Existing law, the Dental Practice Act, provides for the licensure and regulation of dentists by the Dental Board of California within the Department of Consumer Affairs. Existing law authorizes a licensed physician and surgeon to administer deep sedation or general anesthesia in the office of a licensed dentist for dental patients if specified conditions are met, including that they hold a valid general anesthesia permit issued by the board as prescribed.

This bill would authorize a certified registered nurse anesthetist to administer general anesthesia or deep sedation in the office of a licensed dentist for dental patients if specified conditions are met, including that they hold a valid general anesthesia permit issued by the board as prescribed. To obtain that permit, the bill would require a nurse anesthetist to apply to the board on an application form prescribed by the board and to submit, among other things, payment of an application fee. Prior to issuance or renewal of a permit pursuant to these provisions, the bill authorizes the board to require an onsite inspection and evaluation of the facility, equipment, and personnel, as specified. If a nurse anesthetist fails an onsite inspection and evaluation, the bill would require their permit be automatically suspended for 30 days, as specified. The bill would authorize a nurse anesthetist who additionally meets certain requirements to apply to the board for a pediatric endorsement to provide general anesthesia or deep sedation to a child under 7 years of age.

By expanding the scope of existing crimes under the Nurse Anesthetists Act and the Dental Practice Act, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

The Dental Practice Act provides for the licensure and regulation of dentists by the Dental Board of California within the Department of Consumer Affairs. The act, among other things, prescribes requirements for dentists who administer or order the administration of deep sedation or general anesthesia, as those terms are defined.

This bill would make a nonsubstantive change to the provision that defines those terms.

Date of Hearing: May 1, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 2526

Author:(Gipson) – As Amended Ver:April 17, 2024

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill authorizes a certified registered nurse anesthetist (CRNA) to administer general anesthesia or deep sedation in the office of a licensed dentist to dental patients, if certain conditions are met. The bill also authorizes a CRNA to obtain a pediatric endorsement to provide general anesthesia or deep sedation to a child under seven years of age.

FISCAL EFFECT:

The Dental Board of California (Board) estimates it will need $822,000 in fiscal year (FY) 2027-28, $774,000 in FY 2028-29, $2.9 million in FY 2029-30, $1.2 million in FY 2030-31 and FY 2031-32, and $1.3 million in FY 2032-33 and ongoing (State Dentistry Fund). The Board explains these costs as follows:

1. The Board estimates it will need six new positions to promulgate regulations and process 2,841 nurse anesthetist’s initial applications, conduct inspection/site evaluation, and review and process initial applications and renewals for the pediatric endorsement. The Board estimates it will need $822,000 in 2027-28 and $774,000 ongoing to support these positions.
   
2. In addition, the Board would need funds for Subject Matter Experts (SMEs) to conduct an estimated 2,841 site evaluations the first year and within five years thereafter. Two SMEs are required for each inspection at $600 per site evaluation. The Board will need to contract with an SME to review 20 cases per applicant for the issuance and renewal of permits with the pediatric endorsement. The Board estimates SME costs of $2.1 million in 2029-30 and $462,000 ongoing.

The funds will be derived from fees charged to licensees.

The Office of Information Services estimates changes to the online licensing system will cost $32,000, which is absorbable.

COMMENTS:

1. Purpose. This bill is sponsored by the California Association of Nurse Anesthesiology. According to the author:

General anesthesia plays a crucial role in dental care, especially for pediatric patients and those with developmental disabilities, who often face challenges in receiving timely treatment. Consequently, many of these individuals require intensive restorative procedures under deep sedation or general anesthesia. However, accessing such care can be problematic due to a shortage of providers offering these services. An LAO study highlighted the issue, revealing long waitlists of up to three years in some cases at hospitals and oral surgery centers. Consequently, children and patients with disabilities often endure oral pain for extended periods of time. To address these challenges, this bill seeks to increase the number of anesthesia providers available to provide these services. This bill would allow Certified Registered Nurse Anesthetists to obtain a general anesthesia permit from the Dental Board of California and allow them to order anesthesia medications to administer in the dental office. This would enable the dentist to offer in-office anesthesia services provided by a licensed anesthesia provider while the dentist focuses on providing high-quality dental care. This would increase access to care for some of California’s most vulnerable populations while maintaining stringent safety standards, with the goal of minimizing risks and maximizing patient outcomes. This bill embodies an unwavering commitment to prioritizing patient safety and increasing access to quality dental care.

1. Background.

CRNAs. CRNAs are advanced practice registered nurses (RNs) who specialize in anesthesia services. As RNs, CRNAs are licensed to perform health care functions that require a substantial amount of scientific knowledge or technical skill, including direct and indirect patient care; disease prevention and restorative measures; administration of medication and therapeutic agents upon order of a physician, dentist, podiatrist, or specified clinical psychologists; skin tests; patient assessment, analysis, planning, and treatment implementation; and laboratory tests. In addition to the base training required of an RN, CRNAs must obtain a minimum of a master’s degree from a CRNA educational program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs. CRNAs generally practice in all settings where anesthesia is provided, but may provide anesthesia services in dental settings only if the dentist has a GA permit or there is an anesthesiologist with a GA permit.

Dental Anesthesiology. There are varying levels of anesthesia, with higher levels of anesthesia presenting a higher risk of serious complications. Deep sedation (DS) and general anesthesia (GA) are the highest levels of anesthesia. Anesthesia can be useful for facilitating dental care in certain populations, such as patients with anxiety or special needs. Restrictions on dental offices where dental anesthesia is practiced include requiring a dentist who wishes to administer or order another provider to administer DS or GA in their office to obtain a permit. Anesthesiologists are physician providers of anesthesia and must also apply for a GA permit. CRNAs may administer DS or GA upon the order of a GA-permitted dentist or physician.

The Board reported 949 active dental GA permits and 153 physician GA permits at the end of fiscal year (FY) 2022-23.

1. Opposition. The California Association of Oral Maxillofacial Surgeons, the California Society of Anesthesiologists, and the California Medical Association separately expressed opposition to this bill, expressing concerns about patient safety and the level of training of CRNAs, among other things.
   
2. Prior Legislation.
   
   1. SB 501 (Glazer), Chapter 929, Statutes of 2018, revised the requirements for the administration of various levels of outpatient dental sedation into what is currently required, including training, permitting, pediatric endorsement, physical evaluation, onsite inspection, and unprofessional conduct, among other things.
   2. SB 889 (Ochoa-Bogh), of the 2021-22 Legislative Session, would have established the CRNA General Anesthesia permit aspect of this bill. SB 889 died pending a hearing in the Senate Business, Professions and Economic Development Committee.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Marc Berman, Chair

ABPCA Bill Id:AB 2526

Author:(Gipson) – As Amended Ver:April 8, 2024

SUBJECT: Nurse anesthetists.

SUMMARY: Creates a general anesthesia (GA) permit under the Dental Board of California (DBC) that authorizes a certified registered nurse anesthetist (CRNA) to administer deep sedation (DS) and GA in any dental office and authorizes a GA-permitted CRNA to select and order anesthesia, as defined, upon the request of a dentist.

Existing State Law:

1. Regulates the practice of nursing through the licensure of registered nurses (RNs) under the Nursing Practice Act. (Business and Professions Code (BPC) §§ 2700-2838.4)
   1. Establishes the Board of Registered Nursing (BRN) until January 1, 2027, within the Department of Consumer Affairs (DCA) to administer and enforce the Nursing Practice Act. (BPC § 2701)
   2. Defines the RN scope of practice as functions, including basic healthcare, that help people cope with or treat difficulties in daily living that are associated with their actual or potential health or illness problems, and that require a substantial amount of scientific knowledge or technical skill. (BPC § 2725)
   3. Includes within the scope of RN practice all of the following:
      1. Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (BPC § 2725(b)(1))
      2. Direct and indirect patient care services, including the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist. (BPC § 2725(b)(2))
      3. The performance of skin tests, immunization techniques, and the withdrawal of human blood from veins and arteries. (BPC § 2725(b)(3))
      4. Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with “standardized procedures,” or the initiation of emergency procedures. (BPC § 2725(b)(4))
   4. Defines “standardized procedures” as either of the following:
      1. Policies and protocols developed by a licensed health facility through collaboration among administrators and health professionals including physicians and nurses. (BPC § 2725(c)(1))
      2. Policies and protocols developed through collaboration among administrators and health professionals, including physicians and nurses, by an organized health care system that is not a licensed health facility. (BPC § 2725(c)(2))
   5. Defines “nurse anesthetist” as a licensed RN who has met standards for certification from the BRN, which must consider the standards of the National Board of Certification and Recertification for Nurse Anesthetists, or a successor national professional organization approved by the BRN. (BPC § 2826(a))
   6. Authorizes a CRNA to provide anesthesia services in (1) an acute care facility if approved by the acute care facility administration and the appropriate committee, and at the discretion of the physician, dentist or podiatrist, and (2) in a dental office, the dentist holds a GA permit. (BPC § 2827)
2. Regulates the practice of medicine through the licensure of physician and surgeons under the Medical Practice Act and establishes the Medical Board of California (MBC) until January 1, 2028, to administer and enforce the act. (BPC §§ 2000-2529.6)
3. Regulates the practice of dentistry through the licensure of dentists and dental auxiliaries under the Dental Practice Act and establishes the DBC until January 1, 2025, to administer and enforce the act. (BPC §§ 1600-1976)
   1. Regulates the use of DS and GA in dentistry. (BPC §§ 1646-1646.13)
   2. Defines “deep sedation” as a drug-induced depression of consciousness during which (1) patients cannot be easily aroused but respond purposefully following repeated or painful stimulation; (2) the ability to independently maintain ventilatory function may be impaired; (3) patients may require assistance in maintaining a patent airway; and (4) spontaneous ventilation may be inadequate; but (5) Cardiovascular function is usually maintained. (BPC § 1646(a))
   3. Defines “general anesthesia” as a drug-induced loss of consciousness during which (1) patients are not arousable, even by painful stimulation; (2) the ability to independently maintain ventilatory function is often impaired; (3) patients often require assistance in maintaining a patent airway; (4) positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function; and (5) cardiovascular function may be impaired. (BPC § 1646(b))
   4. Requires a dentist to possess (1) either a current license in good standing, a permit in oral and maxillofacial surgery, or a special teaching permit and (2) a DBC-issued GA permit to administer or order the administration of DS or GA on an outpatient basis for dental patients. (BPC § 1646.1(a))
   5. Requires a dentist to be physically within the dental office at the time of ordering, and during the administration of, GA or DS. (BPC § 1643.1(c))
   6. Requires a dentist to possess a pediatric endorsement of their GA permit to administer or order the administration of DS or GA to patients under seven years of age. (BPC § 1643.1(b))
   7. Requires, for patients under 13 years of age, all of the following:
      1. The presence of the operating dentist and at least two additional personnel throughout the procedure involving DS or GA. (BPC § 1643.1(d)(1))
      2. If the operating dentist is the permitted anesthesia provider, then both of the following:
         1. The operating dentist and at least one of the additional personnel maintain current certification in Pediatric Advanced Life Support (PALS) or other DBC-approved training in pediatric life support and airway management, and the additional certified personnel is solely dedicated to monitoring the patient and is be trained to read and respond to monitoring equipment including, but not limited to, pulse oximeter, cardiac monitor, blood pressure, pulse, capnograph, and respiration monitoring devices. (BPC § 1643.1(d)(2)(A))
         2. The operating dentist is responsible for initiating and administering any necessary emergency response. (BPC § 1643.1(d)(2)(B))
      3. If a dedicated permitted anesthesia provider is monitoring the patient and administering DS or GA, both of the following:
         1. The anesthesia provider and the operating dentist, or one other trained personnel, must be present throughout the procedure and must maintain current certification in PALS and airway management or other DBC-approved training in pediatric life support and airway management. (BPC § 1643.1(d)(3)(A))
         2. The anesthesia provider is be responsible for initiating and administering any necessary emergency response and the operating dentist, or other trained and designated personnel, must assist the anesthesia provider in emergency response. (BPC § 1643.1(d)(3)(B))
   8. Requires a dentist who desires to administer or order the administration of DS or GA to apply to the DBC on an application form prescribed by the DBC. The dentist must submit an application fee and produce evidence showing that they have successfully completed a minimum of one year of advanced training in anesthesiology and related academic subjects approved by the DBC, or equivalent training or experience approved by the DBC, beyond the undergraduate school level. (BPC § 1646.2(a))
   9. Requires the application for a permit to include documentation that equipment and drugs required by the DBC are on the premises. (BPC § 1646.2(b))
   10. Authorizes a dentist to apply for a pediatric endorsement for the GA permit by providing proof of successful completion of all of the following:
       1. A Commission on Dental Accreditation (CODA)-accredited or equivalent residency training program that provides competency in the administration of DS and GA on pediatric patients. (BPC § 1646.2(c)(1))
       2. At least 20 cases of DS or GA to patients under seven years of age in the 24-month time period directly preceding application for a pediatric endorsement to establish competency, both at the time of initial application and at renewal. The applicant or permit holder must maintain and be able to provide proof of the cases upon request by the DBC for up to three permit renewal periods. (BPC § 1646.2(c)(2))
       3. Current certification in Advanced Cardiac Life Support (ACLS) and PALS or other DBC-approved training in pediatric life support and airway management for the duration of the permit. (BPC § 1646.2(c)(3))
   11. Authorizes applicants for a pediatric endorsement who otherwise qualify for the pediatric endorsement but lack sufficient cases of pediatric sedation to patients under seven years of age to administer DS and GA to patients under seven years of age under the direct supervision of a GA permit holder with a pediatric endorsement. The applicant may count the cases toward the 20 cases required to qualify for the applicant’s pediatric endorsement. (BPC § 1646.2(d))
   12. Requires a physical evaluation and medical history to be taken before the administration of DS or GA. (BPC §1646.3(a))
   13. Requires any dentist holding a permit to maintain medical history, physical evaluation, DS, and GA records as required by the DBC. (BPC § 1646.3(b))
   14. Requires, prior to the issuance or renewal of a permit for the use of DS or GA, and authorizes the DBC to additionally require, an onsite inspection and evaluation of the licentiate and the facility, equipment, personnel, and procedures utilized by the licentiate; requires the permit of any dentist who has failed an onsite inspection and evaluation to be automatically suspended 30 days after the date on which the board notifies the dentist of the failure, unless within that time period the dentist has retaken and passed an onsite inspection and evaluation; requires every dentist issued a GA permit to have an onsite inspection and evaluation at least once every five years; and requires the refusal to submit to an inspection to result in automatic denial or revocation of the permit. (BPC § 1646.4(a))
   15. Authorizes the DBC to contract with public or private organizations or individuals expert in dental outpatient GA to perform onsite inspections and evaluations, but prohibits the DBC from delegating its authority to issue permits or to determine the persons or facilities to be inspected. (BPC § 1646.4(b))
   16. Authorizes a physician and surgeon to administer DS or GA in the office of a licensed dentist for dental patients, without regard to whether the dentist possesses a GA permit, if all of the following conditions are met:
       1. The physician and surgeon possesses a current license in good standing. (BPC § 1646.9(a)(1))
       2. The physician and surgeon holds a valid GA permit issued by the DBC. (BPC § 1646.9(a)(2))
       3. The physician and surgeon meets the requirements patients under 13 years of age. (BPC § 1646.9(a)(3))
   17. Requires a physician and surgeon applicant for a GA permit to apply to the DBC on an application form prescribed by the DBC and submit all of the following:
       1. The payment of an application fee. (BPC § 1646.9(b)(1))
       2. Evidence satisfactory to the MBC showing that the applicant has successfully completed a postgraduate residency training program in anesthesiology that is recognized by the American Council on Graduate Medical Education. (BPC § 1646.9(b)(2))
       3. Documentation demonstrating that all equipment and drugs required by the DBC are on the premises for use in any dental office in which they administer DS or GA. (BPC § 1646.9(b)(3))
       4. Information relative to the current membership of the applicant on hospital medical staffs. (BPC § 1646.9(b)(4))
   18. Requires, prior to issuance or renewal of a physician GA permit, and authorizes the DBC to additionally require, an onsite inspection and evaluation of the facility, equipment, personnel, including, but not limited to, the physician and surgeon, and procedures utilized. At least one of the persons evaluating the procedures utilized by the physician and surgeon must be a licensed physician and surgeon expert in outpatient DS or GA who has been authorized or retained under contract by the DBC for this purpose. (BPC § 1646.9(c))
   19. Requires the permit of a physician and surgeon who has failed an onsite inspection and evaluation to be automatically suspended 30 days after the date on which the DBC notifies the physician and surgeon of the failure unless within that time period the physician and surgeon has retaken and passed an onsite inspection and evaluation; requires every physician and surgeon issued a GA permit to have an onsite inspection and evaluation at least once every five years; and requires refusal to submit to an inspection to result in automatic denial or revocation of the permit. (BPC § 1646.9(d))
   20. Authorizes a physician and surgeon who additionally meets the requirements for a pediatric endorsement to provide DS or GA to a child under seven years of age to apply for the endorsement, and authorizes a physician and surgeon without sufficient cases to obtain an endorsement to qualify for the endorsement via supervised cases. (BPC § 1646.9(e))
   21. Includes in the definition of unprofessional conduct for a dentist the failure to report to the DBC in writing within seven days any of the following: (A) the death of the licensee’s patient during the performance of any dental or dental hygiene procedure; (B) the discovery of the death of a patient whose death is related to a dental or dental hygiene procedure performed by the licensee; or (C) except for a scheduled hospitalization, the removal to a hospital or emergency center for medical treatment of any patient to whom oral conscious sedation, conscious sedation, or GA was administered, or any patient as a result of dental or dental hygiene treatment, unless removal to a hospital or emergency center is the normal or expected treatment for the underlying dental condition. (BPC § 1680(z)(1))
4. Prohibits the operation of an outpatient setting unless the setting is one of several authorized settings. (HSC § 1248.1)
   1. Defines “outpatient setting” as any facility, clinic, unlicensed clinic, center, office, or other setting that is not part of a general acute care facility and where anesthesia, except local anesthesia or peripheral nerve blocks, or both, is used in compliance with the community standard of practice, in doses that, when administered have the probability of placing a patient at risk for loss of the patient’s life-preserving protective reflexes. (Health and Safety Code (HSC) § 1248(b)(1))
   2. Includes as an authorized outpatient settings those used by a dentist or physician and surgeon in compliance with the GA and moderate sedation requirements of the Dental Practice Act. (HSC § 1248.1(f))

EXISTING Federal LAW:

1. Regulates the manufacturing, importing, exporting, distributing, and dispensing of controlled substances under the Controlled Substances Act of 1970. (Title 21, U.S. Code (USC) §§ 800-971)
2. Establishes five schedules of drugs and other substances, known as schedules I, II, III, IV, and V, based on potential for abuse, medical utility, and dependence. (21 USC §§ 811-814)
3. Defines "controlled substance" as a drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V. (21 USC § 802(6))
4. Defines "administer" as the direct application of a controlled substance to the body of a patient or research subject by (A) a practitioner (or, in their presence, by their authorized agent), or (B) the patient or research subject at the direction and in the presence of the practitioner. (21 USC § 802(2))
5. Defines "dispense" as delivering a controlled substance to an ultimate user or research subject by, or pursuant to the lawful order of, a practitioner, including the prescribing and administering of a controlled substance and the packaging, labeling or compounding necessary to prepare the substance for such delivery. (21 USC § 802(10))
6. Requires every person who dispenses, or who proposes to dispense, any controlled substance, to register with the U.S. Drug Enforcement Administration (DEA). (21 USC § 822(a)(2); Title 28, Code of Federal Regulations (CFR) § 0.100; 21 CFR § 1301.11)
7. Authorizes controlled substance registrants to possess, manufacture, distribute, or dispense the substances or chemicals to the extent authorized by their registration type. (21 USC § 822(b); 21 CFR § 1301.13)
8. Defines “mid-level practitioner” as an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which they practice, to dispense a controlled substance in the course of professional practice, including health care providers such as nurse practitioners, nurse midwives, CRNAs, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the State in which they practice. (21 CFR § 1300.1)
9. Establishes exemptions to the registration requirement, including: (1) an agent or employee of any registered manufacturer, distributor, or dispenser of any controlled substance if the agent or employee is acting in the usual course of their business or employment; (2) an individual practitioner who is an agent or employee of a non-mid-level practitioner registered to dispense controlled substances when acting in the normal course of business or employment; and (3) an individual practitioner who is an agent or employee of a registered hospital or other institution when acting in the normal course of business or employment. (21 USC § 822; 21 CFR § 1301.22)

THIS BILL:

1. Authorizes a CRNA to administer GA or DS in the office of a licensed dentist to dental patients without regard to whether the dentist possesses a GA permit if both of the following conditions are met:
   1. The CRNA holds a valid GA permit issued by the DBC.
   2. The CRNA meets the existing requirements for patients under 13 years of age.
2. Requires a CRNA applicant for a GA permit to apply to the DBC on an application form prescribed by the DBC and submit all of the following:
   • 1. Payment of an application fee.
     2. Evidence satisfactory to the DBC and the BRN showing that the applicant has successfully completed an accredited CRNA program approved by the BRN.
     3. Documentation demonstrating that all equipment and drugs required by the DBC are on the premises for use in any dental office in which the CRNA administers GA or deep sedation.
3. Requires, prior to issuance or renewal of a CRNA GA permit, and authorizes the DBC to additionally require, an onsite inspection and evaluation of the facility, equipment, and personnel, including, but not limited to, the CRNA and procedures utilized, and requires at least one of the people evaluating the procedures utilized by the CRNA to be a CRNA expert in outpatient general anesthesia or deep sedation who has been authorized or retained under contract by the DBC for that purpose.
4. Requires a CRNA who has failed an onsite inspection and evaluation to have their permit automatically suspended for 30 days after the date on which the DBC notifies the CRNA of the failure unless within that time period the CRNA has retaken and passed an onsite inspection and evaluation.
5. Requires a CRNA who is issued a GA permit to undergo an onsite inspection and evaluation at least once every five years.
6. Requires a CRNA’s refusal to submit to an inspection to result in automatic denial or revocation of the permit.
7. Authorizes a CRNA who additionally meets the requirements for a pediatric endorsement to provide GA or DS to a child under seven years of age to apply to the DBC for the endorsement.
8. Authorizes a CRNA without sufficient cases to obtain a pediatric endorsement to qualify for the endorsement via supervised cases.
9. Authorizes a CRNA to administer GA or DS in any dental office if in accordance with the DBC permit requirements and the RN scope of practice.
10. Defines “order” as the process of directing a licensed individual, pursuant to their statutory authority, to directly administer a drug or to dispense, deliver, or distribute a drug for the purpose of direct administration to a patient, under instructions of the CRNA to provide prescription drugs.
11. Defines “prescription drugs” as Schedule II through Schedule V controlled substances under the California Uniform Controlled Substances Act.
12. Defines “select” as the decisionmaking process of choosing a drug, dosage, route, and time of administration.
13. Grants a CRNA who is registered with the DEA the “prescriptive authority” to select, order, or administer prescription drugs upon a request issued by a dentist for purposes of DS and GA to administer anesthesia for diagnostic, operative, or therapeutic procedures in an outpatient dental setting.
14. Requires a CRNA in outpatient dental settings to prescribe prescription drugs based on their level of professional education, training, and certification by the National Board of Certification and Recertification for Nurse Anesthetists, or a successor national professional organization approved by the BRN.
15. Specifies that a CRNA may only prescribe prescription drugs in a dental setting for an individual whom the CRNA has, at the time of the prescription, established a client or patient record.
16. Requires a CRNA upon registration or renewal of registration with the DEA to complete the required training as set forth by the agency.
17. Specifies that nothing in the Nursing Practice Act affects the authority of a CRNA to select, order, or administer prescription drugs for the delivery of perioperative anesthesia services beyond the outpatient dental setting.

FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the California Association of Nurse Anesthesiology. According to the author, “General anesthesia plays a crucial role in dental care, especially for pediatric patients and those with developmental disabilities, who often face challenges in receiving timely treatment. Consequently, many of these individuals require intensive restorative procedures under deep sedation or general anesthesia. However, accessing such care can be problematic due to a shortage of providers offering these services. An LAO study highlighted the issue, revealing long waitlists of up to three years in some cases at hospitals and oral surgery centers. Consequently, children and patients with disabilities often endure oral pain for extended periods of time. To address these challenges, this bill seeks to increase the number of anesthesia providers available to provide these services. This bill would allow Certified Registered Nurse Anesthetists to obtain a general anesthesia permit from the Dental Board of California and allow them to order anesthesia medications to administer in the dental office. This would enable the dentist to offer in-office anesthesia services provided by a licensed anesthesia provider while the dentist focuses on providing high-quality dental care. This would increase access to care for some of California’s most vulnerable populations while maintaining stringent safety standards, with the goal of minimizing risks and maximizing patient outcomes. This bill embodies an unwavering commitment to prioritizing patient safety and increasing access to quality dental care.”

Background. CRNAs are advanced practice RNs who specialize in anesthesia services. As RNs, CRNAs are licensed to perform health care functions that require a substantial amount of scientific knowledge or technical skill, including direct and indirect patient care, disease prevention and restorative measures, administration of medication and therapeutic agents upon order of a physician, dentist, podiatrist, or specified clinical psychologists, skin tests, immunizations, blood withdrawal, patient assessment, analysis, planning, and treatment implementation, and laboratory tests.

In addition to the base training required of an RN, CRNAs must obtain a minimum of a master’s degree from a CRNA educational program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs. CRNAs generally practice in all settings where anesthesia is provided but may only provide anesthesia services in dental settings if the dentist has a GA permit or there is an anesthesiologist with a GA permit.

Dental Anesthesiology. Anesthesiology is the medical practice of inducing anesthesia, which is a temporary state of controlled loss of sensation or awareness for purposes of pain management or other perioperative care. There are varying levels of anesthesia, with higher levels of anesthesia presenting a higher risk of serious complications. DS and GA are the highest levels of anesthesia.

Anesthesia can be useful for facilitating dental care in averse populations, such as patients with anxiety or special needs. However, due to the safety risks of anesthesia, existing law establishes requirements on dental offices where dental anesthesia is practiced, including requiring dentists who wish to administer or order another provider to administer DS or GA in their office to obtain a permit. Anesthesiologists, the physician providers of anesthesia, must also apply for a GA permit. CRNAs may administer DS or GA upon the order of a GA-permitted dentist or physician.

The DBC reported 949 active dental GA permits and 153 physician GA permits at the end of fiscal year (FY) 2022-23.

Harm Data. Existing law requires dentists to report the death of the licensee’s patient during the performance of any dental procedure, the discovery of the death of a patient whose death is related to a dental procedure performed by the licensee, or the removal to a hospital or emergency center for medical treatment of any patient to whom oral conscious sedation, conscious sedation, or GA was administered, or any patient as a result of dental treatment, unless removal to a hospital or emergency center is the expected treatment for the underlying dental condition.

Between January 1, 2017, and August 1, 2023, the DBC received 516 incident reports, and of the 516 incident reports, the DBC determined that:

• 215 reports related to incidents in which oral conscious sedation, moderate sedation, DS, or GA was administered, and the patient was subsequently hospitalized.
• 28 reports related to incidents in which oral conscious sedation, moderate sedation, DS, or GA was administered, and the patient died during or shortly after the dental procedure.

According to the DBC:

Of the 28 reports of death during or shortly after a dental procedure in which sedation/anesthesia was administered, the Board found 1 report of an incident in which general anesthesia or deep sedation was administered to a pediatric patient resulting in a death during a dental procedure. A summary of the reported death is as follows:

On June 12, 2017, the patient presented for dental rehabilitation under general anesthesia, which was administered by a dental anesthesiologist in a dental office. During the procedure, the patient experienced a life-threatening cardiac rhythm that required emergency medication and defibrillation. The incident was reported to the Board on June 15, 2017. The case was assigned to an investigator on June 15, 2017. The investigative report and all records were sent to an anesthesia expert, who determined that the attending dentist did not deviate from the standard of care in the dentist’s care and treatment of the patient. On February 1, 2018, the case was closed with no violation.

Pediatric Dental Anesthesia. Pediatric dental anesthesia is being discussed in the DBC’s sunset review this year.^[1] The existing requirements for pediatric dental anesthesia are the result of a bill (SB 501 (Glazer), Chapter 929, Statutes of 2018) following the death of a child undergoing dental work under anesthesia. Specifically, that bill created a new process for the DBC to issue a GA permit (that may include a pediatric endorsement) as well as moderate and pediatric minimal sedation permits to applicants based on their level of experience and training and established new requirements for DS or GA administered to patients under thirteen years of age.

In its sunset report, the DBC reports that it is still working to implement the provisions of SB 501 and continues to identify areas in the Dental Practice Act where technical changes may be necessary, including the following:

• Implementation of the new GA and sedation permits.
• Fees for GA and sedation permits.
• Ambiguities in the GA and sedation permits for physicians and surgeons.
• Outdated language for Oral Conscious Sedation for Adults certificates.
• Continuing education requirements and expiration dates for Pediatric Minimal Sedation Permits.
• Physical presence requirements when administering or ordering the administration of general anesthesia or sedation.
• Confidentiality concerns over submission of patient case information.
• Pediatric Minimal Sedation Permit requirements for physical evaluation and medical history.
• The definition of “good standing” and moving the good standing requirement to the sections on permit applications.
• Which kind of permit (and endorsement, if applicable) a permit holder should have, if not already specified.
• Medical recordkeeping requirement consistency.
• Ensuring patient safety and compliance with minimal sedation administration requirements by requiring that all minimal sedation procedures, including those performed to obtain a minimal sedation permit, in a private dental office meet established requirements for minimal sedation permit holders.

The DBC reported that there were 60 active pediatric endorsements at the end of FY 2023-24.

Current Related Legislation. SB 1453 (Ashby), which is pending in the Senate Business, Professions and Economic Development Committee, is the sunset review bill for the DBC.

Prior Related Legislation. SB 889 (Ochoa-Bogh) of 2022 would have established the CRNA GA permit aspect of this bill. SB 889 died pending a hearing in the Senate Business, Professions and Economic Development Committee.

SB 652 (Bates) of 2021 would have extended the requirements for dental patients under 13 years of age, specifically that an operating dentist and at least two additional personnel be present throughout a procedure involving deep sedation or general anesthesia, and that the dentist and one additional personnel maintain current certification in Advanced Cardiac Life Support (ACLS), to all patients regardless of age. SB 652 died pending a hearing in this committee.

SB 501 (Glazer), Chapter 929, Statutes of 2018, among other things, revised the requirements for the administration of various levels of outpatient dental sedation into what is currently required, including training, permitting, pediatric endorsement, physical evaluation, onsite inspection, and unprofessional conduct.

ARGUMENTS IN SUPPORT:

The California Association of Nurse Anesthesiology (sponsor) writes in support:

Increased hospital wait times for dental care with general anesthesia lead to more patient complications. Often, patients will not seek dental care of any kind unless sedation or general anesthesia is available. This situation is compounded for pediatric patients who are unable to cooperate due to their developmental stage or intellectual disabilities and cannot tolerate effective dental care without the services of an anesthesia professional.

Since 2021, there has been a progressive increase in delinquent and canceled general anesthesia permits. This trend reflects an increased need for dental anesthesia providers. Patients frequently avoid seeking dental care altogether due to the high cost of anesthesia, even when it is available. This situation in California has led to an unacceptable and inequitable lack of dental care for low-income patients, which has persisted for decades, creating major morbidity, illness, and even fatalities….

Many Californians need anesthesia for dental care, and those dentists who desire anesthesia services from a CRNA can do so without the regulatory burden of obtaining a permit themselves. This allows the dentist to focus on providing dental care, while the CRNA is solely responsible for the anesthesia, and physiologic well-being of the patient. In addition, under [this bill], a CRNA would be authorized to order the necessary medications to provide this service. This prescriptive authority would only be authorized in a dental setting for these procedures. At the national level, CRNAs with prescriptive authority are eligible to apply for and obtain an individual DEA number. Liability and responsibility for anesthesia lies with the anesthesia provider, regardless of whether they are a physician anesthesiologist or CRNA.

California CRNAs practice independently everywhere anesthesia is needed in the state. The dental outpatient setting, which is in need of anesthesia services, is the only place where a permit is required. CRNAs have been independent anesthesia providers in California since 2009. In fact, CRNAs are the sole anesthesia providers in 4 California counties. The impression that CRNAs operate solely as members of a physician-led care team is inaccurate and outdated. CRNAs are fully independent providers of anesthesia services and work in care team models only by choice. Also antiquated is the belief that liability lies with the ordering physician or dentist. CRNAs have accepted full liability for the administration of anesthesia since the inception of our licensure.

CRNAs have advanced training and expertise in providing safe anesthesia in all settings, for all types of anesthesia for patients of all ages and medical complexities, with a proven safety record. In fact, CRNAs meet and exceed all the safety requirements the Dental Board requests of their current permit holders for General Anesthesia and Pediatric Endorsement. CRNAs are safe, experienced, and dedicated anesthesia providers who are qualified to contribute their services to the dental care community that needs our help.

ARGUMENTS IN OPPOSITION:

The California Association of Oral Maxillofacial Surgeons (CALAOMS) writes in opposition:

The Legislature approved SB 501 by Senator Glazer in 2018, which strengthened the requirements for the delivery of deep sedation/general anesthesia (DS/GA) to pediatric patients. That bill — which took effect January 1, 2022 — requires practitioners treating patients under the age of 13 to operate under a team delivery approach, with at least three individuals present during the administration of DS/GA….

CALAOMS supports and seeks to apply these same SB 501 standards to patients of all ages - creating one standard for the delivery of DS/GA in the dental office and eliminating conflicting standards that could lead to confusion. These changes would not only streamline the delivery of anesthesia, but they would also bring California into compliance with the nationally recognized American Dental Association, American Association of Oral and Maxillofacial Surgeons, and American Society of Anesthesiologists' standards for the administration of office-based dental anesthesia.

The California Society of Anesthesiologists write in opposition:

… we provide the following rationale as to how dangerous it would be to allow Certified Registered Nurse Anesthetists (CRNAs) to independently prescribe and order sedation and anesthesia in dental offices, as proposed by [this bill].

First, all liability and responsibility for any anesthetic being ordered or administered in a dental office, must be maintained with the ordering dentist and/or anesthesiologist and the qualified dentist and/or anesthesiologist administering that anesthesia. Under existing law, CRNAs are already eligible to obtain a GA permit for administration of anesthesia in dental offices but they would need to have an “order” from an anesthesiologist or qualified dentist who has obtained the GA permit and pediatric endorsement from the Dental Board of California (hereafter; Board), if administering anesthesia to children under seven….

It is inconceivable why we would allow CRNAs, who are not currently eligible to even obtain a DEA license in the state of California, to independently order and prescribe medication that will render a patient lifeless and unable to control any life-saving motor skills. Furthermore, many children and young adults receiving dental care under anesthesia in dental offices are often those with special needs and disabilities requiring a more complex level of care from a medical doctor (i.e. anesthesiologist).

Nowhere else in California can you order or administer a level of anesthesia where the patient loses all forms of life-saving motor skills without that facility being state licensed, nationally accredited or Medicare certified. [This bill] would bypass these regulations for CRNAs in dental offices, which are solely intended to protect patient safety. These regulations and state oversight are in place to ensure that the facility is equipped with the necessary equipment, staffing, safety protocols, regular inspections, emergency transfer agreements, etc….

Although undergoing anesthesia is now safer than ever before, there still remains the potential for complications and side-effects that may occur during procedures, especially in dental offices. Anesthesiologists and dentists with a GA permit and pediatric endorsement (when necessary) from the California Dental Board have the advanced training and expertise to help minimize these risks by vigilantly monitoring for any problems, immediately responding to complications, exercising medical judgment, and making split-second decisions that save lives. Although CRNAs are also an important part of the healthcare system and provide high quality care in many settings and situations in a physician-led anesthesia care team model. However, CRNA training is not the same as physicians, and therefore their skills and capabilities are not the same.

The California Medical Association is opposed to this bill unless it is amended, writing:

This bill would bypass current California facility requirements where general anesthesia is currently being administered by Certified Registered Nurse Anesthetists (CRNAs) and physicians. This bill would allow for CRNAs to independently prescribe and order sedation and anesthesia in dental offices. Which would create substantial patient safety concerns with the proposed expansion in this measure.

We respectfully request that all language relating to CRNAs independently prescribing or dispensing anesthesia in dental offices be struck from this bill. We are also concerned with the language regarding CRNAs ordering anesthesia in dental offices but are committed to working with all stakeholders involved to resolve those concerns.

POLICY ISSUES FOR CONSIDERATION:

1. “Independent” Practice. Multiple statutory restrictions prevent CRNAs from administering DS or GA in a dental office if the dentist is not GA-permitted and there is no GA-permitted physician. The restrictions also limit CRNAs from administering DS or GA without a dentist or physician assuming responsibility for the administration of the anesthesia. This bill establishes the new CRNA GA permit and “prescriptive authority” with the goal of allowing CRNAs to provide DS and GA via their own GA permit, independent of dentist or physician responsibility or delegation.

The first statutory restriction is that the Dental Practice Act restricts the provision of DS and GA by any provider in a dental office, requiring the provider who will administer the anesthesia to obtain a GA permit. Only dentists and physicians may currently obtain the permit. This bill adds CRNAs to the list of providers who may obtain the permit.

The second restriction is that the Nursing Practice Act requires the dentist to hold a GA permit if a CRNA provides services in a dental office and GA is being administered. This bill deletes that restriction.

The third restriction is that the RN scope of practice in the Nursing Practice Act, which still applies to CRNAs, only authorizes the administration of medication or therapeutic agents in a dental setting “ordered by and within the scope of licensure of” a physician or dentist. Although not currently defined in statute, an order is generally used as a mechanism for delegating something, such as the treatment of a condition or performance of tests, to another provider. When giving an order, the ordering provider has determined the medical necessity of the order. Even if DS or GA could be provided in a dental office without a GA permit, the CRNA if the dentist is unwilling or unqualified to order a CRNA to administer the anesthesia, then the CRNA cannot.

This bill addresses the scope restriction in two ways. First, it authorizes a GA-permitted CRNA to administer GA or DS in a dental office “notwithstanding any other law.” It also defines the terms “select,” and “order” in the Nursing Practice Act and grants a CRNA “prescriptive authority” to directly “select, order, or administer” anesthesia upon the “request” of a dentist.

The fourth restriction is that, even if a CRNA could administer without an order from a dentist or physician, CRNAs do not have a DEA registration allowing them to obtain the anesthesia, and a dentist is unlikely to purchase the anesthesia on the CRNA’s behalf if they are not willing to assume the responsibility of the anesthesia through an order. The authorizations under this bill, including the ability to administer GA or DS independent of an order from a dentist or physician, meet the definition of “dispense” under the federal Controlled Substances Act of 1970, requiring GA-permitted CRNAs to register with the DEA.

The opposition argues that the independence granted under this bill presents patient safety concerns, specifically that CRNAs, although qualified to provide anesthesia services, are not qualified to do so outside of licensed facilities or upon the order of a qualified dentist or physician. The sponsor argues that dental cases are of lower complexity than those in licensed facilities and that CRNAs are trained to identify patients who are not suitable for DS or GA in a dental setting.

The ability to utilize a CRNA in dental settings varies across the US:^[2]

• 1. 22 states authorize CRNAs to provide services without regard to a dental permit.
  2. 25 states, including CA, and the District of Columbia authorize CRNAs to provide services if the provider has a dental permit.
  3. 3 states do not authorize CRNAs to practice in dental offices.

1. Prescriptive Authority. CRNAs are currently not authorized to prescribe, which is the act of issuing an order for the dispensing of drugs or devices to a patient. This bill does not authorize the act of “prescribing,” but instead grants CRNAs “prescriptive authority” to “select, order, or administer prescription drugs.” However, in the dental settings where CRNAs would practice, they would not be prescribing or dispensing medications outside of the administration of the anesthesia. Any pre- or post-operative care medications would be prescribed by the operating dentist.

In addition, the bill authorizes a CRNA to “order” when providing DS and GA services at the request of a dentist. However, there are no licensees who would be able to execute the order other than another CRNA or other licensee already authorized to administer, dispense, deliver, or distribute the anesthesia within their scope of practice. Therefore, the prescriptive authority under this bill is not necessary to accomplish the goals of the bill.

Currently, the ability for CRNAs to prescribe varies across the US:^[3]

• 1. 16 states and the District of Columbia authorize full, independent prescribing.
  2. 20 states authorize limited prescribing under physician supervision, limited schedules, or both.
  3. 14 states, including, CA authorize no prescribing.

1. Three Provider Model. CALAOMS is opposed to this bill because it believes the requirement on the use of DS or GA for patients under 13 years of age under SB 501 should be applied to the general population. In the DBC’s response to the issue during its sunset review, the DBC wrote, “DBC is willing to consider the expansion of the pediatric staffing of anesthesia in dental office standards to the adult population. However, there does not appear to be an identifiable problem justifying the increased regulation. Since the last Sunset bill there have been no pediatric deaths related to general anesthesia and deep sedation in dentistry reported.”

IMPLEMENTATION ISSUES:

1. Unnecessary Requirements and Declarations. This bill contains provisions that are not necessary or may have no effect, including:
   1. Requiring CRNAs to prescribe based on their competence, but this bill does not authorize prescribing.
   2. Requiring CRNAs to only prescribe if there is an established client or patient record.
   3. Requiring CRNAs to complete any training required by the DEA, but if registration is conditioned on that training, then the provision is duplicative of the DEA’s requirements.
   4. Declaring that nothing in the Nursing Practice Act affects the authority of a CRNA to select, order, or administer prescription drugs for the delivery of perioperative anesthesia services beyond the outpatient dental setting, but nothing in the act (or this bill) would have that effect.
2. Definition of “Request.” This bill conditions the administration of DS or GA by a permitted CRNA on a “request” issued by a dentist but does not define it. Because the term “request” is intended to be something other than an “order” in the context of the assessment of the patient and overall liability of the DS and GA services provided, the author may wish to clarify the distinction if this bill passes this committee.
3. Ongoing Discussions. As noted above, the implementation of the permitting requirements established under SB 501 is being discussed as part of the DBC’s sunset review, including potential changes to the physician GA permit, which the language under this bill is modeled after. If this bill passes this committee, the author may wish to continue to work with this committee, the Senate Business, Professions and Economic Development Committee, the DBC, and relevant stakeholders to avoid conflicts.

AMENDMENTS:

1. Prescriptive Authority. Delete the new “prescriptive authority” and accompanying definitions as follows:

On pages 6-7, strike lines 27-19:

SEC. 3. Section 2831.5 is added to the Business and Professions Code, to read:

2831.5. (a) As used in this section, the following definitions apply:

“Order” means the process of directing a licensed individual, pursuant to their statutory authority, to directly administer a drug or to dispense, deliver, or distribute a drug for the purpose of direct administration to a patient, under instructions of the certified registered nurse anesthetist to provide prescription drugs.

“Prescription drugs” includes Schedule II through Schedule V controlled substances under the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code).

“Select” means the decisionmaking process of choosing a drug, dosage, route, and time of administration.

(b) (1) A certified registered nurse anesthetist who is licensed pursuant to this article and is registered with the federal Drug Enforcement Agency shall have prescriptive authority to select, order, or administer prescription drugs upon a request issued by a dentist under Article 2.75 (commencing with Section 1646) of Chapter 4 to administer anesthesia for diagnostic, operative, or therapeutic procedures in an outpatient dental setting.

(2) A certified registered nurse anesthetist under paragraph (1) shall prescribe prescription drugs based on their level of professional education, training, and certification by the National Board of Certification and Recertification for Nurse Anesthetists, or a successor national professional organization approved by the board.

(c) A certified registered nurse anesthetist shall only prescribe prescription drugs under subdivision (b) for an individual whom the certified registered nurse anesthetist has, at the time of the prescription, established a client or patient record.

1. Independent Practice. Add additional guardrails but maintain the goals of the bill, including administration of DS and GA without a dentist or physician order and the ability to purchase anesthesia under a DEA registration as follows:
   1. Maintain the ability to administer DS or GA pursuant to the GA permit at the request, rather than the order of, a dentist without a GA permit.
   2. Keep the requirement to register with the DEA.
   3. Clarify that the CRNA may only practice within their individual competence.
   4. Require a referral plan for complex cases and emergencies.
   5. Require CRNAs to refuse DS or GA for patients not suited for it.
   6. Require CRNAs to maintain DBC standards for facilities, equipment, personnel, and procedures as a condition of their RN license, in addition to the GA permit.
   7. Clarify that the DBC is not required to enforce the Nursing Practice Act:

On page 6, after line 21:

(b) General anesthesia or deep sedation administered in a dental office at the request of a dentist by a nurse anesthetist shall be in accordance with both of the following:

(1) Article 2.75 (commencing with Section 1646) of Chapter 4.

(2) Paragraph (2) of subdivision (b) of Section 2725. (A) If administering general anesthesia or deep sedation to dental patients in the office of a licensed dentist who does not possess a permit issued pursuant to Article 2.75 (commencing with Section 1646) of Chapter 4, the nurse anesthetist shall do all of the following:

(i) Register with the United States Drug Enforcement Administration.

(ii) Practice within the scope of their clinical and professional education and training.

(iii) Establish a plan for referral of complex cases and emergencies.

(iv) Decline or refer a patient with a preexisting disease or condition that is not optimized and may adversely interact with general anesthesia or deep sedation.

(v) Ensure that the facilities, equipment, personnel, and procedures utilized by the nurse anesthetist meet the Dental Board of California’s onsite inspection requirements under subdivision (c) of Section 1646.14. Failure of an onsite inspection constitutes unprofessional conduct and is grounds for disciplinary action by the board.

(B) This paragraph shall not be construed to require the Dental Board of California to enforce the requirements of this paragraph or verify compliance with this paragraph for purposes of Section 1646.14.

1. Conforming Change. Cross-reference the new requirements in the Nursing Practice Act in the Dental Practice Act as follows:

On page 5, between lines 5 and 11:

1646.14. (a) Notwithstanding any other law, including, but not limited to, Sections 1646.1 and 1647.2, a certified registered nurse anesthetist licensed pursuant to Chapter 6 (commencing with Section 2700) and certified as a nurse anesthetist pursuant to Article 7 (commencing with Section 2825) of Chapter 6 may administer general anesthesia or deep sedation in the office of a licensed dentist to dental patients without regard to whether the dentist possesses a permit issued pursuant to this article, if both of the following conditions are met:

(1) The nurse anesthetist meets the requirements of paragraph (2) of subdivision (b) of Section 2827.

(2) The nurse anesthetist holds a valid general anesthesia permit issued by the Dental Board of California pursuant to subdivision (b).

(2) (3) The nurse anesthetist meets the requirements of subdivision (d) of Section 1646.1.

1. Unnecessary Requirements and Declarations. Delete sections 4 and 5 of the bill:

On page 7, strike lines 20-39 and page 8, strike lines 1-14:

SEC. 4. Section 2833 of the Business and Professions Code is amended to read:

2833. (a) Each certificate issued pursuant to this article shall be renewable biennially, and each person holding a certificate under this article shall apply for a renewal of their certificate and pay the biennial renewal fee required by Section 2830.7 every two years on or before the last day of the month following the month in which their birthday occurs, beginning with the second birthday following the date on which the certificate was issued, whereupon the board shall renew the certificate.

(b) Each certificate not renewed in accordance with this section shall expire but may within a period of eight years thereafter be reinstated upon payment of the biennial renewal fee and penalty fee required by Section 2830.7 and upon submission of proof of the applicant’s qualifications as may be required by the board. During the eight-year period, no examination shall be required as a condition for the reinstatement of any expired certificate that has lapsed solely by reason of nonpayment of the renewable fee. After the expiration of the eight-year period the board may require, as a condition of reinstatement, that the applicant pass an examination as it deems necessary to determine their present fitness to resume the practice of nurse anesthesia.

(c) Upon registration or renewal of registration with the federal Drug Enforcement Agency, a certified registered nurse anesthetist shall complete the required training as set forth by the agency.

SEC. 5. Section 2833.3 of the Business and Professions Code is amended to read:

2833.3. (a) Nothing in this article shall be construed to limit a certified nurse anesthetist’s ability to practice nursing.

(b) Nothing in this chapter shall affect the authority of a certified registered nurse anesthetist licensed pursuant to this article to select, order, or administer prescription drugs for the delivery of perioperative anesthesia services beyond the outpatient dental setting.

REGISTERED SUPPORT:

California Association of Nurse Anesthetists (sponsor)

American Nurses Association/California

14 individual dentists

REGISTERED OPPOSITION:

California Association of Oral and Maxillofacial Surgeons

California Society of Anesthesiologists

California Medical Association (unless amended)

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301

1. The sunset review process provides an opportunity for the DCA, the Legislature, the boards, and interested parties and stakeholders to discuss the performance of the boards, and make recommendations for improvements. Each year, the Assembly Business and Professions Committee and the Senate Business, Professions, and Economic Development Committee hold joint sunset review oversight hearings to review the boards and bureaus. For more information, see the background paper for the DBC’s 2024 Sunset Review, accessible at: https://abp.assembly.ca.gov/jointsunsethearings. ↑

2. American Association of Nurse Anesthesiology, Dental Permit Map, https://www.aana.com/wp-content/uploads/2023/07/CRNA-Dental-Board-Permit-Map.png (accessed April 12, 2024). ↑

3. American Association of Nurse Anesthesiology, Prescriptive Authority Map, https://www.aana.com/wp-content/uploads/2023/04/CRNA-Prescriptive-Authority-1.png (accessed April 12, 2024). ↑