WASHINGTON – In a letter to the head of the Department of Veterans Affairs on Wednesday, hundreds of VA anesthesia doctors warned a proposal to let nurses practice anesthesiology without a doctor’s supervision could jeopardize patient safety.
The letter, signed by 265 doctors, asks VA Secretary Denis McDonough for an urgent meeting and to reconsider an initiative set in motion under the Trump administration to develop national standards that override state laws, potentially allowing nurse-only anesthesia care in VA facilities, which is not currently permitted in most states.
“We believe that lowering the anesthesia standard of care for Veterans is a risky solution in search of a problem that doesn’t exist,” the doctors wrote, arguing there is no shortage of VA anesthesiologists. “It is unfair for our nation’s Veterans to needlessly receive a lower standard of care than that provided to nearly all U.S. civilians.”
The plea came after three earlier letters from the Association of VA Anesthesiologists – one sent to McDonough and two to his predecessor Robert Wilkie – went unanswered, according to the doctors. In an email, VA press secretary Terrence Hayes confirmed the department had received Wednesday’s letter and said “leadership will respond appropriately.”
The Spokesman-Review obtained Wednesday’s letter along with the three previous letters, which had not been made public. All four letters invoke a VA whistleblower program called “Stop the Line,” which lets employees of the Veterans Health Administration go outside the chain of command to report patient safety concerns directly to the agency’s chief.
The letters are part of a long-running debate between physicians and other VA health care workers over the standards governing what care nurses can provide without a doctor’s supervision. The effort to adopt national standards that override state laws also is linked to the VA’s rollout of a new computer system that has caused a range of problems since it was launched in Spokane in October 2020.
In the wake of a 2014 scandal over long wait times at its hospitals, in 2017 the VA gave nurses broader authority in an effort to improve access to care, but nurse anesthetists were excluded from the change at the time.
Randall Clark, president of the American Society of Anesthesiologists, said that because anesthesia care involves urgent, high-stakes decisions based on a patient’s health conditions, the additional training and experience doctors receive can help prevent problems caused by a patient’s medications and health conditions.
“Keeping them safe during surgery, that’s our primary responsibility as anesthesiologists,” Clark said. “Taking the physician out of that equation can only harm veterans.”
Jimmie Watkins, who served as chief of anesthesiology at the VA medical center in Richmond, Virginia, until 2016, said because the average veteran has more health problems than those who didn’t serve in the military, they often require more complex anesthesia care.
“VA patients are older and they’re sicker,” Watkins said. “The sicker the patients you have, the more experience and training one needs in order to make sure that they can navigate the problems associated with anesthesia. Anesthesia’s not just like taking a nap.”
Groups representing VA nurses have a different view. Dina Velocci, president of the American Association of Nurse Anesthesiology, said in response to the doctors’ letter that setting new national standards will reduce costs and wait times and give veterans better access to care.
Removing barriers for certified registered nurse anesthetists to treat patients “has allowed our nation’s facilities to maximize their workforces and increase access to care for patients, particularly during the pandemic,” Velocci said in a statement, adding that letting nurses “practice to the full extent of their education, certification and licensure” will help VA facilities meet veterans’ needs “now and in the future.”
After nurse anesthetists were excluded from the 2017 rule change, former Veterans Health Administration chief Richard Stone issued a memo in April 2020 – in response to the COVID-19 pandemic – “strongly” encouraging VA facilities to change their bylaws to let nurse anesthetists work independently.
Washington and Idaho are among 18 states that already gave nurses that authority, according to the Congressional Research Service, but the doctors’ letter expresses concern that the new national standards could force VA hospitals in every state to change their standards to the “lowest common denominator.”
In November 2020, the VA published a proposed rule on the Federal Register, where it received more than 13,000 public comments, that would make the change in Stone’s memo permanent.
Doctors and nurses associations have sent competing letters to McDonough on the VA effort to develop national standards, with the American Medical Association and more than 100 other physicians groups in July calling on the agency to make the process more transparent and address concerns about lowering care standards for veterans. In October, 34 nurses associations sent a letter in support of the project.
Hayes, the VA spokesman, said in a statement the department will give state medical licensing boards a chance to weigh in on new proposed standards, which also will be published to the Federal Register for public comment. He emphasized that developing national standards “will not change the way most VA health care professionals practice health care” and will not allow anyone to work beyond their training, experience and skill.
“In most cases, VA is adopting standards that are consistent with current State requirements,” Hayes said in the statement, “and will only deviate to the extent necessary to effectively furnish health care services to Veterans.”
The effort to develop national standards of practice, and the resistance it has met from some health care providers, mirrors the VA’s adoption of a new electronic health record system that has been piloted at Mann-Grandstaff VA Medical Center in Spokane since October 2020. That computer system has disrupted care and left staff exhausted and demoralized, a Spokesman-Review investigation found in December.
The two projects are also linked, although Hayes said the new standards are not a direct result of the rollout of the new record system, which is scheduled to gradually replace the existing system VA employees use to keep track of patient information and coordinate care. The new standards, he said, will ensure “VA can maximize the implementation” of the new system.
“The new electronic health record emphasizes the need to move this work forward to assure we have a seamless standard of practice across our health care system and continuum of care,” Hayes said, emphasizing that the effort to adopt national standards would take place regardless of the new computer system.
The new VA standards of practice have not gone into effect and there will be a public comment period once the proposed changes are published in the Federal Register.
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