Move over eyeball wars, here come the sleep battles

COVID-19 forces Florida hospitals to hit the pause button on elective surgeries.

“Dr. Sleep” is the name of a 2013 Stephen King novel and follow up to the 1980s flick, The Shining. It could also be the title of the real-life fight over the delivery of anesthesia in Florida and who is authorized to do what.

Two Republicans are sponsoring legislation this year that strikes a requirement for certified registered nurse anesthetists (CRNAs) to put patients under without having to enter into written protocol agreements with physicians.

Cape Coral Republican Rep. Mike Giallombardo says striking the paperwork requirement will help improve access to health care and will keep highly trained nurses working in the state. But opponents say HB 257 is “scope creep” and will work to kill it.

“Scope of practice” is a term used to describe the duties and activities that health care professionals are permitted to perform.

There have been many “scope of practice” battles in the halls of the Florida Capitol. Pharmacists and physicians have tussled over flu shots, and dental hygienists and dentists have wrestled over the delivery of oral health care.

Former Senate President Don Gaetz coined the term “Eyeball Wars” and promised to once and for all settle the scope of practice battle between optometrists and ophthalmologists.

This year, there will be a battle over the administration of anesthesia, which is a lucrative business. The Senate counterpart to HB 257 has not been filed, but Sen. Blaise Ingoglia will sponsor the bill.

In Florida, there are three different anesthesia providers: anesthesiologists, CRNAs and anesthesiologist assistants (AAs), all of which have different roles and educational and training backgrounds.

CRNAs in Florida are required to practice under a supervising physician’s protocol. They can, under the on-site medical direction of a licensed physician or dentist, provide anesthesia to patients before, during and after surgery. CRNAs made a median salary of $195,610 in 2021, according to U.S. News & World Report.

AAs, meanwhile, work under the direct supervision of anesthesiologists in the same surgical or obstetric suites as the procedure being performed. According to Salary.com, the average anesthesiologist assistant salary in Florida is $164,962 as of Sept. 25, 2023.

Giallombardo says his legislation isn’t a “scope of practice” bill. CRNAs may — within the limitations set by the established protocol of the facility in which they are working — conduct pre-anesthesia evaluations, order and administer the anesthetic, monitor and interpret the patient’s vital signs, and manage the patient during surgery and in recovery.

His bill doesn’t change that. It deletes the requirement that the CRNAs have written protocols with supervising physicians.

“It’s not expanding scope, it is just simply removing that paper protocol, to make it easier, to make it more affordable, to make it more efficient, ” Giallombardo told Florida Politics.

Giallombardo and other proponents — including Director of the University of South Florida Nurse Anesthesiology Program, Michelle Canalea — also say the bill is necessary to help solidify the state’s workforce and to increase access to health care.

The Florida Hospital Association and the Safety Net Hospital Alliance of Florida released reports showing a pending nursing shortage and a physician shortage in the state.

Canale says many of the CRNA graduates trained at the College of Nursing are leaving the state. Of the 253 CRNAs who graduated between 2018 and 2023, 27% are working outside of Florida, many in states where autonomous practice is allowed.

Jacksonville health care lawyer and lobbyist Chris Nuland says he understands why the bill proponents are steering clear of the “scope of practice” description. “Legislators don’t like those words, because they know that they’re not going to get a consensus on the bill and it will be controversial. You will have the parties on either side coming at you. And there’s no way to win,” Nuland said.

But Nuland, who represents a number of physician specialty organizations before the Legislature and executive branches, does consider Giallombardo’s legislation a scope creep.

“They are, indeed, changing what a CRNA can do by removing the supervision and protocol with an anesthesiologist,” Nuland said. “Allowing somebody to perform a service independently is, in fact, allowing them to perform a new service.”

Meanwhile, AAs also will be looking to alter their governing statutes. Florida Academy of Anesthesiologist Assistants past resident Jeff Carroll told Florida Politics that AAs are also looking to update their governing statutes to better reflect today’s health care environment. Similar to Giallombardo, Carroll stressed that the yet-to-be-filed legislation is not a scope of practice expansion for AAs.

Nuland predicted the CRNAs would not support the AAs’ efforts.