Nurse Anesthesia History and Practice in the United States. Debra Maloy CRNA, EdD Director Graduate Programs of Nurse Anesthesia

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1 Nurse Anesthesia History and Practice in the United States 1

2 Hospital Based Training Hospital based, Sisters schools 3 years of service Little education Laundry Housekeeping hour/week Few paying jobs Historical Preparation of Nurses in the US 2

3 17 and 35 years old Unmarried Average height and weight Intelligent Good moral character Sound heath Admission Requirements 3

4 Poor pay Limited Job Availability TB 4

5 Nurse Anesthesia 1 st Clinical Nurse Specialty Catherine S. Lawrence provided anesthesia U.S. Civil War 1877 Sister Mary Bernard 1 st nurse to specialize in anesthesia s postgraduate training Sisters st Nurse Anesthesia School 5

6 Why delegate anesthesia administration to nurses in the US? Dropping ether or chloroform relegated to junior residents who were more interested in the operation than the anesthesia. Many hospitals were without residents. Nurses were trained to monitor patients and kept their mind on the task. Nurse were women and accepted lower compensation. Some theory - ether more stable than chloroform 6

7 Alice Magaw Mayo Clinic, Rochester Minnesota worked and published in the field of anesthesia, most articles released in medical journals as Mayo Clinic Staff s anesthesia was a nursing service in 75% of the hospitals in the US 7

8 Increased Demand for Professional Nurses 1940 New hospitalization insurance plans Influx of World War II casualties Post war increase in the birth rate 8

9 U.S. Anesthesia Provider Shortage ,400 General Hospitals 1,400,00 beds 4,500 Registered Nurse Anesthetists 400 Certified Anesthesiologists Approximately 10 million anesthetics / year 9

10 Lucille Petry RN Army Nurse Corps Surgeon General and Chief Nurse Officer of the U.S. Public Health Service on June 7, Department of Nursing Education Shift vocational training to professional nursing education. 10

11 Lucille Petry RN Approved education requirements basic sciences fundamentals of nursing Class + Clinical experience > 48 hours Could not exceed 30 months in length Nursing programs separate budget resulting Adequate numbers of qualified instructors strengthen curriculum design and course development. Graduate level funded for clinical/teaching skills 11

12 Nurse Anesthesia Clinical Nurse Specialty Advance Practice Nurses education progressed to Master s 1935 American Association of Nurse Anesthetists 1936 California Supreme Court; nurse anesthesia is a uniformly accepted practice of nursing 1945 National Certification Exam 1957 CRNA national credential st nursing specialty accorded direct reimbursement Entry level Practice Doctorate 12

13 > 140,000 RN Graduates per Year Diploma Nursing Programs (4,000) Descendants of hospital based. Larger public hospitals collaborate with local colleges. Three years in length Before 1970 over 800 programs, now Associate Degree in Nursing (78,000) After 1950 growth of community colleges Designed to promote a more efficient way to educate nurses Baccalaureate of Science in Nursing (58,000) Located in colleges or universities Four year program: 2 years general studies, 2 years nursing 13

14 The U.S. Bureau of Labor Statistics 2.86 million now 3.44 million nurses by the year ,000 US citizens turn 65 every day. 65 million by % over 85 years old 45 million improved access from Affordable Care Act 14

15 Why is this important to nursing? Average person over 70; 3 or more chronic disease states 4.5 prescription medications 25% doctors office visits Occupying 50% - 80% of acute care beds. 14% - 47% increase surgical work load 45 million backlog of needs 15

16 Critical Resource Management Increased Patient Acuity Critical Shortage of Faculty Increased demand for care Healthcare $ Shortfall APRNs needed for access to care. Advanced degree decreases medical errors & improves patient recovery > BSN

17 Million Registered Nurses 17

18 CRNAs are 1.7% of the nursing work force, approximately 49,000 Administer 40 million anesthetics / year Primary rural anesthesia providers MDAs 4.5% of the physician workforce, approximately 43,000 Administer 40 million anesthetics / year 18

19 Traditional hospital surgical suites Obstetrics Critical access hospitals Ambulatory surgical centers CRNA Practice Settings Dental, podiatric, ophthalmic and plastic surgeons offices Pain management U.S. military, Public Health Services, and Department of Veterans Affairs Military 19

20 Scope & Standards of Practice Standard I: Preanesthesia evaluation Standard II: Obtain informed consent Standard III: Anesthesia care plan Standard IV: Adjust plan as needed Standard V: Monitor the patient Standard VI: Documentation Standard VII: Transfer of care Standard VII: Patient & Equipment safety Standard IX: Infection control Standard X: Quality assurance Standard XI: Patients rights 20

21 Nurse Anesthesia Education and Experience A Bachelor of Science Degree A current license as a registered nurse. At least one year of experience as a registered nurse in an acute care setting month program 600 case minimum, 2000 hour minimum Successful completion of a national certification exam. 21

22 How to build an anesthetist. Critical Care Experience Strong Academic Foundation Expanded Scientific Knowledge Acquire Technical Skills Residency

23 Declarative Knowledge Procedural Knowledge Know what.. Know that Know why.. Know how Zone of Novice Proximal Development Know when. Conditional Knowledge Advanced beginner Competence Proficiency The Conceptual Model of Nurse Anesthesia Education Maura McAuliffe

24 Phase I Curriculum Human Patient Simulation Professional Aspects of Anesthesia Applied Chemistry for the Nurse Anesthetist Advanced Pharmacology Advanced Anatomy, Physiology, and Pathophysiology Research Methods in Nurse Anesthesia Advanced Physical and Health Assessment Advanced Anesthesia Pharmacology Principles of Anesthesia Practice 43 Credit Hours 24

25 Phase II Curriculum 16 Months Clinical Practicum, hours per week The study of the advanced anesthesia principles throughout the life cycle Part 1-4, 2 hours per week Clinically based scholarly work Cumulative program exam 23 Credit Hours 66 Total Program Hours 25

26 Patient Status Class I Class II Class III & IV 200 a. Class III 50 b. Class IV 10 Total Cases 650 Specialty Cases Geriatric 65+ years 100 Pediatric Pediatric 2 to 12 years 30 Less than 2 years 10 Trauma/Emergency (E) 30 Obstetrical management 30 Anatomical Categories Intra-abdominal 75 Intracranial 5 Oropharyngeal 20 Intrathoracic 15 Cardiac 5 Lung 5 Neck 5 Neuroskeletal 20 Vascular 10 Methods of Anesthesia Other General anesthesia 400 IV catheter placement 100 Inhalation induction 25 Arterial catheter insertion 25 Mask management 25 Intra-arterial monitoring 30 Supraglottic 35 Central venous catheter 10 Tracheal intubation 250 insertion Alternative Tracheal 25 Central venous monitoring 15 Intubation Pulmonary artery catheter 5* Emergence 300 insertion Regional Techniques Actual Administration 35 PAC monitoring Ultrasound 10* Spinal 10 Regional 5 Epidural 10 Vascular 5 Peripheral Upper Peripheral Lower Pain Management Deep Sedation 35 Clinical Requirements

27 Practice Doctorate Degree equity Master s degree credit hours CRNA programs credit hours Expanding scope of instrumentation and technology Health care policy, finance, advocacy Quality care improvement Disseminate research evidence Anesthesia delivery settings and business practices 27

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