Nurse Anesthetists in Southeastern Kentucky: A Survey of ... · Data were collected during one brief time period and therefore provide a snapshot of vacancies and nurse anesthetist

750 Morton Boulevard • Hazard, Kentucky 41701• (800) 851-7512 • www.mc.uky.edu/ruralhealth

August 2005

Univers i ty of K entuck y Center for Rural Heal th

Nurse Anesthetists in Southeastern Kentucky: A Survey of Supply Versus Demand

Authored By: Judy Owens, J .D. Director, Univers i ty o f Kentucky Center for Rural Heal th

David A. Gross Director, External Af fairs

Peggy Lewis Community Health Liaison


TABLE OF CONTENTS PAGE Introduction ............................................................................................................................. 2 Methodology............................................................................................................................ 3 Findings ................................................................................................................................... 3 A. Geographic Discrepancy............................................................................................... 3 Effect............................................................................................................................ 6 B. Potential Applicant Pool for CRNA Program in Southeastern Kentucky ................... 7 Conclusions ............................................................................................................................. 7 Endnote ................................................................................................................................... 9 Appendices A. Education of nurse anesthetists in the United States B. Accredited nurse anesthesia programs C. The cost of starting a nurse anesthetist educational program D. An economic analysis of the investment in nurse anesthesia education

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INTRODUCTION One of the University of Kentucky Center for Rural Health’s missions is to ensure an adequate and well-distributed supply of health care professionals throughout rural portions of the state. To accomplish this goal, the Center offers health professions education programs in a rural setting and administers a loan repayment program that targets primary care providers willing to practice in medically underserved areas. The Center also performs periodic rural health workforce analyses. It was in regard to the latter objective that the Center was contacted on numerous occasions in late 2004 and early 2005. Several southeastern Kentucky hospital officials expressed concern about a shallow applicant pool for certified registered nurse anesthetist vacancies at their facilities. CRNAs are registered nurses with advanced training in anesthesiology. They are responsible for selecting and administering anesthetic agents, monitoring surgical patients’ responses to those anesthetics, and selecting and administering – or ordering the administration of – drugs required during the recovery from anesthesia. Nurse anesthesia education programs range from 24 to 36 months in length, depending on university requirements, and are at the master’s degree level or higher. The educational costs of preparing a nurse anesthetist are roughly one-eighth those of an anesthesiologist, according to the American Association of Nurse Anesthetists – one of the reasons CRNAs serve as the sole providers of anesthetics for surgeries and other procedures in more than 70 percent of rural hospitals. The average annual salary for a nurse anesthetist in the Commonwealth is approximately $145,000, according to a 2005 Kentucky Hospital Association salary survey. While more than 90 nurse anesthesia educational programs exist in the United States, Kentucky is home to but one – the Trover Foundation/Murray State University Program of Anesthesia, located about seven hours’ driving distance west of Hazard, the Center’s headquarters and southeastern Kentucky’s geographic midpoint. Twenty-three states have multiple CRNA training programs, according to the Council on Accreditation of Nurse Anesthesia Educational Programs. In response to the hospital officials’ inquiries and a subsequent request from the Kentucky Hospital Association, the Center initiated a project to track the status of nurse anesthetist positions and vacancies within all southeastern Kentucky hospitals. Among the project’s purposes were to determine whether a geographic imbalance exists in the distribution of CRNAs in Kentucky and to evaluate the need for a nurse anesthesia training program in the state’s eastern half.

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METHODOLOGY A survey was conducted during May 2005 to determine southeastern Kentucky hospitals’ level of need for nurse anesthetists and their difficulty in filling CRNA vacancies. Telephone interviews were conducted with the human resources director or chief executive officer at each of the 19 hospitals located in the Big Sandy, Cumberland Valley and Kentucky River area development districts, a 21-county region that encompasses all of southeastern Kentucky. (For a complete list of the questions asked and results by county, see Table 1 on Page 6). An online search was conducted on April 15, 2005, to track Kentucky Board of Nursing registrations for nurse anesthetists by county of residence. The nursing board’s electronic records also were analyzed to determine the number of bachelor’s- and master’s-level nurses – those eligible for enrollment in a nurse anesthesia training program – residing in southeastern Kentucky. Data were collected during one brief time period and therefore provide a snapshot of vacancies and nurse anesthetist employment trends within the surveyed hospitals. The findings did, however, concur with a January 2001 “CRNA Needs Assessment Survey” conducted by the Center and therefore suggest a persistent health workforce problem for this region. Though a 2004 Kentucky Hospital Association evaluation found a much smaller nurse anesthetist vacancy rate than the Center’s more recent survey (16 vacancies statewide to 44.5 within southeastern Kentucky alone), it is believed that the KHA estimate of need was substantially low because of employment arrangements that KHA’s survey instrument did not measure, such as contracted nurse anesthetists not being considered hospital employees. FINDINGS

A. GEOGRAPHIC DISCREPANCY Kentucky has a significantly lower per-capita ratio of nurse anesthetists as residents than two of its similarly rural border states – West Virginia, with 18.3 CRNAs per 100,000 residents, and Tennessee, with 17.7. With 476 resident nurse anesthetists as of mid-April and a total population in excess of 4.1 million, Kentucky had nearly 11.5 CRNAs per 100,000 residents, still higher than the national rate of 9.3, according to federal Health Resources and Services Administration workforce profiles. Yet, while Kentucky as a whole exceeds the national rate, southeastern Kentucky lags far behind, with fewer than six nurse anesthetists per every 100,000 residents. On April 15, the state nursing board’s online database showed 31 nurse anesthetists registered as living within the Big Sandy, Cumberland Valley and Kentucky River area development districts. Pike County had six resident nurse anesthetists, the most of any southeastern

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Kentucky county. By contrast, the entire eight-county Kentucky River district had just one resident nurse anesthetist. Of the state’s 15 area development districts, southeastern Kentucky had the lowest (Kentucky River, with one), fifth-lowest (Big Sandy, with 13) and seventh-lowest (Cumberland Valley, with 17) totals for nurse anesthetist residency. In fact, five individual area development districts – representing nearly every other region of Kentucky – had more resident nurse anesthetists than the three southeastern Kentucky districts combined (Figure 1). For further comparison, consider that southeastern Kentucky’s cumulative total of resident nurse anesthetists was less than one-third that of Jefferson County’s alone (94). Yet, while Jefferson County had over 300 percent more resident nurse anesthetists than southeastern Kentucky, its overall population was just 26 percent greater than the 21 southeastern counties’ combined total, according to the Census Bureau’s July 15, 2005, estimate. Southeastern Kentucky’s number of resident nurse anesthetists also was considerably less than Fayette County’s total of 42. While southeastern Kentucky had 11 fewer resident nurse anesthetists than Fayette County, it is home to nearly twice as many total residents, according to the Census estimate (520,408 to 266,358). Finally, southeastern Kentucky’s total of 31 resident nurse anesthetists was just two more than that of McCracken County. Although home to just two hospitals, McCracken’s abundance of

FIGURE 1Number of CRNAs by county of residence

grouped by Kentucky Area Development Districts

Adair

Allen

Anderson

Ballard

Barren

Bath

Bell

Boone

Bourbon

Boyd

Boyle

Bracken

Breathitt

Breckinridge

Bullitt

ButlerCaldwell

Calloway

Campbell

Carlisle

Carroll

Carter

Casey

Christian

Clark

Clay

Clinton

Crittenden

Cumberland

Daviess

Edmonson

Elliott

Estill

Fayette

Fleming

Floyd

Franklin

Fulton

Gallatin

Garrard

Grant

Graves

Grayson

Green

Greenup

Hancock

Hardin

Harlan

Harrison

Hart

Henderson

Henry

Hickman

Hopkins

Jackson

Jefferson

JessamineJohnson

Kenton

Knott

Knox

Larue

Laurel

Lawrence

Lee

Leslie Letcher

Lewis

Lincoln

Livingston

Logan

LyonMccracken

Mccreary

Mclean

MadisonMagoffin

Marion

Marshall

Martin

Mason

Meade Menifee

Mercer

Metcalfe

Monroe

Montgomery

Morgan

Muhlenberg

Nelson

Nicholas

Ohio

Oldham

Owen

Owsley

Pendleton

Perry

Pike

Powell

Pulaski

Robertson

Rockcastle

Rowan

Russell

Scott

Shelby

Simpson

Spencer

Taylor

ToddTrigg

Trimble

Union

Warren

Washington

Wayne

Webster

Whitley

Wolfe

Woodford

127

98

38

15

37

30 17

1

13

10

5

7

Purchase

Pennyrile

Green River Barren River

Lincoln Trail

KIPDA Northern Kentucky Buffalo Trace

Gateway

FIVCO

Big Sandy

Kentucky RiverCumberland ValleyLake Cumberland

Bluegrass

Source: Kentucky Board of Nursing, 2005

20

4318

FIGURE 1Number of CRNAs by county of residence

grouped by Kentucky Area Development Districts

Adair

Allen

Anderson

Ballard

Barren

Bath

Bell

Boone

Bourbon

Boyd

Boyle

Bracken

Breathitt

Breckinridge

Bullitt

ButlerCaldwell

Calloway

Campbell

Carlisle

Carroll

Carter

Casey

Christian

Clark

Clay

Clinton

Crittenden

Cumberland

Daviess

Edmonson

Elliott

Estill

Fayette

Fleming

Floyd

Franklin

Fulton

Gallatin

Garrard

Grant

Graves

Grayson

Green

Greenup

Hancock

Hardin

Harlan

Harrison

Hart

Henderson

Henry

Hickman

Hopkins

Jackson

Jefferson

JessamineJohnson

Kenton

Knott

Knox

Larue

Laurel

Lawrence

Lee

Leslie Letcher

Lewis

Lincoln

Livingston

Logan

LyonMccracken

Mccreary

Mclean

MadisonMagoffin

Marion

Marshall

Martin

Mason

Meade Menifee

Mercer

Metcalfe

Monroe

Montgomery

Morgan

Muhlenberg

Nelson

Nicholas

Ohio

Oldham

Owen

Owsley

Pendleton

Perry

Pike

Powell

Pulaski

Robertson

Rockcastle

Rowan

Russell

Scott

Shelby

Simpson

Spencer

Taylor

ToddTrigg

Trimble

Union

Warren

Washington

Wayne

Webster

Whitley

Wolfe

Woodford

127

98

38

15

37

30 17

1

13

10

5

7

PurchasePurchase

PennyrilePennyrile

Green RiverGreen River Barren RiverBarren River

Lincoln TrailLincoln Trail

KIPDAKIPDA Northern KentuckyNorthern Kentucky Buffalo TraceBuffalo Trace

GatewayGateway

FIVCOFIVCO

Big SandyBig Sandy

Kentucky RiverKentucky RiverCumberland ValleyCumberland ValleyLake CumberlandLake Cumberland

BluegrassBluegrass

Source: Kentucky Board of Nursing, 2005

20

4318

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resident CRNAs could be explained by its location – Paducah, the county seat, is less than 90 miles away from Madisonville’s Trover Regional Medical Center, the primary clinical site for Kentucky’s lone nurse anesthesia training program. With 29 nurse anesthetists as residents among a total population of 64,700, McCracken County’s CRNA-to-general population ratio is 1-to-2,231; southeastern Kentucky’s was nearly eight times that, at 1-to-16,787. Another method of demonstrating the maldistribution of nurse anesthetists in Kentucky is through per-surgical operation ratios. Below are relevant data for southeastern Kentucky, the Bluegrass Area Development District and the Kentuckiana Area Development District, with 2004 surgical operations totals accessed from the state Department for Public Health’s online Data Warehouse:

While it should be noted that the large medical centers in Fayette and Jefferson counties perform a much higher number of intricate surgeries, such as open-heart operations, from a look at just these raw numbers consider that:

Southeastern Kentucky’s hospitals performed an average of 1,976 surgeries per resident CRNA, more than twice as many as Bluegrass hospitals (968 per) and nearly double Kentuckiana hospitals (1,050 per).

Kentuckiana has more than 400 percent as many resident nurse anesthetists as southeastern Kentucky, but its hospitals only performed 218 percent more surgeries during 2004. The ratio was nearly identical for hospitals in the Bluegrass region, which has over 300 percent more resident CRNAs than southeastern Kentucky but performed only 155 percent more surgeries.

While Kentuckiana and Bluegrass hospitals performed substantially more surgeries than their southeastern Kentucky counterparts, the ratio of operations per population was not overly disparate. During 2004, Kentuckiana and Bluegrass hospitals performed an average of one surgery for every 6.7 residents and 7.5 residents, respectively. In southeastern Kentucky, the ratio was one surgery per 8.5 residents.

Resident CRNAs

Total Population Surgeries

Southeastern Kentucky 31 520,408 61,246

Bluegrass Area Development District (Fayette and surrounding counties) 98 713,939 94,846

Kentuckiana Area Development District (Jefferson and surrounding counties) 127 895,634 133,307

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So, a combined analysis of nurse anesthetist per-population and per-surgical operation data reveals this: Southeastern Kentucky has 12.5 percent of Kentucky’s total population and performs 11.5 percent of the state’s total surgeries – but has only 6.5 percent of the state’s total resident CRNAs.

EFFECT

The above analysis provides strong evidence of the shallowness of the nurse anesthetist applicant pool available to southeastern Kentucky hospitals. Surveyed hospital officials also cited difficulty in recruiting those who live elsewhere to relocate to the region for permanent employment. On a five-point scale, those officials rated nurse anesthetist as the second-most-difficult position to recruit, behind only physicians (Table 1). This set of circumstances has forced most southeastern Kentucky hospitals to contract their anesthesia services to companies that, in many instances, are based outside the state. In those cases, transient nurse anesthetists employed by the contracted companies work for a period of

time at one of the region’s hospitals, then transfer elsewhere and may be replaced by another of the company’s mobile nurse anesthetists. In fact, less than half of the hospitals within the survey region – nine out of 19 – had at least one full-time CRNA on staff as an employee (Table 1). Of the 50 full-time nurse anesthetist positions reported at the surveyed hospitals, nurses who were not actual employees of the facility occupied 32 slots. Another 13 part-time nurse anesthetist positions were filled on a contracted basis, meaning that of 63 full- and part-time CRNA positions at southeastern Kentucky hospitals, 45 – or 71.5 percent – were held by non-employees.

Southeastern Kentucky has 12.5 percent of Kentucky’s total population and performs 11.5 percent of the state’s total surgeries – but has only 6.5 percent of the state’s total resident CRNAs.

TABLE 1

Comparison of CRNAs employed/contracted in counties with hospitals located in study area

1. How many full-time nurse anesthetists are employed by your facility? 2. How many part-time nurse anesthetists are employed by your facility? 3. How many full-time nurse anesthetists are contracted by your facility? 4. How many part-time nurse anesthetists are contracted by your facility? 5. How many nurse anesthetist vacancies does your facility expect within the next

year? 6. Rank the level of difficulty your facility has experienced in recruiting nurse

anesthetists, in comparison to other health professionals.

County FTEs

employed Part Time employed

FTEs contracted

Part Time contracted

Vacancy within

one year Recruiting difficulty*

Bell 4 0 3 1 4 4Breathitt 0 0 1 2 1.25 5Clay 2 0 0 1 1 4Floyd 1 0.25 5 2 6.25 4Harlan 2 0 0 1 2 4Johnson 1 0 0 0 1 4Knox 0 0 2 0 2 4Laurel 3 0 0 0 1 3Leslie 0 0 0 1 1 5Letcher 0 0 5 1 6 4Perry 1 0 3 0 4 5Pike 3 0 9 0 7 5Rockcastle 1 0 0 1 1 5Whitley 0 0 4 3 7 3Totals 18 0.25 32 13 44.5 4

Study area contains counties in three southeast Kentucky Area Development Districts: Big Sandy,

Cumberland Valley, and Kentucky River. *Range for degree of recruiting difficulty is 1-5 with 5 the hardest and 1 the easiest. The total displayed for this column is an average.

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Several hospital representatives expressed satisfaction with the use of contract nurse anesthetist companies. In particular, a Baptist Regional Medical Center official said the Corbin-based facility was so pleased with its contract company that it is unclear whether the hospital would hire local nurse anesthetists even if they were available.

For the most part, however, surveyed hospital officials said they would prefer to hire nurse anesthetists as full-time employees of their facility, citing increased local control and other benefits. A higher percentage of on-staff CRNAs within southeastern Kentucky could result in better access to care and less travel time for patients, as well as improved quality of care because of timely surgical intervention for required procedures. Nurse anesthetists who are full-time employees also could be better incorporated into hospitals’ surgical teams. As a result, southeastern Kentucky hospital officials estimated a potential 44.5 CRNA vacancies within the next year – assuming there would be local applicants for the positions now largely held by contracted workers (Table 1).

B. POTENTIAL APPLICANT POOL FOR CRNA PROGRAM IN SOUTHEASTERN KENTUCKY

As of April 15, the state nursing board listed 608 bachelor’s-level and 248 master’s-level nurses as residents of the three southeastern Kentucky area development districts. That means there would be more than 800 potential applicants should a nurse anesthetist program be made available within the region. (Note: Not all of the BSN/MSN nurses would be candidates, as most nurse anesthesia programs require at least one year of critical-care experience as a prerequisite for enrollment. Also, the potential applicants have not been surveyed to gauge their interest in attending a nurse anesthesia training program.). Online records showed there were 1,545 bachelor’s- and master’s-level nurses within Kentucky’s three westernmost area development districts, which are home to Murray State University and its nurse anesthesia clinical site at Madisonville. Though the western region’s applicant pool is nearly twice as large, so is the number of students to be served. Murray State’s nurse anesthesia program admits 12 students each year, while a program operating in southeastern Kentucky likely would be designed for no more than six students and perhaps as few as four. CONCLUSIONS From the perspective of the entire state of Kentucky, the current workforce supply of nurse anesthetists falls short of crisis designation. In fact, Kentucky as a whole exceeds the national CRNA-to-population ratio. And where a shortage does exist, hospitals have managed to

Hospital officials estimated a potential 44.5 CRNA vacancies within the next year – assuming there would be local applicants for the positions now largely held by contracted workers.

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continue surgery services – although largely with CRNAs provided by out-of-state contract companies. Yet, whether examined for per-population or per-surgical operation ratios, the data contained in this workforce survey report definitively confirm what southeastern Kentucky hospital officials already knew to be true: There indeed is a serious maldistribution of nurse anesthetists in the state – a discrepancy that has the potential to impact the availability and quality of surgical care in Eastern Kentucky. Perhaps the most telling numerical evidence is this: 127-to-1. That is the ratio of nurse anesthetists living in the greater Louisville area compared to the entire Kentucky River Area Development District. There seem to be two main reasons for the discrepancy:

Metropolitan areas such as Jefferson and Fayette counties are home to large medical centers that perform high volumes of surgical procedures, so it stands to reason that is where most nurse anesthetists would settle.

The state’s only nurse anesthesia training program is located in western Kentucky, too far for many southeastern Kentucky-based nurses – particularly those who are in mid-career or have started a family – to travel in search of an advanced degree, even one as financially rewarding as CRNA. The latter item leads to the consideration that nurses are likely to work near the geographic area in which they were educated, according to workforce profiles. This validates a long-held premise of the Center for Rural Health that health care professionals tend to practice in the area in which they receive their terminal training. For instance, more than 75 percent of graduates from the family medicine residency based at the Center – and nearly 90 percent of its physical therapy graduates – currently practice in rural Kentucky. Other rural medicine training programs, such as the Pikeville College School of Osteopathic Medicine, are based on the same rationale. Therefore, one potential solution would be to train nurse anesthetists within southeastern Kentucky, whether through the extension of an existing program or, however less likely, the creation of a new one. State nursing board records indicate there is an adequate applicant pool within the region for annual classes of four to six students. After repeated inquiries, the Center for Rural Health has begun exploring the possibility of recruiting a nurse anesthesia education program to Hazard. That would be a significant first step toward easing southeastern Kentucky’s nurse anesthetist shortage. In the interim, southeastern Kentucky’s deficiency of resident nurse anesthetists leaves most of the region’s hospitals no viable option but to rely on contracted companies for the provision of anesthesia services. This circumstance could subject a hospital to the mercy of an out-of-state

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interest. For instance, a gap in the administration of anesthesia services could force a rural hospital to refer a surgical patient to another – likely urban – facility. It also has another negative financial impact: Money spent on contracted services is not reinvested in local economies. Other factors that should be considered in future research, but which were outside the scope of the Center’s survey, include:

As was mentioned in the Center’s report, bachelors- and masters-level nurses living within southeastern Kentucky were not polled as to their interest in applying to a nurse anesthesia program. It seems at least a random sampling of this group would be necessary before substantial movement was made toward establishing a CRNA training program in the region.

The survey process revealed that 31 nurse anesthetists live within southeastern Kentucky, yet the region’s hospitals employ just 18 full-time CRNAs out of 50 such positions, with the remainder filled by outsourced contract workers. The region’s resident CRNAs could be surveyed to discern their work status. This information could be especially useful in projecting retention rates for prospective CRNAs trained within the region. ENDNOTE The authors wish to recognize the contributions of those who helped make this report possible. Lola M. Dixon, the Center’s director of internal affairs, compiled data for the appendix section. Tena R. Smith, a staff support associate with the State Office of Rural Health, designed the report and its graphical elements. Editorial consultants included Elmer T. Whitler, the Center’s director of research; Emery A. Wilson, director of UK’s Office of Health Research and Development; Joseph E. Smith, executive director of the Kentucky Primary Care Association; David Bolt, chief operating officer of the Lewis County Primary Care System and president-elect of the Kentucky Rural Health Association; and Carol Blevins Ormay and Joy Knight, representatives of the Kentucky Hospital Association.


APPENDICES

A. Education of nurse anesthetists in the United States

B. Accredited nurse anesthesia programs

C. The cost of starting a nurse anesthetist educational program

D. An economic analysis of the investment in nurse anesthesia education


APPENDIX A

Education of nurse anesthetists in the United States

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APPENDIX B

Accredited nurse anesthesia programs

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APPENDIX C

The cost of starting a nurse anesthetist educational program

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APPENDIX D

An economic analysis of the investment in nurse anesthesia education

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Nurse Anesthetists in Southeastern Kentucky: A Survey of ... · Data were collected during one brief time period and therefore provide a snapshot of vacancies and nurse anesthetist