia; however, programs lack capacity to accommodate all qualified candidates.
Currently, there are three anesthesiology residency programs in Virginia, located at Virginia
Commonwealth University (VCU), the University of Virginia (UVA), and Eastern Virginia
Medical School (EVMS). Data from the National Residency Matching Program reports the
number of residency slots for anesthesiologists in Virginia has increased from 27 residents
in 2020 to 33 residents in 2024. Except for 2020, when there was one less resident than
slots, residency slots for the three programs in Virginia have been filled. In addition, Mary
Baldwin University announced a new anesthesiology residency program to begin in July
2025 with a class of 6 residents.
Old Dominion University (ODU), Virginia Commonwealth University (VCU), and Mary
Baldwin University operate Virginia’s three accredited CRNA training programs. Program
capacity varies, with VCU admitting 55 students, ODU admitting 30 students, and Mary
Baldwin admitting 25 students into their most recent cohorts. These programs are very
18
popular and competitive; one program director reported turning away over 500 qualified
applicants.
Most anesthesia providers who graduate from Virginia programs gain
employment in Virginia
Among physicians with a board certification in anesthesiology currently practicing in
Virginia, 34 percent completed graduate school or their post-graduate training in Virginia
and an additional 25 percent completed graduate school or their post-graduate training in a
state/locality bordering Virginia. Similarly, most graduates from CRNA training programs at
VCU and ODU gain employment in Virginia following graduation (FIGURE 6). iii In 2023, 70
percent of graduating CRNAs reported employment in Virginia whereas 30 percent
reported employment in other states.
FIGURE 6. CRNAs graduating from Virginia programs seek employment in Virginia following
graduation
27% 33% 30%
73% 67% 70%
2021 Cohort 2022 Cohort 2023 Cohort
Employed in Virginia Employed in Another State
SOURCE: JCHC analysis of CRNA training program data, 2024.
Adding capacity to existing programs or creating new programs requires careful
consideration to balance the resources needed for additional faculty and clinical training
opportunities within existing workforce needs. Proper planning also avoids workforce
saturation and ensures programs are of appropriate educational quality and can provide
meaningful clinical training to their students.
iii Mary Baldwin expects their first graduating cohort in 2025.
19
OPTION 5: JCHC could submit a budget amendment, providing funding to the Virginia
Health Workforce Development Authority (VHWDA) to, in collaboration with the State
Council of Higher Education for Virginia, and other relevant stakeholders, study the
capacity and needs of current anesthesiology residency programs and CRNA training
programs in Virginia and make recommendations for further expansion. VHWDA would
submit a report to the Joint Commission on Health Care and to the Chairs of the House
Appropriations Committee and Senate Finance and Appropriations Committee by October
1, 2026.
20
Appendix 1a: House Bill 1322
21
22
23
24
25
26
Appendix 1b: Senate Bill 33
27
28
29
Appendix 2: Operative responsibilities by anesthesia provider
TABLE 3. Anesthesiologists and CRNAs are capable of performing similar preoperaƟve,
intraoperaƟve, and postoperaƟve responsibiliƟes
AN CRNA CAA
Preoperative Responsibilities
Obtain pre-anesthesia health history X X X
Provide patient education and counseling X X
Examine, assess, and evaluate patient X X X
Order tests X X X
Obtain Informed Consent X X X
Select, order and prescribe preanesthetic medications X X
Develop anesthesia plan for anesthesia, analgesia, multimodal pain
X X
management, and recovery
Intraoperative Responsibilities
Implement plan of care X X
Administer anesthetic agent and anesthetic techniques, such as
general, regional, and local anesthesia, sedation, and multimodal X X
pain management
Select, order, and prescribe anesthetic medication X X
Select and insert invasive and noninvasive monitoring modalities X X
Establish airway intervention X X X
Monitor patient X X X
Assist in induction, maintenance, and emergence of patient
X
anesthetic
Record intraoperative events X X X
Postoperative Responsibilities
Facilitate emergence and recovery from anesthesia X X
Select, order, and prescribe post anesthetic medication X X
Conduct post anesthesia evaluation X X
Ensure transfer of care information X X
Remain with patient until receiving provider arrives X X X
Record patient progress X X X
Perform duties delegated by anesthesiologist X
Perform administrative duties X
Record patient progress X
Educate patient on recovery X X
Discharge patient X X
AN = Anesthesiologist; CRNA = Certified Registered Nurse Anesthetist; CAA = Certified Anesthesiologist Assistant
SOURCE: JCHC staff review of documents and literature.
30
Appendix 3: Anesthesia models by health district
FIGURE 7. Proportion of procedures among Medicare recipients performed by solo
anesthesiologists varies by health district
1 - Lenowisco 2% 40% 59%
2 - Cumberland Plateau 5% 40% 55%
3 - Mount Rogers 6% 52% 42%
15 - Richmond Regional 8% 77% 15%
23 - Hampton Roads 12% 58% 29%
16 - Radco 14% 67% 20%
22 - Accomack-Northampton 14% 55% 31%
14 - Piedmont 16% 51% 32%
4 - New River Valley 17% 64% 19%
19 - Crater 17% 64% 18%
18 - Middle Peninsula 19% 67% 14%
12 - West Piedmont 20% 30% 50%
13 - Southside 20% 37% 42%
17 - Northern Neck 23% 62% 15%
5 - Fifth 26% 54% 20%
8 - Northern Virginia 29% 53% 17%
9 - Rappahannock-Rapidan 38% 38% 24%
10 - Thomas Jefferson 49% 39% 12%
11 - Central Virginia 52% 36% 12%
7 - Lord Fairfax 58% 38% 4%
6 - Central Shenandoah 60% 26% 14%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Solo Anesthesiologist Medically Directed Model Consultative/Collaborative Model
NOTE: Percentages may not equate to 100% due to rounding.
SOURCE: JCHC staff analysis of Medicare claims data, 2022.
31
Appendix 4: Sources and methods
Narrative Review
JCHC staff conducted a literature review to address three study questions: (1) what is the
scope of current and projected shortages for anesthesia providers and do shortages
disproportionately impact specific populations; (2) how have historical licensing changes
among anesthesia providers impacted the anesthesia provider workforce and do changes in
the workforce disproportionately impact specific populations; and (3) how does patients’
access, quality, and safety vary by anesthesia provider type and do variations in patient
outcomes disproportionately impact specific populations.
Staff identified common words and phrases associated with the anesthesia workforce in
existing literature. Using these key terms, a search phrase was created for each study
question:
(1) anesthes* AND workforce shortage
(2) “nurse anesthetist AND licens*” OR “nurse anesthetist AND regulat*”
(3) “anesthesiologist AND nurse anesthetist AND patient outcomes” OR
“anesthesiologist AND nurse anesthetist AND access” OR “anesthesiologist AND
nurse anesthetist AND quality” OR “anesthesiologist AND nurse anesthetist AND
safety”
JCHC staff used these phrases to conduct an advanced literature search, identifying articles
in which these terms were used in either the title or the abstract. This search was
conducted in research databases available through VCU libraries and staff identified 118
articles which fit the search criteria. JCHC staff independently reviewed articles for
relevance to the inclusion criteria. The inclusion criteria required that studies be: (1)
written in English, (2) published between 2000 and 2024, and (3) published in a credible
peer-reviewed journal.
Staff then reviewed articles for applicability to the three study questions of interest.
Articles could be relevant to more than one category, which resulted in some article overlap
between study questions. 547 articles were removed for lack of relevance to study
questions, 15 articles were removed due to article type, and 107 articles were removed
because they were not based in the United States, leaving 118 articles for content analysis.
JCHC staff reviewed the remaining articles in detail, using content analysis techniques to
identify significant themes across studies addressing each study question.
Interviews
JCHC staff conducted stakeholder interviews to address three study questions: (1) what is
the current standard of care for administering anesthesia and how are anesthesia services
being delivered in Virginia; (2) how have historical licensing changes among anesthesia
providers impacted the anesthesia provider workforce and do changes in the workforce
disproportionately impact specific populations; and (3) how does patients’ access, quality,
and safety vary by anesthesia provider type and do variations in patient outcomes
disproportionately impact specific populations.
32
JCHC staff conducted interviews with relevant stakeholders to develop a clearer
understanding of the three study questions. These interviews were conducted with
numerous types of anesthesia providers, proceduralists and operating physicians, provider
associations, and health systems. Detailed notes were taken by a secondary interviewer and
JCHC staff transcribed interview notes. JCHC staff performed qualitative analysis to identify
overarching categories and themes. Any categories and themes that emerged were used to
derive a deeper understanding of anesthesia services in Virginia.
Data Analysis
JCHC staff analyzed data from multiple sources to understand trends in the anesthesia
provider education pipeline and workforce in Virginia and nationally, including:
Health Care Profession reports from the Virginia Department of Health Professions,
available for Advanced Practice Registered Nurses, including CRNAs, and MD/DOs
that summarize data from the state’s licensure database and voluntary surveys
completed during licensure renewal;
Virginia Department of Health Professions Provider Profile that maintains
individual-level data on physicians licensed in Virginia;
Data on enrollment, graduation and employment rates from the three accredited
CRNA training programs in Virginia;
Anesthesia provider billing modifiers from Medicare claims data on anesthesia
services, provided in aggregate by Virginia Health Information;
Anesthesiology residency match data from the National Resident Matching Program;
Provider-level practice location data on providers with National Provider Identifiers
from the National Plan and Provider Enumeration System; and
State and county-level data on providers with National Provider Identifiers from the
US Health Resources and Services Administration Area Health Resources Files.
50‐State Scan
JCHC staff used WestLaw, a legal research database, to identify state statute or
regulation relevant to the practice of CRNAs in 50 states and the District of Columbia. Staff
used the search terms, “nurse anesthetist,”, “CRNA”, and “anesthesia” to identify relevant
sections of state statute that described the nature of the relationship between CRNAs and
other health care professionals, including operating physicians, podiatrists, dentists, and
anesthesiologists. If such language was not explicit in state statute, staff used the same
search terms to review state regulations. Staff were able to capture language in all 50 states
and the District of Columbia, current as of September 2024.
33
Appendix 5: State statutes and regulations
Table 4 summarizes the language in either state statute or regulation relevant to the
relationship between CRNAs and other health care professionals, typically operating
physicians or anesthesiologists, in hospital settings. Key words to describe the relationship,
if applicable, are bolded. States that use different standards for other health care settings,
such as critical access hospitals, ambulatory surgical centers, or medical offices are noted.
TABLE 4. CRNA supervision language by state, hospital settings
NOTE: * indicates states where CRNA practice varies by health care setting.
State Citation Language
Alabama Ala. Code § 34- The nurse anesthetist…functions under the direction of or in
21-81 coordination with a physician licensed to practice medicine, a
podiatrist, or a dentist, who is immediately available. Nothing in this
paragraph shall be construed to restrict the authority of a health care
facility to adopt policies relating to the provision of anesthesia and
analgesia services.
Alaska* Alaska Admin. Anesthesia care may be provided only by a physician or dentist with
Code tit. 7, § anesthesia privileges, a registered nurse anesthetist, or an
12.130 appropriately supervised trainee in an educational program approved
by the department.
Arizona Ariz. Rev. Stat. A certified registered nurse anesthetist may administer anesthetics
Ann. § 32- under the direction of and in the presence of a physician or
1634.04 surgeon in connection with the preoperative, intraoperative or
postoperative care of a patient or as part of a procedure performed by
a physician or surgeon.
Arkansas Ark. Code Ann. § “Practice of certified registered nurse anesthesia” means the
17-87-102 performance for compensation of advanced nursing practices by a
certified registered nurse anesthetist that are relevant to the
administration of anesthetics in consultation with, but not
necessarily in the presence of, a licensed physician, licensed dentist,
or other person lawfully entitled to order anesthesia.
California* Cal. Code Regs. Anesthesia care shall be provided by physicians or dentists with
tit. 22, § 70235 anesthesia privileges, nurse anesthetists, or appropriately supervised
trainees in an approved educational program.
Colorado Colo. Rev. Stat. An advanced practice registered nurse shall practice in accordance
Ann. § 12-255- with the standards of the appropriate national professional nursing
111 organization and have a safe mechanism for consultation or
collaboration with a physician or, when appropriate, referral to a
physician.
34
State Citation Language
Connecticut Conn. Gen. Stat. An advanced practice registered nurse…shall, for the first three years
Ann. § 20-87a after having been issued such license, collaborate with a physician
licensed to practice medicine in this state…except such advanced
practice registered nurse licensed pursuant to section 20-94a and
maintaining current certification from the American Association of
Nurse Anesthetists who is prescribing and administrating medical
therapeutics during surgery may only do so if the physician who is
medically directing the prescriptive activity is physically present in
the institution, clinic or other setting where the surgery is being
performed.
District of D.C. Code Ann. § A certified registered nurse anesthetist may plan and deliver
Columbia 3-1206.05a anesthesia, pain management, and related care to patients or clients
of all health complexities across the lifespan. This practice
incorporates the use of independent judgement as well as
collaborative interaction with other health care professionals.
Delaware Del. Code Ann. “Advanced practice registered nurse” includes certified nurse
tit. 24, § 1902 practitioners, certified registered nurse anesthetists, certified nurse
midwives, or clinical nurse specialist. Advanced practice nursing is an
expanded scope of nursing licensed as an independent licensed
practitioner in a role and population focus approved by the Board of
Nursing, with or without compensation or personal profit, and
includes the RN scope of practice.
Florida* Fla. Stat. Ann. § An advanced practice registered nurse shall perform those functions
464.012 authorized in this section within the framework of an established
protocol that must be maintained on site at the location or locations at
which an advanced practice registered nurse practices, unless the
advanced practice registered nurse is registered and practicing under
s. 464.0123. In the case of multiple supervising physicians in the same
group, an advanced practice registered nurse must enter into a
supervisory protocol with at least one physician within the
physician group practice.
Georgia* Ga. Code Ann. § In any case where it is lawful for a duly licensed physician practicing
43-26-11.1 medicine under the laws of this state to administer anesthesia, such
anesthesia may be administered by a certified registered nurse
anesthetist, provided that such anesthesia is administered under the
direction and responsibility of a duly licensed physician.
Hawaii Haw. Rev. Stat. “Anesthetist” means a registered nurse-anesthetist who performs
Ann. § 431:10C- anesthesia services under the supervision of a licensed physician.
103
Idaho Idaho Code Ann. Advanced practice registered nurses shall include the following four
§ 54-1402 (4) roles: certified nurse-midwife; clinical nurse specialist; certified
nurse practitioner; and certified registered nurse anesthetist as
defined in board rule. An advanced practice registered nurse
collaborates with other health professionals in providing health care.
35
State Citation Language
Illinois* 225 Ill. Comp. In the case of anesthesia services provided by a certified registered
Stat. Ann. nurse anesthetist, an anesthesiologist, a physician, a dentist, or a
65/65-35 podiatric physician must participate through discussion of and
agreement with the anesthesia plan and remain physically present
and available on the premises during the delivery of anesthesia
services for diagnosis, consultation, and treatment of emergency
medical conditions.
Indiana Ind. Code Ann. § A certified registered nurse anesthetist may administer anesthesia if
25-23-1-30 the certified registered nurse anesthetist acts under the direction of
and in the immediate presence of a physician.
Iowa Iowa Admin. Written policies and procedures governing anesthesia services shall
Code r. 481- be developed and implemented in consultation with and with the
51.19(135B) approval of the hospital's medical staff and, at a minimum, provide
for… anesthesia services under the direction of a qualified doctor of
medicine or osteopathy.
Kansas Kan. Stat. Ann. § A registered nurse anesthetist shall perform duties and functions in
65-1158 an interdependent role as a member of a physician or dentist
directed health care team.
Kentucky Ky. Rev. Stat. Nothing in this chapter shall be construed as requiring an
Ann. § 314.042 advanced practice registered nurse designated by the board as a
certified registered nurse anesthetist to enter into a
collaborative agreement with a physician, pursuant to this chapter
or any other provision of law, in order to deliver anesthesia care.
Louisiana La. Stat. Ann. § The registered nurse administers anesthetics and ancillary services
37:930 under the direction and supervision of a physician or dentist who
is licensed to practice under the laws of the state of Louisiana.
Maine* Me. Rev. Stat. A certified registered nurse anesthetist is responsible and
Ann. tit. 32, § accountable to a licensed physician or dentist for aspects of
2211 anesthesia practice that require execution of the medical regimen as
prescribed by that physician or dentist.
Maryland Md. Code Ann., A nurse anesthetist shall collaborate with an anesthesiologist, a
Health Occ. § 8- licensed physician, or a dentist in the following manner:
513 (1) An anesthesiologist, a licensed physician, or a dentist shall be
physically available to the nurse anesthetist for consultation at all
times during the administration of, and recovery from, anesthesia;
(2) An anesthesiologist shall be available for consultation to the
nurse anesthetist for other aspects of the practice of nurse anesthesia;
and (3) If an anesthesiologist is not available, a licensed physician or
dentist shall be available to provide this type of consultation.
Massachusetts 244 Mass. Code A CRNA who does not register for prescriptive authority administers
Regs. 4.06 anesthesia pursuant to the signed order of a registered prescriber.
Such CRNA may select anesthetic agents based upon protocols that
are mutually developed with a registered prescriber responsible for
the perioperative care of a patient, as appropriate for the practice
setting.
36
State Citation Language
Michigan Mich. Comp. All of the following apply to a registered professional nurse who holds
Laws Ann. § a specialty certification as a nurse anesthetist:
333.17210 B. If he or she meets both of the following requirements, he or she
may provide the anesthesia and analgesia services described in
subdivision (a) without supervision: (i) He or she meets either of the
following: (A) He or she has practiced in the health profession
specialty field of nurse anesthetist for 3 years or more and has
practiced in that health profession specialty field in a health care
facility for a minimum of 4,000 hours. (B) He or she has a doctor of
nurse anesthesia practice degree or doctor of nursing practice degree.
(ii) He or she is collaboratively participating in a patient-centered
care team. (c) He or she may provide the anesthesia and analgesia
services described in subdivision (a) in a health care facility if the
health care facility has a policy in place under subsection (4) allowing
for the provision of the anesthesia and analgesia services and
ensuring that a qualified health care professional is immediately
available in person or through telemedicine to address any urgent or
emergent clinical concerns.
Minnesota Minn. Stat. Ann. “Registered nurse anesthetist practice” means the provision of
§ 148.171 anesthesia care and related services including: (1) selecting,
obtaining, and administering drugs and therapeutic devices to
facilitate diagnostic, therapeutic, and surgical procedures; (2)
ordering, performing, supervising, and interpreting diagnostic
studies, excluding interpreting computed tomography scans, magnetic
resonance imaging scans, positron emission tomography scans,
nuclear scans, and mammography; (3) prescribing pharmacologic and
nonpharmacologic therapies; and (4) consulting with, collaborating
with, or referring to other health care providers as warranted by the
needs of the patient.
Mississippi Miss. Code Ann. An advanced practice registered nurse shall perform those functions
§ 73-15-20 authorized in this section within a collaborative/consultative
relationship with a dentist or physician with an unrestricted license
to practice dentistry or medicine in this state and within an
established protocol or practice guidelines, as appropriate, that is
filed with the board upon license application, license renewal, after
entering into a new collaborative/consultative relationship or making
changes to the protocol or practice guidelines or practice site. The
board shall review and approve the protocol to ensure compliance
with applicable regulatory standards.
Missouri Mo. Ann. Stat. § A certified registered nurse anesthetist…shall be permitted to provide
334.104 anesthesia services without a collaborative practice arrangement
provided that he or she is under the supervision of an
anesthesiologist or other physician, dentist, or podiatrist who is
immediately available if needed.
Montana Mont. Admin. R. Certified Registered Nurse Anesthetist (CRNA) practice is the
24.159.1480 independent and/or collaborative performance of any act involving
the determination, preparation, administration, or monitoring of
anesthesia care and anesthesia-related services, and the management
of acute and chronic pain.
37
State Citation Language
Nebraska Neb. Rev. Stat. The determination and administration of total anesthesia care shall be
Ann. § 38-711 performed by the certified registered nurse anesthetist or a nurse
anesthetist temporarily licensed pursuant to section 38-708 in
consultation and collaboration with and with the consent of the
licensed practitioner.
Nevada* Nev. Admin. A certified registered nurse anesthetist who is under the direction of
Code 449.388 the operating practitioner or of an anesthesiologist who is
immediately available if needed.
New N.H. Code The anesthesiologist shall be qualified in anesthesiology in
Hampshire* Admin. R. He-P accordance with the medical staff bylaws of the hospital.
802.33
New Jersey* N.J. Admin. General or major regional anesthesia shall be administered and
Code § 8:43G- monitored only by the following… (3) An APN/anesthesia, in
6.3 accordance with a joint protocol established in accordance with
N.J.A.C. 13:37–6.3, which joint protocol shall require sections
governing: i. The availability of an anesthesiologist to consult with
the APN/anesthesia on site, on-call or by electronic means; and
ii. The presence of an anesthesiologist during induction, emergence
and critical change in status.
New Mexico N.M. Stat. Ann. § Certified registered nurse anesthetists shall function in an
61-3-23.3 interdependent role as a member of a health care team in which the
medical care of the patient is directed by a licensed physician,
osteopathic physician, dentist or podiatrist licensed in New Mexico
pursuant to the Dental Health Care Act, the Medical Practice Act or the
Podiatry Act. The certified registered nurse anesthetist shall
collaborate with the licensed physician, osteopathic physician,
dentist or podiatrist concerning the anesthesia care of the patient. As
used in this subsection, “collaboration” means the process in which
each health care provider contributes the health care provider's
respective expertise. Collaboration includes systematic formal
planning and evaluation between the health care professionals
involved in the collaborative practice arrangement.
New York* N.Y. Comp. Anesthesia shall be administered in accordance with their credentials,
Codes R. & Regs. competencies and privileges by the following…(iv) certified registered
tit. 10, § 405.13 nurse anesthetists (CRNA's) under the supervision of an
anesthesiologist who is immediately available as needed or under
the supervision of the operating physician who has been found
qualified by the governing body and the medical staff to supervise the
administration of anesthetics and who has accepted responsibility for
the supervision of the CRNA.
North Carolina 21 N.C. Admin. Only a registered nurse who completes a program accredited by the
Code 36.0226 Council on Accreditation of Nurse Anesthesia Educational Programs,
is credentialed as a certified registered nurse anesthetist by the
Council on Certification of Nurse Anesthetists, and who maintains
recertification through the Council on Recertification of Nurse
Anesthetists, shall perform nurse anesthesia activities in
collaboration with a physician, dentist, podiatrist, or other lawfully
qualified health care provider.
38
State Citation Language
North Dakota N.D. Admin. The advanced practice registered nurse has evolved into the roles of
Code 54-05- certified nurse practitioner, certified registered nurse anesthetist,
03.1-03.1 certified nurse midwife, or certified clinical nurse specialist.
The advanced practice registered nurse functions in any setting as a
member of the interdisciplinary team and provides care to the fullest
extent of the scope of practice which includes…Collaborate with the
interdisciplinary team.
Ohio Ohio Rev. Code A nurse authorized to practice as a certified registered nurse
Ann. § 4723.43 anesthetist, consistent with the nurse's education and certification
(West) and in accordance with rules adopted by the board, may do the
following: (1) With supervision and in the immediate presence of a
physician, podiatrist, or dentist, administer anesthesia and perform
anesthesia induction, maintenance, and emergence.
Oklahoma Okla. Stat. Ann. “Certified Registered Nurse Anesthetist” is an Advanced Practice
tit. 59, § 567.3a Registered Nurse who…(2) administers anesthesia in collaboration
(West) with a medical doctor, an osteopathic physician, a podiatric physician
or a dentist licensed in this state and under conditions in which timely
onsite consultation by such doctor, osteopath, podiatric physician or
dentist is available.
Oregon Or. Admin. R. “Anesthesia care” means the Certified Registered Nurse Anesthetist
851-006-0010 (CRNA) independent or collaborative performance of any act
involving the treatment of a client presenting for a procedure
including, but not limited to, sole or concurrent use of sedation,
analgesia or anesthesia.
Pennsylvania 63 Pa. Stat. Ann. A certified registered nurse anesthetist shall have the authority to
§ 218.9 (West) perform anesthesia services in cooperation with a physician,
podiatrist or dentist involved in a procedure for which anesthesia
care is being provided.
Rhode Island 5 R.I. Gen. Laws “Practice of certified registered nurse anesthesia” means providing
Ann. § 5-34.2-2 certain healthcare services in collaboration with anesthesiologists,
(West) licensed physicians, or licensed dentists.
South Carolina S.C. Code Ann. § A CRNA must practice in accordance with approved written
40-33-20 guidelines developed under supervision of a licensed physician or
dentist or approved by the medical staff within the facility where
practice privileges have been granted.
South Dakota S.D. Codified The certified registered nurse anesthetist shall collaborate with a
Laws § 36-9-3.1 physician, a dentist, a podiatrist, a certified nurse practitioner, a
certified nurse midwife, or a physician assistant when providing
anesthesia services.
Tennessee* Tenn. Comp. R. Anesthesia must be administered only by:
& Regs. 0720- 1. A qualified anesthesiologist;
14-.07 2. A doctor of medicine or osteopathy (other than an
anesthesiologist);
3. A dentist, oral surgeon, or podiatrist who is qualified to administer
anesthesia under State law;
4. A certified registered nurse anesthetist (CRNA); or
5. A graduate registered nurse anesthetist under the supervision of an
anesthesiologist who is immediately available if needed.
39
State Citation Language
Texas Tex. Occ. Code In a licensed hospital or ambulatory surgical center, a physician may
Ann. § 157.058 delegate to a certified registered nurse anesthetist the ordering of
(West) drugs and devices necessary for the nurse anesthetist to administer
an anesthetic or an anesthesia-related service ordered by the
physician.
Utah Utah Code Ann. Practice of advanced practice registered nursing includes:
§ 58-31b-102 (a) maintenance and promotion of health and prevention of disease;
(b) diagnosis, treatment, correction, consultation, and referral;
(c) prescription or administration of prescription drugs or devices
including:
(i) local anesthesia;
(ii) Schedule III-V controlled substances; and
(iii) Schedule II controlled substances; or
(d) the provision of preoperative, intraoperative, and postoperative
anesthesia care and related services upon the request of a licensed
health care professional by an advanced practice registered nurse
specializing as a certified registered nurse anesthetist
Vermont 20-4 Vt. Code R. An APRN with fewer than 24 months and 2,400 hours of licensed
§ 1100 active advanced nursing practice in an initial role and population
focus or fewer than 12 months and 1,600 hours for any additional role
and population focus shall have a formal agreement with a
collaborating provider as required by 26 VSA § 1613.
Virginia Va. Code Ann. § A certified registered nurse anesthetist shall practice under the
54.1-2957 supervision of a licensed doctor of medicine, osteopathy, podiatry, or
dentistry.
Washington* Wash. Admin. ARNP practice is grounded in nursing process and incorporates the
Code 246-840- use of independent judgment. Practice includes interprofessional
300 interaction with other health care professionals in the assessment and
management of wellness and health conditions.
West Virginia W. Va. Code In any case where it is lawful for a duly licensed physician or dentist
Ann. § 30-7-15 practicing medicine or dentistry under the laws of this state to
administer anesthetics, such anesthetics may lawfully be given and
administered by any person (a) who has been licensed to practice
registered professional nursing under this article, and (b) who holds a
diploma or certificate evidencing his or her successful completion of
the educational program of a school of anesthesia duly accredited by
the American association of nurse anesthetists: Provided, That such
anesthesia is administered by such person in the presence and
under the supervision of such physician or dentist.
Wisconsin Wis. Admin. A nurse anesthetist shall perform services in the presence of a
Code HS § supervising anesthesiologist or performing physician.
107.065
40
State Citation Language
Wyoming* Wyo. Admin. Policies and procedures for the administration of all anesthetics shall
Code be in place. In hospitals where there is no department of anesthesia,
048.0061.12 § the department of surgery and/or medical staff shall assume the
10 responsibility for establishing general policies regarding the
administration of anesthetics. For hospitals with (twenty-five) 25
licensed beds or less, a CRNA may administer anesthetics without
physician supervision if the CRNA's practice is otherwise consistent
with the medical staff bylaws. The medical staff shall designate those
individuals qualified to administer anesthetics and shall delineate
what each individual is qualified and approved to do.
41
JOINT COMMISSION ON HEALTH CARE
411 EAST FRANKLIN STREET, SUITE 505
RICHMOND, VIRGINIA 23219
804-786-5445
http://jchc.virginia.gov
File and source
- File
- 2024-RD939.pdf
- Size
- 2,581,181 bytes
- SHA-256
- 25a36c32503856492b4482fabf371151bfb36af50859b9be786067e73c224a94
- Our copy
- 2024-RD939.pdf
- Original
- No public link identified.