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The Honorable Robert Petzel, M.D.

July 2, 2013 Page 1 of 3

July 2, 2013 The Honorable Robert Petzel, M.D. Department of Veterans Affairs Office of the Under Secretary for Health 810 Vermont Avenue NW Washington, D.C. 20420 Dear Dr. Petzel, We are writing on behalf of the more than 50,000 members of the American Society of Anesthesiologists (ASA) to express our concern regarding the draft document from the Veterans Health Administration (VHA) Office of Nursing Services (ONS) titled “VHA Nursing Handbook.” If finalized, this handbook would designate all advanced practice nurses (APRN) within the VHA, including nurse anesthetists, as licensed independent practitioners (LIP) 1 2 who would be required to function without physician support, supervision or oversight. ASA has significant concerns regarding this proposed policy and its consequences for the team-based anesthesia care currently provided within the VHA system. We request the opportunity to meet with you to discuss the contents of the Nursing Handbook and its conflict with the current anesthesia-related policies within the VHA. Surgery is a complex medical procedure with many opportunities for complications and emergencies to arise. As practicing physician anesthesiologists, one of whom previously trained and practiced as a nurse anesthetist, we know that physician anesthesiologists play a critical role in surgery by serving as the patient’s advocate in the operating room, and by respond ing to emergencies when they arise. Often, these emergencies have nothing to do with anesthesia, but with the patient’s underlying medical condition or an unforeseen medical complication. Physician anesthesiologists, who have 12,000 - 16,000 hours of clinical training, are best prepared to address emergency situations especially in the patients served by the VHA. Indeed, in recognition of the complexity and high-risk nature of anesthesia, anesthesia services are currently the subject of a separate handbook, “VHA Handbook 1123, Anesthesia Services.” This handbook currently addresses both physician and non-physician anesthesia care. Of particular note, this document advocates for a team approach to anesthesia care, stating that “care needs to be approached in a team fashion taking into account the education, training, and licensure of all practitioners.”3
1 2

Department of Veterans Affairs. Draft VHA Nursing Handbook 1180. July 2012. Department of Veterans Affairs. APRN Practice: Facts and Background Information about APRN Independent Practice. Updated February 20, 2013. 3 Department of Veterans Affairs. VHA Anesthesia Service Handbook 1123. March 7, 2007.

The Honorable Robert Petzel, M.D. July 2, 2013 Page 2 of 3 The Anesthesia Handbook further provides that “state license scope of practice establishes the maximum breadth of practice allowable for a provider.” 4 Most states require some level of physician involvement in the delivery of anesthesia care. The majority of states are still subject to Medicare’s Conditions of Participation: Anesthesia Services, which require physician supervision of nurse anesthetists unless that state is exempt from the standards. The ASA endorses physician administered or supervised anesthesia care, especially for vulnerable populations such as those in the VHA. The draft Nursing Handbook conflicts directly with the longstanding Anesthesia Handbook by effectively eliminating physician-nurse team-based, coordinated care. In lieu of team-based care, the draft handbook requires nurses to “attain independent practice” and penalizes those who do not wish to attain such status. Specifically, nurses who do “not wish to pursue independent elements of practice…will no longer be granted privileges to practice as an APRN in the facility.”5 Moreover, local facilities wishing to continue to provide team-based care are prohibited from doing so. The draft handbook states “A local policy that restricts APRN privileges is not appropriate…local polices shall not restrict privileges for APRNs.”6 ASA is concerned about the impact of these polices on surgical anesthesia care within the VHA. The policies are particularly troublesome given the population serviced in the VHA. Significant peer reviewed literature highlights the vulnerable health status of VHA patients. A study in the Archives of Internal Medicine revealed that veterans utilizing VHA services were 14.7 times more likely to have poor health status than the general population and 14 times more likely to have 5 or more medical conditions than the general population.7 A study in the Journal of American Geriatric Society found that elderly veterans under VHA care have disproportionately poor health status compared to those of the same age enrolled in Medicare managed care.8 Among the most prevalent conditions found in VHA patients are hypertension and angina. Other common conditions include diabetes, chronic lung disease, depression and alcohol-related problems.9 These conditions subject the patient to increased risk of complications during and surrounding the time of a surgical procedure. This perioperative period is a critical time for this vulnerable population and creates an imperative to assure the involvement of a physician in the delivery of care. ASA believes that the proposal to eliminate team-based anesthesia care could decrease the quality of care within the VHA. Physician involvement in the delivery of anesthesia remains the current standard of practice within the VHA and remains a requirement in the majority of states.

Ibid. Department of Veterans Affairs. APRN Practice: Facts and Background Information about APRN Independent Practice. Updated February 20, 2013. 6 Ibid. 7 Agha Z, Lofgren RP, et al. Are patients at Veterans Affairs Medical Centers Sicker? Arch. Intern Med. 2000; 160:3252-3257. 8 Selim AJ, Berlowitz DR, et al. The health status of elderly veteran enrollees in the veterans health administration. JAGS. 2004;52:1271-1276 9 Kazis LE, Miller DR, et al. Health-related quality of life in patients served by the Department of Veterans Affairs: Results from the Veterans Health Study. Arch Intern Med. 1998; 158(6): 626-632.

The Honorable Robert Petzel, M.D. July 2, 2013 Page 3 of 3

We believe that physician involvement is in the best of interest of all patients and is particularly appropriate and necessary for VHA patients. Our position is supported by a national outcomes study that concluded that anesthesia care is improved with the involvement of a physician anesthesiologist in a team. The independent study published in Anesthesiology on anesthesia outcomes found that after adjustments for severity of illness and other confounding variables, mortality and failure-to-rescue rates were higher for patients who underwent operations without medical direction by a physician anesthesiologist.10 Advanced medical training may allow for better management of complications, thereby decreasing the severity of such complications, and leading to fewer negative outcomes.11 On behalf of the ASA, we request your support for maintaining the Anesthesia Services Handbook as the relevant VHA document prescribing procedures related to the delivery of anesthesia within the VHA and we would appreciate the opportunity to meet with you to further discuss this important matter. Thank you in advance for your time and attention. Sincerely,

John W. Zerwas, M.D. American Society of Anesthesiologists President

Jane C.K. Fitch, M.D. American Society of Anesthesiologists President-elect


Silber JH, Kennedy SK, Even-Shoshan O, Chen W, Koziol LFL, Showan AM, Longnecker DE. Anesthesiologist direction and patient outcomes. Anesthesiology. 2000;93:152-63. 11 Ibid.