Certified Registered Nurse Anesthetists and Perioperative Medicine

The Certified Registered Nurse Anesthetist Lens

The concept of “upstream thinking” is ingrained in nurses early in their education. Nurses attempt to avoid the downstream fallout of a particular condition by focusing on the origin of a pathophysiological problem and the relevant social concerns and not just reacting to the presenting illness. This concept necessarily involves and addresses health inequalities and population health, which, as presented in an earlier chapter, overlaps with perioperative medicine (POM). The foundational education and experience of certified registered nurse anesthetists (CRNAs) is rooted in this “upstream thinking” (i.e., not “reacting” but being “proactive” in caregiving). On the path to becoming a CRNA, many nurses witness postoperative complications first-hand, such as comforting a disoriented elderly patient, attempting to ease the intractable nausea and vomiting of a young woman, and denying a hungry patient food while awaiting bowel sounds to return. However, on becoming a CRNA, nurses are empowered to make decisions that directly impact those outcomes that they seemingly had no control over as a nurse. The problem was upstream. Now as a CRNA the nurse is working upstream, positioned to make an impact.

An additional aspect of CRNA training, rooted in the nursing background, is developing the ability and desire to provide patient education and to use empathetic communication with patients and colleagues. CRNAs enter anesthesia understanding the importance of multidisciplinary teamwork in patient care. This team-based experience creates an ideal opportunity for CRNAs to engage in interdepartmental education, helping healthcare teams recognize the importance that a multidisciplinary contribution brings to patient healing and recovery.

CRNAs can act as touchpoints in multiple phases of care as they monitor the evolution of the patient's condition across the surgical continuum. Many CRNAs lead or staff preadmission clinics, perform preoperative evaluations, deliver intraoperative care, collaborate care in the postanesthesia care unit, and often round on patients postoperatively. With this vantage point, CRNAs possess the ability to bridge disparate groups of clinicians brought together in perioperative care models. The value of the CRNA role in POM can be overlooked because of their clinical workload, but their work inside and outside of the operating room (OR) links physicians and nursing.

Implementation of Perioperative Medicine: The CRNA Perspective

Previous chapters offer an in-depth discussion and multiple examples of the “what, whys, and hows” of POM. Although there is no silver bullet or “secret sauce” to success, countless enhanced recovery after surgery (ERAS) programs and perioperative pathways are based on following the general principles of enhanced recovery and using implementation science and quality improvement (QI) to put these pathways into practice. The intent of this chapter is to highlight the CRNA's ability to adopt such principles and operationalize them. The CRNA's perspective enables them to be effective leaders, champions, and active participants in the organization, planning, and delivery of POM. This chapter also aims to inspire and empower fellow CRNA colleagues and all providers in the perioperative space to examine their practice and to ask these key questions:

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  “Do I know my own outcomes?”

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  “Can my practice be enhanced through perioperative medicine models?”

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  “Can I, as a (insert provider type), use my training and experience to be the catalyst for better patient care?”

The following are three real-world examples of CRNA providers and their contribution to POM.

Example 1: “Being Part of the Bigger Picture”

A small team of providers (an anesthesiologist, general surgeon, advanced practice nurse, and a CRNA) developed, implemented, and disseminated the adoption of an ERAS initiative in a large community facility in 2015.