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In the wake of heightened attention on certified registered nurse anesthetist (CRNA) scope-of-practice in California, the state's Department of Public Health has to general acute care hospitals outlining the requirements for using CRNAs in anesthesia services.

The all-facilities letter was sent after two Modesto hospitals were hit with "Immediate Jeopardy" violations that were issued in part due to reports of CRNAs operating beyond their scope of practice.

"In California, a CRNA administering anesthesia services is not required to be under the supervision of the operating practitioner or of an anesthesiologist, however they may only provide services within their scope of practice," the Department of Public Health wrote in its letter.

The department noted that it is the Nursing Practice Act that gives CRNAs "legal authority to administer anesthesia after a physician orders a course of treatment that includes anesthesia," citing and of the California Business and Professions Code (BPC).

Among other provisions, the letter also specified that, except as provided in section 2725 of the BPC, a CRNA is not authorized to practice medicine or surgery, and that a hospital's Committee on Interdisciplinary Practice is responsible for policies and procedures for granting expanded role privileges to registered nurses -- whether they are employed by the facility or not -- to provide assessment, planning, and direction of diagnostic and therapeutic care of patients.

In a statement, Sandra Bordi, DNP, CRNA, president of the California Association of Nurse Anesthesiology (CANA), which previously pushed back on the citations at the Modesto hospitals, commended the Department of Public Health for "maintaining the precedent" set by the court decision referenced in the letter.

"Despite the all facility letter's clarifications of existing state and federal law and regulations, false statements about CRNAs' scope continue to decimate care in underserved regions of the state," she noted.

Antonio Hernandez Conte, MD, MBA, immediate past president of the California Society of Anesthesiologists (CSA), likewise told MedPage Today that the letter is "very much appreciated by CSA."

It is important that "patients have a transparent informed consent process"; healthcare providers accurately represent their title, licensure, education, and board certification; and providers use the title or introduction of "doctor" only when appropriate in healthcare settings, he noted.

"We recognize that there is a physician shortage, and we also recognize that there is a nursing shortage," Conte added. "But we always have to design care ... that is equitable across any sector."

Earlier this year, the Modesto Bee reported that hundreds of surgeries were when a pair of Modesto hospitals suspended CRNA practice in response to the "Immediate Jeopardy" citations they received after surveys of their facilities by the Department of Public Health.

Some of the findings reportedly included that a CRNA had changed a doctor's order for general anesthesia for a surgery to higher-risk spinal anesthesia and sedation, that several patients had negative health outcomes following care provided by CRNAs, and that hospital policy had been that physicians oversee anesthesia, according to the Modesto Bee.

At the time, CANA spokesperson Kaitlin Perry said in a statement to MedPage Today that there is "no debate about scope of practice, particularly in California, as CRNAs have practiced anesthesia care independently for decades."

Unsurprisingly, the CSA took a different viewpoint.

"We have long been an advocate for physician-led anesthesia care," CSA spokesperson Alison MacLeod told MedPage Today at the time. Recent reporting on the surveys at Modesto hospitals "puts a very important spotlight on how hospitals and healthcare facilities are choosing to staff," she noted.

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