On behalf of the Virginia Society of Anesthesiologists, we respectfully offer the following comments in connection with the Notice of Intended Regulatory Action (NOIRA) filed September 5, 2012 regarding the Regulations Governing the Practice Sedation and Anesthesia Permits for Dentists. 

            Certified Registered Nurse Anesthetists (CRNAs) are subject to joint regulation by the Boards of Medicine and Nursing.  Paragraph D of 18VAC90-30-120 provides as follows:

D. A certified registered nurse anesthetist shall practice in accordance with the functions and standards defined by the American Association of Nurse Anesthetists (Scope and Standards for Nurse Anesthesia Practice, Revised 2005) and under the medical direction and supervision of a doctor of medicine or a doctor of osteopathic medicine or the medical direction and supervision of a dentist in accordance with rules and regulations promulgated by the Board of Dentistry. (Emphasis added).

It should be noted that all medical doctors receive training in anesthesia.  Even a doctor who is not an anesthesiologist receives critical care training, including advanced resuscitation techniques.  Moreover, Virginia regulation, 18VAC85-20-320, requires doctors providing office-based anesthesia to abide by a number of requirements, including:

• Perform a pre-anesthetic evaluation and examination or ensure that it has been performed;
• Develop the anesthesia plan or ensure that it has been developed;
• Ensure that the anesthesia plan has been discussed and informed consent obtained;
• Ensure patient assessment and monitoring through the pre-, peri-, and post-procedure phases, addressing not only physical and functional status, but also physiological and cognitive status;
• Ensure provision of indicated post-anesthesia care; and
• Remain physically present or immediately available, as appropriate, to manage complications and emergencies until discharge criteria have been met. (Emphasis added).

Additionally, 18VAC85-20-330 requires that “doctors who utilize office-based anesthesia shall ensure that all medical personnel assisting in providing patient care are appropriately trained, qualified and supervised….” (Emphasis added).

            The VSA is concerned with proposed changes to 18 VAC 60-20-110 (Requirements for a permit to administer deep sedation/general anesthesia).   Section E of this regulation, which is all new language, states:

A dentist not qualified to administer deep sedation and general anesthesia shall only use the services of a dentist with a current deep sedation/general anesthesia permit or an anesthesiologist to administer deep sedation or general anesthesia in a dental office. In a licensed outpatient surgery center, a dentist not qualified to administer deep sedation or general anesthesia shall use either a permitted dentist, an anesthesiologist, or a certified registered nurse anesthetist to administer deep sedation or general anesthesia.  (Emphasis added).  

The last sentence suggests that CRNAs do not have to be supervised in the outpatient surgery setting, which is clearly contrary to Virginia law. 

            The VSA supports current regulations contained in Regulations of the Board of Dentistry dealing with Anesthesia, Sedation and Analgesia, 18VAC60-20-107 et seq.  In particular, we support the educational requirements provided in 18VAC60-20-110 setting forth the training requirements to administer deep sedation/general anesthesia.  We further support the provision set forth in 18VAC60-20-110-B that permits a dentist who has fulfilled the training requirements in subsection A to employ the services of a CRNA.  That level of training for the dentist gives true and appropriate meaning to the principle of medical direction and supervision of a CRNA as is required by Virginia law and regulation.  A practitioner who does not have appropriate anesthesia and critical care training and experience cannot provide adequate medical direction and supervision to a CRNA.

We hope that any proposed revision to the regulations is consistent with this important principle and complies with applicable law and regulation.  In particular, we ask the Board to amend 18 VAC 60-20-110 Section E to make clear that CRNAs can only operate under the medical direction and supervision of a doctor of medicine, a doctor of osteopathic medicine or a dentist, even in the outpatient surgery context.

            The VSA respectfully submits that the interests of patients are best served by having skilled physicians or dentists supervising CRNAs.  This position has been amply borne out by decades of actual experience.