MAGAZINE.compressed

UNPRECEDENTED:170 PHYSICIANS SUPPORT UPDATE

AR I ZONA

TO APRN SCOPE OF PRACTICE

L E A R N M O R EA T

APRN A Z . O RG

Designs and Editing by Joseph A. Rodriguez | 2

THE PROBLEM

Arizona Supports Nursing - Highlights from the #NursesCare4AZ Campaign to Update APRN Scope of Practice

Patient demand for healthcare in Arizona hasnever been greater. The immense challenge ofdelivering accessible, high-quality, fiscallyresponsible care to nearly 7 million Arizonacitizens requires every healthcare team memberto be operating at the top of their game.

Policy actions at the state and federal level havebrought hundreds of thousands of Arizonans andtens of millions of Americans into the traditionalhealth care system - not to mention physicianshortages in primary care.

Meeting Arizona'sHealthcare Demands

That's why the Arizona Nurse'sAssociation and groups representingnearly 7,000 Advanced PracticeRegistered Nurses (APRNs) have bandedtogether with patients, therapists, andphysicians representing 30 differentspecialities to support updating thescope of practice for APRNs.

A truly unprecedented level of supportfor this legislation exists. With thousandsof citizens represented, our coalition alsohas bound together with over 170physicians, as well as community groupslike AARP and the Goldwater Institute.

Included in this publication are lettersfrom all over the state: from leaders,physicians, administrators, patients,business owners, and of course, APRNsthemselves. Also included is notablesummaries of research and recenteditorials in local publications.

It's our pleasure to present thesetestimonies of quality APRN care. It'spast time to let APRNs give the high-quality care they are educatedto provide.

APRNs can meet the challenge - and they have the

support of the public, patients, and physicians.

A R I Z O N A H E A L T H C A R E THE SOLUTION

Ali J. Baghai, a Midwestern University graduate, is a

Certified Registered Nurse Anesthetist, Chief of

Anesthesia at Tempe St. Luke’s Hospital, and is

president of the Arizona Association of Nurse

Anesthetists. Learn more at aprnAZ.org

DID YOU KNOW?

Ali J. Baghai, CRNA, President, AZANA

40 years of Independent,3rd-party research

has repeatedly confirmed the safety

and quality of APRN care.

Dr. Steven Washburn, MDOrthopedic Surgeon, Show Low AZ

StevenD.Washburn,M.D.,A.B.O.S.,F.A.A.O.S.OrthopedicSurgeryandSportsMedicine

4830Highway260,Suite103

Lakeside,AZ85929

928-537-8777Telephone

928-537-1914Fax

To:ArizonaMedicalAssocaition&Towhomitmayconcern;

Insupportofthecertifiedregisterednurseanesthetists,particulariltyNortheasternAnesthesiaPLLC.

DearArizonaMedicalAssociation;

MynameisStevenD.Washburn,M.D.,Iamaboardcertifiedorthopedicsurgeon,practicingintheShowLowWhiteMountainareaforthelast20years.Duringthistime,IhavegottoknowtheCRNAgroupverywell.Theyhaveprovidedthevastmajorityofanesthesiaservicesoverthelast20yearswithrareM.D.anesthesiaearlyon.Allthemembersofthisgrouphavebeenhonest,ethical,andextremelycompetentandresponsibleinboththehospitalsystemwhereIhaveworkedwiththemaswellasintheSunriseAmbulatorySurgicalCenter.Duringthistimeperiod,Ihaveseennothingbutprofessionalismandtheabilitytomanageallphasesofanesthesiafromlittleanesthesiarisktosevererisk.TheyhaveprovidedservicestoouremergencyroomandICUwithpatientmanagementandskillssuchasdifficultintubation,lumbarpunctures,centrallinesandtraumacases.Theyhavealsoprovidedservicesintheemergencyroomforclosedreductions,manipulationoffracturesanddislocations.

IwouldliketostatethatIfeelfirmlythatCRNAsareanessentialelementofruralhealthcare,especiallyinthisarea.Withoutthem,wewouldnotbeabletoperformthecareandsurgicalserviceswecurrentlyoffer.Theyareextremelycompetentinmanagingthecomplexmedicalpatient,difficultairways,acuteandchronicpainmanagement.InfirmandextremelysickpeopleliveeverywherenotjustthebigcityandyettheCRNAsheremanagethemataswellasanyanesthesiaproviderIhaveworkedwithincludingphysicians.Inmanyways,theyhaveexceededmyexpectationsincapabilityandprofessionalismforanyanesthesiaprovider.

IhavebeeninformedthatthecurrentlanguageforCRNAsisacenturyoldanditcertainlydoesnotreflectcurrentpractice.Outdatedlanguagerequiringphysician“presenceanddirection”whichcreatesafalseconcernforsurgeonsofliabilitydoesnotenhancepatientcareorsafetytodayregardinganesthesiaservices.Whatthislanguagedoesdo,however,iscreatemisperceptionsaboutwhoisliableforwhat.EverytimewebringinanewsurgeonwehavetoeducatethemonthisissueandletthemknowthattheyareNOTliablefortheactionsoftheCRNAstheyareworkingwithanymorethantheywouldbewithananesthesiologist.WeinformthemthatCRNAsareanesthesiaprofessionals,trained,licensedandcredentialedtopracticeanesthesia,whilewearethesurgeons,trained,

licensedandcredentialedtoperformthesurgicalprocedure.The“presenceanddirection”statuteiswhythishastobeconstantlyexplained.

Ihavealsobeeninformedthatremovingthislegislationwouldconstitute“breakinguptheteam”howevernothingcouldbefurtherfromthetruth.Inrealityremovingthe“presenceanddirection”languageenhancestheteam.The“presenceanddirection”requirementonlyaddsconfusiontotheteamandcreatingaperceptionofliabilitywhichdoesnotexist.Itresultsinaconstantquestionaboutthisconcernbynewsurgeonswhichinnowaybenefitsthepatient.Issueslikethisreflect‘dissention’not‘teamwork’andremovingthis“presenceanddirection”allowstheteamtogetbacktotherealfocuswhichisthepatient.

IalsosupportCRNAshavingDEAnumbersandhavingfocusedprescriptiveauthority.Thisisespeciallyimportantwhenproceduresresultinperioperativeanxiety,postoperativepainmanagement,andpostoperativenauseaandvomiting.

ThelastthingIwanttoaddressisChronicPainManagement.IfnotfortheCRNAinmycommunityperformingfluoroscopicsteroidinjectionsandotherinjectionsforourpatientstheywouldwait2-3monthsandtravel3+hourstogettreatment.ThisisGOODforruralArizonanswhoneedtheseinterventionstogobacktoworkandbeproductive.Thisservicecertainlysavesthesystemmoneyindisabilityexpensesandhelpsgetthesepatientsofforonmorereasonabledosesofnarcoticpainmedicines.TheseCRNAsprovideahighly-valuedservicetoourpatientswhosufferfromchronicpainandanaccessibleoptionfortreatmentsclosetohome.CRNAsareproposinga“goldstandard”approachtopaincertification,andwouldbetheonlyhealthcareprovidersintheUnitedStates–includingphysicians–torequirepaincertification.Istronglyurgeyoutoembracetheseupgradestoourpainmanagementservices.

Again,asapracticingorthopedicsurgeoninmy20thyearIhaveintimateassociationandcontactwiththeCRNAgrouplocally.Theyareabsolutelynecessaryfortheruralpracticewehavehereandwithoutthemwewouldnotexist.Weasphysiciansshouldembraceandsupportthemexpandingaccesstocarenotfightthemtoothandnail.Ifthereareanyquestionsorconcernsaboutthisissue,pleasefeelfreetocallmepersonally.IamverymuchinsupportofallCRNAshavingfullscopeofpracticeandremoving“presenceanddirection”fromthestatute.

Sincerely,

192392 YEARS AGO

LANGUGE

FROM

Signed by Arizona's 1st Governor: George P. Hunt

ANESTHSIOLOGISTS SUPPORT"Anesthesia providers do not work in a

vacuum; we work in a team with thesurgeon. The new language will

enhance the team with clarity - I fullysupport the proposed legislation."

"The outdated language doesnot make any sense and in my

opinion does not offer anypatient saftey. I am completely

comfortable with the updateproposed by CRNAs."

Dr. Ned Sciortino, DO Anesthesiologist, Director of Anesthesiology, IASIS Healthcare

Phoenix, Arizona

Dr. David Beauchamp MD Anesthesiologist, Phoenix, Arizona

CRNA SCOPE OF PRACTICE

"I support CRNAs being ableto practice to the fullest

extent of their education,training, and ability."

"'Direction and presence' creates confusion."

"Surgeons, by virtue of theirtraining and experience, are not

qualified to direct theanesthesiologist or CRNA while

providing anesthesia care topatients."

Dr. David Vertullo, MD, Cardiovascular Anesthesiologist Former Board Examiner, American Board of Anesthesiology

Phoenix, Arizona

Much has changed since the

1920s

So has healthcare.

It's Time to Update Scope of Practice.

O f L e s s

R e s t r i c t i v e

R e g u l a t i o n f o r

A P R N sBENEFITS

NEW JOBSTHOUSANDS OF

ECONOMICOUTPUT

$400-$800 MILLION IN

HEALTH SYSTEMSAVINGS

$400 MILLION TO $4.3 BILLION IN

INDEPENDENT, 3rd PARTY RESEARCH

Landmark 2014 Report: "Policy Perspectives, Competition andRegulation of Advanced Practice Nurses"

NEVERUntil Now.

You guessed it...


MedicineThe Institute of

A Division of the National Academies of Science

RESEARCHCRNA-ANESTHESIA OUTCOMESAPRNAZ.ORG

A P R E P O N D E R A N C E O F E V I D E N C E

COMPILED & COMPRESSED BY JOSEPH A RODRIGUEZ

"There simply is no ignoring 40 years of researchpointing toward one conclusion.

For the benefit and welfare of Arizona's citizens, Arizona legislators should recognize CRNA Full Practice Authority."

Justin B. McBride, CRNA Chief of Anesthesia, Phoenix St. Lukes Hospital

A PREPONDERANCE

1977

1981

1980

1982

1994

2004

2003

2007

O F E V I D E N C E2008

2010

20102010

2014

2014

2015

2015

2015

Dr. Rob Schuster, MD, FACS

Bariatric Surgeon, PhoenixFellow, American College of Surgeons

Surgeons Speak Out

"I endorse removing

'direction and presence.'

Nayan Patel, DO

Gastroenterology and Transplant Hepatology

Physicians Speak Out:

9.29.2015

FROM Dr. Ned Sciortino, DO Anesthesioloigst and Medical Director, Mountain Vista Medical Center, Phoenix St. Luke’s Hospital, Tempe St. Luke’s Hospital. Director of Medical Education and Residency, Mountain Vista Medical Center TO Mr. Pete Werheim Executive Director, Arizona Osteopathic Medical Association Sent to: [email protected] CC: Arizona Senate and House Health Committees

Dear Mr. Werheim:

Hello, my name is Dr Ned Sciort ino DO. I am the director of anesthesia for

over 30 Cert i f ied Registered Nurse Anesthetists (CRNAs) at 3 hospitals in the

Phoenix area. I have worked with my team of CRNAs for over 5 years now. I

am very famil iar with their practice and level of professionalism. I am also

aware of the challenges they face with their current scope of practice

language and the legislat ion they are proposing this year in efforts to amend

that language.

The team I work with at these 3 faci l i t ies are exceptional anesthesia providers.

The CRNAs current scope states that they must work under the direction of

and in the presence of a physician, which in our faci l i t ies and many others in

the state means that the operating surgeon/physician is present and directing

them. I would agree with the CRNAs, that this creates a unique challenge as

operating surgeons/physicians can mean orthopedic surgeon, vascular

surgeon, general surgeon, gastroenterologist, dentist, interventional

radiologist, etc... . And although these physicians are excellent at what they

do, they are not anesthesia experts nor are they credentialed to practice

anesthesia. For them to "direct" and be "present" for a CRNA to practice does

not make any sense and in my opinion does not offer any patient safety. I t can

also create a concern for some surgeons that perceive this language to mean

they are more l iable for the actions of a CRNA. I am completely comfortable

with their efforts to remove the direction and presence language from their

current scope of practice.

The CRNAs that I work with are also very competent in providing our patients

preoperative and postoperative pain/nerve blocks. One of our CRNAs in fact

has brought over 10 years of pain management experience to our group which

has been extremely helpful for us. The surgeons at our 3 faci l i t ies have been

very pleased with our anesthesia group and the service we provide which is

the ult imate reason we have held these contracts for nearly 10 years now.

Please feel free to contact me if I can be of any further assistance.

Dr Ned Sciortino DO, Director Anesthesia

[email protected]

480-544-6446

or contact;

Justin McBride CRNA Chief, Phoenix St. Lukes Hospital

[email protected]

602-370-3103

Joseph Rodriguez

Dr. Hilario Juarez, MD, FACS

Bariatric Surgeon, Phoenix

Fellow, American College of Surgeons

Surgeons Speak Out

Frank Joseph Fara, M.D., FACOG 19191 North Palermo Street Surprise, AZ 85374 October 20, 2015

Govenor Ducey and the Arizona Legislature Dear Legislators: I am writing today to add clarity to and support for the issues surrounding CRNA practice in Arizona. As a practicing Obstetrician and Gynecologist, I have had the pleasure of practicing with CRNAs in many settings over the 33 years of my career and have continually been impressed with their knowledge, expertise and professionalism. In several of these settings, CRNAs were the only anaesthesia providers serving my patients, and they did so uniformly with a high degree of success. Of interest, my most recent experience with CRNAs happened as they began to practice at my home hospital, Banner Del E. Webb Medical Center in Sun City West. As they joined our medical staff, several of my colleagues who had never practiced with these dedicated clinicians questioned their qualification and capacity in the provision of care to the surgical patient. Gratifyingly, and to no surprise to me, each of these skeptical colleagues were rapidly impressed with the quality of service they have delivered, and are now very supportive of the CRNA service at Del Webb. This has been especially notable in our Labor and Delivery unit, where they do their job with aplomb, to the benefit of doctors, nursing staff, and patients alike. When CRNAs are administering anaesthesia, they are managing the anaesthesia and are thus responsible for the anaesthetic portion of the procedure. The surgeon does not assist the CRNA in providing anaesthesia, the choice of medication, airway management, and so on. In this capacity, the CRNA makes numerous second-to-second decisions which ultimately allow the surgeon to perform the operation with the secure knowledge that the patient is being well cared for. The outdated language that, in some sources, require the “presence and direction” of the surgeon in the provision of anaesthetic service was written in the start of the 20th century, and in no way currently contributes to patient safety or anaesthetic outcome. What this outdated language does accomplish, however, is the perpetuation of misperceptions about who is liable for anaesthetic outcomes. Let me be clear: the CRNA is a highly trained, experienced medical professional, licensed by the state and credentialed by their professional board to provide anaesthesia, while the surgeon is similarly licensed and credentialed to perform the surgical procedure itself. This current and contemporary relationship between CRNA and surgeon must be supported by the medical team, and also by any legislative action that may seek to more carefully define such relationships. I also strongly support the provision of DEA credential to CRNAs and the allowance of focused prescriptive authority that will allow them to practice to their fullest and most effective level of education and training. This is especially important in systems such as the Veteran’s Administration, where DEA certification is required for employment, but also in situations in which preoperative and postoperative prescribing is necessary to provide adequately for conditions involving significant preoperative anxiety and the control of postoperative nausea, vomiting and pain. Arizonans deserve to have every member of the surgical team functioning at his/her highest levels of expertise. Physicians and surgeons have enough liability and enough work without adding to it this burdensome and ambiguous regulation which slows down our health care system and fosters inefficiency. Further, this legislative action is in close accord with recommendations from the universally recognized and respected Institutes of Medicine. Please work to remove this confusing language from the statue and allow all members of the surgical team to get back to doing what we seek to do best: the expert care of our patients. Sincerely, Frank Joseph Fara, M.D., FACOG (Electronically Signed)

Dr. Frank Joseph Fara, MD,FACOG

Obstetrician and Gynecologist, Phoenix AZ

Fellow, American College of OBGYNs

"CRNAs were the

They performed with a uniformly

on ly anesthes iaproviders . . .

h igh degreeof success"

Joseph Rodriguez

Dr. James Chow, MD

Orthopedic Surgeon, Phoenix Arizona

Surgeons Speak Out

Joseph Rodriguez

Dr. Katharine Raymer, MD, FACS

General Surgeon, Banner Payson Hospital

Fellow, American College of Surgeons

"I fully support the removal of'direction and presence', it only causes

delaysand

confusion"

Dr. Akash Makkar, MD, FHRS

Cardiologist, Electrophysiologist, Phoenix

Fellow, Heart Rhythm Society

Physicians SupportUpdated Scope of Practice

.

WWW.FUTURE-OF-ANESTHESIA-CARE-TODAY.COM

Dr. Steven Washburn, MD

Orthopedic Surgeon, Show Low AZ


Vijay Swarup, MD, FACC, FHRS 500 W Thomas Rd #750 � Phoenix, AZ 85248� Phone: 480-227-4563 E-Mail: [email protected] Web: azheartrhythm.com

October 8, 2015

Senate Health and Human Services Committee Chairwoman: Nancy Barto Members: David Bradley, Katie Hobbs, Debbie Lesko, Lynne Pancrazi, Kelli Ward (Vice Chair, Kimberly Yee House Health Committee Chairwoman: Heather Carter Members: Paul Boyer, Regina Cobb (Vice Chair), Randall Friese, Jay Lawrence, Eric Meyer

Dear Legis lators:

I am writing today to add clarity to issue of CRNA practice in Arizona.

The anesthesia care that my patients receive from the Certified Registered Nurse Anesthetists

is second to none. The CRNAs that I work with function independently at an incredibly high

level, managing without oversight or supervision all aspects of the anesthetic. This is how it

should be, since they are trained for (and able to provide) the independent provision and

management of anesthesia; I am not. In my experience, CRNA’s are often my preferred

anesthesia provider for my cases due to their attentiveness, focus, skill, and ongoing

education. Actually, the only anesthesia provider in the state (and country) who is a certified

cardiac device specialist and fellow of the heart rhythm society is a nurse anesthetist! It

benefits my practice and the patient when he is able to practice to the full scope of his

training without hindrance or confusion, which the current law could create.

Thus the century-old language requiring physician “presence and direction” is unnecessary,

practically meaningless, and does not enhance patient safety. In fact, it only serves to

confuse. When I practice with a CRNA I am the physician “present” offering “direction.”

However, the presence of the CRNA provides for safe anesthetic, and I am not qualified nor

should I actually direct in any way. The provision of anesthesia should be (and in the reality of

21st century practice is) left in the hands of those trained to provide anesthesia. Thus the

current law’s language is confusing and does not reflect current practice. I support the

updates to the law that the CRNA’s are proposing. Unfortunately, I am not able to attend the

Sunrise Hearing in person, but please accept this letter as my support for the proposed

legislative changes.

2

When CRNAs are administering anesthesia, they are managing the anesthetic and are

responsible for the anesthetic portion of the procedure. The surgeon/physician/proceduralist

performing the procedure do not and should not assist CRNAs in providing anesthesia,

choosing medications, airway management, and so on. CRNAs make numerous second-to-

second decisions which allow me to perform the procedure knowing the patient is cared for; I

do not direct the CRNA how to perform the anesthetic as this is not my specialty. The

outdated language requiring physician “presence and direction” was written at the start of

the 20th century, and does nothing to enhance patient safety.

What this language does, however, is create misperceptions about who is liable

for anesthesia outcomes. Let me be clear: CRNAs are anesthesia professionals, trained,

licensed and credentialed to practice anesthesia, while I am the surgeon/proceduralist

trained, licensed, and credentialed to perform the procedure which the anesthesia is

facilitating.

I also support CRNAs having DEA numbers and allowing them the focused prescriptive

authority they need to practice to their full education and training. This is especially

important in systems like the Veteran’s Administration (where DEA numbers are required for

employment), but also essential in situations where pre-op and post-op prescriptions are

needed which are directly related to my procedure such as preoperative anxiety, post-

operative pain management, and post-operative nausea and vomiting. I believe that the

current restriction on CRNA’s keeping them from being employed at the VA may actually be

keeping the best quality care away from our state’s and nation’s veterans.

Arizonans deserve every member of their team functioning at the highest levels. Surgeons

and Physicians have both enough liability and enough work without dealing with this

burdensome and ambiguous regulation which slows down our health care system. Further,

this update is in line with recommendations from the universally recognized and respected

Institute of Medicine Please remove this confusing language. It does nothing to enhance

patient safety but rather only creates confusion and potential inappropriate liability and

inappropriate limits on practice.

Sincerely,

Vijendra Swarup, MD, FACC, FHRS

Dr. Vijay Swarup, MD, FHRS

Cardiologist, Electrophysiologist, Phoenix

Fellow, Heart Rhythm Society

Arizona's Advanced Practice Registered Nurses

(APRNs) are the VERY BEST.

IT'S TIME TO LET

THEM DO THEIR

JOBSUpdate Scope of Practice, Lawmakers.

#NursesCare4AZ

La Paz Regional Hospital M. Victoria Clark, Chief Executive Officer 1200 W. Mohave Road, Parker, AZ 85344 (928) 669-7300 FAX (928) 669-7417 [email protected]

November 30, 2015

TO: Arizona Senate and House Health Committees and All Interested Arizona Legislators

Dear Legislators:

As the Chief Executive Officer of La Paz Regional Hospital, I am writing today to ask for your help in updating the legislative statutes regarding Certified Registered Nurse Anesthetists (CRNAs) and their ability to direct the care of the patients they serve.

At La Paz Regional, anesthesia is administered only by Certified Registered Nurse Anesthetists (CRNAs) and has been for many years. I have been very pleased with their expertise and professionalism. CRNAs are extremely competent and they manage all phases of anesthesia for our patients, which range from healthy-low risk patients to high-risk patients with severe comorbidities. CRNAs cover our entire hospital from the Emergency Department to the Surgery Department for difficult airway access, central line insertion, lumbar punctures, emergency and difficult airway access, as well as trauma surgery. Without these anesthesia services, our community would be drastically limited in our ability to provide healthcare and patients would suffer from lack of access to proper medical care.

The current statute is outdated and does not reflect real practice. Language requiring physician/surgeon “presence and direction” creates a false concern for surgeons of liability and does not enhance patient care or safety. The language creates misperceptions about who is liable for anesthesia. CRNAs are responsible for the anesthetic management, and surgeons are responsible for their surgery. Surgeons are not trained or credentialed in anesthesia or to direct anesthesia from a CRNA. CRNAs are not trained to be directed. When we bring in new surgeons we have to educate them on this issue and let them know that they are not liable for the actions of the CRNAs they are working with any more than they would be with an anesthesiologist - a fact has been borne out in decades of case law and research. This language has been a barrier in our community, with some surgeons unwilling to practice here due to their unfounded idea that they would be liable for anesthesia care, even as we show them the case law that proves they are not liable.

Open Letter to Arizona Legislators November 30, 2015 Page ! 2

I have been informed that some are stating that removing this language would be “breaking up the team.” However, nothing could be further from the truth. In reality removing the outdated language enhances the team by making statute reflect practice, removing confusion about roles, and removing a perception of liability that does not exist. The proposed language from CRNAs, which still ensures CRNAs work as part of a healthcare team helps create a safe, accessible, and cost-effective healthcare system.

I also support CRNAs having DEA numbers and allowing them the focused prescriptive authority they need to practice to their full education and training. This is especially important in systems like the VA where DEA numbers are required for employment, but also essential in situations where pre-op and post-op prescriptions are needed which are directly related to the procedure such as preoperative anxiety, post-operative pain management, and post-operative nausea and vomiting.

Last, I also want to voice support for the CRNAs providing Chronic Pain Management. While CRNAs in nearly every state including Arizona practice interventional pain management currently, CRNAs are proposing a “gold standard” approach to pain certification, and would be the only healthcare providers in the United States to require pain certification. CRNAs can provide this highly-valued service to patients who suffer from chronic pain and an accessible option for treatments close to home. Their interventions offer an adjunct to medication-only pain management, thus decreasing potential for opioid addiction, a problem which is a plague for our communities. I urge you to embrace these upgrades to Arizona’s pain management services. According to the universally respected Institute of Medicine of the National Academies, CRNAs and other Advanced Practice Nurses “have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted.”

Current statistics and research demonstrates that nurse practitioners, physician assistants and nurse anesthetists will have a greater and greater role in healthcare in the future, as the number of doctors in practice falls far short of the number needed. Arizonans deserve every member of their team functioning at the highest levels. Surgeons and Physicians have both enough liability and enough work without dealing with this burdensome and ambiguous regulation which slows down our health care system. Please remove this confusing language and allow all members of the healthcare team to get back to the work we want to do: taking care of our patients.

Sincerely,

M. Victoria Clark Chief Executive Officer
































































































































































































































































"Educating future CertifiedRegistered Nurse Anesthetists

(CRNAs) remains strong. Therigorous training at Midwestern

exceeds requirements, and its trackrecord of excellence is evidenced by

success of 185 graduates whoprovide anesthesia care that meets

the healthcare needs of society."

#NursesCare4AZPhoto: Dan Lovinaria

Dr. Shari Burns, EdD, CRNA,

Program Director, Midwestern

University, Glendale Arizona

Contentbreakdown:

6hours:localanesthetics

4hours:opioids

4hours:analgesics

2hours:steroids

12hours:casestudyanalysis(includingpainandregionalanesthesia)

2hours:medicationsafety

8hours:paintheoryandclinicalapplication

10hours:regionalanesthesia

8-10hours:additionalconferencetimededicatedtopainmanagementand/orregional/ultrasoundanesthesia

B.ClinicalCurriculum

·Allstudentscomplete5-11weekclinicalrotationsdedicatedtocompletingtheCOAclinicalcaserequirements.

·Allstudentsrotatetourban,rural,anesthesiacareteamandCRNAonlypractices.AllstudentsexceedtheclinicalcaserequirementsrequiredbytheCOA.Forexamplein2015,thecohortmeanof1100casesisdoubletherequirednumber.Forthenextcohort,600casesistheminimumrequiredbytheCOA.

Eachofthepast5years,theprogram’smeannumberofcasesincreased.

Regionalanesthesiaandpainmanagementclinicalexperienceisaffordedatallofthe33clinicalsitesusedbytheprogram.Notethat70%ofthesitesareoutsideofArizona.

Datafromthemostrecentcohort(2015)exemplifiestheexperienceaffordedtheMWUclinicalstudentsascomparedtotheCOArequirement.Pleasenote:theseexperiencenumberscontinuetogrowastheprogramaddsclinicalsites(Tablebelow).

Skill COARequirement

MinimumRequirement

MidwesternUniversityStudentExperience(Mean)

RegionalManagement 30 145

RegionalAdministration 25 184

Spinaladministration 1 78

Epidural 1 47

PeripheralNBlock 1 59

Becauseofthebreadthanddepthofclinicalexperience,100%ofthegraduatingclasswasemployedpriortograduation.Infact,somestudentswereofferedmultiplepositions.

Someofthestudentsremainedinruraland/orcriticalaccesshospitalswheretheytrained.

Withregardtopainmanagementencounters,eachstudent:

·Initiatesepiduraland/orintrathecalanalgesia

·Facilitatesorinitiatespatientcontrolledanalgesia

·Initiatesregionalanalgesiaforpostoperativepain

·Adjustsanalgesia

·Initiatesacutepainmanagement(PACU)

·Managespatientswithacuteandchronicpain

Asclinicalexperienceopportunitiesimprove,additionalpainmanagementencounterswillbeprovided,i.e.triggerpointinjection;electricalnervestimulation.

3.Thedevelopmentofaccreditedpostgraduatesub-specializationsandfellowshipsinpainmanagement.

a.WhiletheMWUprogramdoesnotofferasub-specializationorfellowshipinpainmanagement,theprogramstronglysupportsandadvocatesforthiseducation.TheadvancededucationforCRNAsonlystrengthenstheacademicandclinicalknowledgeneededtoprovideconsistentqualityofcare.Theadditionaltrainingfacilitatesprovisionofservicestoruralandcriticalaccesshospitalcommunities.(Note:thiswouldbeagreatareaforaqualitystudyforaDNAPstudent).

ItisapleasuretosharetheexcitingeducationalexperienceaffordedstudentnurseanesthetistsatMidwesternUniversity,Glendale,AZ.IfIcanbeoffurtherassistance,pleasedonothesitatetocontactme.

Regards,

ShariM.Burns,CRNA,Ed.D.

[email protected]

623-572-3455

CRNA Education and Training

CRNAs must pass a National Certification Examination and be recertified every 2 years so they

are current on the latest anesthesia techniques and technologies. Anesthesiologists are recertified every 10 years.

CRNAs obtain an average of Constant Learners

Minimum1 Year

24 – 36 Months

Manage difficult cases Use advanced monitoring equipment

CRNAs are qualified to administer every type of anesthesia in any healthcare setting, including pain management for acute or chronic pain.

of critical care nursing experience before entering a nurse anesthesia program.2 They are the only anesthesia professionals with this level of critical care experience prior to entering an educational program.

3.5 years

Interpret diagnostic information Respond appropriately in any emergency situation

less costly to educate and train than anesthesiologists.3

85%

of employers report high satisfaction levels with the preparedness of recently graduated CRNAs.4

97%

Baccalaureateprepared RN

Critical care nursing experience Classroom and clinical education and training

By 2025, all anesthesia program graduates will earn doctoral degrees

Master’s or Doctoral Degreefrom a COA-accredited nurse

anesthesia educational program1

Certified Registered Nurse Anesthetists (CRNAs) are highly educated, advanced practice registered nurses who deliver anesthesia to patients in exactly the same ways, for the same types of procedures and just as safely as physician anesthesiologists.

For more information, visit www.future-of-anesthesia-care-today.comAmerican Association of Nurse Anesthetists© 2014

1. Council on Accreditation of Nurse Anesthesia Educational Programs2. National Board of Certification and Recertification for Nurse Anesthetists 2012 NBCRNA Annual Report of NCE Performance Data3. Cost Effectiveness Analysis of Anesthesia Providers, Nursing Economics, June 20104. Assessment of Recent Graduates Preparedness for Entry into Practice, AANA Journal, November 2013

As the demand for healthcare continues to grow, increasing the number of CRNAs will be key to containing costs while maintaining quality care.

CRNAs have a minimum of 7 to 8 years of education and training specific to nursing and anesthesiology before they are licensed to practice anesthesia.

Minimum 40 hours of approved continuing

education

Documentation of substantial

anesthesia practice

Maintenance of current state

licensure

Research shows that CRNAs are

November 27, 2015 To: Arizona State Legislature: I am the president of the American Association of Nurse Anesthetists (AANA), which represents more than 49,000 nurse anesthetists (including Certified Registered Nurse Anesthetists (CRNAs) and student nurse anesthetists) nationwide. The AANA submits the following comments in support of Sunrise Application for expanded scope of practice, submitted by Arizona Nurses Association, the Arizona Association of Nurse Anesthetists, the Arizona Affiliate of the American College of Nurse-Midwives and the Arizona Nurse Practitioner Council, which would allow for more independent practice for advanced practice nurses in Arizona. Potential Impact of the amendment to Title 32, Chapter 15 in Arizona: CRNAs have been providing high quality, cost effective anesthesia care to the citizens of Arizona and this country for over 150 years. This amendment would help to improve quality of health care and reduce costs by eliminating the outdated physician oversight requirements and allowing residents of Arizona to have improved access to the services provided by CRNAs. The amendment will remove the outdated requirements of direction and presence of a physician or surgeon for CRNAs. The amendment will also allow CRNAs ability to obtain certification for prescribing authority. By removing the above barriers to CRNA practice, this will improve access to care, promote competition and decreaseFeF health care costs to the residents of Arizona. National Trend In recent years, the national trend has been toward removal of the barriers to practice and toward allowing advanced practice nurses, including CRNAs, to practice to the full extent of their education and training. 32 states and the District of Columbia have no supervision or direction requirement concerning nurse anesthetists in nurse practice acts, board of nursing rules/regulations, medical practice acts, board of medicine rules/regulations, or their generic equivalents. Further, 17 states have opted-out of the federal physician supervision requirement for CRNAs, with the most recent being Kentucky in April 2012. CRNA Scope of Practice

As healthcare professionals, CRNAs practice according to their expertise, state statutes and regulations, and institutional policy. The AANA supports the full scope of CRNA practice as set forth in the AANA’s “Scope Nurse Anesthesia Practice” and “Standards for Nurse Anesthesia Practice” (at

2

http://www.aana.com/resources2/professionalpractice/Pages/Professional-Practice-Manual.aspx). Practice by CRNAs and other APRNs to the full extent of their education and training is also supported by the 2010 Institute of Medicine (IOM) report titled, The Future of Nursing: Leading Change, Advancing Health (the IOM report, at http://www.nap.edu/catalog.php?record_id=12956). The IOM report includes the “key message” that: “Nurses should practice to the full extent of their education and training.” [page 3-1] The IOM report further indicates “…regulations in many states result in APRNs not being able to give care they were trained to provide. The committee believes all health professionals should practice to the full extent of their education and training so that more patients may benefit.” [page 3-10] CRNAs Provide High Quality, Cost-Effective Care There is overwhelming evidence, most recently documented in studies released in 2010, that CRNAs provide superb, cost-effective anesthesia care. Nurse anesthetists have been, since their inception, professionals who are acknowledged by the surgeons with whom they practice to be experts regarding anesthesia. The excellent safety record of CRNAs is reflected in a study titled, “No Harm Found When Nurse Anesthetists Work without Supervision by Physicians,” which was published in the August 2010 issue of Health Affairs, the nation’s leading health policy journal. (The study is available at http://www.aana.com/optoutstudy/.) In that study, which was conducted by Jerry Cromwell, a senior fellow in health economics at the Research Triangle Institute (“RTI”) and Brian Dulisse, a health economist at RTI, the authors analyzed nearly 500,000 hospitalizations in 14 opt-out states (i.e., the 14 states that, at the time of the study, had opted out of the federal physician supervision requirement for CRNAs; there are now a total of 17 opt-out states) and concluded that allowing CRNAs to administer anesthesia services without physician supervision does not put patients at risk. In fact, the authors found no increase in the odds of a patient dying or experiencing complications in states that had opted out. The study also compared outcomes by provider type and found that there are no differences in patient outcomes of anesthesia services delivered by solo CRNAs, by solo anesthesiologists, or by CRNAs being supervised by anesthesiologists. An article that appeared in the May-June 2010 issue of the Journal of Nursing Economic$ titled, “Cost Effectiveness Analysis of Anesthesia Providers” had similar findings regarding the quality of CRNA care. (The article is available at http://www.aana.com/advocacy/federalgovernmentaffairs/Documents/Value%20of%20CRNA%20Care%20Study.pdf .)That article, which was written by a group of researchers for The Lewin Group, an Ingenix company which is, in turn, a wholly-owned subsidiary of UnitedHealth Group, analyzed the cost-effectiveness of various anesthesia models. This article also concluded that CRNAs can perform the same set of anesthesia services as anesthesiologists and said that research studies have found “no significant differences in rates of anesthesia complications or mortality between CRNAs and

3

anesthesiologists or among delivery models for anesthesia that involve CRNAs, anesthesiologists, or both after controlling for other pertinent factors.…” The article further noted that “[g]iven the low incidence of adverse anesthesia-related complications and anesthesia-related mortality rates in general, it is not surprising that there are no studies that show a significant difference between CRNAs and anesthesiologists in patient outcomes.” In addition, the Lewin Group article analyzed the cost-effectiveness of various anesthesia models and concluded that “CRNAs acting independently provide anesthesia services at the lowest economic cost.…” The article also concluded that models that require physician oversight of CRNA practice are inefficient in areas of low demand such as rural communities. In such communities, CRNAs acting independently is the only model likely to result in positive net revenue. For additional information regarding anesthesia quality of care studies, see the AANA publication titled Quality of Care in Anesthesia. (Available at http://www.aana.com/resources2/professionalpractice/Pages/Professional-Practice-Manual.aspx under Quality of Care in Anesthesia.) The Quality of Care synopsis includes evidence that documents the high quality of anesthesia care that CRNAs deliver. Based on the foregoing, the AANA would like to express our support for this amendment and encourage you to continue advocating for solutions that improve the quality of health care and reduce costs. Please do not hesitate to contact Anna Polyak, RN, JD, the AANA’s Senior Director, State Government Affairs, at 847-655-1131 or [email protected] if you have any questions or require further information. Sincerely,

Juan F. Quintana CRNA, DNP, MHS AANA President

Amesh Adalja, M.D.

University of Pittsburgh

FULL SCOPE OF PRACTICE

"A solution that can actuallywork, but is hampered by a

regime of onerous...guild-mindedstate government medical

boards"


JEFFERY KIVAT MD jefnjoy@gmail .com, 85086 December 1, 2015

VIA EMAIL

Members of the Arizona Legis lature committee of reference:

Advanced practice registered nurses (APRN) are a vital part of the health system of the United States. They are registered nurses educated at Masters or Doctoral level for practice in a specific role and with a defined patient population to provide basic and specialty healthcare services in a wide variety of settings. APRNs are prepared by education and certification to assess, diagnose, and manage patient problems, order and interpret tests and consult with other members of the healthcare team as the condition of a patient requires. Where APRNs have received appropriate education and training, and qualified through certification, they should have consistent prescriptive authority aligned with their scope of practice.

A large body of published research conducted by expert panels and government agencies has consistently demonstrated that the care provided by APRNs meets or exceeds established standards for quality. It has been my experience that APRNs provide safe and effective health care to my family in our community.

In the report of the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine of the National Academies (The Future of Nursing: Leading Change, Advancing Health), “Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses.”

I agree that APRNs represent a pool of qualified professionals ready and able to meet the increasing demand in Arizona for timely access to preventive and restorative healthcare services. I value and support legislation that will permit APRNs to practice to the full extent of their education and training.

As a retired physician who started practice in 1976, I have witnessed an explosion of knowledge in the various medical subspecialties. This has created a need, not adequately met at this time, for large numbers of general practitioners who can handle basic medical needs and make appropriate referrals to sub-specialists. I do not believe that this role requires an MD degree. I have seen it performed well by APRN's, NP's and PA's. Giving them prescriptive authority is a must, if society is to get the full benefit of their abilities.

Respectfully,

Jeffrey Kiviat MD (sent electronically)

Dr. Jeffery Kivat, MD

Clinical Pathologist, Phoenix AZ.

Physicians Advocate for APRNs:

Advanced Practice Nurses can bridge Arizona’s health gap By: Guest Opinion December 17, 2015 , 3:58 pm

Patient demand for health care in Arizona has never been greater. As front-line health care professionals working in both metro Phoenix and the White Mountains, we see it every day. Graying members of the Baby Boomer generation require more care with each passing year. And policy actions at the state and federal level have brought hundreds of thousands of Arizonans and tens of millions of Americans into the traditional health care system. Meanwhile, the Association of American Medical Colleges projects that the U.S. faces a shortage of up to 31,000 primary-care physicians by 2025. Who is going to meet our growing health care needs? In Arizona, we believe that Advanced Practice Nurses can help bridge the gap. That is why the Arizona Nurses Association and groups representing our state’s nearly 6,500 Advanced Practice Nurses have banded together under the banner of the Arizona Coalition of Advanced Practice Nurses. What the Coalition seeks is an update of Arizona’s Scope of Practice for the four Advanced Practice Nursing groups: Nurse Practitioners, Nurse Midwives, Certified Registered Nurse Anesthetists (CRNAs) and Clinical Nurse Specialists. As supporters of this effort, we are grateful a joint state committee of House and Senate legislators recently gave a positive recommendation to this Scope of Practice expansion. We are also mindful this was but the first step in the legislative process that lies ahead. Advanced Practice Nurses have graduate-level education, advanced clinical knowledge and specialized focus. They work in areas like family practice, pediatrics, geriatrics, psychiatric/mental health and women’s health. Some sections of the existing statutes governing Advanced Practice Nurses are antiquated, dating back decades or more. Other provisions are confusing or misleading, such as a provision requiring CRNAs to provide anesthetics “under the direction of and in the presence of a physician or surgeon.” What does “under the direction of” mean? The statute doesn’t define it and there is no case law. Additionally, requiring that CRNAs operate “in the presence” of a physician is both unnecessary and, frankly, impossible in rural and other settings where the physician is likely scrubbing in, reviewing test results in another room, assisting another patient or conducting any of a thousand other tasks necessary in today’s busy health care world. Here’s a reality check: a lack of area anesthesiologists means CRNAs are safely and securely providing virtually all anesthetic services to patients in the White Mountains.

F R E S H S T A R TG O O D N E S S I N O N E H I T

Vitamin C+

VITAMINFRESH.NET

Tanya R. Sorrell, PhD, Psychiatric Nurse Practitioner, Yuma

Karen Watts, MSN, Family Nurse Practitioner, Yuma

Annette Casey, MSN, Certified Nurse Midwife, Yuma

"Advanced PracticeNurses have graduate-level education. It has

been over 10 years sincewe practiced under

physician supervision."

#NursesCare4AZ

Guest Column: Critical nursing legislation offers changes By Tanya R. Sorrell, PhD, PMHNP-BC, Psychiatric Nurse Practitioner, Yuma Karen Watts, MSN, FNP, Family Nurse Practitioner, Yuma Annette Casey, MSN, CNM, Certified Nurse Midwife, Yuma. December, 2015.

As Yuma health professionals, we are concerned Yuma Sun readers may have been misled by Dr. Uribe’s recent letter to the editor (“Option could compromise quality of health care,” Dec. 14, 2015). We write to correct the record.

Dr. Uribe’s letter conjures up century-old concepts in which the nurse was subservient to the doctor. To put it mildly, those ideas are not relevant to the approximately 6,500 Advanced Practice Registered Nurses across Arizona providing world-class healthcare to patients every day.

Here are the facts: Advanced Practice Nurses have elevated (at least graduate-level) education and specialized training. It has been more than a decade since Arizona required that we practice under the “supervision” of a physician.

Advanced Practice Nurses safely deliver babies, diagnose and treat illnesses (yes, Dr. Uribe, even patients with diabetes and cancer), provide anesthetic care for pain management and provide the kind of quality care our patients expect and deserve. We serve in communities both urban and rural. And we are increasingly relied upon within a healthcare system in which physician shortages are chronic and patient demand is surging.

The good news? There are a number of studies and a multitude of research that demonstrate the high quality of care provided by Advanced Practice Nurses.

One such report, jointly issued in 2010 by the Institute of Medicine and Robert Wood Johnson Foundation, stated: “Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence. The current conflicts between what (Advanced Practice Nurses) can do based on their education and training and what they may do according to state and federal regulations must be resolved so that they are better able to provide seamless, affordable, and quality care.”

In the coming months, a coalition representing Nurse Practitioners, Certified Nurse Midwives, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists will seek legislation updating the regulations governing Advanced Practice Nurses in Arizona. The changes are modest and common sense — clarifying sections of existing law that have been the source of confusion and granting greater autonomy so that Advanced Practice Nurses like us can provide care in accordance with our elevated education, training and experience.

Contrary to Dr. Uribe’s assertions, nobody seeks to replace the role of your doctor in your health care.

More than 700 Arizona nurses, patients and healthcare advocates have signed letters in support of this critical nursing legislation. So have approximately 70 physicians from every corner of our state. Anyone who would like to learn more may visit AZnurse.org for more information.

A Chapter of the American Physical Therapy Association

President Linda Duke, PT Gilbert [email protected] Vice President Sara Demeure, PT, MSPT, OCS Scottsdale [email protected] Secretary Staci Whitman, PT, DPT Flagstaff [email protected] Treasurer Justin Dunaway, PT, DPT, OCS Gilbert [email protected] Chief Delegate John Heick, PT, DPT, NCS, OCS Gilbert [email protected] PTA Caucus Representative Jane Jackson, PTA Tempe [email protected] District 1 - Western Maricopa Kyle Guidry, PT, DPT, ATC Surprise [email protected] District 2 - Central Maricopa Tabitha Kuehn, PT, DPT Scottsdale [email protected] District 3 – Eastern Maricopa Katie Larson, PT, DPT, OCS Gilbert [email protected] District 4 - Southern Arizona Joni Raneri, PT, DPT Tucson [email protected] District 5 - Northern Arizona Lorie Kroneberger, PT, DPT, GCS Flagstaff [email protected] Executive Director Catherine Langley, CAE 1055 N. Fairfax St., Suite 205 Alexandria, VA 22314 602.569.9101 [email protected]

Arizona Physical Therapy Association 1055 N. Fairfax St., Suite 205 Alexandria, VA 22314 www.aptaaz.org To the Honorable members of Arizona Senate and House Health Committee: We believe advanced practice registered nurses (APRN) are a vital part of the health care delivery system of the United States. These are registered nurses, educated at a Masters or Doctoral level for specific practice with a defined patient population to provide basic and specialty health services across a variety of settings. APRNs are prepared by both education and certification to assess, diagnose, and manage health concerns, order and interpret tests, and collaborate with other team members as each patient condition requires. In areas where APRNs have received appropriate education and training, qualified through certification, they should have consistent prescriptive authority in alliance with their scope of practice. Published research conducted by expert panels and government agencies has consistently demonstrated that the care provided by APRNs meets or exceeds established standards for quality. We know that APRNs provide safe and effective health care to persons treated in collaboration with our respective physical therapy practices, across various settings, and for ourselves and our families. One published example of this is in the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine of the National Academies (The Future of Nursing: Leading Change, Advancing Health) report which states: “Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses.” We have discussed this legislation and our respective viewpoints based on personal and professional relationships, and agree that APRNs represent a pool of qualified professionals ready and able to meet increasing demand in Arizona for timely access to preventive and restorative healthcare services. We value and support legislation that will permit APRNs to practice to the full extent of their education and training. Respectfully,

Dr. Linda Duke, PT, DPT President AZPTA

http://www.aptaaz.org/

HAVE TO BE LIFTED"

#NursesCare4AZ

Date: October 15, 2015

Dear Members of the Arizona Legislature Committee of Reference: The National Association of Pediatric Nurse Practitioners (NAPNAP) has been the leading voice for pediatric nurse practitioners in America for over 40 years. As a division of this organization, the Arizona Chapter of NAPNAP works collectively to support advanced practice registered nurses (APRN) and improve the health of infants, children and adolescents in Arizona. I am writing of behalf of the leadership team from the Arizona Chapter of NAPNAP to support that advanced practice registered nurses (APRN) are a vital part of the health system of the United States. They are registered nurses educated at Masters or Doctoral level for practice in a specific role and with a defined patient population to provide basic and specialty healthcare services in a wide variety of settings. APRNs are prepared by education and certification to assess, diagnose, and manage patient problems, order and interpret tests and consult with other members of the healthcare team, as the condition of a patient requires. Where APRNs have received appropriate education and training, and qualified through certification, they should have consistent prescriptive authority aligned with their scope of practice. A large body of published research conducted by expert panels and government agencies has consistently demonstrated that the care provided by APRNs meets or exceeds established standards for quality. It has been our experience that APRNs provide safe and effective health care to children across our state. In the report of the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine of the National Academies (The Future of Nursing: Leading Change, Advancing Health), “Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses.” We agree that APRNs represent a pool of qualified professionals ready and able to meet the increasing demand in Arizona for timely access to preventive and restorative healthcare services for children. We value and support legislation that will permit APRNs to practice to the full extent of their education and training. Sincerely,

Daniel Crawford, DNP, RN, CPNP Legislative Chair Arizona Chapter of the National Association of Pediatric Nurse Practitioners

Arizona Chapter of the National Associationof Pediatric Nurse Practitioners

Dr. Daniel Crawford, DNP, RN, CPNP

"We agree that APRNs representa pool of qualified professionals

ready and able to meet theincreasing demand in Arizonafor timely access to preventive

and restorative healthcareservices for children."

November 17, 2015 Dear Committee of Record, As advanced practice nurses and advanced practice nursing faculty, we are urging the Health Committee of Reference as well as the entire legislature to approve the Sunrise Application that amends Title 32-3106 Chapter 15 of Arizona Revised Statutes. This application aims to enlarge the scope of practice of advanced practice registered nurses (APRNs) in Arizona. In 2008, through the work of the APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee the Consensus Model for APRN regulation was developed. This document came about due to the fact that each state independently determines each APRN specialty’s legal scope of practice, the roles recognized, the criteria for entry-into advanced practice and the certification examinations accepted for entry-level competence assessment. This inconsistency of state laws creates a significant barrier for APRNs to easily move from state to state and has led to decreased access to care for patients. Furthermore, in 2010, the Institute of Medicine of the National Academies published a report entitled The Future of Nursing Leading Change, Advancing Health. This report listed 8 recommendations which include removing scope-of-practice-barriers, expanding opportunities for nurses to collaborative improvement efforts, and prepare and enable nurses to lead change to advance health. Shortly after the publication of the Future of Nursing report, the Robert Wood Johnson Foundation and AARP began a Campaign for Action to the promote recommendations in these reports. The National Council on State Boards of Nursing (NCSBN) also created the Campaign for Consensus, an initiative to create uniformity in the laws of all states to permit advanced practice nurses to practice to the full extent of their education and training. As advanced practice nursing educators/practitioners at the University of Arizona, we adhere to the goal that all of the advanced practice nursing specialties prepare advanced practice nurses at the doctoral level of education. This level of education education includes hundreds of hours of supervised practice in the clinical setting as well as 3 years of didactic preparation. In addition, we are responsible for preparing all advanced practice nursing students to successfully complete a certification exam in their specialty which psychometrically demonstrates competency as an advanced practice nurse. The quality and cost-effectiveness of APRN delivered care has been studied repeatedly and shown to be of high quality and at lower cost. As a result, it is crucial that in today’s healthcare environment that APRNs be able to have practice barriers removed which will then enable state’s to improve access to care to quality care at lower health care costs. This Sunrise application to enlarge scope of practice of advanced practice nurses will undoubtedly be of great benefit to the residents of Arizona. Sincerely, Allen V. Prettyman, Ph.D., FNP-BC, FAANP Clinical Associate Professor Director of Practice Innovations FNP Specialty Coordinator [email protected]

1305 North Martin Avenue P.O. Box 210203 Tucson, AZ 85721-0203 Tel: (520) 626-6152 Fax: (520) 626-2669 www.nursing.arizona.edu

"As Advanced PracticeNursing Faculty, it is

crucial that APRNs beable to have practice

barriers removed whichwill then enable Arizona

to improve access to care"

#NursesCare4AZ

Dr. Allen V. Prettyman, Ph.D., FNP-BC

Fellow, American Academy of Nurse Practitioners

University of Arizona College of Nursing

Director of Practice Innovations

10/14/15 From: Kelly M. McCormick

Arizona Anesthesia Solutions (AzAS) Practice Administrator To: Senate Health and Human Services Committee

Chairwoman: Nancy Barto

Members: David Bradley, Katie Hobbs, Debbie Lesko, Lynne Pancrazi, Kelli Ward (Vice Chair), Kimberly Yee

House Health Committee

Chairwoman: Heather Carter

Members: Paul Boyer, Dr. Regina Cobb (Vice Chair), Dr. Randall Friese, Jay Lawrence, Eric Meyer

All Interested Legislators in Arizona

Dear Legislators, I’m writing to you today as the administrator of an anesthesia business that services facilities, surgeons, and dentists throughout Arizona. Our anesthesia staff consists of both Certified Registered Nurse Anesthetists (CRNAs) as well as board-certified physician anesthesiologists. While both of these professions deliver excellent anesthesia care, the statute concerning CRNAs is not only outdated, it also affects my business’s ability to give anesthesia care in a safe and accessible fashion. The current language is obsolete to the delivery of anesthesia. When an anesthesia provider is delivering the anesthetic, they are the only person in the operating suite with any formal training and education in the field of anesthesia. The same is true of all our our anesthesia providers – neither our CRNAs or our anesthesiologists are “directed” by the surgeon, nor could the relationship between CRNAs and surgeons in any way be construed as “direction.” CRNAs and anesthesiologists possess a similar knowledge base and act in the same role when delivering anesthesia – they are the sole expert in anesthesia management, airway management, and hemodynamic control. The surgeon is the expert in their procedure, and while we are responsible for the same patient, our areas of expertise are very different. When surgeons are approached on this issue and read the current statute, their reaction is one of shock. That’s because anyone with surgical or anesthesia experiences realizes that no surgeon “direction” ever occurs, and they recognize that this language does not protect the public in any fashion, but rather, creates confusion about liability and responsibility for anesthesia and hinders access to care. The risks to patient care posed by keeping this outdated language are not theoretical. My company was recently approached by a Phoenix urology group to administer anesthesia for in-office procedures. Due to this statute, a two-week delay occurred before the surgeons and my anesthesia group could go into the office and deliver care. This statute is not just a patient care issue but also an economic one. My company has lost business because of the confusing, outdated, ambiguous language. Multiple studies have demonstrated the economic boon that results when reducing unproven, unneeded regulations for providers such as CRNAs. Free-market solutions, with reasonable restrictions and guidelines, are what will drive healthcare costs down for patients while ensuring they receive the highest quality of care. CRNA care is not a new phenomenon as CRNAs have been administering anesthesia since the late 1800’s. Their skill on the battle field is well-known among the armed forces, where CRNAs are the only providers of anesthesia care in forward-surgical hospitals, and often are required to administer two simultaneous anesthetics to patients with severe trauma. Taking that skill into the civilian sector, CRNA outcomes have been researched exhaustively and have been found, like their anesthesiologist colleagues, to have an outstanding record of safety.

From the front lines to the VA hospitals, Certified

Registered Nurse Anesthetists (CRNAs)

have proudly and courageously

provided anesthesia care to

enlisted men and women, officers, and veterans in all branches of the military, from World War I to the present.

Certified Registered Nurse Anesthetists: Honoring a tradition of caring for those who protect our nation.

January 24-30, 2016

Vietnam Women’s Memorial, Washington, DCCopyright 1993, Vietnam Women’s Memorial Foundation, Inc. Glenna Goodacre, Sculptor

c e l e b r a t e n a t i o n a l c r n a W e e k

847-692-7050 | ©2016 American Association of Nurse Anesthetists www.future-of-anesthesia-care-today.com

December 4, 2015 Arizona Legislature Arizona Senate and House Health Committees Capitol Complex 1700 West Washington Phoenix, AZ 85007-2890 Re: Advanced Practice Registered Nurse Sunrise Review Dear Members of the Arizona Senate and House Health Committee: On behalf of the American Association of Nurse Practitioners (AANP), our Arizona members, and the patients served by our membership, AANP welcomes the opportunity to provide comment during the Senate and House Health Committees’ sunrise review process for Advanced Practice Registered Nurses (APRNs), a group of health care providers to which Nurse Practitioners (NPs) belong.

Nurse Practitioners in Arizona are currently licensed to provide a range of health care services. Existing statute authorizes nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments, and prescribe medications. This scope of service is regulated under the exclusive licensure authority of the Arizona Board of Nursing, and has benefited the people of Arizona significantly.

In the years since the last licensure update for NPs, the state has seen tremendous growth in the number of NPs providing care across the state. In fact, the 2002 licensure changes resulted in a substantial increase of the NP workforce. According to the Arizona Rural Health Workforce Trend Analysis study produced by the Arizona Rural Health Office, there was a 52% increase in the number of nurse practitioners working in the state between 2002 and 2006, with the largest area of NP workforce growth according in rural counties. 1 Arizona’s Full Practice Authority practice environment for NPs continues to serve as an incentive for NP provider recruitment to the state. During the 2015 Colorado legislative session, the Colorado legislature noted that NPs from Colorado were relocating to Arizona because the state’s licensure laws were more closely aligned with NP education, national certification, and the National Council of State Boards of Nursing Consensus Model for Advanced Practice Registered Nursing regulation. 2

The American Association of Nurse Practitioners supports the APRN sunrise proposal as it will not alter the existing scope of services, scope of practice, or regulatory oversight for nurse practitioners in the state. The purpose of this proposal is to align language with the national consensus model for nurse practitioner licensure. Adopting the standardized language will help Arizona remain competitive in recruiting NP providers to the state, especially as more states adopt the Consensus Model framework and compete for provider workforce resources.

Additionally, there is compelling evidence to support the growth of Arizona’s NP workforce and ensure that patients

continue to receive full and direct access to nurse practitioner services. Recent studies have underscored that states

with licensure frameworks consistent with the Consensus Model have better access to health care services, improved

health outcomes, lower hospital readmission rates, and lower costs of care. 3,4,5,6

Adopting the sunrise proposal to align

language with the Consensus Model will help cultivate the state’s health care workforce and maintain the safe, high

quality of care nurse practitioners have been providing to Arizonans.

The American Association of Nurse Practitioners, along with our Arizona membership, respectfully asks that the Arizona

Senate and House Health Committee move forward the sunrise proposal to adopt the Consensus Model for nurse

practitioners. We appreciate the opportunity to provide comment on this process and its implication to care delivery. If

there are any questions regarding AANP’s comments, please contact our office at (512) 442-4262.

Sincerely,

Cindy Cooke, DNP, FNP-C, FAANP

President

American Association of Nurse Practitioners

1. Arizona Rural Health Workforce Trend Analysis. Retrieved February 3, 2012 from

http://crh.arizona.edu/sites/crh.arizona.edu/files/pdf/publications/Final_AHEC_WorkforceReport.pdf

2. Hearing on Colorado Senate Bill 15-197, Colorado State Senate Health and Human Services Committee, 2015 Regular Session (March

12, 2015)

3. Oliver GM, Pennington L, Revelle S, Rantz M. Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients.

Nursing Outlook. 2014 Nov-Dec;62(6):440-7.

4. Kuo, Y., Chen, N., Baillargeon, J., Raji, M. A., & Goodwin, J. S. (2015). Potentially Preventable Hospitalizations in Medicare Patients With

Diabetes: A Comparison of Primary Care Provided by Nurse Practitioners Versus Physicians. Medical Care, 53(9), 776-783.

5. Yong-Fang Kuo, Figaro L. Loresto, Jr., Linda R. Rounds and James S. Goodwin. States With The Least Restrictive Regulations Experienced

The Largest Increase In Patients Seen By Nurse Practitioners. Health Affairs, 32, no.7 (2013):1236-1243

6. Richards, M.R., & Polsyk, D. (2015) Influence of provider mix and regulation on primary care services supplied to US patients. Health Economics, Policy and Law, 2015 Oct;(7):1-21.

http://crh.arizona.edu/sites/crh.arizona.edu/files/pdf/publications/Final_AHEC_WorkforceReport.pdf

The32MinuteClinicsinArizonadailyhelpasignificantnumberofpatientsinprovidingquality,accessibleandaffordablehealthcareandourprovidersareexclusivelyAdvancedpracticeregisterednurses(APRN).APRNsconstituteavitalpartofthehealthsystemoftheUnitedStatesandarepreparedbyeducationandcertificationtoassess,diagnose,andmanagepatientproblems,orderandinterprettestsandconsultwithothermembersofthehealthcareteamastheconditionofapatientrequires.WhereAPRNshavereceivedappropriateeducationandtraining,andqualifiedthroughcertification,theyshouldhaveconsistentprescriptiveauthorityalignedwiththeirscopeofpractice.AlargebodyofpublishedresearchconductedbyexpertpanelsandgovernmentagencieshasconsistentlydemonstratedthatthecareprovidedbyAPRNsmeetsorexceedsestablishedstandardsforquality.Minuteclinicprovidersconsistentlyprovideexcellenthealthcareasdemonstratedbymanyqualityindicators.InthereportoftheCommitteeontheRobertWoodJohnsonFoundationInitiativeontheFutureofNursingattheInstituteofMedicineoftheNationalAcademies(TheFutureofNursing:LeadingChange,AdvancingHealth),“Nurseshavetheopportunitytoplayacentralroleintransformingthehealthcaresystemtocreateamoreaccessible,high-quality,andvalue-drivenenvironmentforpatients.Ifthesystemistocapitalizeonthisopportunity,however,theconstraintsofoutdatedpolicies,regulations,andculturalbarriers,includingthoserelatedtoscopeofpractice,willhavetobelifted,mostnotablyforadvancedpracticeregisterednurses.”IagreethatAPRNsrepresentapoolofqualifiedprofessionalsreadyandabletomeettheincreasingdemandinArizonafortimelyaccesstopreventiveandrestorativehealthcareservices.WevalueandsupportlegislationthatwillpermitAPRNstopracticetothefullextentoftheireducationandtraining.Respectfully,Pat Moore, MSN, FNP-C Arizona State Practice Manager, CVS/MinuteClinic One CVS Drive -100 SVD, Woonsocket, RI o:520-269-2750 | f:401.216-3344

Health is everything.

It's past time to update scope of practice laws for

Arizona's APRNs.

LESS

BUREAUCRACY.

MORE PATIENT

CARE.

#NursesCare4AZ

Photo: Dan Lovinaria

8403 Colesville Road, Suite 1550, Silver Spring, MD 20910-6374 240.485.1800 fax: 240.485.1818 www.midwife.org

November 25, 2015 TO: Members of the Committee of Reference and All Interested Legislators in Arizona I am writing on behalf of the American College of Nurse-Midwives (ACNM), the national professional organization representing the interests of certified nurse-midwives (CNM) and certified midwives (CM) practicing in the United States, to express support for legislation that will allow CNMs and other Advanced Practice Registered Nurses (APRNs) to practice to the full extent of their education and training. The sunrise application currently under consideration presents sound policy initiatives that will increase access to quality health care providers, control health care costs, and align advanced practice regulation with recommended national standards. Nurse-midwives are highly trained providers who earn graduate degrees and must pass a national certification examination to demonstrate mastery of ACNM's core competencies, which meet or exceed international recommendations for midwifery care. Nurse-midwifery practice encompasses a full range of primary healthcare services for women from adolescence to beyond menopause. Midwifery services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers. Decades of research indicate that services provided by nurse-midwives compare favorably to those provided by physicians. For example, in a recent systematic review of studies comparing midwifery care to physician care, researchers concluded that women cared for by CNMs compared to women of the same risk status cared for by physicians had lower rates of cesarean birth, lower rates of labor induction and augmentation, a significant reduction in the incidence of third and fourth degree perineal tears, and higher rates of breastfeeding.1 Moreover, a 2012 meta-analysis of midwifery outcomes as compared to labor and delivery care provided by physicians concluded that there was no difference in CNM versus MD care and, for some variables, that midwifery care demonstrated better outcomes. The study concluded that midwifery care "is safe and effective" and urged that midwives "should be better utilized to address the projected health care workforce shortages."2 Importantly, the midwifery model of care also results in significant savings in health care spending by appropriate use of expensive technology and reducing cesarean rates. This is particularly important to the state, given that Arizona’s Medicaid program covers approximately

1 Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nursing outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):1-22. 2 Johantgen M et al. Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians: A Systematic Review, 1990 to 2008. Women's Health Issues 22-1 (2012) e73–e81.

53 percent of all births in the state. ACNM estimates that in 2013 alone, if CNMs had attended all Arizona births to low risk women, the savings from reduced cesarean births alone would have amounted to nearly $6.4 million for Arizona’s Medicaid program and nearly $12 million for individuals with commercial insurance or paying out of their own pocket.3 A robust midwifery workforce would greatly improve the delivery of and access to women’s health care in Arizona while reducing the state’s health care expenditures. A modernization of the regulation of nurse-midwives would likely yield an increase in the midwifery workforce, as “the single best predictor” of the distribution of nurse-midwives has been shown to be the degree to which state policies “facilitated or restricted” practice.4 The proposals expressed in the sunrise application are vitally important policy initiatives with positive, far-reaching implications for Arizona’s health care workforce, maternal-child health outcomes, and health care expenditures. Now more than ever, the high quality care and lower costs associated with midwifery care matters. And perhaps more importantly, midwives matter to the mothers and babies of Arizona. Respectfully,

Jesse Bushman Director, Advocacy and Government Affairs

3 Estimate based on the cost of vaginal and cesarean births in “The Cost of Having a Baby in the United States,” available at: http://transform.childbirthconnection.org/reports/cost/ (cost figures inflated to 2013 dollars by the Medicare Economic Index). Estimate takes into account the percent of births covered by Medicaid, commercial and self-pay, as reported by the CDC at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm. Estimate assumes 80% of women are appropriate for midwifery care. 4 Eugene Declerq et al, “State Regulation, Payment Policies, and Nurse-Midwife Services,” Health Affairs 17 (1998): 190-200.

Are standing togetherwith one voice, saying:

MembersoftheArizonaLegislature:

Advancedpracticeregisterednurses(APRN)areavitalpartofthehealthsystemof

theUnitedStates.TheyareregisterednurseseducatedatMastersorDoctorallevel

forpracticeinaspecificroleandwithadefinedpatientpopulationtoprovidebasic

andspecialtyhealthcareservicesinawidevarietyofsettings.APRNsareprepared

byeducationandcertificationtoassess,diagnose,andmanagepatientproblems,

orderandinterprettestsandconsultwithothermembersofthehealthcareteamas

theconditionofapatientrequires.WhereAPRNshavereceivedappropriate

educationandtraining,andqualifiedthroughcertification,theyshouldhave

consistentprescriptiveauthorityalignedwiththeirscopeofpractice.

Alargebodyofpublishedresearchconductedbyexpertpanelsandgovernment

agencieshasconsistentlydemonstratedthatthecareprovidedbyAPRNsmeetsor

exceedsestablishedstandardsforquality.IthasbeenourexperiencethatAPRNs

providesafeandeffectivehealthcaretoArizonafamiliesinthecommunity.

InthereportoftheCommitteeontheRobertWoodJohnsonFoundationInitiative

ontheFutureofNursingattheInstituteofMedicineoftheNationalAcademies(The

FutureofNursing:LeadingChange,AdvancingHealth),“Nurseshavethe

opportunitytoplayacentralroleintransformingthehealthcaresystemtocreatea

moreaccessible,high-quality,andvalue-drivenenvironmentforpatients.Ifthe

systemistocapitalizeonthisopportunity,however,theconstraintsofoutdated

policies,regulations,andculturalbarriers,includingthoserelatedtoscopeof

practice,willhavetobelifted,mostnotablyforadvancedpracticeregistered

nurses.”

WeagreethatAPRNsrepresentapoolofqualifiedprofessionalsreadyandableto

meettheincreasingdemandinArizonafortimelyaccesstopreventiveand

restorativehealthcareservices.Wevalueandsupportlegislationthatwillpermit

APRNstopracticetothefullextentoftheireducationandtraining.

Respectfully,

StaceyPiccinatiWoods,CNM

ArizonaSectionChair

AssociationofWomen’sHealth,Obstetrics,andNeonatalNurses

National Association of Clinical Nurse Specialists 100 N. 20th St., Suite 400 Philadelphia, PA 19103

www.nacns.org [email protected]

November 25, 2015 To members of the Arizona Legislature: On behalf of the National Association of Clinical Nurse Specialists (NACNS) and the millions of patients who receive care from and supervised by Clinical Nurse Specialists (CNSs), I strongly encourage you to enlarge the scope of practice for Advanced Practice Registered Nurses (APRNs), including CNSs, that is consistent with their education and training, as outlined in the Sunrise Application submitted by the Arizona Nurses Association, the Arizona Association of Nurse Anesthetists, the Arizona Affiliate of the American College of Nurse-Midwives and the Arizona Nurse Practitioner Council. APRNs, including CNSs are a vital part of the United States health system. We are registered nurses educated at the master’s or doctoral level to practice in a specific role and with a defined patient population to provide basic and specialty healthcare services in a wide variety of settings. APRNs are educated and certified to assess, diagnose, and manage patient problems, order and interpret tests and consult with other members of the healthcare team as needed. Where APRNs have received appropriate education and training, and qualified through certification, they should have consistent prescriptive authority aligned with their scope of practice. A large body of published research has consistently demonstrated that the care provided by APRNs meets or exceeds established standards for quality. In its 2010 landmark report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine noted, “Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses.” APRNs represent a pool of qualified professionals ready and able to meet the increasing demand in Arizona for timely access to preventive and restorative healthcare services. NACNS strongly supports legislation that will permit APRNs to practice to the full extent of their education and training. Respectfully,

Peggy Barksdale, MSN, RN, OCNS-C, CNS-BC President National Association of Clinical Nurse Specialists

August 10, 2015 Esteemed Members of the Arizona Legislature, On behalf of the National Association of Hispanic Nurses, Phoenix Chapter, we strongly ask for your support of allowing Advanced Practice Registered Nurses (APRNs) to practice to their full scope of education and practice, in order to meet the health care needs of patients and their families throughout our state. The need for more primary care providers is especially critical in underserved and rural Arizona communities and this is a gap in health care that APRNs can fill. As you know, APRNs are a vital part of the health system of the United States. They are registered nurses educated at Masters or Doctoral level for practice in a specific role and with a defined patient population to provide basic and specialty healthcare services in a wide variety of settings. APRNs are prepared by education and certification to assess, diagnose, and manage patient problems, order and interpret tests and consult with other members of the healthcare team as the condition of a patient requires. Where APRNs have received appropriate education and training, and qualified through certification, they should have consistent prescriptive authority aligned with their scope of practice. A large body of published research conducted by expert panels and government agencies has consistently demonstrated that the care provided by APRNs meets or exceeds established standards for quality. It has been by experience that APRNs provide safe and effective health care to our patients and communities that we serve as a non-profit, professional organization. In the report of the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine of the National Academies (The Future of Nursing: Leading Change, Advancing Health), “Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses.” We agree that APRNs represent a pool of qualified professionals ready and able to meet the increasing demand in Arizona for timely access to preventive and restorative healthcare services. We value, need and support legislation that will permit APRNs to practice to the full extent of their education and training. Respectfully, Adriana Perez, PhD, ANP-BC, FAAN President, Phoenix Chapter National Association of Hispanic Nurses

FROM: Aaron Ketcher, DNP, CRNA, President of Anesthesia Consultants of ArizonaTO: Senate and House Health Committee Members

My name is Dr. Aaron Ketcher. I am writing to encourage you to please support Arizona Nurses Associations Sunrise application, which will allow all Advanced Practice Registered Nurses (APRNs) to practice to the full extent of their education and training. Arizona’s current statutes and regulations are outdated and unnecessary. The Nurses Association is proposing a reasonable update that will increase access to affordable care to all of Arizona, but especially to the underserved rural communities.

I currently have extended family spread across Arizona’s rural communities. They rely on these APRNs to give them the health care they need. In the Phoenix and Tucson metro areas if it were not for the large number of APRNs not only would patients have long weight times to get needed care but also health care prices would be drastically higher.

I am a Certified Registered Nurse Anesthetist (CRNA) and I own and operate my own anesthesia company. I provide anesthesia services throughout Arizona in both medical and dental offices, surgery centers, and hospitals. Many of the procedures that I provide anesthesia services for are not covered by health insurance. If it were not for the affordable care I provide, these patients simply would not be able to receive the care they need.

One obstruction that I have in growing my business is that many physicians are concerned that they are somehow liable for my services because of outdated statutes that state they must direct the anesthesia. None of the operating practitioners I work with (surgeons, dentists, or physicians) have any formal training in anesthesia. It does not make sense that any physician, untrained in anesthesia, would required to direct another provider who is an expertly trained anesthesia provider.

It is important, as we continue to grapple with fixing this country’s health care problem, that we use every member of the health care team to their fullest potential. In Arizona we are handcuffing APRNs of all specialties and not allowing them to provide the care they are trained to provide. Let me assure you that all APRNs function as part of a health care team, but within that team they should be able to utilize all of their training. Every increase in scope of practice that the Nurses Association is asking for is already a standard practice in multiple states across the country. In those states, APRNs are functioning safely within these capacities, and have for decades.

I ask you to support the Nurses that Care for Arizona, and remove this harmful and outdate verbiage. Thank you for your service to our beautiful state, and for your time.

Respectfully and Professionally,

Aaron Ketcher, DNP, CRNAPresident, Anesthesia Consultants of Arizona

CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNAs) At a Glance

CRNAs are highly valued in today’s healthcare environment because they deliver the same safe, high-quality anesthesia care as other anesthesia professionals but at a lower cost, helping to control rising healthcare costs.

Nursing Economic$

CRNAs deliver essential healthcare in thousands of communities and are able to prevent gaps in access to anesthesia services, especially in rural, inner-city and other medically underserved areas of the country.

CRNAs consistently deliver upon their main mission – to achieve a safe anesthesia experience and quality outcome for each patient.

Health Affairs

CRNAs are highly educated, advanced practice registered nurses who deliver anesthesia to patients in exactly the same ways, for the same types of procedures and just as safely as physician anesthesiologists. CRNAs are well prepared to respond appropriately in emergency situations.

The patient and patient care team count on CRNAs to fulfill many roles and responsibilities that contribute to excellent patient care.

www.future-of-anesthesia-care-today.com


A Division of the National Academies of Science

MEDICINEThe Institute of