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VA pushes expanded rule for nurse practitioners in veterans' medical care

A proposed Department of Veterans Affairs rule change that would expand the role of nurse practitioners in caring for patients in VA facilities has set off heated verbal volleys between national physicians and nurses groups while generating more than 16,700 comments on the federal government’s eRulemaking website as of Tuesday.

Designed to reduce delays for veterans seeking medical care and to address personnel shortages within the VA system, the proposed rule would allow advanced-practice registered nurses to make diagnoses, prescribe medications and interpret diagnostic tests. The rule breaks down the nurse practitioners, who have advanced medical degrees, into four roles: certified nurse practitioners; clinical nurse specialists; certified registered nurse anesthetists, or CRNAs; and certified nurse midwives.

In a prepared statement, VA Undersecretary for Health David Shulkin said: “At this time, the VA is not seeking any change to [Veterans Health Administration] policy on the role of CRNAs, but would consider a policy change in the future to utilize full practice authority when and if such conditions require such a change.”

Juan Quintana, president of the American Association of Nurse Anesthetists, told AMI Newswire Tuesday that the limitations on nurse practitioners vary tremendously from state to state and that a consistent federal rule would better ensure excellent care for veterans.

“I think that the VA is doing the right thing by working to standardize services among all VA hospitals,” said Quintana, who added that the rule might take effect by the end of the year.

He pointed to a study published in the June issue of the journal Medical Care that he said supports the expansion of the nurse practitioner role. The study concluded that practice limitations and physician supervision requirements that many nurse practitioners now work under do not increase anesthesia safety among patients.

Quintana said the study also found that such restrictions reduced patients’ ability to receive high-quality health care while increasing overall health care costs.

Quintana said that, once the advanced-placement nurses begin to provide services to veterans, they will discover more medical issues among their patients, leading to a greater demand for surgical services overall, including those provided by CRNAs.

Physicians, however, see the proposed rule change as a life-endangering threat to the medical care of veterans.

Dr. Daniel Cole, president of the American Society of Anesthesiologists, said last week during a press conference that the change would abandon a proven team approach to health care involving physician anesthesiologists and nurses.

The president of the National Association of VA Physicians and Dentists, Samuel Spagnolo, said during the same press briefing that the rule change would provide a lower level of patient care – one lacking in physician oversight. And he emphasized the need for seasoned, skilled professionals in the care of veterans.

“Patients may look to be doing well, but then a few seconds later they are at death’s doorstep,” Spagnolo said.

He said of the proposed rule: “It is so filled with jargon that it will take 10 Harvard lawyers to decipher it.”

Physicians opposed to the rule emphasize that physician anesthesiologists receive 12 to 14 years of education and training, including up to 16,000 hours of clinical training. In contrast, CRNAs get half as many years of education and only about 2,500 hours of training, they said.

Quintana described the position of physician groups as an effort to protect their professional turf. National organizations representing nurses point out that the American military, 21 states and the District of Columbia have allowed expanded roles for advanced-placement nurses in patient care.

“It’s interesting that the same doctors who argue that they need to be involved in the care of our military veterans don’t insist on being assigned to the front lines during military actions to care for soldiers horribly injured during battle, leaving this up to CRNAs to handle,” Quintana said.

Some members of Congress also seem troubled by the proposed rule.

“The VA proposes to eliminate the requirement for physician involvement in anesthesia delivery, striking the physician-nurse ‘team’ model,” Rep. David Jolly (R-Fla.) wrote on his Facebook page. “I am deeply concerned that this change by the VA will compromise the quality and safety of anesthesia care administered to our veterans.”

Shulkin,However, however,Shulkin the undersecretary told the Washington Post last week that “I’ve looked at the data in the VA, and I do not assess that we have an access problem in anesthesia. We are using team-based approaches.”

The public comment period on the proposed VA rule concludes on July 25.