Vermont Legislature SmartTranscripts:

[Speaker 0]: Hi, welcome back. Said it would be either five or

[Alyssa Black (Chair)]: thirty, then here it is. So we have our next witnesses in. Thank you for coming a little bit earlier. We knew you were in the building though. You're advocating today and we've asked you to come in because of the important role that you play in our system of health care state. So just wanted to give you the opportunity to introduce yourself and tell us anything you'd like to tell us. Excellent.

[Toneal Critchlow, CRNA]: Well, thank you for having us. I'm Toneal Critchlow. Daughter, not daughter, everyone's calling me daughter-in-law of Wendy. I have no idea. We are all certified nurse anesthetists, Dave Kaplan, Janine Parsons. We work in various hospitals across the state. We really want to come to you to talk to you about what we do so that you're informed. Some people really don't know what we do. Maybe we hand someone a syringe. If you watch our video that's playing in the card room, you'll notice that Dave and I are both in that video. And it's going to be broadcasted throughout Vermont, The goal is that people can get a little sneak peek into what we do because people aren't allowed in the Operating Room to check out our practice. So I have a doctorate degree, a doctor of nursing practice in anesthesia. I am a sole anesthesia provider at times at Cockley Hospital. All of the anesthesia providers are certified registered nurse anesthetists. We're licensed as a parents in Vermont. Sometimes I'm the only anesthesia provider in the hospital. But regardless, if there's a regular day in the Operating Room, we have four Operating Rooms, we have four or five nurse anesthetists, and we each take care of our

[Brian Cina (Member)]: own patients. You come in to

[Toneal Critchlow, CRNA]: have your gallbladder out, you get to meet me. Hopefully you don't have to, but if you do, I'll be there. We give you the medication that gets you off to sleep. We put breathing tubes in. We keep people safe on ventilators. Then at the end of the surgery, we wake them up, bring them to recovery so you can move on with your day. There are other things we do, such as labor epidurals. If somebody's having a baby and wants a little pain management, you need a colonoscopy, which almost everyone does, we're there for you for that too.

[Francis McFaun (Vice Chair)]: You don't drink the juice?

[Toneal Critchlow, CRNA]: We don't drink it. They don't let us drink it. We don't get to try, but we give. People might ask us what it feels like, we can't always stay, but we can give our best guess based off of our education. So we do give you those slides. We keep you safe and comfortable so you can have the procedures done, whatever it is that you need done at the time.

[Dave Kaplan, CRNA]: Dave Kaplan, I work at Northeastern Vermont Regional Hospital, also an independent Cina practice. There's six of us that work up there, I'm really proud of what we do. We do a lot of opioid sparing or opioid free anesthesia. Really focused on Opiates have their place. On the street isn't really one of them. And so we do use other means, other medications in order to help alleviate that, recognizing that Vermont's been through a lot with that. We provide local regional anesthetics. So we will do nerve blocks and various techniques in order to numb areas of the body so that you're not experiencing that discomfort from the beginning. But again, we do the full host of services just like Tania was describing up at Addison as well.

[Tania Parsons, CRNA]: I'm Tania Parsons. I work as a CRNA at University of Vermont and at Dartmouth Hitchcock. I work in the team model with, the physicians, the anesthesiologists. I think that one of the things that I can do working in the team model is be a patient advocate because I've been a nurse for so long, and get to know my patient and to be able to speak with my anesthesiologist or my physician that I'm working with that day to collaborate and come up with, like, the best plan for a patient for that day so that they can have the best outcome. I think one thing in medicine these days is people that are not familiar with health care and do not have an advocate are really in a golden rule spot. And I think that it is something that I take very seriously, and it's something that I can do for my patients.

[Toneal Critchlow, CRNA]: As far as bills that we are following, we work with Gail Zatz and her lobbying firm. So she helps us keep up to date on all the things that we really need to know. There is not a specific bill related to nurse anesthesia. I'm going to let you speak to a couple of the bills that we're interested in. But before we do that, I just want to let you know of something that's going on in the governor's office right now, because this has been something that's spoken about publicly. You may have heard of opt out. What does that mean? What's going on there? So all advanced practice registered nurses in the state of Vermont have the ability to work to the full scope of their education. That's been in statute since 2011. There is one limiting factor that prevents CRNAs from fully utilizing full scope of their practice. It's a CMS federal rule. That rule requires operating practitioner supervision of CRNAs. What does that mean? That means that the dentist, podiatrist or surgeon that we work with is listed on billing as the supervising provider. They don't want to be there. It's quite nonsensical because they're not trained in anesthesia. So why would they want to or be capable of supervising us? So in a way, Vermont has already opted out of that supervision requirement, but CMS explicitly requires the governor to write a letter saying we opt out of this. In addition to having full scope of practice, the governor has to write a letter to opt out of that one thing. So the governor is currently considering this very strongly. And part of the process, which could be a very short process, the governor is doing excellent due diligence and looking at all aspects of how this would impact care. Currently, they're at the final stage of consulting with the board of nursing and the board of medical practice. Each of those boards has an opportunity to provide their opinion on this matter. We know the Board of Nursing is supportive and we do not expect the Board of Medicine to be supportive. And that's not a requirement for the governor to proceed. But that's where we're at right now waiting for that. So in any way that you are interested, please reach out to us if you want more information on that. But interestingly enough, it doesn't normally go through any kind of legislative process. It's a letter from the governor. So I wanted to let you know because you may have been hearing about that, but that's what's happening with us.

[Francis McFaun (Vice Chair)]: Can

[Alyssa Black (Chair)]: I ask clarifying? Absolutely. So currently, right now, your name is on the claim and then there's your supervising physician or supervising doctor, their name, I'm assuming NPI and all of that on there. CMS requires, in order for that to stop happening and just have your name on claim, they require sort of a waiver from the governor saying we're opting out of that requirement, which would allow the removal of the supervising physician's name on the claim.

[Toneal Critchlow, CRNA]: Correct. The board of medical practice, you said, is not in support of this? The reason is that Janine expressed that she works in a team model. So there are some facilities that choose to require certified registered nurse anesthetist to work on a team with a physician anesthesiologist. And those are the facilities that are going to post something like this. Financial reasons are really the only thing that's really on the table that we can put any merit on. So in order to be prospective, we have to be working. Some hospitals need us to be working independently to pay one salary instead of two to do the job. And so that's where

[Alyssa Black (Chair)]: the opposition comes from. If you're a licensure, is it required that you have a supervising? And I realize that it's not.

[Toneal Critchlow, CRNA]: No, there's no supervision required

[Alyssa Black (Chair)]: at all. No supervision required. Okay, go ahead, So

[Karen Lueders (Member)]: am I hearing that the primary benefit for a facility I might say this wrong but the primary benefit for a facility to maintain a policy that a MD who is an anesthesiologist provide oversight for a nurse anesthetist, the primary benefit of that would be financial for the facility, not a safety issue for the patient, not a licensing issue, not a clinical standard.

[Toneal Critchlow, CRNA]: Yeah, and it's really, we support facilities doing what works best for them. And some facilities choose to be physician centric facilities, and that's really their option. That's their business model. And while that might not be best for the health care climate in Vermont, they have the ability to do that. So we're not looking necessarily to say, hey, facility, you should do this. We're saying, hey, at the facility that I work at, which is Cockley hospital, I'm not here representing them, but, I work in an independent model. And so one of the conditions of participation so the hospital can receive CMS funding is that all surgeons that come on board, all podiatrists and dentists have to sign on saying that they'll supervise us. And they say, I don't know how to do anesthesia. So why would I supervise? Your supervisor doesn't have

[Alyssa Black (Chair)]: to be an anesthesiologist. That's

[Toneal Critchlow, CRNA]: the crazy part.

[Karen Lueders (Member)]: Thanks for clarifying because I did not say that so that I understand better. You don't have to be

[Dave Kaplan, CRNA]: an anesthesiologist. What Sunil just mentioned there, it is tied for the full conditions of participation for facilities. So this addendum is tied to all CMS reimbursement for that hospital. That hospital does not maintain this supervision requirement, then they will lose the ability to receive CMS funding.

[Karen Lueders (Member)]: For all services. All services.

[Dave Kaplan, CRNA]: It is linked intrinsically to that. Thanks.

[Daisy Berbeco (Ranking Member)]: Hi, I was wondering two things. Has the governor written an opt out letter previously or would this be the

[Toneal Critchlow, CRNA]: first time? There's only one opt out letter that's ever required unless a future governor takes that back. So this is a sort of a simple ask. Number one, yep. It happens usually once per state and then it's done.

[Daisy Berbeco (Ranking Member)]: Yep. And then what additional expense is there in having a physician supervise a specialty? They don't know anything about that sort of. I understand each institution can run its own best practices as they wish. Having the opt out letter doesn't mean they can't do that. But if you do have the opt out letter, what do you say to the system if you don't have any idea?

[Toneal Critchlow, CRNA]: It's a really good idea. So anesthesia models vary widely. I work at Houghton Hospital. It's independent practice. So you have one provider writing anesthesia for one patient. Other facilities that require physician oversight by a physician anesthesiologist will have a physician anesthesiologist supervising possibly two nurse anesthetists. So that's three providers for the patient. So as far as how many states and how many hospitals in Vermont, how many anesthesiologists are employed, I know that at my specific facility, our salaries would increase by one to one point five million by hiring one physician to supervise us to do the same work with no increased safety, no generating, not generating any extra revenue. So that's at one facility in hospital or in the state. I'm sorry. But that much I know.

[Alyssa Black (Chair)]: Daisy has a question, but wait, hold on now, but her question isn't about this, but if yours is, then you can go first. Okay, my question You're up.

[Francis McFaun (Vice Chair)]: In the emergency room, the doctor prescribes some kind of a pain killer or whatever. Do you people administer that or does any nurse administer that?

[Toneal Critchlow, CRNA]: That's a great question. So whenever a physician prescribes a drug, that's not going to be something that we are typically giving. We don't, for all intents and purposes, follow orders. We basically write our own orders and give our own medications. So we aren't typically people who are prescribing for someone else to give a medication. I see a patient, I assess them, I give the drug of my choice. So it's very much an immediate assessment and immediate action. Because if I'm taking care of you, it's almost always because you're having a procedure. And so you are then under my care and anything that you need, whether it be breathing assistance, blood pressure assistance, anything like that, it all comes from me

[Dave Kaplan, CRNA]: Specifically to the emergency department. So if an emergency physician, emergency medicine physician is writing an order for a patient receiving med, then usually it's an ER nurse that's providing that medication to ER. Sometimes we're consulted to come down to our ER to assist with pain issues like broken ribs, we might do a particular block to the back, or they're having issues with a shoulder dislocation, we might go down and block their shoulder. We've been consulted on different things like that. But no, in general, aren't, like Daniil was saying, we're not executing another provider's order. I

[Tania Parsons, CRNA]: think it's important to stress that the CRNAs in Vermont are practicing, a lot of them are practicing rural areas, including Dave and Taneil. And it can be a hindrance for some surgeons to come onto a facility that have to take on the responsibility of this CMS requirement to say that they would actually be supervising. So I couldn't say for sure, but I'm assuming that there are providers that have not signed on because they do not want to take this on as a responsibility. So in the state of Vermont, which is very rural and needs practitioners, I think that this is something that, since it's only to do with billing specifically, it's not having to do anything with our practice, that it would be an easy thing for the governor to do to just open up some more doors. I'm assuming you're at specialized

[Alyssa Black (Chair)]: level

[Tania Parsons, CRNA]: up in the APRN. You are an APRN with higher level training with a specific training in anesthesia.

[Alyssa Black (Chair)]: I know that APRNs can practice independently in Vermont. Is there any other APRN level that requires supervision?

[Dave Kaplan, CRNA]: Not my understanding, and a lot of this is like when you get focused on your wheelhouse, right? From my understanding, this is a very particular condition that was written into the conditions of participation, a rule. It was really focused at anesthesia services. So I do not believe there's any additional CMS requirements for supervision on other APRN classes. However, that's

[Toneal Critchlow, CRNA]: a great transition, Representative Goldman's bill that essentially looks has moved to the Senate. You mind if I hop

[Brian Cina (Member)]: in and ask a question before you?

[Toneal Critchlow, CRNA]: Please do.

[Brian Cina (Member)]: Sorry, I'll make that It's important. I just want to make sure that we address

[Toneal Critchlow, CRNA]: That was going to be smooth already.

[Brian Cina (Member)]: So I want to hear from each of you a bit about racial disparities when it comes to pain management. We know that Black people experience significant racial bias when it comes to pain management? How are each of you making sure that you and those that you work with are bringing health equity into the treatment rooms?

[Toneal Critchlow, CRNA]: Absolutely. Janine mentioned being an advocate for the patient, and that is one of our biggest jobs because when we need a patient, we have about five to ten minutes to develop a rapport with that person. They don't come to the hospital for our care. They come for the surgeon. They just, I always just say, you just get me, right? You signed up for surgery with Doctor. So and so, and I'm going to be doing your anesthesia. I have a very short time to meet them, understand what their concerns are, alleviate any concern they might have, and develop a plan that works for them that is safe. And then I render them unconscious and unable to breathe on their own and protect themselves. And so regardless of who that patient is, I automatically feel that I need one. Obviously I need to care for them, but two, we need to be able to honor who they are and respect what their wishes were. And so in that covenant we make in that first five to ten minutes where they sign that permission slip or consent form to let me take care of them, I have to learn a lot about them and also have a plan. Like I mentioned, basically honors what their wishes are and honors maybe it's their heritage, whatever it might be. We know that certain racial or ethnic groups have different practices. So some people need to have extra people in the preoperative area. And we allow that to happen because for them, they need to have those four women with them. If somebody is telling me they're in pain, then they are in pain. And our assessments are based off of what I would say are a little bit different than when people are awake. So when people are under anesthesia, we are monitoring vital signs and the person's asleep. So typically when they're under my care, I don't get to ask that question. Are you in pain? I see blood pressure. I see heart rate and respiratory rate. And those are all the things that I target my anesthetic off of. Now, when I transfer that patient to the recovery room, I pass on all of those things to recovery room nurse and let them know where we are at. One of the most important things that we can acknowledge is all the biases we have and whether or not we're aware of those, the unconscious ones and the ones that we're conscious of. And so I think as nurses, first and foremost, we're educated on those things. And as providers, we learn more every day about all the different groups of people that we take care of and to treat each person as an individual and understand that because of their skin color or because of some of the things they've been through, they might be more sensitive. They might need extra care in certain areas and meeting them where they're at and asking them and like having that conversation upfront, What are your concerns? So as far as pain management specifically to answer your question, we use a lot of regional anesthesia so that most people have controlled pain, fortunately without opiates. But if there was a patient where I was worried that there might be some kind of bias on the recovery room nurses part, giving the medications personally, I would be checking in to ensure that that patient is getting the meds that they need and ensuring that the nurse's assessment is the same as my assessment. Because it is hard when I'm with them to be able to ask those questions. But in that covenant that we make that agreement, I carry that through and that they're awake and can advocate for themselves. So it's sort of hard to specifically answer that question because in what we do, I don't get to assess pain and medicate for that pain a lot of the time because the people are typically asleep.

[Brian Cina (Member)]: But when you make your plan with them.

[Toneal Critchlow, CRNA]: When you make your plan with them. That's where that all comes out, absolutely. And we absolutely know that different racial and ethnic groups are treated differently. And coming to the table, being aware of that, I think, is one of the biggest things that we can do. And then asking people, where are you at? Where's your pain? The other thing that we ask is what works for you? What have you had before that doesn't work for you? And that's something that I ask everybody, but certainly if anybody has concern, of where they're coming from, It's our job to ensure that that is heard and that's carried through the period.

[Dave Kaplan, CRNA]: It's meeting people where they're at. Even if you're coming in for an elective surgery, you are coming in to a lot of unknowns. And you may be acting chill, a lot of times there's a huge undercurrent of concern, of giving up autonomy, of meeting a stranger and you're putting a lot of faith in somebody you just met. And so I do take, I take more than my five to ten minutes. I've been told I'm a little bit slower in the CRNAs, but I'm like, this is my office. I've never met you before. This is my office time. I need to have a complete understanding of where you're at before we go to the you are asleep portion. So it's really about meeting people where they're at and making sure that you are meeting them.

[Alyssa Black (Chair)]: I think so. Sorry, go Oh, go ahead. I'm sorry. I think

[Tania Parsons, CRNA]: it's very important that you ask people what they want and what they're expecting, what do they have for questions for the anesthesia that you're going to be providing. Because during that preoperative time, that's when you're building a rapport with the patients as well. And just because we don't know each other, just simply asking them what they need, what they're expecting, what we can do for them. And then to speak on to Neil's point of when after they've gone off to sleep, we do rely on the vital signs to let us know what they need for pain control. And that sometimes is not enough, but in the recovery room, we're able to see them as they wake up. And then if we're, personally, myself, if I feel like my patient is having some issues, whether it be pain control or something else, we have time to double back on them before we go into the next case. If you're you just need to make sure personally, just to make sure that they're doing okay, they're getting the care that they need in the recovery room. And this is for any patient that I would have, even ethnicity, color, it doesn't matter. Just want to make sure that we're doing the right thing for them and doing everything that we can for them.

[Alyssa Black (Chair)]: I did want to talk about the bill that's here, and also, I believe, in the Senate. And then we really do need to pivot, too. It's really quick.

[Toneal Critchlow, CRNA]: Very quick. What is the level of supervision? Does the doctor actually go into the Operating Room with these? Well, whoever the provider is performing the surgery is the one who's supervising. So they're just automatically the person. So if someone is removing your toe because you have terrible diabetes, they're the person who's technically supervising us for billing.

[Dave Kaplan, CRNA]: From a CMS standpoint, they're supposed to stay readily available within the Operative Suite. So there's some guidelines as to how far away they can be and what else they can get into before their next case.

[Alyssa Black (Chair)]: Thank you. Did you want to really quickly just talk about the bill that's on our wall?

[Toneal Critchlow, CRNA]: So I'm not sure if it has moved to the Senate. Were Are we talking about H five sixty nine?

[Alyssa Black (Chair)]: Yes. Although I think there's Isn't there a companion bill in the Senate?

[Toneal Critchlow, CRNA]: Yes. It's acting like

[Alyssa Black (Chair)]: a bill, but it's What's

[Karen Lueders (Member)]: the number? Would you say?

[Toneal Critchlow, CRNA]: So H five sixty nine. That's Representative Goldman's bill. And really, what's interesting is as advanced practice registered nurses, we support our colleagues, support nurse practitioners and nurse midwives. We can't think of any circumstance where we would be the admitting provider. However, we can say that on a daily basis, nurse practitioners who are also APNs are the admitting provider functionally, and they have to seek a physician to sign a piece of paper. So these nurse practitioners are running the care, and there might not be a position there. So this bill addresses the fact that the a parent is actually doing the work and the job and is supervising the care of the patient without a physician present. So this just changes things to match what is actually happening. It's not a change in scope of practice or an increased scope of practice. So we support that.

[Dave Kaplan, CRNA]: H577, we are constantly dealing with pharmaceuticals, we recognize how hard it is for neighbors and our patients to be able to access care, to be able to get effective and safe medications at an appropriate price point. So we really appreciate that and support that.

[Alyssa Black (Chair)]: Stick around for five minutes. Yeah. Okay.

[Toneal Critchlow, CRNA]: That's what we're that we got to get to So, thank you for

[Dave Kaplan, CRNA]: room.