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Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.
Congressional Super Committee Fails to Yield $1.2 Trillion Deficit Cuts on Schedule—What’s Next for CRNAs?What does the congressional super committee’s failure mean for CRNAs? News reports Nov. 21 indicated that the Joint Select Committee on Deficit Reduction was unlikely to yield a plan to cut the deficit $1.2 trillion over the next 10 years, as the Budget Control Act enacted last summer requires by Nov. 23. With lawmakers pointing fingers—Republicans saying Democrats would not cut spending enough, and Democrats accusing Republicans of shielding the wealthy from tax increases—the next steps are challenging indeed. - Through a process called “sequestration,” across-the-board cuts to certain programs begin in 2013. Of CRNA interest, the cuts include 2 percent reductions to Medicare payments; 7 percent-8 percent reductions to discretionary spending programs including Title 8 workforce development programs, nursing and medical research, law enforcement, and regulation of food and drugs; and 10 percent reductions from national security and homeland security accounts. The across-the-board cuts may not apply evenly; Congress or agencies may direct cuts to apply more severely to some programs in order to spare others.
- Some programs are exempted from the cuts by law, such as Medicaid and Veterans programs (including Veterans health programs).
- Issues the super committee was considering fixing must now be fixed by Congress by the end of the year through the regular (and holiday-rushed) legislative process. These issues include reversing the 26.2 percent Medicare Part B cuts to anesthesia and physician payments that take effect Jan. 1, 2012.
See the super committee’s site and also a summary of articles noting the fallout of the supercommittee’s outcome.
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Inside the Association
Hot Topics The AANA is in the process of redesigning its website to offer a new, branded design, a more robust search engine, self-service functionalities, improved navigation, and much more! While we make these changes, the day-to-day updating of the current site will cease until the official launch of the new site, which will take place in early December. For a sneak peek, see page 10 of the November AANA NewsBulletin.
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The newest course in the AANALearn® online CE system, “Coalition Activity and the CRNA” will remain on sale until Dec. 31. The course provides CRNAs with information on coalition activity supported by the AANA and a general perspective on the effectiveness of coalitions for protection of patient and practitioner rights. One CE credit will be provided upon completion of the course, and the credit will automatically transfer into the CE transcript record.
With the Holiday weekend ahead, this might be a good time to check out the course catalogs in AANALearn® – available courses provide over 45 CE credits on a range of topics for the nurse anesthetist. Explore the expanded learning opportunities by clicking on the Member login link at www.aanalearn.com.
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AANA Foundation 2012 Student Scholarship Program
Deadline: December 31 In 2011, the AANA Foundation’s Student Scholarship Program awarded 64 scholarships totaling $129,000. This year will be the ninth year of the program, and the Foundation is once again seeking sponsors to support nurse anesthesia students through their nurse anesthesia program. The minimum donation to sponsor a student is $3,000 per scholarship. The increase in the minimum scholarship donation coincides with the increase in tuition expenses. The average student will graduate nurse anesthesia school having paid over $30,000 in tuition alone. The impact this gift can make on a student’s quality of life is immeasurable.
The deadline date for sponsoring a student scholarship for 2012 is December 31, 2011. If you wish to be part of this important program, visit the AANA Foundation website at www.aanafoundation.com and access the Sponsor a Student Scholarship link to the application. Complete the application and mail it with your tax-deductible donation to the AANA Foundation, Scholarship Sponsor, 222 S. Prospect Ave., Park Ridge, IL 60068
Thank you in advance for having an impact on the life of a future CRNA.
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Acting at the request of the AANA and other healthcare professional organizations, 94 U.S. representatives wrote the bipartisan House leadership on Nov. 16 urging the longest possible fix to the 26.2 percent Medicare Part B “sustainable growth rate” cuts to CRNA and physician payments coming Jan. 1, 2012. The letter also urged the rejection of the Medicare Payment Advisory Commission (MedPAC) recommendation to cut Medicare CRNA and other specialty payments 17 percent over three years. “MedPAC’s recommendation fails to value the role that all providers have in the continuum of care, and if implemented, the impact on access to care for millions of Americans would be devastating,” the letter stated. “As a result, we strongly oppose the recommendation that an SGR fix should be funded by provider payment cuts that could endanger Medicare beneficiaries’ access to care.”
The letter was circulated by Reps. Michael Burgess MD (R-TX) and Gene Green (D-TX), and spurred by over a thousand AANA member messages to Capitol Hill acting at the recommendation of CRNAdvocacy alerts from AANA President Debra Malina, CRNA, DNSc, MBA.
Read the AANA’s Sept. 27 letter to MedPAC (requires AANA login and password).
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With the adoption of three appropriations bills at once, but not the Labor-Health and Human Services (HHS)-Education bill that funds nurse workforce development programs, Congress extended “continuing resolution” funding for Title 8 and myriad health programs important to CRNAs through Dec. 16, 2011, in hopes of continuing work on completing a final budget. Now nearly two months into the new fiscal year, Congress has completed a quarter of its annual appropriations bills for FY 2012. Remaining of CRNA interest are the Defense and Labor-HHS-Education bills whose total spending dwarfs the package adopted Nov. 17 and signed into law by the President Nov. 18.
See how they voted in the House at and the Senate. See a summary of the bill, and the bill itself (H.R. 2112) and accompanying conference report (H. Rept. 112-284).
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The Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) is seeking nominees by Jan. 30, 2012, for work on that critical Medicare agency advisory panel, according to a notice in the Nov. 18 Federal Register. The AANA, through its Board of Directors, seeks to nominate and place qualified CRNAs on federal advisory panels like the MEDCAC. If you know of an AANA member who might meet the agency’s qualifications, please contact AANA FGA at info@aanadc.com and include “MEDCAC Nomination” in the subject line.
The Medicare agency states that the 100-member body is particularly seeking experts in “hematology; genomics; Bayesian statistics; clinical epidemiology; clinical trial methodology; knee, hip, and other joint replacement surgery; ophthalmology; psychopharmacology; rheumatology; screening and diagnostic testing analysis; and vascular surgery. We also need experts in biostatistics in clinical settings, cardiovascular epidemiology, dementia, endocrinology, geriatrics, gynecology, minority health, observational research design, stroke epidemiology, and women’s health.”
Read the Federal Register notice.
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More than 100 CRNAs attending the AANA Fall Leadership Academy (FLA) participated in the CRNA-PAC “Jammin Good Time” event on Sat., Nov. 12, and over the three days of the Academy your CRNA-PAC raised nearly $37,000 through both the PAC event and member gifts and pledges—including five new Presidential Club members. The cool weather moved the event inside, but that did not discourage the attendees from showing their beach wear and competing in the flip-flop contest. Great food, drink, music, and camaraderie made the evening fun for all. Thanks to everyone who attended.
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Deadline: January 31, 2012
From a slate of member nominees provided by the AANA Board of Directors in February, the CRNA-PAC Committee elects two CRNAs each year for three-year terms and one student nurse anesthetist for a one-year term, at the Mid-Year Assembly committee meeting. If you are interested in serving on the CRNA-PAC Committee, see the instructions (AANA member login required). The deadline for applications is Jan. 31, 2012.
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Please consider answering the call to join the CRNA-PAC so we can assure CRNA issues and concerns are heard in Washington, D.C. 2012 is a Presidential election year so it is vital that we remain to have a strong voice in Washington. One of those ways is to have a strong CRNA-PAC to assure access to the decision makers. Your CRNA-PAC is a non partisan group that supports U.S. House and Senate candidates and campaigns with influence over or commitment to the issues that affect us all. But why wait? Please “Care to be Counted” today by contributing to the AANA CRNA-PAC at www.caretobecounted.org (AANA member login required).
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Professional Practice
A special panel of the Food and Drug Administration (FDA) is hosting a public meeting in Gaithersburg, Md., on Dec. 14 on whether the agency should approve the Ethicon Endo-Surgery Sedasys® Computer-Assisted Personalized Sedation System for sale and marketing in the United States, according to an agency notice in the Federal Register on Nov. 21.
The AANA had presented to another FDA advisory panel in May 2009 concerns about authorizing a nonanesthesia professional to administer propofol, which has FDA-approved labeling requiring that a professional expert in general anesthesia administer it, through an automated device. The advisory panel conditionally recommended SEDASYS® for sale and marketing. However, its decision was overturned by the FDA’s Center for Device and Radiological Health in October 2010, setting off an appeals process to the Commissioner that includes the Dec. 14 hearing.
Read the AANA’s May 2009 comments (requires AANA member login and password).
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News from the Councils
A Council on Accreditation of Nurse Anesthesia Educational Programs (COA) meeting will be held on Jan. 17-19, 2012, at the AANA Headquarters, 222 S. Prospect Avenue, Park Ridge, IL 60068. The business portion of the meeting is open to the public (program representatives and others who are interested in observing the proceedings). However, the portion of the meeting where the COA deliberates on program accreditation decisions will be closed to observers. Call the COA office at (847) 655-1160 for further information.
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A study was held to characterize the clinical effectiveness of ultrasound-guided (USG) ankle block in comparison with conventional anatomic landmark-guided (ALG) techniques through a six-year retrospective cohort study of all ankle blocks performed for foot surgery and demographic, intraoperative, and postoperative outcome data. The researchers identified 655 patients who received unilateral ankle block and 58 patients who received bilateral ankle block, and analyzed them separately. In patients to whom unilateral ankle block was administered, successful surgical anesthesia was more likely in the USG group (84 percent versus 66 percent). ALG group patients were more likely to need supplemental local anesthesia (10 percent versus 5 percent), unplanned general anesthesia (17 percent versus 7 percent), or supplemental fentanyl (18 percent versus 9 percent). The groups exhibited similar postanesthetic care unit pain scores, but patients in the ALG group were more likely to receive intravenous opioids (21 percent versus 12 percent), and they received a higher average opioid dose (10.6 mg versus 8.7 mg intravenous morphine, ALG versus USG). In patients receiving bilateral ankle block, successful surgical anesthesia also was more likely in the USG group (84 percent versus 57 percent), but this was not statistically significant given the small sample size.
From "Ultrasound-Guided Versus Anatomic Landmark-Guided Ankle-Blocks: A 6-Year Retrospective Review"
Regional Anesthesia & Pain Medicine (12/01/2011) Vol. 36, No. 6, P. 611 Chin, Ki Jinn; Wong, Natalie; Macfarlane, Alan James Robert; et al.
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Dual guidance can help deliver safer, more effective peripheral nerve blocks. This involves the use of ultrasound imaging with electrical stimulation to locate and target nerves. The technique can be helpful especially for providers who are still developing their regional anesthesia skill sets. The use of dual guidance can confirm anatomy, provide a backup, and offer visualization. To use dual guidance for regional anesthesia, facilities must acquire a peripheral nerve stimulator, an ultrasound imaging unit, and needles and nerve block supplies. Optional accessories include a local anesthetic infusion pain pump, depending on the facility's post-op pain management protocol. Anesthesia providers must also be committed to attend courses for hands-on training in ultrasound imaging techniques.
From "Dual Guidance, Multiple Advantages"
Outpatient Surgery (11/01/11) Vol. 12, No. 11, Melton, Gregg
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Rather than general anesthesia, many healthcare providers are choosing to use propofol in combination with other pain medications and anesthetics in appropriate cases. Some patients may be wary of propofol because it has been associated with patient death; but when used properly, it can be beneficial for patients who receive minimally invasive spine surgery. Intravenous anesthetic agents primarily target the ion channel link receptors for the neurotransmitters glutamate (principle excitatory transmitter) and GABA (principle inhibitory transmitter). Propofol acts on the receptors to induce unconsciousness in a patient. Depending on the dosing schedule for certain procedures, patients may still be responsive but comfortable. Propofol may be ideal for the ambulatory surgery center because patients should be able to wake up quickly and leave the center soon after the procedure without feeling the symptoms of general anesthesia. Propofol has rapid redistribution and hepatic elimination, and it causes less nausea and vomiting than thiopental. In the use of propofol, the plasma concentrations decrease rapidly when an infusion is terminated, meaning the drug does not stay long in the blood stream. At The Bonati Spine Institute, anesthesia providers use propofol in combination with other drugs that locate the GABA receptor, such as midazolam (Versed). Propofol may also be used with Sufentanil, a drug related to morphine.
From "Local Anesthesia for Minimally Invasive Spine Surgery: 4 Points on Propofol Use"
Becker's Orthopedic & Spine Review (11/11) Miller, Laura
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Older people are less likely to receive pain medication in an emergency room (ER) compared to younger people with similar pain levels, according to a seven-year nationwide study of emergency room patient data. Researchers found that 49 percent of patients over age 75 years received pain medication, compared with more than 65 percent of those under 75. The study, which included data on more than 88,000 emergency room visits, is published in the Annals of Emergency Medicine. The research did not include elderly people who were cognitively impaired or otherwise unable to report pain. Reasons for this difference are unclear, but the authors hypothesized that ER personnel may be more concerned about adverse effects of pain medications on the elderly or may be more concerned about the diagnosis in older patients, rather than pain relief.
From "In the E.R., the Elderly Get Less Pain Relief"
New York Times (11/22/11) P. D6 Bakalar, Nicholas
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President Obama recently ordered the U.S. Food and Drug Administration (FDA) to boost its efforts to prevent shortages and price fixing of vital prescription drugs. The FDA is ordered to more broadly enforce reporting requirements for manufacturers experiencing drug shortages, expedite review of new prescription drug suppliers, and work with the Justice Department to prosecute price gouging. The number of shortages of potentially life-saving drugs has been on the rise in recent years, reaching at least 232 this year, according to industry experts. Such drugs include those given to cancer patients, heart attack victims, and accident survivors. There is also legislation pending in Congress that would require pharmaceutical companies to notify the FDA of potential shortages earlier than the current requirements. Some experts say, however, that an executive order may not have any immediate effect, as it does not address the fundamental causes of drug shortages. These include fewer manufacturers for older, less profitable products and shortages of raw material or functioning equipment.
From "Obama Issues Executive Order Aimed at Curbing Drug Shortages"
Washington Post (11/01/11) P. A3 Nakamura, David; Stein, Rob
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A recent study from St. Luke's-Roosevelt Hospital Center in New York suggests that by placing the tourniquet on the forearm when using Bier block anesthesia during hand surgery, it is possible to reduce the amount of ischemic pain experienced by the patient. The research compared 56 patients, half with the tourniquet placed on the forearm and half with it placed at the conventional upper-arm location; the patients were initially anesthetized with lidocaine and ketorolac, with the forearm group receiving about half the dose of the upper-arm group. Patient pain levels were monitored on a visual analog scale (VAS) and administered pain medication at certain points along the scale—fentanyl at VAS 4 and propofol at VAS 6. The forearm group had 64 percent of its patients indicate a VAS or 3 or less, compared to just 4 percent in the upper-arm group. Meanwhile, the upper-arm group had 80 percent of its patients indicate a VAS level higher than 6, compared to 4 percent in the forearm group. The forearm group received less pain medication, allowing nearly half to skip the post-anesthesia care unit (PACU) and go directly to phase II recovery, which none of the upper-arm group were able to do. The investigators indicated that the disparity in pain level could be due to anatomical differences, citing the different amount of pressure placed on the humerus compared to the amount of pressure that would be split between the radius and ulna with the forearm approach. The results indicate that forearm tourniquet placement could reduce costs and drug usage by minimizing the need for sedation, speeding recovery, and helping bypass the PACU.
From "For Bier Block, The Ties That Bind Dictate Pain"
Anesthesiology News (11/01/11) Vol. 37, No. 11, Blum, Karen
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Anesthesia & Analgesia recently published a study in which the researchers confirmed, as found by half a dozen earlier investigations, that the use of forced-air warming in operating rooms neither reduces air quality nor puts the patient at greater risk of bacterial contact. The study indicated that laminar air flow was not disrupted by forced-air warming and that temperature management using forced-air helped to reduce incidents of infection in patients. The research, which showed that the downward stream of laminar air flow actually lowers bacteria around the surgical site, was conducted in the operating rooms of two hospitals in the Netherlands.
From "Forced-Air Warming Does Not Reduce Quality of Operating Room Air"
Becker's ASC Review (11/11) Fields, Rachel
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The most common causes of unplanned hospital admissions after ambulatory surgery include cardiac and respiratory complications, according to the results of a retrospective study at Duke University Medical Center. Researchers found that surgical-related reasons, including complications or necessary additional procedures, were also common. The study included a chart review of 28,456 patients who underwent ambulatory surgery between May 2006 and May 2010. During this period, unplanned hospital admissions accounted for 127 patients, a rate of 0.45 percent, comparable to previous findings. Medical-related issues accounted for 32 percent of admissions and were associated with the highest total charges. Cardiac complications were the most expensive to treat. Surgical-related reasons accounted for 22 percent of admissions. Postsurgical admissions were also caused by the need for additional pain control, postoperative bleeding, anesthesia-related complications, and adverse drug reactions. Study co-author Dr. Steve Melton, assistant professor of anesthesiology at Duke, said the study "shows we're doing a better job of identifying appropriate patients for ambulatory surgery, and identifying and managing risk factors beforehand." A larger study involving ambulatory surgical centers in New York found that risk factors for unplanned hospital admissions included surgical time of more than two hours and the use of general anesthesia. The authors of the new study presented their findings at the 2011 annual meeting of the American Society of Anesthesiologists.
From "Management Strategies for Ambulatory Surgical Patients Paying Off"
Anesthesiology News (11/01/11) Vol. 37, No. 11, Blum, Karen
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Researchers have recommended that physicians performing bronchoscopy use topical anesthesia, analgesic, and sedative agents, when practical. When best performed, bronchoscopy involves patient comfort, physician’s ease of execution, and minimal risk. The American College of Chest Physicians Interventional/Chest Diagnostic Network convened a panel of experts to examine literature taken from a search conducted on MEDLINE from 1969 to 2009. Results showed that, when there are no contraindications, patients undergoing bronchoscopy should receive topical anesthesia, analgesia, and sedation, as these yielded the most patient tolerance and satisfaction. Anticholinergic agents, when administered prebronchoscopy, were not found to produce a clinically meaningful effect. Lidocaine is the preferred topical anesthetic for bronchoscopy. The panel suggests the use of a combination of benzodiazepines and opiates due to their synergistic effects on patient tolerance and opioids' antitussive properties. The panel said that propofol is effective for sedation when compared with the combined administration of benzodiazepines and opiates.
From "American College of Chest Physicians Consensus Statement on the Use of Topical Anesthesia, Analgesia, and Sedation During Flexible Bronchoscopy"
CHEST (11/01/11) Vol. 140, No. 5, P. 1342 Wahidi, Momen M.; Jain, Prasoon; Jantz, Michael; et al.
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Among individuals with axial spine pain, more than 40 percent may meet criteria for fibromyalgia, according to researchers presenting a database review at the American Society of Anesthesiologists' 2011 annual meeting. The findings showed that patients who meet fibromyalgia criteria reported less relief from opioid medications and spinal injections than those without fibromyalgia. Because of this, clinicians recommend that such patients be screened for fibromyalgia before they receive interventions that may be ineffective. "Patients with fibromyalgia and neck and back pain present much differently and so their treatments may need to be approached differently," said primary investigator Dr. Chad Brummett, assistant professor of anesthesiology and director of pain research at the University of Michigan. "These individuals may derive greater benefit from centrally acting medications." The study authors prospectively collected data from 166 patients with a primary complaint of back or neck pain with or without radicular symptoms. Researchers found that 43.4 percent of the patients met criteria for fibromyalgia. These patients reported higher pain-intensity and pain-interference scores and had higher depression and anxiety scores. Although fibromyalgia-positive patients were more likely to receive opioid medications for their pain, they were less likely to report relief from the medications.
From "Screen for Fibromyalgia in Axial Pain Patients, Study Suggests"
Pain Medicine News (11/01/2011) Vol. 9, No. 11, Wild, David
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