SRNA

[anbuitachi]

Not talking about what you do at your practice, but are there laws regarding leaving SRNA alone in a room? I believe ASA does not recommend it but thats more of a recommendation [?] than a law?

I'm trying to see if there are documents saying it isnt allowed

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[GassYous]

Why would you risk the liability? Why would you even be in a room with an srna?

 

[vector2]

Why would you risk the liability? Why would you even be in a room with an srna?

I think he's talking about supervising CRNAs who leave the SRNA paired with them unattended in a room.

I'm also curious whether this violates any CMS regs

 

[MirrorTodd]

I don't think there are any laws against the practice. FWIW, the crna's generally leave the 2nd year's to their own devices at military hospitals. I think they leave the 1's alone based on their skill level as well but I don't know that for sure.

 

[vector2]

I don't think there are any laws against the practice. FWIW, the crna's generally leave the 2nd year's to their own devices at military hospitals. I think they leave the 1's alone based on their skill level as well but I don't know that for sure.

I always laugh to myself whenever the CRNA tells me their SRNA that day is a "senior student." Most of the "seniors" are, at best, at the level of a late CA-1 / early CA-2.

Scary to think they're mere months from being on their own in the room all the time.

 

[ASA6]

Where I did my residency two ancillary sites had srnas. At one the crna was not allowed to leave the room. At the other place they were treated like residents and an attending would have 1 resident room and 1 srnas room.

 

[jwk]

SRNA supervision?

Hey all, just wondering if anyone has this information. Are there actual rules on SRNA supervision ratios like how residents can only be 2:1 with an attending and CRNAs 4:1? If an SRNA is in a room, do they need an attending or CRNA 1:1 with them or are they treated as a resident (2:1...

forums.studentdoctor.net

 

[DolphinVA]

This is a major issue in the Houston area. Most teaching hospitals here that have SRNAs rotating will use them like a CRNA in a room alone supervised at least 1:2.

It's a dirty way to operate and doesn't jive with ASA stance or the CMS requirements for "qualified" personnel in rooms. What I don't understand around here is that this occurs even in places that have surplus staff like the Houston VA, who could staff these SRNAs 1:1 or paired with CRNA, but still continue to give the patients unqualified providers for large portions of cases.

Also becomes an ethical issue for the supervising MD, once you realize a lone SRNA is an "unqualified" provider -- do you disclose to patient? Argue with your chief and/or board runner? Bend over and take it?

 

[Dr. Rude]

This is a major issue in the Houston area. Most teaching hospitals here that have SRNAs rotating will use them like a CRNA in a room alone supervised at least 1:2.

It's a dirty way to operate and doesn't jive with ASA stance or the CMS requirements for "qualified" personnel in rooms. What I don't understand around here is that this occurs even in places that have surplus staff like the Houston VA, who could staff these SRNAs 1:1 or paired with CRNA, but still continue to give the patients unqualified providers for large portions of cases.

Also becomes an ethical issue for the supervising MD, once you realize a lone SRNA is an "unqualified" provider -- do you disclose to patient? Argue with your chief and/or board runner? Bend over and take it?

According to ASA, SRNAs are not “qualified anesthesia personnel”. While relevant, specialty society position statements do not carry the force of law.

 

[DolphinVA]

According to ASA, SRNAs are not “qualified anesthesia personnel”. While relevant, specialty society position statements do not carry the force of law.

Not just according to ASA.

Look for reference at CMS guidelines for participation https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R59SOMA.pdf

Many hospital systems are staffing like this knowing full well that it's murky territory. I think they get away with it because there's a huge lack of understanding from anyone outside anesthesia how exactly supervision works and how fast disasters can unfold to the person standing in the room.

 

[vector2]

According to ASA, SRNAs are not “qualified anesthesia personnel”. While relevant, specialty society position statements do not carry the force of law.

CMS carries the force of law. Medicare/caid fraud is a crime.

 

[JiPo]

I think he's talking about supervising CRNAs who leave the SRNA paired with them unattended in a room.

I'm also curious whether this violates any CMS regs

It actually might be just the SRNAs without CRNAs. One of the hospitals I rotated as a resident had SRNAs cover a room like a resident would, and the attending would have a second room with a senior resident or an experienced CRNA they trust

 

[ProPropofol]

I always laugh to myself whenever the CRNA tells me their SRNA that day is a "senior student." Most of the "seniors" are, at best, at the level of a late CA-1 / early CA-2.

Scary to think they're mere months from being on their own in the room all the time.

At my institution, the SRNAs actually introduce themselves as anesthesia residents. My complaints to the department have gone unanswered. It's very disrespectful to the actual anesthesia residents taking 24 hour call, being on call for 7 days in a row, and staying late to get the CRNAs out on their contract negotiated time.

 

[JiPo]

At my institution, the SRNAs actually introduce themselves as anesthesia residents. My complaints to the department have gone unanswered. It's very disrespectful to the actual anesthesia residents taking 24 hour call, being on call for 7 days in a row, and staying late to get the CRNAs out on their contract negotiated time.

Wow.... that is truly a WTF situation. Spineless leadership...

 

[MirrorTodd]

Wow.... that is truly a WTF situation. Spineless leadership...

Well they are all called NAR's now (Nurse Anesthesia Residents) instead of SRNA's.

 

[Mehd School]

Well they are all called NAR's now (Nurse Anesthesia Residents) instead of SRNA's.

Not where I'm at. One of them tried to pull this **** and on the spot was told to find a different rotation spot. Stand up to this crap yourself, your boss might not give enough of a ****. No SRNA will ever be left alone in one of my rooms and they certainly won't be falsely introducing themselves as a resident. My day carries on the same whether that person exists or doesn't.

 

[anbuitachi]

Not just according to ASA.

Look for reference at CMS guidelines for participation https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R59SOMA.pdf

Many hospital systems are staffing like this knowing full well that it's murky territory. I think they get away with it because there's a huge lack of understanding from anyone outside anesthesia how exactly supervision works and how fast disasters can unfold to the person standing in the room.

i skimmed thru that but it doesnt specifically mention SRNA? this document seems to place them in similar category as anesthesia resident

 

[anbuitachi]

Why would you risk the liability? Why would you even be in a room with an srna?

i dont want the liability. i much prefer not to have SRNA. but i dont call the shots. so unless i find another job, i probably will cross paths with SRNA sooner or later since they are starting a program here

 

[vector2]

i skimmed thru that but it doesnt specifically mention SRNA? this document seems to place them in similar category as anesthesia resident

Unfortunately looks like SRNAs are treated just like residents in this teaching physician guideline. Absurd.

https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1859cp.pdf

 

[Precedex]

Interesting. Where I've been for the past 15 years the SRNAs are staffed like residents, up to 2:1, never had any problems, they've always been very good.

 

[Gasworks]

I’ve worked at places where the previous groups had crnas supervising 2 rooms with solo srnas. In a lot of these rural / underserved areas groups are fighting for srnas because they are basically free labor. Most of these groups get away with this for years until a patient dies with “no physician in house” and all of the sudden it’s a problem for administration.

Funny thing is, once these hospitals get a taste of what proper ratios and 24x7 MD coverage cost the very first thing they do is try to revert to the old “gross negligence” ways. It’s amazing how far $$$ can go to mitigate administrations outrage de jour. One man’s malpractice is another man’s shareholder value I guess.

 

[anbuitachi]

srnas dont get a salary correct? they pay tuition?

 

[DolphinVA]

i skimmed thru that but it doesnt specifically mention SRNA? this document seems to place them in similar category as anesthesia resident

If you look for example at section 482.52(a) Standard: Organization and Staffing, it is very specific who should be administering anesthesia in a CMS accredited organization. It includes anesthesiologists, MD/DO physicians (which would include residents), CRNAs, and AAs.

While it doesn't explicitly exclude SRNAs, they certainly do not fulfill any of the listed categories. They are still students being trained in the administration of an anesthetic and qualified provider should be physically present throughout a case.

I reckon the reason this persists in practice is multifaceted, but mostly from two reasons: 1) dependence on SRNAs as a cheap source of labor with "lean" supervision and 2) fear of agencies with teeth like CMS of the political blowback from specifically excluding SRNAs alone in rooms

Personally, from the ASAs historical impotence of pushing back against SRNA/CRNA encroachment, I'm surprised their Statement on the Anesthesia Care Team ever saw the light of day. But I do agree with their statement and have had to make personal sacrifices to make sure my patients aren't unknowingly affected by what I consider to be inadequate staffing of their anesthetic. We as individuals should be appalled that this is as prevalent as it is.

 

[bigdan]

Well they are all called NAR's now (Nurse Anesthesia Residents) instead of SRNA's.

The “anesthesia school” affiliated with my hospital did this, too, effective on Jan 1st. Our Chair made things plain: the SRNA are SRNA or the affiliation is terminated immediately. Furthermore, the terms “anesthesiologist”, “attending”, “resident”, “physician”, and “doctor” can only be used within the hospital by those who with MD or DO credentials.

The “nurse resident” went away overnight. We get very very very very very few wins in the current milieu, but I’m grateful for this one.

 

[Anesthesia_Guy]

Interesting. Where I've been for the past 15 years the SRNAs are staffed like residents, up to 2:1, never had any problems, they've always been very good.

Good to know Precedex, CRNA.

 

[Anesthesia_Guy]

The “anesthesia school” affiliated with my hospital did this, too, effective on Jan 1st. Our Chair made things plain: the SRNA are SRNA or the affiliation is terminated immediately. Furthermore, the terms “anesthesiologist”, “attending”, “resident”, “physician”, and “doctor” can only be used within the hospital by those who with MD or DO credentials.

The “nurse resident” went away overnight. We get very very very very very few wins in the current milieu, but I’m grateful for this one.

That's great to hear. Your chairman is one of the very very very very very few who would do that.

 

[sevo00]

Interesting. Where I've been for the past 15 years the SRNAs are staffed like residents, up to 2:1, never had any problems, they've always been very good.

How much is the crna school paying you

 

[Precedex]

How much is the crna school paying you

Personally? Nothing. I think our department gets something, I’m not sure.

 

[Precedex]

Good to know Precedex, CRNA.

I hope so. My experience has not been contentious with them or the crnas. No I am not a crna personally.

 

[anaesthetic]

Interesting. Where I've been for the past 15 years the SRNAs are staffed like residents, up to 2:1, never had any problems, they've always been very good.

To contradict this, we work with CRNAs who train SRNAs (big metro level I trauma center), and a fair number of them stay on after graduating. Invariably, they still need about a year or so before they are actually up to speed on the acuity and pace of the practice (revise preop plans, PIV bailouts, intubation bailouts, intraop redirection, etc.). I can’t imagine leaving them alone in rooms as SRNAs.

We’ve hired recent CRNA grads from different, smaller, lower volume “training” programs, and most of us have had to work pretty hard to have them not kill patients outright. Some surgeons have complained about the new hires as well. Scary to think that SRNAs are being treated the same as residents at some places. The money must be good.

 

[DarkHorizon]

This is the situation at one of my local community hospital. 2nd year SRNA students in the room by themselves after the induction. Also calling themselves CRNA residents. I just smile back.

Apparently the anesthesia group gets paid by the local CRNA school to take these students. I keep quiet as long as I can keep my cases moving with good anesthesia.

 

[Ashers]

I do locums at a hospital with SRNAs. They leave the SRNAs a alone in the room for breaks occasionally (Usually with CRNAs sometimes with MDs). They asked me if I would take students, when I asked if they were med students, they said SRNAs, I said absolutely not. I won't supervise (while doing locums, I have medically directed at a previous job), and I won't work with SRNAs.

 

[Status Sciaticus]

Interesting. Where I've been for the past 15 years the SRNAs are staffed like residents, up to 2:1, never had any problems, they've always been very good.

How much is the crna school paying you

 

[MirrorTodd]

I do locums at a hospital with SRNAs. They leave the SRNAs a alone in the room for breaks occasionally (Usually with CRNAs sometimes with MDs). They asked me if I would take students, when I asked if they were med students, they said SRNAs, I said absolutely not. I won't supervise (while doing locums, I have medically directed at a previous job), and I won't work with SRNAs.

That is bonkers that a place would ask a locums doc to take srna's.

 

[Anesthesia_Guy]

I hope so. My experience has not been contentious with them or the crnas. No I am not a crna personally.

Your sychophantic attitude towards mid-levels does not support that.

 

[Anesthesia_Guy]

We’ve hired recent CRNA grads from different, smaller, lower volume “training” programs, and most of us have had to work pretty hard to have them not kill patients outright. Some surgeons have complained about the new hires as well. Scary to think that SRNAs are being treated the same as residents at some places. The money must be good.

Frightening......terrifying even. It's ALWAYS about the money.

 

[Dr. Rude]

Not where I'm at. One of them tried to pull this **** and on the spot was told to find a different rotation spot. Stand up to this crap yourself, your boss might not give enough of a ****. No SRNA will ever be left alone in one of my rooms and they certainly won't be falsely introducing themselves as a resident. My day carries on the same whether that person exists or doesn't.

 

[neutro]

Interesting. Where I've been for the past 15 years the SRNAs are staffed like residents, up to 2:1, never had any problems, they've always been very good.

This is illogical. You are using absolute language like "they have always been very good"

Either you're unable to discriminate what is "good" and what's not? or you are not paying attention or in the room.

It is not statistically possible for every SRNA student to be good, or they're only doing ASA-1 cases...

A SRNA dependent group (and we all know which ones these are) are lower in quality because they have less qualified people being supervised immediately by an inferior product than a physician - thats the bottome line.

By the time you get your turn to intubate - SNRA tried twice (its typically 3-4 times but theyll tell you its twice), CRNA tried once and then glidescope and of course by the time you try its already a cluster...

Thank God I do my own cases now.

 

[DrOwnage]

Since working at my new job I've had 3 difficult intubation warnings on patients through Epic. Every single time it was because an SRNA failed multiple times in care everywhere. I'm beginning to not take it seriously.

 

[PAC2DO]

I’m part of a large academic institution and we have started training SRNAs recently (maybe 1-2 years ago). Sometimes SRNAs are posted solo with an attending and it does get into sticky situation. A few attendings/coordinators mentioned they need to train these SRNAs to retain them once they graduate as we have a major staffing crisis in our department. Their expectation is that residents will spend their 3/4 years and leave the institution while SRNAs may stay after to gain more training if you give them some good cases. I was pretty shocked when I heard this…

 

[GassYous]

I’m part of a large academic institution and we have started training SRNAs recently (maybe 1-2 years ago). Sometimes SRNAs are posted solo with an attending and it does get into sticky situation. A few attendings/coordinators mentioned they need to train these SRNAs to retain them once they graduate as we have a major staffing crisis in our department. Their expectation is that residents will spend their 3/4 years and leave the institution while SRNAs may stay after to gain more training if you give them some good cases. I was pretty shocked when I heard this…

They don't care about getting good cases they care about getting paid just like everyone else.

 

[amyl]

I’ve been told it’s fine to do this and I said no. In my opinion this exploits a grey area no one wants to define and get away with until they don’t. That SRNA doesn’t have a license aside from an RN… I wouldn’t leave a pacu RN in the OR with a patient under anesthesia. I think this would qualify as patient abandonment and gross negligence

 

[2Fast2Des]

I’ve been told it’s fine to do this and I said no. In my opinion this exploits a grey area no one wants to define and get away with until they don’t. That SRNA doesn’t have a license aside from an RN… I wouldn’t leave a pacu RN in the OR with a patient under anesthesia. I think this would qualify as patient abandonment and gross negligence

Agreed! I remember during my peds rotation, student RNA came to offer breaks (with no CRNA to supervise her).. I quickly said hell no... That ish is scary.

The academic shop 15 minutes down the road from me now call their student RNAs as RRNAs, and the attendings even defend it 🤮

 

[jwk]

The academic shop 15 minutes down the road from me now call their student RNAs as RRNAs, and the attendings even defend it 🤮

Making money off of free labor. Simple as that - and the reason lots of anesthesiologists are silent about CRNA issues.

 

[amyl]

To contradict this, we work with CRNAs who train SRNAs (big metro level I trauma center), and a fair number of them stay on after graduating. Invariably, they still need about a year or so before they are actually up to speed on the acuity and pace of the practice (revise preop plans, PIV bailouts, intubation bailouts, intraop redirection, etc.). I can’t imagine leaving them alone in rooms as SRNAs.

We’ve hired recent CRNA grads from different, smaller, lower volume “training” programs, and most of us have had to work pretty hard to have them not kill patients outright. Some surgeons have complained about the new hires as well. Scary to think that SRNAs are being treated the same as residents at some places. The money must be good.

Are we partners?

 

[Dr. Rude]

Making money off of free labor. Simple as that - and the reason lots of anesthesiologists are silent about CRNA issues.

More commonly a weak department where the subset of docs who want to push back about this would make life harder for themselves.

 

[cchoukal]

Looked into this a year or two ago at my prior gig. The ASA is unambiguous in that an SRNA is not, as they put it, a "qualified anesthesia personnel," simply meaning they are not allowed to be left in a room alone, more akin to a medical student. Furthermore, they state that a physician supervising an SRNA does not constitute a valid anesthesia care team. Sure, the ASA statement is not law, but if billing medical direction, you would potentially be exposed to liability for medicare fraud. From a medico-legal standpoint, speaking as someone who has consulted on both sides, should an event occur and a suit were brought, you would be eviscerated.

That having been said, we talked to people from name-brand places across the country, and the practice is common.

 

[vector2]

Looked into this a year or two ago at my prior gig. The ASA is unambiguous in that an SRNA is not, as they put it, a "qualified anesthesia personnel," simply meaning they are not allowed to be left in a room alone, more akin to a medical student. Furthermore, they state that a physician supervising an SRNA does not constitute a valid anesthesia care team. Sure, the ASA statement is not law, but if billing medical direction, you would potentially be exposed to liability for medicare fraud. From a medico-legal standpoint, speaking as someone who has consulted on both sides, should an event occur and a suit were brought, you would be eviscerated.

That having been said, we talked to people from name-brand places across the country, and the practice is common.

I don't think this is correct from a CMS standpoint. See my post earlier in this thread.

 

[cchoukal]

I don't think this is correct from a CMS standpoint. See my post earlier in this thread.

View attachment 377166

That’s interesting. Fair enough. So 2:1 for SRNA direction, at least from a billing perspective?

 

[nimbus]

Do CMS rules apply to commercial, non-Medicare patients? Can you medically direct 3-4 SRNAs if all the patients are young working age United Health or Aetna patients?