My name is Michael D. Fallacaro. I am a certified registered nurse anesthetist (CRNA), Doctor of Nursing Science, Professor and Chair of the Department of Nurse Anesthesia at Virginia Commonwealth University. I appreciate the opportunity to offer my testimony to this committee regarding nurse anesthesia education and preparation, and how that translates into high quality health care for patients across the country. Nurse anesthetists take great pride in our history, our education, our practice, our contributions to the field of anesthesia, and our national association, the American Association of Nurse Anesthetists (AANA).

HISTORY OF THE EDUCATION AND PROFESSION OF NURSE ANESTHESIA

It was well over one-hundred years, dating back to the late 1870's, when surgeons began to invite nurses to come to their hospitals, learn how and provide anesthesia services for the purpose of enhancing the safety of anesthesia for their patients. These surgeons believed that the establishment of a nursing specialty in the field of anesthesia would resolve the problems of high mortality rates they associated with the occasional anesthetist-a physician, nurse, medical student, or anyone who happened to be free. Nurses responded to that call, and surgeons, both in their laboratories and the operating rooms taught the first nurses to become anesthetists.

Initially, the need for anesthetists was so great, that some of the more notable teams of surgeons and nurse anesthetists trained other nurses, physicians, and dentists in short courses of a few weeks or months. By 1909, the need for formalized nurse anesthesia educational programs was evident. By 1914, four such programs, each approximately six months in length, were in existence. These programs included both academic and clinical courses and were built on the applicable science known at the time. Their nurse applicants were graduates of professional nursing education programs. They usually had a few years of nursing experience, and held a nursing license or registration from the state. Both physicians and nurse anesthetists served as instructors in the academic and clinical portions of these programs.

Prior to World War I, the US Army and Navy sent nurses to these notable centers to be prepared as anesthetists based on projected military needs. Many nurse anesthetists signed up with the Red Cross, becoming Army or Navy nurses and accompanying these units to Europe. Nurse anesthetists gained a remarkable reputation for their service in WWI. They also trained other nurses and physicians as anesthetists in British and French hospitals during that war. World War I served as a major impetus to increase the number of educational programs for nurse anesthetists in the US, and programs were developed in numerous major hospitals and medical centers.

At this time, there were a few physician anesthetists who devoted their full practice to anesthesia. However, AMA did not recognize the anesthesiology medical specialty until 1940, about a half century after the nurse anesthesia specialty was formalized. At that time there were only 285 anesthesiologists devoting their full practice to the field. Of these only about 33% were certified in the specialty. Further, there were only 7 anesthesiology residencies of at least a year in length at the beginning of World War II According to a noted hospital historian, there were 17 qualified nurse anesthetists for every one anesthesiologist in 1942.

During the war, the military also undertook to prepare both physician and nurse anesthetists to meet their needs. While the war-time physician training program in the Army was four-five months in length, according to Dr. Robert B. Dodd, an anesthesiologist who had taken such training, the Army Nurse Corps configured their nurse anesthesia education program to meet the AANA's curricular standards when and where possible. These were six months in length. The Army prepared about 2,000 nurse anesthetists during World War II, including four Army nurse anesthetists who spent three years as POWs after the attack on the Phillipines. There were no anesthesiologists stationed in the Philippines at that time. Put simply, CRNAs have been an integral part of the nation's armed forces and tend to be the predominant anesthesia provider in combat situations.

EDUCATIONAL STANDARDS HAVE BEEN CONSISTENTLY HIGH

One of the primary aims for AANA upon its founding in 1931 was to assure the educational quality of nurses who would provide much of the anesthesia services in this country. Setting standards for the educational programs and developing a program approval system were the first critical undertakings of the AANA. During World War II, the AANA moved forward with its plans to develop an accreditation process for nurse anesthesia educational programs, and a national certification examination for nurse anesthetists. The first certification examination was given in 1945. A more formalized nurse anesthesia education accreditation program was developed and implemented in 1955. As science and technology advanced affecting the field of anesthesiology, the educational standards for these programs changed to accommodate such changes, as did admission requirements.

In addition to expanding the academic component, the clinical program was also expanded, growing to one year in length in the 1950s, expanded to 18 months in the 1960s, and in 1970, it was mandated that the programs be at least 24 months in length. Like anesthesiology residencies, most of the nurse anesthesia programs during this period were hospital based. Many nurse anesthesia educational programs co-existed with anesthesiology residency programs, using the same textbooks, and attending many of the same classes. This co-existence of nurse anesthesia education and anesthesiology residency training came about despite the American Society of Anesthesiologists adopting an ethical code stating that anesthesiologists that participated in the education and practice of nurse anesthetists were in violation of the ASA code of ethics.

The first graduate program to prepare nurse anesthetists within a University setting was initiated in 1969, awarding graduates of that program masters degrees and eligibility for certification. From the 1970s up to today, nurse anesthesia education has progressively moved from hospital-based certificate programs to University-Hospital cooperative programs at the baccalaureate level, until 1998, when all accredited nurse anesthesia programs had to be at the graduate level, offering at least a Master's degree.

A growing number of our programs have their own, or have access to anesthesia and critical care simulators where students can gain experience through simulation prior to entering the operating room and learning on actual patients. As educational technology changes the profession continues to make adjustments based on their value for application to our particular field, just as we modify the basic and advanced curriculum based on changes in the science and technology.

Today's graduate nurse anesthesia programs range from 24 to 36 months in length, depending upon the university. The typical applicant to the nurse anesthesia program is approximately 32 years of age, they must be a registered nurse possessing an undergraduate degree in science with a superior grade point average and must have scored well in the national graduate record examination. Additionally, applicants must possess at least one year of critical care hands-on professional nursing experience. Gaining admission to a nurse anesthesia program is difficult; many apply but acceptances are reserved for only the best and brightest. Once enrolled, graduate students enter a rigorous full-time program of study. Coursework includes Advanced Physiology, Medicinal Chemistry, Advanced Pharmacology, Pathophysiology, a research core, extensive Principles of Anesthesia content and a demanding Clinical Practicum. The anesthesia portion of the education for nurse anesthetists is very similar to the anesthesia education received by physician anesthesiologists.

But here is one difference between nurse anesthetists and anesthesiologists. Upon successful completion of study, nurse anesthetists graduates must pass a national certification examination administered by the Council on Certification of Nurse Anesthetists, an autonomous body recognized by the U.S. Department of Education. They must be recertified every two years thereafter in order to continue practicing the profession of anesthesia. It is my understanding that board certification is not required for anesthesiologists.

In total, most CRNAs will have spent nearly 10 years in preparation when one considers undergraduate work, critical nursing experience and up to 3 years of graduate nurse anesthesia study. Even in light of the substantial time commitment in CRNA educational preparation, we must all be careful not to necessarily equate competency or quality of any provider with the duration in years of their preparation alone. Instead we should judge educational preparation in terms of the quality of the time spent in study and outcomes of such preparation, which for nurse anesthetists have been measured and continue to be exemplary.

Our educational programs are conducted utilizing university faculty, nurse anesthetists, basic and applied scientists, pharmacologists, physicians (including anesthesiologists), and others. Clinical instruction of students is performed by both CRNAs and anesthesiologists. AANA has had four autonomous credentialing Councils since the mid-1970's-Accreditation, Certification, Recertification, and one for Public Interest that also serves as the appellate body for the other Councils. These are multidisciplinary Councils, including members of the CRNA communities of interests. They include CRNAs, hospital administrators, anesthesiologists, surgeons, students, and public members. They are fully compliant with national standards promulgated by federal and civilian oversight/recognition organizations, both federal and civilian. Their credentials are accepted by State Boards of Nursing in recognizing CRNAs as advanced practice nurses. The National Council of State Boards of Nursing has evaluated our examination and certification process and deemed it psychometrically credible.

NURSE ANESTHETISTS PROVIDE HIGH QUALITY, SAFE ANESTHESIA

Graduates of our programs are prepared to practice as full service anesthesia providers, working with and without anesthesiologists. This is imperative because CRNAs are the sole anesthesia providers in close to 1/3 of America's hospitals-as well as in a majority of rural hospitals. We must prepare them well, to meet the needs of the American people wherever they live.

The US military has long recognized the superior education and the quality of care that nurse anesthetists provide. Nurse anesthetists have gained a remarkable reputation for their service in every war and conflict the United States has participated since World War I. In fact they have been called to service in far greater numbers than any other anesthesia provider in every war or conflict this nation has ever endured. Today you will find a single nurse anesthetist serving as the sole provider of anesthesia on isolated missions such as Kosovo and Macedonia, with no anesthesiologists present. Nurse anesthetists routinely work alone on aircraft carriers and on isolated bases such as Reykjavik, Iceland. The reputation of CRNAs in the military is undisputed.

Anesthesia is now safer then it has ever been. In the past 20 years we have seen dramatic improvements in both CRNA and anesthesiologist educational preparation. We have experienced an explosion in advanced patient monitoring technology giving us vital moment-to-moment physiologic information. Our pharmaceutical industry has equipped providers with far safer therapeutics. Additionally, nursing care, preventative health care, and patient education have all contributed to safer outcomes. The fact is, that anesthesia has gotten increasingly safer over the years. In fact, St. Paul Insurance Company, which is the nation's largest provider of liability insurance for healthcare professionals (both CRNAs and anesthesiologists included) has reported that from 1988 to 1998, nurse anesthetists liability premiums decreased across the country by a full 52 percent, which demonstrates the high quality of care and safety record provided by CRNAs recognized and fully appreciated by the insurance industry as well.

Despite the opinion of the American Society of Anesthesiologists and American Medical Association, anesthesia is not the exclusive practice of medicine or any one discipline. Anesthesia is a body of knowledge onto itself and is taught as such "an art, grounded in science." It is far more accurate to state that it is within the scope of practice of physicians, nurses, dentists, podiatrists etc…to deliver anesthesia care so long as they have been properly educated and certified.

CONCLUSION

Our aim, as it has always been is to prepare highly qualified nurse anesthetists capable of meeting America's needs for anesthesia service. However, we would like to assure you that research has proven anesthesia care is safe regardless of whether a CRNA or anesthesiologist administers it. CRNAs have an excellent safety record, and they provide high quality anesthesia care in all types of settings. I hope that you will keep these indisputable facts in mind as you face this controversial issue. I look forward to responding to any questions you may have.