Maintaining high standards: from the past to the future

Kenneth M. Kirsner, JD, MS, CRNA

Professor of Nursing

Director, Nurse Anesthesia Concentration

Caylor School of Nursing


I am surprised at the vitriol directed at the NBCRNA when it announced its move to alter the recertification process.  Thirty one years ago this past summer I began my journey into the world of nurse anesthesia.  I was fortunate in receiving mentorship under the late Ira Gunn.  As many readers recognize, she was the creative mind behind the movement to the Council structure.
Roughly 40% of my career involved faculty roles in academic anesthesia programs.  The rest of the time I have been a clinician.  Regardless of my role, the need to advance knowledge was always at the forefront of my thinking, primarily because it provided a pathway to offer excellence and improvement in anesthesia care.  Additionally it afforded a systematic defense should one be drawn into the contentious domains of law and politics.  Why then have nurse anesthetists fought against a rigorous recertification process and testing?

I wonder if it is not the insular nature of our work.  We work behind the locked doors and red lines of the operating room.  We have special clothes and wear masks.  We sit behind a drape we refer to as the blood-brain barrier.  Although modern monitors conspicuously display minute to minute outcomes, commonly no one really knows what is happening with the patient but me.  We like to compare ourselves to airline pilots, but there often is no copilot, there are no black boxes, few checklists, rarely simulators, and in what was once the sterile cockpit, now noise conversation and distraction predominate.

Indeed our world has changed from a time past.  We now have electronic records, quality improvement and root cause analyses.  Infection rates are recorded as are all manner of complications.  Our anesthesia machine notes whether or not you performed a check.  Your monitors archive for the curious what the blood pressure was even absent an automated anesthesia record.  Our cellular phones list our conversations, texts and internet usage.  Credentialing, background checks and drug screening are the norm.  Checklists, procedural time outs AND infection control specialists who observe hand hygiene are ubiquitous.
When I present issues at anesthesia meetings regarding the standard of care, five years after CDC promulgated injection safety standards, four years after the Las Vegas debacle, two years after our association’s formal declaration syringe safety standards, I continue to encounter arguments about dividing propofol ampules or using small IV bags for administration of phenylephrine to multiple patients.  If the CDC, AANA AND ASA agree that best evidence mandates that providers adhere to a set of standards, than deviant practices that are known to injure patients should be abandoned. 
We need testing.  In the future, testing in a simulator will likely be mandated.  Recent entrants into the profession see this as the norm having been exposed to simulation in their training.  We must advance our profession or someone else will do it for us. Candidates for this include state and federal agencies, insurance companies, medical doctors and healthcare institutional administrators.
I would ask those who question the need for rigorous testing for recertification to consider something.  You plan to board a Boeing 777 bound for Paris.  You can choose between two airlines.  On one, the pilots recertify with a few hours at a continuing education junket where they may not even attend the lectures that they report, where there is little to no oversight of the speakers or entities providing the education.  The other mandates attendance, provides simulation and assesses the resultant learning and skillset.
Which do you choose?