North Carolina Department of Justice
North Carolina Department of Justice
North Carolina Department of Justice
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December 31, 1998

The Honorable James S. Forrester, M.D. North Carolina General Assembly Senate Chamber State Legislative Building Raleigh N.C. 27601-2808

RE: Advisory Opinion: Certified Registered Nurse Anesthetists; Nursing Practice Act, Article 9A, Chapter 90 of the N.C. General Statutes

Dear Senator Forrester:

You asked whether it is lawful for certified registered nurse anesthetists ("CRNAs") to provide anesthesia care without physician supervision. For reasons which follow, it is our opinion that it is not. Anesthesia care largely constitutes diagnosis of, or prescription of medical treatment for a human ailment, thus constituting the practice of medicine under the Medical Practice Act, (Article 1, Chapter 90, of the N.C. General Statutes). The statutory scope of practice for nurses, including CRNAs, specifically prohibits "prescribing a medical treatment regimen or making a medical diagnosis, except under supervision of a licensed physician." CRNAs may, however, assist dentists who are themselves permitted to use general anesthesia for dental patients.

CRNAs are licensed nurses who have completed additional training requirements, who have been certified by the Council on Certification of Nurse Anesthetists, and who maintain recertification through the Council on Recertification of Nurse Anesthetists. In most hospitals in North Carolina, nurse anesthetists work together with anesthesiologists as part of the anesthesia team; in smaller hospitals, CRNAs work under the supervision of the physician surgeon performing the operation. CRNAs often administer drugs and perform other skilled techniques as part of the anesthesia team and under the supervision of the anesthesiologist or surgeon. Many hospitals have standing protocols regarding the appropriate use of CRNAs. A CRNA may also assist a dentist who is authorized to use anesthesia or sedation as a part of the dentist's practice.

The practice of nurse anesthesia is governed by the Nursing Practice Act (Article 9A, Chapter 90, of the N.C. General Statutes) and the rules of the North Carolina Board of Nursing. The practice of nursing is defined in N.C.G.S. § 90-171.20(7) as follows:

The "practice by a registered nurse" consists of the following nine components:
Assessing the patient's physical and mental health including the patient's reaction to illnesses and treatment regimens;
Recording and reporting the results of the nursing assessment;
Planning, initiating, delivering and evaluating appropriate nursing acts;
Teaching, delegating to or supervising other personnel in implementing the treatment regimen;
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;
Implementing the treatment and pharmaceutical regimen prescribed by any person authorized by State law to prescribe such a regimen;
Providing teaching and counseling about the patient's health care;
Reporting and recording the plan for care, nursing care given, and the patient's response to that care; and
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