Health 1M

Timeline of American Healthcare - date each

first hospital

AMA founded

BC

BS

Organ X

BCBS

Privacy

ACA

1758: First Hospital founded in Philadelphia, PA by Benjamin Franklin

1849: American Medical Association founded

1929: Blue Cross

1939: Blue Shield

1958: First Organ Transplant

1982: BCBS merger

1996: HIPPA

2010: Affordable Care Act (obamacare)

Colonial America

who provided

for what service mostly

Since immigrants included few classically trained physicians, healthcare was often provided by women, and it was mostly reserved for childbirth

What was colonial healthcare like?

3 no’s

No government regulation

No emphasis on public health (all individualized come as you go)

No preventative medicine

Early American Medical Advancements

first public health

population disparagy?

Continental Army and smallpox vaccine - first public health

Smallpox disparagingly affected African Americans (7X)

Civil war

battle vs disease = soldier deaths

what is changing? towards?

2X as many soldiers died due to disease than battle

We begin to see that healthcare is becoming more organized, hospitals became larger, medical education becomes more formal, and public health becomes increasingly important.

Perhaps the most important thing is that medicine begins to move towards a scientific model.

Civil war advances - 3

date

Advances include:

• Aseptic technique

• sterilization techniques (1860)

• antiseptic surgery (1965)

Who improved Army hospitals

A general and medical director

Under USSG Alexander Hammond and medical director Letterman, an ambulance and hospital system was developed

Industrial revolution

urbanization

labor unions

MD profession pushed for 3 things

urbanization = bigger need for public health

labor unions negotiated for members to receive healthcare benefits

Due to the need for specialization and technology, the hospital became the core of delivery of services

Physicians gained professional sovereignty and resisted socialized medicine

• Universal medical licenses became commonplace

• tremendous educational reform = AMA took over control of medical education

The Great War (WWI)

amputation rate and cause

who made dakins solution? 2

compared to what 2

solution composition? why b_ acid?

70% of amputations were due to gas gangrene because teams had no antiseptic

Outcomes improved so that 92% of battle wounded that reached hospitals survived

Henry Dakin: Protein/amino acid specialist who sought an antiseptic that could kill bacteria without damaging human tissue or white blood cells.

• Existing antiseptics such as *iodine and peroxide** killed bacteria but also damaged human cells and were quickly inactivated by amino acids.

Alexis Carrel: Prominent surgeon and Dakin's colleague who recruited Dakin to develop a better wound antiseptic.

• Together they developed *Dakin’s solution** = Sodium hypochlorite + boric acid + water.

• Boric acid: Buffers the solution to approximately pH 9–10, reducing tissue irritation, while also providing mild antiseptic activity.

Rise of private insurance

dallas did what? what structure? when?

x (state) medical association started what? when?

merged when?

The Baylor Plan (1929) - a Prepaid plan

• birth of private insurance

• Later renamed to Blue cross - helped with hospital coverage

1939, the California Medical Association started the Blue Shield plan - MD coverage

Merged in 1982 to become the bad@ss it is today

The Great Depression

what was made obvious?

why did gov have to step in?

What was signed in and by whom?

it did 3 things?

• Great Depression: Many people could no longer afford healthcare.

• Key pattern: Government involvement expands when private systems cannot adequately meet population needs.

Social Security Act of 1935 – signed by FDR as part of “New Deal”

• Social security, which decreased poverty among the elderly

• Unemployment insurance

• Aid to Dependent Children – assistance for children of single mothers

Post-world war 2

what was discovered? by who 2? when?

what else developed 4

Discovery of antibiotics was revolutionary

• 1945 – Florey and Fleming shared Nobel Prize for penicillin

Blood transfusions

medical specializations

improvements in anesthesia

Increase in employer-sponsored health insurance

1960’s

rising theme?

what act got an expansion? when?

Advances in science and technology, as well as specialized training in medicine and surgery led to many groundbreaking advances in healthcare and rise in $$$

Expansion of Social Security Act of 1935, leading to the Social Security Act of 1965 → laid the groundwork for Medicare and Medicaid

1980’s

COBRA? when?

Public Health of?

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

• COBRA: Allows eligible employees to temporarily continue employer-sponsored health insurance after leaving a job.

• The individual generally pays much more of the premium, making it expensive.

• Major benefit: prevents an immediate gap in health insurance coverage between jobs.

HIV awareness pushed more Public Health

1990’s - when for all

HSA?

privacy act?

CHIP?

• Health Security Act (1993) — Clinton

  • Address rising healthcare costs

  • Protect preexisting conditions

  • Require employer-sponsored insurance for full-time employees

  • ❌ Did not pass Congress

• HIPAA (1996)

• Children's Health Insurance Program (CHIP) - 1997

  • Health coverage for uninsured children <19

  • Targets families earning too much for Medicaid

  • Important correction: CHIP did not expand Medicare; it created/expanded coverage alongside Medicaid for children.

  • Bridging the gap for Medicaid ineligibility

2000s

Medicare expansion?

ACA?

• Medicare Modernization Act (2003) created Medicare Part D

  • Voluntary prescription drug coverage

• Affordable Care Act (ACA) — 2010

  • Major U.S. healthcare reform

  • Expanded access to health insurance

  • Required many employers to offer coverage

  • Established an individual coverage mandate

  • Prohibited denial of coverage due to preexisting conditions

Current

trend?

new frontier? 1

• U.S. healthcare spending

  • Higher administrative costs than other wealthy countries

  • Lower spending on long-term care

• Mental health & substance use disorders

  • Affect patients across all healthcare settings

  • Inadequate behavioral healthcare contributes to:

    • Substance abuse & overdose

    • Chronic and psychiatric illness

    • Medication interactions

    • Poor treatment adherence

Early Anesthesia

administered by whom?

outcome? reputation?

leading morbidity cause?

administered by nurses, students, and even janitors

Outcomes were poor → hypoxia reigned supreme and often was the reason that anesthesia as a service wasn’t widely accepted

Patient monitoring simply didn't exist. Came decades later

Anesthesia gained a reputation for being dangerous largely because of poor technique rather than because of anesthetic agents themselves.

The leading cause of anesthesia related mortality during this era was hypoxia.

Even today, hypoxia remains one of the most preventable causes of anesthesia morbidity.

“Ether frolics”

who discovered it but was an idiot? when?

nitrous oxide and ether were commonly used recreationally by medical students and surgeons, Participants noticed that people could injure themselves while under ether's influence without feeling pain.

“Ether frolics” were hosted even by esteemed physicians like Crawford Long, who used ether for surgical anesthesia in 1842 but did not report his work, thus it’s largely uncredited.

Ether Dome

who? when? where?

1846: William Morton famously administered surgical anesthesia with ether in an operating room in Mass General Hospital

Boston, Massachusetts

“Gentlemen, this is no humbug” since many thought anesthesia was a parlor trick, since many thought that anesthesia was just something that was made-up at this time.

Morton attempted to hide his method in order to profit from it

“Anesthesia” coined by?

coined by SCOTUS - Oliver Holmes

Morton Inhaler - other methods suck why? 2

alternatives to ether, why?

Techniques used in place of the Morton Inhaler were unsafe and resulted in patient injury

The use of chloroform became prevalent since techniques used to administered ether led to pneumonia

Anesthesia safety in 1800’s

Anesthesia, by any name, was not safe during the 1800s and careless anesthetists caused delay of progress in the field

Surgeons recognized that dedicated anesthesia providers produced better outcomes than rotating assistants.

“nurse anesthetists”

big revelation?

Used who and why? 2

Surgeons recognized that dedicated anesthesia providers produced better outcomes than rotating assistants.

Catholic nursing sisters became the ideal candidates. They’re subordinate and did not expect high pay

They were disciplined, they were detail-oriented, and they consistently presented

So this was at the time not physician delegated.

It was driven by these nurses and nurse anesthesia originated from demonstrative competence rather than legislative authorization.

“nurse anesthetists”

Catherine Lawrence

what war? when?

administered what to whom?

1862 - Second Battle of Bull Run (Civil War)

Catherine S. Lawrence administered chloroform to wounded soldiers

She had no monitors, limited medications, severe trauma, mass casualty situations, and yet she was still able to be recognized as an essential service and also pointed out that anesthesia as a practice was an essential service.

Military anesthesia continues to influence civilian trauma anesthesia today.

Sister Mary Sheridan

first what? where hospital? state?

how did it spread?

The first civilian nurse anesthetist

anesthesia care at St. Vincent’s Hospital of Erie, Pennsylvania

Bernard was influential among nuns and led to the training of nuns who were nurses being trained to administer anesthesia, primarily in the Midwest

The practice of anesthesia during this time was typically observed in Catholic hospitals

Professional growth occurred through mentorship in the 1800s, and it continues that way today.

St. Mary’s Hospital

where? when?

aka now?

Rochester, Minnesota

In 1889, St. Mary’s Hospital was opened by the Sisters of St. Francis, but was led by Dr. William Mayo

This hospital became known as The Mayo Clinic in later years

Dr. William Mayo is known for his advocacy for the use of nurses to provide anesthesia

His support was based on evidence, not professional politics.

Alice Magaw - aka?

administered what?

fatality rate?

No? 3

(1860-1928)

The Mother of Anesthesia

Worked at Mayo Clinic

In addition to a long history of very safe administration of open-drop ether, Magaw spent time documenting and evaluating all her clinical work

she never had a single fatality with over 14,000 anesthetics logged

• No artificial respirations

• No pneumonia from ether use

• No serious adverse outcomes

Perhaps the greatest example of clinical excellence came from one remarkable nurse anesthetist

While surgeons do their thing, she focused on the pt

Ether Drop

who’s technique?

what was the emphasis? 3

The Magaw Technique: Ether Drop

Always remember: The anesthetic is only as safe as the provider administering it.

Modern inhalational inductions still emphasize careful titration and airway observation (vigilance)

• Ether administration was slow

• Airway positioning was intentional

• Respiration was continuously observed

Safe anesthesia depends more upon vigilance than technology.

Agatha Hodgins

Dr. who took her in? when?

Administered what? through what?

Served in war? when? where? with what?

Came back when to open what institution?

Founded what association? when?

Dr. George Crile recruited and employed Agatha Hodgins as his personal nurse anesthetist

• 1911: Placed in charge of anesthesia by Crile

  • Pioneered the use of nitrous/oxygen

  • Delivered gas via a machine called the Ohio Monovalve

• 1914-5: Served in WW1 in France (N₂O use)

• 1915: Opened the first postgraduate program in anesthesia – The Lakeside School of Anesthesia

• 1923 – Founded the Alumnae Association of  the Lakeside School of Anesthesia  à eventually became NANA then AANA, finally

  • Professional organizations began because clinicians recognized the need for standardized education.

Growth and stagnation leading to WWI

which MD petitioned against us? when?

Who closed Lakeside?

What 2 cases overturned these dummies?

In 1916, a physician anesthetist, Francis McMechen, petitioned the Ohio Board of Medicine to prohibit nurses from administering anesthesia.

Initially, George Crile complied with the ruling by closing the Lakeside School of Anesthesia.

In the cases of Chalmers-Francis v Nelson and Frank v South, the courts affirmed that nurses could legally administer anesthesia.

First AANA meeting

by whom? 2

when? where?

under who’s supervision?

attendees?

Outcome? 2

Helen Lamb and Gertrude Fife planned the first national meeting, held in Milwaukee in 1933 under the guidance of the American Hospital Association, or the AHA.

Hodgins developed what would become the National Association of Nurse Anesthetists → first meeting was held at Lakewood and was attended by 40 anesthetists from 12 states

• Attempted to create a standardized anesthesia record (documentation)

• Formed Education Committee – chaired by Helen Lamb

  • Created educational standards for schools

Nurse Anesthetists during WW2

ratio of anes to md?

when = first exam? first male & racial AANA?

First combat male?

During WW2, nurse anesthetists outnumbered physician anesthesiologists 17 to 1

15M patients required anesthesia services and the gap for care was realized by the Army

The first certification examination was administered in 1945

AANA admitted its member of a racial minority in 1944 and its first male member in 1947

First combat male nurse commissioned in 1955 – he was a nurse anesthetist

Post WW2

MD started doing what? coined?

Physicians once again began to attack the right of the nurse anesthetist to practice anesthesiology

Coined term “anesthesiologist” in order to separate the history of physician from nurse accomplishments and to make those of nurse anesthetists diminutive in comparison

Their own training manuals and texts precluded mention of nurse anesthesiology practice, seemingly pretending that the field was new in the 1920s

there was no mention of historic NA work even at the Ether Dome

This is still going on today, even though we have literature and evidence that shows there is no difference in safety between the two providers.

1960s

AANA started what?

spear headed by whom?

the AANA shifted its focus towards strengthening education.

The association began formally accrediting nurse anesthesia education programs, requiring all schools to meet standardization criteria for risk closure.

Florence McQuillan, the first executive director of the AANA, was instrumental in these efforts.

Under her leadership, membership exceeded 10,000 from 40 people.

Meanwhile, the Social Security Act of 1965 increased the demand for anesthesia services, highlighting the need for additional qualified providers.

1970s

Commissioners of Education did what? when?

who spear head this change?

2 options?

AANA can focus on what now?

split again when? to what? 2

• 1974: U.S. Commissioner of Education changed guidelines requiring accreditation & certification to be independent of the professional organization (AANA).

  • Ira Gunn led the reorganization efforts that ended with autonomous councils for both accreditation and for certification

• ASA (MD’s): push for Faculty of Nurse Anesthesia Schools, to oversee CRNA educational programs, but was unsuccessful.

• AANA-sponsored councils: Councils on Accreditation and Certification won instead

• Result: allowed the AANA to focus more on legislation, lobbying & governmental affairs.

  • COAC: Establishes educational standards & accredits CRNA programs & credentials

  • 2007: NBCRNA established as an independent organization to take the credential role

John Garde

first to do what? when?

1976 – first attempt at gaining direct reimbursement for services by John Garde

This effort failed, but signaled that there was an increased need for federal governmental affairs in DC

1980s fraud

by whom?

what % of fraud?

whistleblower!

Ira Gunn reported abuse of the system where physician anesthesiologists were billing for services even when they were out of the hospital or even on vacation.

This included billing for more than two concurrences simultaneously → clearly not possible to be in two places at once.

25% of Medicare fraud and abuse cases were due to anesthesia billing

1980s reform - 2 efforts passed, when both?

TEFRA 2

PPS 2

Two federal efforts to control anesthesia billing were born as a result

• Tax Equity and Fiscal Responsibility Act (1982) – TEFRA → was to ensure that the anesthesiologist was providing services that he/she billed for

  • Seven stipulations must be met in order to gain reimbursement

  • a billing regulation, not as a clinical standard of care

  • TEFRA regulations remain highly relevant today because violations continue to be the basis of Medicare fraud investigations.

• Prospective Payment System - PPS (1983) – Move from cost plus service to pricing based upon diagnosis-related groups

  • Medicare paid hospitals a predetermined amount based on the patient's diagnosis (DRG), regardless of actual costs.

  • Hospitals were incentivized to reduce costs & improve efficiency.

Challenges of TEFRA

eliminated what? resulting in?

violations are a basis for what?

Although TEFRA was intended to prevent billing fraud, its implementation had unintended consequences.

Many institutions interpreted TEFRA billing requirements as mandatory standards of clinical supervision, and this misconception persists today.

• TEFRA eliminated passive supervision

In present day, TEFRA violations are commonly cited in whistleblower Medicare fraud cases

Challenges of PPS

unexpected result?

what 3 aren’t interchangeable?

solution? how many years later?

This change prohibited anesthesiologists to bill for CRNA work under Medicare Part B and essentially made it impossible for the anesthesia component of the bill to cover the cost of the CRNA.

Billing policy, scope of practice, and clinical standards are three separate concepts that are often mistakenly viewed as interchangeable.

After 3 years of effort and lobbying, President Reagan signed COBRA, which provided for nurse anesthetists to be the first nursing group to be eligible for direct reimbursement

1980’s AANA did what?

created a foundation for?

provided a new service for CRNA’s?

• 1981 – AANA Education and Research Foundation was established → renamed AANA Foundation in 1995

  • Presently issues scholarships, grants, and workshops for members and students in excess of $3.5M

• Beginning in 1988, AANA has provided liability insurance for CRNAs as a part of AANA Insurance

Liability standpoint

CRNA vs MD?

court rulings? latin phrase?

2

Traditionally, surgeons were the “captain of the ship”, but if surgeons bear the responsibility for the actions of the CRNA, then they would be more likely to favor the work of anesthesiologists, who will carry their own liability.

No surgeon has even been held liable for the actions of a CRNA

Courts instead assign liability based on the facts of the case: res ipsa loquitor

• Courts rejected the idea that surgeons are automatically liable for CRNA actions.

• Actual liability determined by each provider's actions, negligence & degree of control.

Civil Cases of 1980s

Bahn v NME Hospitals

Oltz v St. Peter’s Community Hospital

Hyde vs Jefferson Parish Hospital District No. 2

• Bahn v NME Hospitals (1985) - win

  • Bahn’s right to sue was challenged first, since he did not possess the same license, the law did not fit and he was not a physician competitor

  • On appeal, CRNAs could challenge exclusion under antitrust law.

• Oltz v St. Peter’s Community Hospital (1988) - win

  • Excluding CRNAs through anticompetitive conduct could violate antitrust law.

• Hyde vs Jefferson Parish Hospital District No. 2 (1983) - loss

  • An exclusive anesthesiologist contract was not found to violate antitrust law, although the Supreme Court stated there was no evidence that CRNAs provided lower-quality care.

1990’s: Clinton healthcare reform

what % reduction in reimbursement?

Clinton’s universal healthcare plan failed, but managed care became increasingly influential.

Healthcare shifted toward cost containment, efficiency, prevention & primary care.

Anesthesia providers experienced substantial decreases in workload/reimbursement (up to ~40%)

1990’s: CRNA reimbursement

Cost diff %: MD & supervised CRNA vs independent?

single payment? %/%

emphasis on the “notion”

GAO: Medically directed/supervised anesthesia could cost up to 140% more than independently provided anesthesia.

Single-payment system: total anesthesia payment = 100%, divided 50% CRNA / 50% MD.

AANA vs. ASA disagreed over this approach → worsened CRNA–MDA relations.

1990s = Managed care → ↓ costs/reimbursement → CRNA vs. MDA payment debate → “Do outcomes actually differ? obviously not”

Comparisons: Political Fuel

3 articles that attacked the “notion”

• Abenstein and Warner

• Silbur, et al

• Wiklund and Rosembaum

Despite the many studies conducted, there were multiple studies performed by MDs to follow that refuted these claims and these are the studies that are commonly used to lobby for the supervision of CRNAs

• Abenstein and Warner – authors claimed there were differences in case dep on the provider, but the actual researchers came to the opposite conclusion

• Silbur, et al – it was found on review that the conclusions they drew were not specific to staffing and that the type provider does not appear to be significant

  • JAMA and NEJM refused to publish bc of questions of objectivity → found to be politically motivated to influence readers to fight the removal of supervision

  • CMS dismissed all claims made by these authors

• Wiklund and Rosembaum – found to be totally irrelevant → they made false assumptions

Federal Supervision Regulation

who and when pushed for eliminating supervision?

which administration approved?

which administration overturned it?

compromise?

Early Ohio law requiring physician presence influenced Medicare’s federal CRNA supervision requirement.

1997: Health Care Financing Administration (HCFA) recommended eliminating physician supervision.

2000: Clinton administration approved CRNA practice without federal physician supervision, but

Bush administration: Delayed/reversed implementation following opposition → supervision requirement remained.

⭐ Compromise: OPT-OUT of federal Medicare physician-supervision requirement

• Important: Opt-out changes the federal Medicare requirement, NOT the state's individual scope-of-practice laws.

Results after opt-out?

“notion” disproved?

• Multiple studies found no negative safety impact after removing physician supervision.

• Dulisse & Cromwell: Opt-out states showed no increase in inpatient mortality or anesthesia complications.

• Institute of Medicine (National Academy of Sciences)

  • Recommended removing unnecessary barriers to APRN practice, including CRNAs.

  • Supported collaborative, team-based care.

• ASA produced studies challenging CRNA safety/efficacy findings.

The Doctoral Mandate

when was this idea introduced?

in what year did AANA support the transition? by when?

Beginning in the 1980s, leaders began advocating for doctoral preparation.

In 2007, the AANA board supported the transition to doctoral education and the Council on Accreditation, or the COA, subsequently required all entry-level nursing anesthesia programs to award doctoral degrees for graduates entering practice and stated that it must take place prior to 2025.

Concerns included educational costs, program length, faculty availability, and workplace implications. Despite these concerns, doctoral education has become the national standard.

CRNA Stats Today

AANA members?

age?

gender split?

race split?

median?

job satisfaction rate?

Work in all states and provide all types of anesthesia to any population in any setting

48,000 members of AANA

Average age is 48.6

58% female

91% identify as white/Caucasian

Median compensation $180,000

90%+ rate job satisfaction highly

Florence Henderson

master of what anesthesia?

• Worked alongside Hodgins at Mayo

• Preferred ether anesthesia → ether specialist

• Published in medical journals about her ether technique

• Presented her article at a medical conference

  • So the important lesson here is expertise becomes more valuable when it is shared.

Alice Hunt

Taught for who? what years?

master of what anesthesia?

• Learned open-drop ether technique then picked the skill of using an ether-nitrous blend.

• Appointed as instructor at Yale University School of Medicine in 1922, and then to asst prof in 1930

  • progression from clinician to educator.

• “Mastered nitrous oxide-oxygen anesthesia with closed circuit breathing, as well as avertin, ethylene, and cyclopropane”

Helen Lamb

First to do 2 things?

AANA and more?

• Trained at Lakeside School and then worked at Barnes Hospital as a thoracic surgery anesthetist → founded NA school at Barnes and was PD until 1951

• Administered first endotracheal anesthetic in the US and the first successful anesthetic for a pneumonectomy

• Founding member of AANA and served as chair of education committee that developed first standards for schools, served as President

Gertrude Fife

trained where? with whom?

AANA and more?

• Trained at Lakeside and was Hodgins' first assistant, then succeeded her as Program Director

• Founding AANA member who served as President

• Published the first AANA Journal and was editor

  • Professional journals allow clinicians to communicate new ideas, research findings, clinical experiences, and professional developments.

  • We need mechanisms for healthcare professionals to share knowledge with one another.

  • And that's how professions develop a collective body of knowledge.

Florence McQuillen

worked where?

AANA and more?

• Clinical work at Mayo Clinic

• Became first AANA Executive Director in 1948 and served until 1970.

• Influential in virtually every area of AANA growth and expansion, including the US government recognition of AANAs authority to grant accreditation for training and certification

  • a profession isn't defined solely by what its practitioners do clinically. It's also defined by education, accreditation, certification standards, regulation, and professional organizations.

  • We have the COA, the Council on Accreditation, the NBCRNA, the National Board of Certification and Recertification of Nurse Anesthetists, and the AANA, the American Association of Nurse Anesthesiology.

  • These systems establish expectations for competence, and they also help protect our patients.

    
    

Mildred Clark

First what?

• Joined the Army Nurse Corps in 1938 and then completed anesthesia training at Jewish Hospital in Philadelphia

• Stationed at Schofield Barracks when Pearl Harbor bombing occurred

• She consistently elevated from one leadership post to another, including serving as Procurement Officer for the USSG where she could still recruit nurses even in times of nation-wide shortage

• Was the first CRNA named as Chief of the Army Nurse Corps

• Her career shows that CRNAs have historically served in environments that require significant leadership and adaptability.

• Military healthcare often requires providers to function in resource-limited, high-pressure environments.

Olmsted and Shoemaker

what war? when?

significance?

• CRNAs serving in the Army during the Vietnam War

• Nov 30, 1967 - They were killed in action as a transport plane crashed into a mountain while moving them back to an evac hospital from a forward location

• First male Army Nurse Corps officers to die in war

• Their contributions remind us that our profession has historically extended far beyond a traditional hospital operating room, and these two men paid the ultimate sacrifice.

Anne Beddow

What war? First to do what?

First to be what?

• Attended St. Vincent’s School of Nursing (1st school in AL) then Lakeside School

• While serving in Italy in WW1, she developed the technique for administering thiopental IV for major surgery patients → used well into 20th century

• 1931 - Charter member and 1st President of the Alabama Association of Nurse Anesthetists → 3x pres.

• It's a historical connection to the development and protection of nurse anesthesia practice in Alabama.

Theresa Culpepper

past presidents of what?

Children’s of Alabama at UAB Hospital

Long-time faculty at UAB, she was a member of the founding faculty at Samford University

Past President of ALANA

President of AANA Foundation

Shannon Scaturro

COO for whom? 2 where?

president of who and did what?

• Currently COO for Cone Health

• Previously COO USA Health and as Dir of Periop Services at Providence Hospital in Mobile and at St Vincent’s Bham, where he was promoted from chief CRNA to a hospital-wide admin role

• Past President of ALANA → integral in the reimbursement of CRNAs by BCBS of Alabama

• This matters because it shows that CRNAs can influence

Terri Cahoon

• Professor and Chair, Department of Nurse Anesthesia, Moffett & Sanders School of Nursing

• Part of the inaugural faculty at Samford

• Fellow of the American Association of Nurse Anesthesiology (FAANA)

• AANA Foundation Advocate & contributing editor

• Clinical practice at St. Vincent's and Brookwood Medical Center

• Eventually, some of you may find yourselves on the other side of this classroom and you may become clinical educators, faculty members, program directors, researchers, or academic leaders.

Brad Hooks -

• ALANA President, 2025-26

• ALANA State Reimbursement Chair

• Faculty at UM

• pain management fellow

• Former owner of a pain service in Montgomery, AL

• They can be an educator, they can be a professional leader, and they can also be in the business of anesthesia with a practice ownership.

• Your career can evolve.

David Gay -

• ALANA Federal Political Director for AANA

• Past President of AANA

• Works clinically at Providence Hospital

• He also maintains clinical practice in South Alabama at Providence Hospital, so y'all will likely run into him in clinic if you haven't ever met him before now.

• He brings clinical experience into the policy environment.

• And that's exactly the type of perspective healthcare policy needs.

• Legislators don't understand what we do every day.

  • They need someone that can explain to them what a CRNA is and how we can provide safe anesthesia care for our patients so that we can then advocate for our profession.

  • Legislators and policymakers make decisions that affect how we practice, how patients access anesthesia, how providers are reimbursed, and how healthcare systems are structured.

  • If clinicians aren't involved in those conversations, other people will make decisions for us.

ALANA PAC -

• This is important because most CRNAs are in the OR while legislative decisions are being made that can affect our practice.

• And our professional PACs main purpose is to protect our practice so that we can keep taking care of our patients.

Accreditation - 3 benefits

the process of recognizing a person or organization as being qualified to perform a specific activity

Benefits:

• Homogeneity

  • There needs to be some consistency across programs.

• Assures minimum skills are present

  • if program has prepared that graduate to meet the minimal professional expectations necessary for safe practice

• ”Gate-keeps” profession

  • ultimately protects the public through standardized educational expectations.

History of Accreditation -

NANA → AANA → COA

• NANA

  • 1933 by Agatha Hodgkins

  • Established educational objectives

• AANA

  • just a name change

• COAC

  • 1975 is only body granted to accredit programs by US Department of Education (USDE) and Council for Higher Education Accreditation (CHEA)

  • Does all accreditation activities

A professional association has broader responsibilities to its membership and profession, where an accrediting organization evaluates educational programs against established standards.

Educational Changes over the decades

Certificate

BSN

MSN

Doctorate

Fellowship

• The CRNA credential was initially a certificate program

  • Shorter in length – often based in hospitals

  • Much of the education was ”hands-on” learning with less didactic preparation

• Then Bachelors into Masters (w/ BSN as prerequisite)

• Doctoral mandate

  • Required all programs to transition to a doctoral degree that can be DNP, DNAP, or PhD

• Fellowships

  • We've continued to grow our profession and our training beyond just the doctoral preparation.

Student Admission Standards - 3

3 main criterias:

• Bachelors or graduate degree in nursing, or an appropriate major

• An unencumbered nursing license to practice as an RN or APRN in the United States or its territories or protectorates

• A minimum of one year full-time work as a RN in a critical care settings

  (focus on independent thinking, assessment with monitoring & pharm)

Accreditation Standards - 8

• Must meet all standards for initial accreditation, which includes

1. admission criteria

2. curriculum

3. qualified faculty and support (must employ doctoral faculty)

4. adequate budget

5. appropriate clinical sites

6. acceptable case volumes

7. programs of evaluation

8. outcomes criteria monitoring

COA monitors 3 outcomes data

• (1) NCE statistics (first time pass rate only)

  • NCE pass rate must be > 80% over three consecutive classes

  • failure leads to monitoring and program remediation or accreditation reversal

• (2) attrition

• (3) graduate employment

Curriculum requirements

Must include 3 separate courses in

Curriculum must combine academic theory and clinical practice

Must include 3 separate courses in:

• Advanced phys/pathophys

• Advanced pharm

• Advanced health assessment

Must also include content in: equipment/tech, biochemistry, physics, professional issues, anatomy, chemistry, pain management, research, ultrasound, clinical correlation, etc

Additionally, doctoral level curriculum requires ethics, multicultural healthcare, health policy, healthcare finance, informatics, leadership, and management.

Doctoral education expands the CRNA's role beyond individual patient care into systems, leadership, policy, quality, and population level thinking.

Graduate Standards -

Be vigilant = no distractions

Perform comprehensive equipment check

Provide individualized, culturally competent care to all populations across the lifespan and in any setting for any procedure

Complete a comprehensive history and physical

Teach others

Act as leaders - begins as a student not when you’re chief CRNA

National Certification Examination

define

% CRNA vs MD that is certified

Graduating from a nurse anesthesia program and becoming certified are related, but they are not the same event.

The purpose of the NCE is to ensure that all CRNAs have met minimum criteria in order to practice clinically

• remember it’s a gateway to patient safety

100% of CRNAs in the United States are board-certified vs MD which is 75%

Passing does not mean that someone has mastered every aspect of anesthesia practice.

Board prep begins on first day of class

Provides data to evaluate training programs

NCE Makeup - 4 segments

%

%

%

%

25% of your exam will be basic science questions

30% will be general principles

30% will be advanced principles

15% will be equipment and technology questions (most missed)

CAT

Exam Length

how man experimental questions?

min-max questions

Variable-length computer adaptive test (CAT)

Three-hour maximum length

Each candidate will receive 30 non-graded pre-test items integrated randomly among their first 70 exam items

Minimum questions = 100

Maximum questions = 170 → beyond #100, all questions “count”

Question Formats - 6

You need to be comfortable interpreting images, performing calculations, identifying anatomical structures, and applying information to clinical scenarios.

1. Multiple Choice

2. Multiple Correct Response – these include select all that apply

3. Calculation – do not enter units!

4. Drag and Drop – similar to matching

5. Hotspot – place the indicator on a particular structure or part of the photo

6. Graphics/Video – used to augment the above question types

NCE Outcomes - 2

Two options:

• Competent

• Not competent

First time pass rate is quite high for a qualifying exam

Over the past few years there has been an upward trend with relation to first-time pass rate → presently it is 85.2%

how quality improvement works -

Think about pass rates as more than a student statistic. It's a quality metric.

We measure, we analyze, we identify opportunities, we intervene, and we re-measure.

Self Evaluation Examination - 3

The NBCRNA Self-Evaluation Examination (SEE) has three objectives:

1. To provide information to students about their progress in the nurse anesthesia educational program

2. To provide information to program administrators on how well their programs are preparing students with the knowledge they need for anesthesia practice

3. To prepare students for the National Certification Examination (NCE) experience.

Our program requires taking the SEE two times (predictive of NCE results)

SEE format - 2

• Similar to the NCE in makeup

• 240 questions for each examinee

• Presented one at a time, just like the NCE

• Four-hour time limit

What is different about studying for an exam like the CE compared with studying for a board examination is that it's broader content, there's cumulative knowledge, there's integration across subjects, there's application rather than isolated facts, and there's identification of knowledge gaps.

So the SEE is an opportunity to identify weaknesses while there is still time to correct them.

SEE Scores - 2

Currently at the end of year 2 a score of 430 predicts high chance of passing the NCE

At end of year 3 a higher score is required

If a cohort's C performance is consistently below benchmark, then a program can potentially identify a problem before students reach the NCE.

And that's quality improvement.

CRNA Demographics -

53,000 CRNAs

60.1% are female (91% RN’s)

90% of practicing CRNAs identify as white/Caucasian

• Hispanic or Latino are 4%

• Black are 3 to 4%.

• Asian or Pacific Islander are 3 to 7%.

Average age of the CRNA is 46.9 years

So the market for CRNAs will grow by nearly 38% by 2032.

Historical demographics -

Over time, the number of CRNAs has increased as the population of the United States and the need for services has increased

• One example is with the conversion of educational requirements from a certificate to a Bachelor’s degree, programs closed; then, with the requirement of a Master’s degree more programs closed

• By 1989, there was a large shortage in CRNAs due to program closures related to accreditation requirements

• This happened to some degree with the doctoral mandate, but some factors prevented a mass closure of programs

• 80% of rural anesthesia is provided by CRNA’s

Closure of Programs Publication -

So here in this piece of publication, she talks about a number of large academic centers closing their nurse anesthesia programs in the 80s.

And the reason cited here is that or rather the reason that she was told initially the official reason was that there was an increasing number of physician anesthesiology residents and the increased need for clinical resources to go to training those physician anesthesiology residents

Well, this publication goes on to tell you that plan backfired because there then weren't enough providers to provide anesthesia services.

And so they couldn't produce enough physician anesthesiologists to keep up with the growing need for patients and what patients needed as far as anesthesia services.

Historical demographics: Diversity -

Historically, diversity has not been a focus due to reasons beyond explanation here, but this is absolutely a focus of all three professional organizations on the national level

While diversity has increased a small amount, we, as a profession have a long way to go – particularly in our region

Well, that right there can be limiting depending on your upbringing, your socioeconomic status, what kind of support you have family wise.

Historically, CRNA candidates are from more often white backgrounds and more often they're usually first generation or sorry, are not first generation college graduates.

Historical demographics: Gender - 2

Over time, there has been an increase in the percentage of male CRNAs compared to female CRNAs, “masculinization.”

Wage gap → there is a disparagement between pay among males and females in almost any industry

The same article cited above reports that men have an increased imprint in administration, which pays more, and that women report working fewer hours due to family or personal commitments when compared to males

Barriers to CRNA training/education - 3

Gatekeeping of certain clinical experiences is the primary means of limitation of CRNA training and education

• In settings where physician anesthesiologists are supervisory, they are in a position that allows them purview over the assignation of clinical skill opportunities to trainees → it is not uncommon for students in some settings to have reduced opportunity for regional anesthesia and OB experiences

• Through the limitation of select experiences, physician anesthesiologists create barriers to the development of a CRNA that can practice at full scope.

Expense → I think we can all agree that this is a large barrier and likely limits increase in diversity due to the increased percentage of minority applicants that come from lower socioeconomic backgrounds

Time – the increase in program length to 36 months has far-reaching implications on the recruitment and matriculation of students

CRNA practice settings - 4

Typical settings for CRNA practice include:

• 62% - Practice as an employee of a healthcare system, organization, or facility

• 31% - Practice independently within a healthcare system, organization, or facility

• Academic setting/Education - professor

• Practice in an academic setting - precepting

Academic practice - 1

Requires doctoral degree to teach in most programs

COA requires DNP, DNAP, or PhD for service in an academic administrative role (PD/APD)

Workflow is much different than clinical practice

Typically, you are mentored into the role by another successful academician → from that point, your ”job” is what you and the program make of it

Schools/Universities have expectations that a certain portion of your time be spent among

• Teaching – includes preparation and delivery of course materials

• Service – can include clinical practice time, organizational service, etc

• Research – can include QIs, ROLs, newsletter publication, and true research

Administrative roles come with additional responsibilities

Clinical Practice in any setting - Large Hospitals - 4

There are similarities and differences among each of the possible practice locations and practice models that can greatly influence job and career satisfaction

Hospital – typically in this setting you will be providing anesthesia for a single patient at a time as a part of a group of anesthesia providers

• Main OR

• Outside the OR – includes radiology, cath lab, endo suite, MRI suite, ER, and patient care units as required

• Obstetrics – around the clock care provided to insure safe labor analgesia

• Critical Care Setting – act as active care agents or consultants

You can have a mix in the hospital setting of anesthesia providers.

• This also includes CRNAs providing anesthesia and OB services and in out of OR sites like MRI, radiology, endoscopy, the emergency room, as well as in critical care units to support patient care there with vascular support. meaning like providing IVs, providing central lines, providing other vascular access.

And then we're called to secure airways in the ICU as well because we are airway experts as CRNAs.

And if there's not an ENT available, you're up.

Clinical Practice in any setting - Rural Hospitals - 2

The size of the hospital can influence the type of anesthetics you provide → small hospitals typically provide general anesthetics and are of lower acuity, however there can be fewer resources in times of need or crisis

Larger hospitals come with full-service lines that require around the clock coverage

Everyone graduating will be trained to handle every scenario facing them independently

Clinical Practice in any setting – Surgery center

pt population

endoscopy vs orthopedics?

which practice model is prevalent?

is there oncall?

Surgery centers by nature have a lower acuity, Some surgery centers refuse to schedule patients of PS4 or PS5

• Because if those patients need or if they need to be admitted to the hospital, well, then you have to put the patient in an ambulance and have them transported to the hospital.

• If there's a possibility that they may get admitted overnight, those patients are just going to get sent to the hospital for their procedures in the beginning.

A tremendous amount of orthopedics, general surgery, ENT, and GYN surgery is performed in the outpatient surgery center setting

Endoscopy centers are classified as outpatient surgery centers

Multiple practice models are observed in the surgery center setting

The nature of the work requires for fast recovery, extubation, and room turnover

Often CRNAs in these settings work specific shift, as there is no call back in the large majority of surgery centers

Clinical Practice in any setting – Office Based

which practice model is prevalent? aka?

who does prescreening?

who can relieve you?

largest expense?

Office based anesthesia is in some ways the “wild west” → often CRNAs are independent anesthesia providers that work in a solo practice

The responsibility for all parts of the patient’s perianesthesia care falls upon the CRNA in this setting

• A preop clinic visit is typical → can be accomplished through telehealth or phone calls

  • preop workup/prescreening is done by CRNA

• Often there is no break relief in this setting

• Compensation is varied, but typically higher than other settings that do not require call responsibilities

Equipment is a large expense for this setting and sometimes CRNAs must use older or slightly outdated equipment and technology

Type of anesthesia can range from general, to regional, to sedation only

Minority report

investigation when?

findings?

There was a investigation, in 1999

So findings from this investigation revealed that racial and ethnic minorities receive substandard health care compared to non-minorities.

That some patients receive better care than others.

unconscious incompetence = stereotyping

Solution? - 1

Among those were that the number, let's say to increase the number of healthcare providers from racial and ethnic minority backgrounds.

Additionally, minority healthcare providers are more likely to serve in minority and underserved communities

Being cared for by someone who looks and speaks like them leads to increased satisfaction with care among patients.

And that leads to better patient outcomes in health disparities.

Rural Disparity: CRNA vs MD - 1

You have 91% of physician anesthesiologists that live and practice within these large metropolitan areas, meaning that only about 8% are in what we will speak more easily about as in rural areas.

But then you have only 81% of CRNAs that live in these large metropolitan areas, meaning that you have about 18, 19% of CRNAs living in those more commonly rural areas.

You've got CRNAs in more rural settings.

Jonas Salk

The physician associated with the development of the polio vaccine in the lecture.

Family and Medical Leave Act (FMLA)

Federal legislation enacted in $1993$ providing up to $12$ weeks of qualifying unpaid, job-protected family or medical leave.

Genetic Information Nondiscrimination Act (GINA)

Federal law enacted in $2008$ that provides protection against certain discrimination based on genetic information.