Modesto hospital shaken by California probe into anesthesia providers. What to know
Doctors Medical Center of Modesto is starting to recover after it was knocked off-balance by a California Department of Public Health survey focused on anesthesia services.
But as more surgeries resume, the hospital has decisions to make about staffing operating rooms with anesthesiologists and midlevel providers called certified registered nurse anesthetists (CRNAs).
Patients most likely assume the practitioner putting them to sleep for surgery is a physician, an anesthesiologist with years of education and specialized training. But increasingly, nurses with an advanced degree in anesthesia are choosing and administering the knock-out drugs at hospitals and surgical centers in the Central Valley.
Moreover, the nurses and their professional associations stress that they should be allowed to work independently.
The state survey in late May essentially called a timeout on the use of CRNAs at Doctors. According to a May 25 in-house memo obtained by The Modesto Bee, the CDPH issued an “immediate jeopardy” order that led to barring CRNAs from hospital operating rooms.
The nurse anesthetists must undergo a credentialing process and proctoring — consisting of 10 procedures testing their skills — before returning to the hospital. The state agency found that CRNAs had been granted privileges at the hospital for certain procedures without showing they could safely perform them.
Until the CRNAs are credentialed, the hospital is using available anesthesiologists for trauma surgeries, C-sections, elective surgeries, heart operations and scoping procedures.
Doctors Medical Center hasn’t commented on the state survey since releasing a public statement May 24, saying it was cooperating with CDPH on an action plan to address issues identified by the state probe. A spokesman did not respond to written questions from The Bee in the past week.
The hospital has used available anesthesiologists to cover urgent surgeries and is trying to arrange for more anesthesia doctors to work on a temporary basis.
“They are bringing back the locums and some of the anesthesiologists they used before,” said Dr. Mark Fahlen, a kidney specialist. “I am seeing some familiar faces again.”
Fahlen, a former member of the hospital’s medical staff leadership, said the center will need to find anesthesiologists to proctor the midlevel providers. It’s not clear how long the credentialing process and proctoring will take.
“I am not opposed to using CRNAs in lower risk procedures. They seem to work better in close collaboration with anesthesiologists in places where there are not these adversarial relationships,” he said.
Corina Fezi of Modesto said she had an elective surgery set for May 28 at Doctors but received a call from the hospital canceling it. She said Wednesday that the hospital talked about rescheduling the operation for June 20, with a physician anesthesiologist.
“I asked to postpone it till August,” Fezi said via email. “I don’t feel comfortable going there, to be honest, knowing that all this is going on.”
Stanislaus County officials said the state action hasn’t affected emergency services or caused ambulance diversions to other hospitals.
The hospital’s contract for CRNAs
Last year, Doctors entered a contract with a Fresno-based group, Valley Regional Anesthesia Associates, that provides mostly CRNA staffing for operating rooms.
Dr. Oji Oji, who founded the provider group, owned Community Regional Anesthesia Medical Group, which had a contract to provide anesthesia services for Community Medical Centers in Fresno.
That contract with Community Medical Centers ended in 2021 and Oji’s anesthesia group declared Chapter 11 bankruptcy. A lawsuit filed by nurse anesthetists seeking unpaid overtime includes content suggesting that Oji’s group had trouble with CRNAs leaving to work for competitors or to form their own group.
A Business Journal report on the bankruptcy said Oji’s business did not submit a proposal to renew its contract with Community Medical Centers in Fresno.
Oji incorporated Valley Regional Anesthesia Associates in June 2022 and the group has since entered contracts with Modesto-area hospitals including Doctors Medical Center, Stanislaus Surgical Hospital, Doctors Hospital of Manteca and other surgery centers.
Joseph Martin, the chief executive officer of Valley Regional, also is the director of nurse anesthetist education programs at National University in Fresno.
Valley Regional’s website says it provides nurse anesthetists for surgeries and other procedures, offering cost savings for hospitals. CRNAs are paid $150 an hour or more in California, while physician anesthesiologists average $325 an hour and may receive more.
The Valley Regional group was also at the center of CDPH survey inspections in August and January at Stanislaus Surgical Hospital on Oakdale Road.
The surveys done on behalf of the federal Centers for Medicare and Medicaid Services rebuffed a CRNA who told inspectors she managed the anesthesia group at Stanislaus Surgical. The agencies rejected the hospital’s stance that CRNAs had full authority to handle diagnoses and prescribe drugs at the surgical hospital.
An immediate jeopardy order on Jan. 17 wasn’t lifted until a plan was approved Feb. 2 that imposed oversight from physician anesthesiologists over those services at Stanislaus Surgical. The survey reports indicate the Stanislaus Surgical contract with Valley Regional has ended, but that hasn’t been confirmed.
Oji and Martin have not returned numerous calls seeking comment. CDPH said it does not comment during the course of investigations.
Two CRNAs are among the defendants in a lawsuit concerning a woman’s death a year ago at River Surgical Institute in Modesto.
Fahlen said Doctors Medical Center previously had a contract with a group of anesthesiologists and wanted to add seven more to work at the hospital. But there were doubts about recruiting them and a “unilateral” decision was made to contract with Valley Regional, he said.
The physician said he’s OK with bringing CRNAs back to the hospital in small batches with careful proctoring. “There is a role for CRNAs,” he said. “I don’t know that it’s good for them to be practicing independently with complex cases.”
Sandra Bordi, president of the California Association of Nurse Anesthesiology, has argued that nurse anesthetists have autonomy in California since the state opted out of the more restrictive rules under the federal Medicare program. “Since 2009, CRNAs have been practicing independently in all settings in California. CRNAs are board-certified and qualified to provide all anesthesia services that are required with peer-reviewed studies demonstrating outcomes that are equivalent to physician anesthesiologists.”
The federal rules for participation in Medicare require that anesthesia in hospitals is furnished in a well-organized manner and must be administered by a physician or nurse anesthetist who is under supervision of an anesthesiologist. The anesthesiologist must be immediately available.
The federal government allows states to opt out, however. California permits CRNAs to administer anesthesia on the condition that it’s ordered by a physician.
This story was originally published June 10, 2024 at 5:30 AM.
