Can a Certified Registered Nurse Anesthetist administer anesthesia in NC without a physician's supervision?

Plain-English summary

The North Carolina Attorney General concluded that a certified registered nurse anesthetist (CRNA) may not manage a patient's anesthesia without physician supervision. The opinion quotes the Nursing Practice Act's restriction on a nurse prescribing a medical treatment regimen or making a medical diagnosis without physician supervision. It says anesthesia management requires those activities.

The opinion also cites Board of Nursing rule 21 NCAC 36.0226. Although the rule lists activities a CRNA may perform, it says a CRNA "may not prescribe a medical treatment regimen or make a medical diagnosis except under the supervision of a licensed physician." The AG concluded that the rule does not eliminate physician supervision for anesthesia care.

The opinion identifies an exception under N.C.G.S. § 90-30.1 for dental practice. That statute authorizes dentists to use anesthesia or sedation under Board of Dental Examiners rules. A dentist authorized to administer anesthetics may be assisted by others, including CRNAs.

Currency note

This opinion was issued in 1998. Check current nursing, dental, and facility rules before applying its conclusion to present-day practice.

Common questions

Does the opinion allow a CRNA to provide anesthesia care independently?

No. It concludes that CRNA anesthesia care requires physician supervision because managing anesthesia involves prescribing treatment regimens and making medical diagnoses.

Do the Board of Nursing rules remove the supervision requirement?

No. The opinion quotes the rule's supervision limit and says its list of permitted CRNA activities does not remove that requirement.

Can a CRNA assist a dentist who administers anesthesia?

The opinion says yes if the dentist is authorized to administer anesthetics under N.C.G.S. § 90-30.1 and the applicable dental board rules.

Does the opinion define what physician supervision requires in practice?

No. It says supervision is required but does not specify whether the physician must be present, immediately available, or responsible for a particular number of CRNAs.

Citations

• N.C. Gen. Stat. § 90-18.2 (limits on nurse prescribing)
• N.C. Gen. Stat. § 90-30.1 (dental anesthesia authority)
• 21 NCAC 36.0226 (Board of Nursing CRNA rules)
• 21 NCAC 36.0226(b), (b)(1) (CRNA qualifications and physician-supervision limit)
• 21 NCAC 36.0226(c) (CRNA permitted activities)

Source

• Landing page: https://ncdoj.gov/opinions/certified-registerd-nurse-anesthetists-nursing-practice-act/

Original opinion text

[Excerpting the body of the opinion as preserved by the Sofya conversion. The opening date/addressee block was lost during markdown conversion.]

(7) The "practice by a registered nurse" consists of the following nine components:

a. Assessing the patient's physical and mental health including the patient's reaction to illnesses and treatment regimens;

b. Recording and reporting the results of the nursing assessment;

c. Planning, initiating, delivering and evaluating appropriate nursing acts;

d. Teaching, delegating to or supervising other personnel in implementing the treatment regimen;

e. Collaborating with other health care providers in determining the appropriate health care for a patient but, subject to the provisions of G.S. 90-18.2, not prescribing a medical treatment regimen or making a medical diagnosis, except under the supervision of a licensed physician;

f. Implementing the treatment and pharmaceutical regimen prescribed by any person authorized by State law to prescribe such a regimen;

g. Providing teaching and counseling about the patient's health care;

h. Reporting and recording the plan for care, nursing care given, and the patient's response to that care; and

I. Supervising, teaching and evaluating those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services. [Emphasis added.]

The Nursing Practice Act prohibits the prescribing of a medical treatment regimen or the making of a medical diagnosis by a nurse, except under the supervision of a licensed physician, and allows the implementing of the treatment and pharmaceutical regimes only when prescribed by others with legal authority.

The Board of Nursing has promulgated rules governing CRNA anesthesia care (21 NCAC 36.0226) (the "CRNA rules"). The CRNA rules delineate the qualifications that a CRNA must meet in order to engage in nurse anesthesia practice (21 NCAC 36.0226(b)) and define the activities constituting nurse anesthesia practice that only a CRNA may perform (21 NCAC 36.0226(c)). Among those activities are such things as selecting preanesthetic medication; selecting general and regional anesthesia modalities consistent with the client's need; recognizing abnormal findings and implementing corrective action; and managing the client's fluid, blood, electrolyte and acid-base balance.

While the list of permitted activities is broad, those activities are limited by a requirement that a CRNA "may not prescribe a medical treatment regimen or make a medical diagnosis except under the supervision of a licensed physician." (21 NCAC 36.0226(b)(1)). Management of a patients' anesthesia requires the prescription of medical treatment regimens and the making of medical diagnoses. The CRNA rules, therefore, do not eliminate the requirement that the anesthesia care of a patient be under the supervision of a physician.

An exception to the requirement that a CRNA be supervised by a physician is provided by N.C.G.S. § 90-30.1, which authorizes dentists to use anesthesia or sedation in their practices pursuant to rules promulgated by the Board of Dental Examiners. A dentist who is himself authorized to administer anesthetics may be assisted by others, including CRNAs.

signed by:

Ann Reed
Senior Deputy Attorney General

Gayl M. Manthei
Special Deputy Attorney General