Is a nurse anesthetist required to have prescriptive authority and register that delegation with the Texas Medical Board?

In outpatient anesthesia settings, the drugs administered and devices applied by a CRNA who provides anesthesia or anesthesia-related services are supplied by the practice setting. Therefore, they are ordered for use in that setting by the surgeon. Just as in the hospital or ambulatory surgery center, the CRNA selects and administers drugs and applies devices pursuant to an order to administer anesthesia or an anesthesia-related service in this setting. Because the surgeon has supplied the drugs and devices for the purpose of providing anesthesia or anesthesia-related services, the CRNA is not required to have prescriptive authority for this purpose. All parties are required to follow the laws and regulations for ordering, storing, wasting and tracking the use of medications and devices in these settings.

If CRNAs are practicing in settings in which they are writing prescriptions, such as a CRNA who may be working with a pain management specialist, the CRNA must have prescriptive authority and all requirements for delegation of prescriptive authority must be met. This includes requirements for a prescriptive authority agreement or facility-based protocol as appropriate and registration of physician delegation on the Texas Medical Board’s website. If controlled substances will be prescribed, the CRNA must also have the required controlled substance registrations.

An APRN (including CRNAs) who possesses the required BON-granted prescriptive authority and DEA number could enter into a prescriptive authority agreement (PAA) with a physician.  This approach is not common for a CRNA, and is associated with significant limitations and administrative burdens for both the CRNA and the physician.     

Please review TAC§222 for details regarding the level of physician supervision required for prescriptive authority.  A very important limitation to this approach is that an APRN may not prescribe controlled substances found on schedule II in an outpatient setting.  Since the majority of the opioids commonly used in anesthesia practice (e.g., fentanyl, meperidine, morphine, etc.) are found on schedule II, this is a huge limitation from a prescriptive authority perspective.  All schedule II controlled substances would have to be purchased under the physicians DEA number, as it would be illegal to purchase them under the CRNA’s DEA number.

When considering these two options (physician delegation of the ordering of drugs/devices versus entering into a prescriptive authority agreement), TxANA recommends that the CRNA make arrangements with the physician in whose office they will practice to purchase drugs under the physician’s authority.  There is nothing that prohibits a CRNA from preparing the purchase orders and tracking drug inventory in the physician’s office to alleviate that burden from the physician.  However, the purchase of drugs (both dangerous drugs and controlled substances) would be under the physician’s prescriptive authority, not the APRNs.  This approach does not require the CRNA to possess prescriptive authority, alleviates all the administrative burden of a PAA (and the associated supervision), and facilitates acquisition of schedule II controlled substances. 

From a practice perspective, please note the very important difference between “ordering” and “prescribing” as it applies to dangerous drugs and controlled substances.  When a CRNA is practicing in an outpatient setting, and a physician has delegated the ordering of drugs and devices necessary to provide anesthesia or anesthesia-related services, the CRNA “orders” the drugs/devices necessary to accomplish the service.  The CRNA has the authority to “order” schedule II controlled substances.  In contrast, if the CRNA is practicing in the office setting under a Prescriptive Authority Agreement (i.e., under BON-granted prescriptive authority), the CRNA cannot “prescribe” schedule II controlled substances because it is prohibited by SB 406.  Therefore, TxANA strongly recommends that a CRNA avoid the prescriptive authority approach in an office setting.