CERTIFIED RN ANESTHETIST
(CRNA)
SCOPE OF PRACTICE
Medical Staff Office Use
NAME:
Please Print
APPOINTMENT DATE:
 Initial Application
to
 Reappointment
Criteria to apply for privileges:
EDUCATION:
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Graduate of an accredited school of nursing and successful completion of an accredited nurse anesthesia educational program; and
PREVIOUS EXPERIENCE:
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CRNA’s not directly from a graduate status must have a documented minimum of 12 months recent clinical practice which demonstrates
that he/she has provided anesthesia services for at least 250 patients; and/or
CRNA’s who have completed their educational program within the past 12 months will need to provide their clinical case logs from their
training program.
LICENSURE/CERTIFICATION:
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Current and unrestricted licensure as a Registered Nurse and CRNA by the State of Texas; and
Current certification by the CCNA; and
Current ACLS certification.
ADDITIONAL REQUIREMENTS:
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Professional liability coverage issued by a recognized company ($200K/600K). This coverage may be independent coverage or as an
endorsement on the supervising physician’s malpractice declaration.
Supervision:
At all times, the CRNA will practice under the supervision of their sponsoring Anesthesiology physician(s) who is/are currently licensed
by the State of Texas Medical Board, and is a/are current member(s) of the Texas General Hospital medical staff. The sponsoring
physician(s) agrees to assume responsibility for supervision and monitoring of the CRNAs practice. A sponsoring physician statement
must be completed.
Request
CORE PRIVILEGES:
(check one)
 All Core
 Partial Core*
*(Cross out those you
do not wish to perform)
 Conduct a pre-anesthetic assessment of the patient, and record pre, intra and postoperative anesthesia information
 Select and administer peri-anesthetic medication
 Interview, assess and examine the patient to determine the selection of anesthetic agent and technique, for the particular
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patient and the contemplated surgical procedure
Request, review and evaluate pertinent laboratory and x-ray studies
Insert intravenous catheters, central venous access and arterial line access
Administer general anesthesia and adjuvant drugs
Administer regional anesthesia techniques: Subarachnoid, Epidural, Caudal, Upper Extremity, Lower Extremity, Diagnostic
and Therapeutic Nerve Blocks, Local Infiltration, Topical, Periocular Block, Transtracheal, Intracapsular, Intercostal
Obtain patient’s informed consent for privileged procedures
Manage the anesthesia process to include induction, maintenance and post-anesthetic care
Utilize all current techniques in monitoring
Recognize abnormal patient responses to anesthesia or to any adjunctive medication or other form of therapy, and take
corrective action including consultation with the Anesthesiologist
Identify and manage emergency situations including assessment of adequacy of recovery of antagonism of muscle relaxants,
and implement appropriate management techniques
Manage fluid, blood and electrolyte loss and replacement within an anesthesia care plan
Endotracheal intubation and extubation
Manage pain relief
Provide professional observation and resuscitation care and request consultation whenever appropriate during the
perioperative period
Follow up post-anesthesia and evaluate patients from perspective of the anesthesia service
Participate in cardiopulmonary resuscitation
Document all aspects of care provided by the CRNA
Maintain knowledge of current techniques appropriate to the conduct of anesthesia and implement these techniques within
established protocols
Maintain anesthesia at required levels
Support life functions during the period in which anesthesia is administered, including induction and intubation procedure
Recognize and take appropriate corrective action (including the requested consultation when necessary) for abnormal
patient response to anesthesia or to any adjunctive medication or other forms of therapy
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CERTIFIED RN ANESTHETIST (CRNA)
Duties and tasks which may NOT be performed by the CRNA:
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A nurse anesthetist cannot independently admit.
A nurse anesthetist may not pronounce death.
A nurse anesthetist may not enter orders pertaining to patient’s resuscitation status, restraints, or withdrawal of life support.
Please do not write in privileges
If you wish to add a privilege that is not listed on this form, please contact Medical Staff Services.
ACKNOWLEDGMENT OF PRACTITIONER
I have requested only those privileges for which, by education, experience and/or licensure/certification, I am qualified to perform, and
that I wish to exercise at Texas General Hospital. I acknowledge that my professional malpractice insurance extends to all privileges I
have requested.
I understand that in exercising any privileges granted, I am constrained by hospital and medical staff policies and rules applicable
generally and any applicable to the particular situation.
Signature of Applicant:
Date:
ACKNOWLEDGMENT OF SPONSOR PHYSICIAN(s)
I understand and agree that I have the burden of responsibility for the actions of the Allied Health Practitioner while engaging in their
privileges at Texas General Hospital as outlined in my signed Sponsorship Agreement on file in the Medical Staff office.
I understand that in delegating any clinical privileges granted, I am constrained by hospital and medical staff policies and rules
applicable generally and any applicable to the particular situation. I have evaluated the allied health professional and attest that he/she
is competent to perform the requested duties.
Signature of Sponsor Physician or Group Representative:
Approved
CC: 05/09/13
MEC: 05/09/13
BOD: 05/09/13
Date:
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