|
Standards of care and the ASA
medical direction statement.
AANA Journal /April 2004/Vol. 72, No.
2
Gene A. Blumenreich, JD
It
should come as no surprise that malpractice attorneys are among the
many people who do not understand what nurse anesthetists do or what
their capabilities are. Recently, a newsletter directed to both
anesthesia providers and lawyers, quoted several malpractice
attorneys who were under the impression that the American Society of
Anesthesiologists (ASA) Statement on the Anesthesia Care Team was a
standard of care and that hospitals employed CRNAs only to save
money.1 When the makers of one brand of a soft drink say
it tastes better than the others (or it opens the door to a fuller
life or whatever), the public judges the statement with some
skepticism and feels no hesitation in buying the other brands. But
in health care, the public has been conditioned to believe that
medicine is based on scientific principles. It assumes that when
physicians make statements, they are based on scientific principles.
Of course, there is no science behind the ASA Statement on the
Anesthesia Care Team. Nonetheless, the Statement does not get the
same scrutiny because of the respect the public gives to physicians.
More......
ASA vs. AANA
Practice Guidelines
CLICK ON A TOPIC
BELOW
Here are three "position statements" issued
by the American Society of Anesthesiologists which are easily
confused by Insurance Companies, Risk Managers and Attorneys as
being Standards of Care. They are not. The facts listed under them states the
reality which renders the statement nothing more than an
opinion.
Fact: 65% of rural hospitals are served by CRNAs
alone. They would have to close their operating rooms if this really
was a "Standard".
ASA Qualifications of
Office Anesthesia Providers
Fact: The majority of office anesthetics are safely
delivered by CRNAs alone.
ASA Statement on Regional
Anesthesia
Fact: CRNAs administer all Regional Anesthetics,
including spinal and epidural, regardless of the presence of an
Anesthesiologists.
These
three examples show the difficulties in using a single source, no
matter how authoritative they might seem, as a final determinant of
what constitutes a standard. In these three examples, the ASA
practice guidelines are inconsistent with state nurse practice laws
and actually have the effect of putting the anesthesiologist at risk
for litigation. Yet lawyers, insurance companies, risk managers and
"experts" often use them as a benchmark for the practice of
anesthesia by nurse anesthetists, much to their own peril. Recently,
a case in Maryland illustrated the pitfalls the ASA has created for
their own members.
Dr. Bernstein and the Maryland Board of
Physicians
Depending on who is asking the
question of what constitutes a standard of care, and further
depending on who replies, a standard of care is a fluid thing, with
the standard for some things becoming more difficult to identify
than others.
The practice of anesthesia is a unique example.
The basic issues regarding monitoring, procedures and various
technical aspects of the delivery of anesthesia are much agreed upon
when it comes to a "standard" within the community of anesthesia
providers. Fiercely disputed however, is who should practice that
standard and when. No where else in medicine does state law
determine a standard of care more than in the practice of
anesthesia. And nowhere else in medicine is state law ignored as
much as possible in a fight aimed at creating separate standards of
care for the same health care. As shown in the documents linked
above, the ASA and the AANA have very different ideas regarding who
may execute the fundamentally agreed upon treatment standards. This
has created a battle not over the right or wrong way anesthesia
procedures should technically be done, but rather over who may do
them. This in spite of a 100 year history of Nurse Anesthetists and
Physician Anesthesiologists safely administering anesthesia, and
even creating a model of safety that is the envy of every medical
and nursing specialty.
Dr. Steven Bernstein, a John's Hopkins trained
anesthesiologist was recently brought before the Maryland Board of
Physicians following a complaint from the physician son of a
patient. The complainants' elderly mother underwent surgery after
fracturing her hip. Dr. Bernstein was on duty in the department of
anesthesia along with two nurse anesthetists. There were two
procedures being done simultaneously, the hip fracture an an
appendectomy. Dr. Bernstein did the appendectomy, while one of the
nurse anesthetists administered the anesthesia for the hip
replacement.
The complaint alleged that Dr. Bernstein failed to
provide the standard of care by not supervising the nurse
anesthetist (who had 30 years of experience) appropriately. The
Board of Physicians agreed, and issued a sweeping reprimand which
detailed multiple violations which were based on the ASA Anesthesia
Care Team position statement. Maryland does not require (nor does
any state) that a physician anesthesiologist provide supervision of
nurse anesthetist practice. Despite their findings creating a
supervision standard contrary to the Maryland Nurse Practice Act,
the Board commented that they did not rely on laws governing nurses
to determine the medical standard of care. Had the case been in a
courtroom in a malpractice action, the standard of care for
supervision might well have been defined very differently. Had the
case been before the Board of Nursing, a different conclusion would
also have been reached. It all depends on who asks, and who answers
the question. Read about the case at the links below.
Maryland Court of Special Appeals Opinion
Hoisted by Your Own Petard
As shown in the
Bernstein case an organizations "guidelines", despite not creating a
legal standard of care under a state practice act or in a courtroom
in a medical or nursing malpractice case, can have far reaching
consequences unanticipated by the organization. Likewise,
institutions and departments of anesthesia can create a standard of
care local to themselves through poorly thought out and unnecessary
policies and regulations which may have been intended to reduce
liability. Unfortunately some of these policies actually increase
liability for the institution and its providers. In the Bernstein
case the hospital had a policy that described the duties of an
anesthesiologist:
Whenever a
[CRNA] administers anesthesia alone or under the supervision of an
Anesthesiologist, the medical responsibility is still that of the
Anesthesiologist.
The Anesthesiologist is responsible for:
1.
Discussing the patient condition andprescribing a plan for that
anesthesia with the [CRNA].
2. Being physically available in the
most demanding procedures in this plan.
Specifically those of
induction and emergence when indicated.
3. Remaining physically
available for diagnosis and treatment of emergencies.
4.
Providing any indicated post-anesthesia
care.
10.27.06.06(A)(1)
(emphasis
added).
|
