Missouri CRNAs and the Missouri BNDD Terri L. Jackson, CRNA, DNAPc

GOOD MORNING!

The memo...

My Capstone The Clinical Practice Impact of Controlled Substance Policies for Missouri CRNAs Twelve question survey emailed to rural CRNAs members of MoANA. Inquired about how their practice has changed since the MHA memo was released. 138 people were emailed, 17 people responded to the survey (15 answered the entire survey, 2 partially answered).

Capstone Answer Highlights Equal split between hospital employees and CRNA-only group members. Most said that the letter hadn’t changed how they practiced. Controlled substances ordered during the perioperative period were from an established protocol. No resistance from surgeon about signing anesthesia order for controlled substances. The supervising physicians are signing the charts, which meets the requirement.

Capstone Answer Highlights (cont.) A couple interesting answers: “This is an ongoing issue for my group. In an attempt to expand our practice and get the contract for an ASC, there was an extensive discussion about supervision and controlled substances with the physician owners. The owners decided to go with an ACT model, in the end...” “It made practice slow and cumbersome with new protocols that added discrepancies in the chart…We are in desperate need of opting out of these supervison rules and establishing prescriptive authority in MO....”

Missouri and The BNDD The Bureau of Narcotics and Dangerous Drugs (BNDD) is required to maintain a registry of all persons and entities with the authority to conduct activities with controlled substances. They needed a more efficient and accurate system for tracking activities and authorizations. This included the need to move away from paper applications in order to move ahead in technology and make the registration process more seamless for health professionals. BNDD was working from a legacy system in which no application updates could be made due to the technology being obsolete.2,3

Who’s supervising our neighboring states? Oklahoma is the only other state with a BNDD. The Oklahoma State Bureau of Narcotics and Dangerous Drugs Control is a law enforcement agency with a goal of minimizing the abuse of controlled substances through law enforcement measures directed primarily at drug trafficking, illicit drug manufacturing, and major suppliers of illicit drugs. The following divisions make up the OBNDD: Diversion, Intelligence, Enforcement, and Human Trafficking.4

Other neighbors… Nebraska (2002), Iowa (2001), Kansas (2003), and Kentucky (2012) have all opted out. Illinois=Department of Human Services. Within that is the Bureau of Pharmacy and Clinical Support Arkansas=Pharmacy Services of Dept. of Health. Tennessee=Tennessee Board of Pharmacy.5,6

Federal requirements to opt-out… “For a state to opt out of the federal requirement for supervision of CRNAs, the state’s governor has to send a letter to to the Secretary of HHS requesting that the state opt out of the supervision requirement. The letter must attest: 1) The state’s governor has consulted with the state boards of medicine and nursing about issues related to the access and to and the quality of anesthesia services in the state; and 2) That it is in the best interest of the state’s citizens to opt-out of the current federal physician requirement; and, 3) That the opt-out is consistent with state law.” CMS believes governors are best suited to make this determination.6

The trouble with Missouri… Missouri does not meet the third requirement: “That the opt-out is consistent with state law.” Missouri las statute enacted under the physician chapter 334.104.7 which states in part, “… a CRNA as defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services without a collaborative practice arrangement provided that he or she is under the supervision of an anesthesiologist or other physician, dentist or podiatrist who is immediately available if needed...”(Mo Rev. Statute 33.104.7)7 Because this has already been legislatively approved and enacted in Missouri, CRNAs are required to follow the state law that requires supervision by a physician. Opt-out at the federal level, won’t change the state’s restrictions.7 Thus Missouri CRNAs would have to start at the very beginning of getting this law removed, or revised first, before we can begin to work on opting-out.

References: 1. https://www.moana.org/wp-content/uploads/2016/03/MHA-Memo-Prescribing-and- Administering-of-Controlled-Substances-by-CRNAs-3.pdf 2. https://www.nascio.org/portals/0/awards/nominations2012/2012/2012MO1- NASCIO_DHSS_MOHWORX.pdf 3.http://archive.org/stream/usbnddhistorybac00unse/usbnddhistorybac00unse_djvu.txt 4. https://www.ok.gov/obndd/About_OBNDD/index.html 5. http://www.nascsa.org/nascsa/stateProfilesALL_list.php. 6. https://www.aana.com/docs/default-source/sga-aana-com-web-documents- (all)/801-fact-sheet-concerning-state-opt-outs-pdf.pdf?sfvrsn=450743b1_6 7. https://www.moana.org/wp-content/uploads/2016/04/Opt-Out-Missouri-What-does-it- Mean_-Covillo-2014.pdf

Thank You!