Anesthesia E-ssential, April 30, 2012

Anesthesia E-ssential

April 30, 2012


Vital Signs

Kentucky Gov. Beshear Removes Physician Supervision for Nurse Anesthetists
Removal of federal requirement strongly supported by recent studies
Kentucky has become the 17th state to opt out of the federal physician supervision requirement for Certified Registered Nurse Anesthetists (CRNAs). A full one-third of all states have now taken advantage of a rule implemented by the Bush Administration in 2001 giving governors the ability to opt out of the supervision requirement and ensure citizens access to safe, cost-effective anesthesia care, especially in medically underserved areas.
Kentucky Gov. Steve Beshear wrote to the Centers for Medicare & Medicaid Services (CMS) on April 25, 2012, that “it is in the best interest of Kentucky’s citizens to opt out of the current federal physician supervision requirement in order to improve access to critical services.” Gov. Beshear noted in his letter that opting out was recommended by the Kentucky Cabinet for Health and Family Services and requested by the Kentucky Hospital Association and Kentucky Association of Nurse Anesthetists. The governor also stated that he “consulted with the Kentucky Board of Medical Examiners and the Kentucky Board of Nursing about issues related to access to and quality of anesthesia services in Kentucky” before concluding that the removal of supervision for nurse anesthetists was in the best interests of Kentucky’s citizens.
The CMS received Gov. Beshear’s letter on April 26, at which time the opt-out immediately went into effect. For further information, read the AANA Press Release.


Vital Signs


The Pulse

Inside the Association
  • AANA Participates in “Joining Forces” to Support Care for Veterans
  • Ira Gunn Laid to Rest in Arlington National Cemetery
  • Online Forum for Candidates for the AANA Board of Directors Available Now
  • AANA Seeks Practicum Instructors for Annual Meeting
  • Member Open Comment Period for AANA Position Statement
  • Article Emphasizes Interprofessional Cooperation in Treating Patients
  • New Centers for Excellence Focus on Traumatic Brain Injury
  • AANALearn®—Providing the CE you need!
  • Participate in the AANA's Social Network
  • Attend the “State of the Science” at the 2012 Annual Meeting
  • Providing Reliable and Relevant Information for Prospective Nurse Anesthesia Students
  • Record Number of AANA Members Advocate for CRNA Issues at AANA Mid-Year Assembly
  • “Affair of State,” and “Coffee Challenge” for Students Clear Over $100,000 for CRNA-PAC
  • Congress to Take Up FDA User Fee Bills Addressing Safe Injection Practices, Drug Shortages
  • HHS Issues Revised Action Plan to Prevent Healthcare Associated Infections; AANA Reviewing
  • AANA Urges Medicare Not to Require 10-Year Recordkeeping
  • Medicare Announces List of Accountable Care Organizations: Are You In?
  • Medicare Still Going Broke, Trustees Say
  • Visit the CRNA Career Center.
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.

Inside the Association

Hot Topics

AANA Participates in “Joining Forces” to Support Care for Veterans
On April 11 First Lady Michelle Obama and Dr. Jill Biden announced a commitment from nurses across the country eager to serve our veterans and military families as well as they have served us. The AANA and numerous other nursing schools and organizations have committed to educating 1.3 million current and future advanced practice and registered nurses about how to recognize and care for veterans impacted by post-traumatic stress disorder, traumatic brain injury, depression, and other combat-related issues, in ways appropriate to each nurse’s practice setting by 2015. The AANA was represented at the ceremony by AANA President Debra Malina, CRNA, DNSc, MBA; Kelly Wiltse Nicely, CRNA, PhD; and Bette Wildgust, CRNA, MS, MSN. For further information, read the AANA's press release and Joining Forces information on the White House website. Photos from the event are available here on the AANA website.
Ira Gunn Laid to Rest in Arlington National Cemetery
Legendary advocate and nurse anesthetist Ira P. Gunn, CRNA, MLN, FAAN, was laid to rest Monday, April 16, in Arlington National Cemetery. Gunn, who passed away on Oct. 25, 2011, is widely recognized for her contributions to nurse anesthesia practice, research, education, publication, consultation, credentialing, and government relations. Photos from the ceremony and a link to her memorial program can be found on a special page of the AANA website.
Online Forum for Candidates for the AANA Board of Directors Available Now
Take advantage of this opportunity to become better acquainted with the candidates seeking election to the AANA Board of Directors. Further information is available on the AANA website. The forum became available to the members on April 16, 2012. The candidates’ speeches, photos, and position statements will be posted prior to May 8. Watch the Candidate Information page for more details. Active members can submit questions to the Forum for approximately 45 days. The final deadline for question submission is June 5, 2012, two weeks before the voting cut-off date (June 19).
AANA Seeks Practicum Instructors for Annual Meeting
The AANA is looking for individuals to serve as practicum instructors for the Difficult Airway or Ultrasound Open Labs at the 2012 Annual Meeting in San Francisco, California. To be considered, fill out the form located on the AANA website.
Interested individuals for the difficult airway lab should be experienced in the use of the flexible fiberoptic endoscope and LMA. Interested individuals for the ultrasound lab should be experienced in basic principles and applications of ultrasound in anesthesia practice.
Selected individuals will receive $50 for each hour of practicum instruction. Each lab will be open Monday, August 6, 8 a.m. – 4 p.m. and Tuesday, Aug. 7, 8 a.m. – 12 p.m.
Travel expenses, lodging and meals are at the instructor’s expense.
Member Open Comment Period for AANA Position Statement
A proposed draft of “Position Statement 2.17 - Patient Safety: Fatigue, Sleep, and Work Schedule Effects” is open for member comments until midnight CST on May 14, 2012. Please read the draft document in its entirety and submit feedback.(Member login required)
Article Emphasizes Interprofessional Cooperation in Treating Patients
An article developed by members of the Coalition for Patients’ Rights examines how healthcare professionals from a variety of disciplines can work together to provide quality care for diabetes patients. AANA member Jeremiah Loch, CRNA, DOMTP, PhD, DAAPM, is a coauthor of the article, “Collaborative Practice Benefits Patients: An Examination of Interprofessional Approaches to Diabetes Care.”
Dr. Loch discusses how a team approach with psychologists can help effectively treat the neuropathic pain often experienced by diabetic patients. The article appears in the current issue of Health and Interprofessional Practice and can be accessed through the Coalition for Patients’ Rights website. The AANA serves as one of the lead organizations in the Coalition for Patients’ Rights, a national coalition of more than 35 organizations committed to ensuring comprehensive healthcare choices for all patients.
New Centers for Excellence Focus on Traumatic Brain Injury
Traumatic brain injury (TBI), a complex type of injury to the brain’s structure, is common among veterans and has been called a “signature injury” of modern combat. The Department of Veterans Affairs recently funded two new Centers of Excellence to focus on TBI: Boston’s Translational Research Center for TBI and Stress Disorder (TRACTS), which uses advanced brain-scan methods and wide-reaching examinations to study how TBI and post-traumatic stress disorder symptoms interact; and Houston’s Neurons to Networks Center for Rehabilitation Research, which focuses on improving diagnoses of Veterans with mild to moderate TBI, and develops and evaluates treatments involving virtual reality and neurobiofeedback.
AANALearn®—Provides the CE you Need!
If this is your year to recertify, now is the perfect time to review your continuing education (CE) transcript and verify that you have at least 40 CE credits available for recertification. AANALearn® can provide as many credits as you may need46 courses providing 50 CE credits. No other CE provider can transfer your CE credits as quickly as AANALearn® willonce you complete a course, the CE credit is transferred to your transcript the same day. The online CE courses are available 24 hours, 7 days a week and AANA members always receive a 30 percent discount off the regular price of courses. Check us out now to browse the catalogs.
Participate in the AANA's Social Network
AANA members can be a part of the discussion on President Malina's Blog and in the Clinical Hot Topics Community at MyAANA. There is no need to "join" these public groups—all members have automatic access by virtue of their membership in the AANA. Just enter and participate by contributing to or reading the ongoing discussion. More discussion groups will be added soon. Check back often! (Login required.)

Attend the “State of the Science” at the 2012 Annual Meeting
In 2012, the AANA Foundation “State of the Science” Oral Poster session will have 12 competitively selected investigators orally present their research in 25-minute presentations with 2 minutes for questions and answers.
Scheduled research presentations include:
  • A Comparison between Filtered Needles vs. Non-Filtered Needles on Glass Particle Contamination of the Aspiration from Glass Ampules
  • A Comparison of Tibial Intraosseous (IO), Sternal IO, and Intravenous Routes of Administration on the Pharmacokinetics of Epinephrine during Cardiac Arrest
  • Acute Painful Stress and Inflammatory Mediator Production
  • An Evidenced-Based Approach to CRNA Grassroots Efforts
  • Attitudes and Perceptions of Newly Graduated Certified Registered Nurse Anesthetists about their Nurse Anesthesia Program’s Ability to Sufficiently Educate Graduates as Full-Service Providers
  • Effects of Multiple Isoflurane Exposures on Long Term Potentiation in the Hippocampus
  • Enhanced Awareness of Obstructive Sleep Apnea Through Education and Use of the STOP/BANG Questionnaire
  • Illioninguinal-Illiohypogastric Block with Intrathecal Morphine Decreases Nausea but not Pain VAS post Caesarean Section
  • Nurse Anesthesia Clinical Faculty Perceptions of Success Factors and Characteristics of Non-traditional Nurse Anesthesia Students: A Mixed Methods Analysis
  • The Effects of QuikClot Combat Gauze on Hemorrhage Control in the Presence of Hemodilution
  • The Effects of Using Simulation vs. CD-ROM on the Performance of Ultrasound Guided Regional Anesthesia
  • Use of the Berlin Questionnaire to Assess Risk of Obstructive Sleep Apnea in Patients Receiving Intravenous Sedation for Colonoscopy
Be sure to attend the AANA Foundation “State of the Science” Oral Poster Session:
Monday, Aug. 6
2–5:10 p.m.
Moscone West Convention Center, San Francisco, CA
For the full list of presenters and research titles, please reference the July 2012 AANA NewsBulletin.

Providing Reliable and Relevant Information for Prospective Nurse Anesthesia Students
The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is developing a new service: the CRNA School Search! This new service will enable prospective students to easily access information regarding nurse anesthesia programs in a centralized location.
The CRNA School Search will be an expansion of the list of accredited programs currently offered by the COA. It will provide advanced search and comparison capabilities of information on accredited nurse anesthesia programs such as cost, clinical sites, program design, and admission requirements. CRNA School Search will save prospective students hours of valuable time and provide information that is sometimes difficult to obtain. CRNA School Search also ensures prospective students are provided with up-to-date and accurate program information so students can make informed choices about their nurse anesthesia education. We anticipate the service will be available in fall 2012. For more information regarding CRNA School Search, please contact the COA at

Record Number of Members Advocate for CRNA Issues at AANA Mid-Year Assembly
More than 800 members of the AANA, including more than 300 student registered nurse anesthetists, learned CRNA issues and effective advocacy principles then put them to use on Capitol Hill April 17-18 where they urged lawmakers to promote ensuring patient access to CRNA pain care.
The meeting featured presentations from AANA National Health Policy Leadership Award winner Sen. Tom Harkin (D-IL), House Energy and Commerce Health Subcommittee member Rep. John Shimkus (R-IL), Mayra Alvarez of the U.S. Department of Health and Human Services Office of Health Reform, former Medicare agency chief Tom Scully, former U.S. Senator Blanche Lincoln (D-AR), Congressional Management Foundation chief Brad Fitch, and members of the AANA team in Washington.
Participants also heard from AANA President Debra Malina, CRNA, DNSc, MBA, met and heard from AANA members seeking election to association offices, and witnessed the full military honors provided to the late Ira P. Gunn, CRNA, MLN, FAAN, on her inurnment at Arlington National Cemetery.
Backed by over a thousand messages from AANA members to Capitol Hill acting through the AANA’s “Virtual Mid-Year Assembly” advocacy push, CRNAs and student nurse anesthetists urged members of Congress to support restoring patient access to CRNA pain care, renewing nurse anesthesia workforce development appropriations, and reversing threatened 32 percent cuts to Medicare Part B.
Read background information on Mid-Year Assembly CRNA issues, including one-page issue briefs and detailed backgrounders (requires AANA member login and password). Record your Hill visits.
Members Advocate for CRNA Issues at AANA Mid-Year Assembly

Left to right: Mindy Miller, Mike Anderson, Brad Zeithamel, Ramona Miller, Senator Harkin, Hayley Smith, Mark Odden, Mary LaMar, and Cormac O'Sullivan

“Affair of State” and “Coffee Challenge” for Students Clear Over $100,000 for CRNA-PAC
AANA members contributed over $100,000 to the CRNA-PAC during AANA Mid-Year Assembly 2012 through participation in the PAC’s “Affair of State” event atop the historic Hay-Adams Hotel overlooking the White House, and through the CRNA-PAC “Coffee Challenge” which encouraged student registered nurse anesthetists’ participation in the PAC.

The Affair of State drew nearly half of the conference attendees. And the Coffee Challenge, which asked students to either get three CRNA-PAC members to sign a card or to make a minimum $25 PAC contribution in exchange for a Starbucks gift card, was taken up by half of the students at the meeting.
“What a strong statement by so many members committed to our strong voice in Washington,” said CRNA-PAC Committee Chair Steven Mund, CRNA, DNP.
Learn more about the CRNA-PAC (requires AANA member login and password).
Congress to Take Up FDA User Fee Bills Addressing Safe Injection Practices, Drug Shortages
Committees in the House and Senate are taking up legislation renewing the drug and device user fee programs that fund the Food and Drug Administration (FDA), and which also are likely to address drug shortage prevention and the promotion of safe injection practices of interest to CRNAs.
The AANA has provided the House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions (HELP) Committee technical comments on their draft legislative proposals being prepared for committee action later this week and in May. The comments urged the panels to include provisions ensuring that the FDA specifically include nursing organizations in drug shortage notification systems, and incorporate legislation intended to combat anesthesia drug shortages through requiring drug companies to give longer advance public notice of circumstances threatening supplies of critical medications.
HHS Issues Revised Action Plan to Prevent Healthcare Associated Infections; AANA Reviewing
The U.S. Department of Health and Human Services issued on April 19 an updated draft action plan to prevent healthcare associated infections (HAIs) in ambulatory surgery centers, an issue important to CRNAs.
The HAIs include surgical site infections, central-line associated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, C. difficile, and Methicillin-resistant Staphylococcus aureus (MRSA). The report also makes mention of issues surrounding unsafe injection practices. The plan is under review by the AANA and is subject to public comment through June 22.
Meanwhile, the Centers for Disease Control and Prevention (CDC) issued a new report comparing the healthcare associated infection rate by state.
Read the revised HHS plan. See AANA’s comments on the previous version of the plan (requires AANA member login and password). See the CDC report.
AANA Urges Medicare Not to Require 10-Year Recordkeeping
The AANA in an April 16 comment letter urges the Medicare agency to adjust its proposal increasing to 10 years the length of time healthcare providers such as CRNAs would be required to keep claims records in case Medicare finds it overpaid. Instead, AANA recommends such records be required to be kept no more than five years.
“Many of our members’ practices will have difficulty going back 10 years as many do not retain their records for more than five years,” wrote AANA President Debra Malina, CRNA, DNSc, MBA. “We believe it would be unrealistic to expect practices to keep these records for longer than records are retained for tax purposes. Furthermore, a 10-year requirement will cause an administrative burden and a resource issue for smaller practices as they may not have the storage capacity to retain records for a long period of time. Therefore, the AANA requests that CMS reduce its look back period to no more than 5 years.” The AANA also urged the agency to clarify the circumstances when a provider or supplier is bound to report a Medicare agency overpayment.
Medicare Announces List of Accountable Care Organizations: Are You In?
The Medicare agency announced April 10 that 27 organizations across the United States have been accepted to become accountable care organizations (ACOs), eligible for alternative Medicare payment systems intended to reward care coordination, quality and cost savings. The development is important to CRNAs because ACOs represent change in how anesthesia and other Medicare services may be reimbursed by public benefit programs and commercial plans. The AANA is interested in learning the degree to which CRNAs are a part of the 27 ACOs announced in the Medicare agency news release of April 10. If you are a part of an ACO, please let us know and describe your experience with ACO development by emailing
Medicare Still Going Broke, Trustees Say
Medicare’s trustees reported in April that the health plan is fiscally about as healthy now as it was a year ago. In other words, the hospital insurance trust fund is still expected to run out of money in 2024, 12 years from now. The report triggered replies along partisan lines, with Democrats arguing that the Affordable Care Act improved Medicare’s fiscal health over what would otherwise have occurred, and Republicans stating that health reform makes Medicare worse off.
Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use our best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. I am a U.S. Citizen.



Healthcare Headlines

Spinal Analgesia for Advanced Cancer Patients: An Update
Spinal analgesia was described in the 1990s as a useful way to control pain in advanced cancer patients. Investigators have conducted a review to update this information with analysis of 27 studies in the last 10 years. In the last decade, few studies have added information on spinal analgesia. Still, spinal analgesia combined with opioids and local anesthetics could achieve analgesia in patients in whom different trials of opioids were unsuccessful. Although adjuvant drugs such as clonidine, ketamine, betamethasone, meperidine, and ziconotide may hold promise, there are several problems to be solved before they can be used regularly in practice. The researchers suggest that "in complex pain situations, spinal analgesia should not be negated to cancer patients, and oncologists should address this group of patients to other specialists."
From "Spinal Analgesia for Advanced Cancer Patients: An Update"
Critical Reviews in Oncology/Hematology (05/01/2012) Vol. 82, No. 2, P. 227 Mercadante, S.; Porzio, G.; Gebbia, V.
A Clinical Assessment Tool for Ultrasound-Guided Axillary Brachial Plexus Block
Researchers from Cork University Hospital and University College Cork in Ireland examined a procedure-specific clinical assessment tool for axillary brachial plexus block in an effort to determine its inter-rater reliability and construct validity in a clinical setting. The authors developed an assessment tool that involved a 63-point task-specific checklist and a global rating scale. Anesthesia providers were assigned to one of three groups based on prior experience in axillary blocks: novices, intermediates, and experts. Each participant performed two consecutive, videotaped blocks, and two independent experts evaluated the tapes. Each group had five participants. According to the results, the inter-rater reliability between assessors was 0.842 and 0.795 for the checklist and global rating scale, respectively. Researchers found a consistent difference between the three groups in both the checklist and global rating scale. The investigators concluded that the objective of a task-specific checklist and global rating scale are reliable, valid measures of axillary block performance among providers of varying expertise levels.
From "A Clinical Assessment Tool for Ultrasound-Guided Axillary Brachial Plexus Block"
Acta Anaesthesiologica Scandinavica (05/01/2012) Vol. 56, No. 5, P. 616 Sultan, S.F.; Iohom, G.; Saunders, J.; et al.
Providers Can and Should Work Toward 'Sustainable Anesthesia'
A special May edition of Anesthesia & Analgesia features nine articles dedicated to the pursuit of environmental sustainability in anesthesia practice. The issue seeks to give anesthesia providers a better understanding of how to provide safe and high-quality patient care with the lowest possible negative impact on the environment. The articles discuss everything from the "greenhouse gas" effects of anesthetics to operating-room recycling and waste reduction to the benefits of "low-flow anesthesia." Dr. Jodi Sherman of Yale School of Medicine, a guest editor, comments: "It's our hope that, after reading the articles in our special collection, anesthesia providers will understand that it is their duty to know and do more to protect public health and safety through minimizing the ecological footprint in anesthesia practice."
From "Providers Can and Should Work Toward 'Sustainable Anesthesia'"
News-Medical (04/25/12)
Do Your Post-Op Patients Feel Good Enough to Eat?
Some patients coming out of surgery suffer from post-operative nausea and vomiting (PONV) as well as severe levels of pain. These patients are likely to spend extra time in the post-anesthesia care unit and to feel generally unhappy with their operating-room experience. Experts say the key to avoiding PONV, which is triggered by unrelieved pain, is to embrace a multimodal approach to pain management—which minimizes the dose and potential negative effects of any single drug. The correlation between PONV and pain is largely tied to the use of opioids, so incorporating methods that reduce reliance on narcotic pain relief is recommended. Using nerve blocks instead of general anesthesia, for example, removes airway management risks, reduces the need for opioids to control post-operative pain, and accelerates recovery and discharge times. Having continuous catheters also better control pain more effectively than any single drug alone could while also reducing the need for opioids. And offering patients analgesia—such as dexamethasone or ondansetron to control nausea and vomiting—before their surgeries has some merit, too, although this approach is only recommended for patients who are at high risk for PONV.
From "Do Your Post-Op Patients Feel Good Enough to Eat?"
Outpatient Surgery (04/01/12) Cook, Daniel
Utah Study: Music Helps Take the Sting Out of Pain
A team from the University of Utah's Pain Research Center has discovered that music has an ameliorating effect on pain. The investigators—five doctors from the center's anesthesiology department—performed a study on 153 volunteer subjects, who received mildly painful stimulation to their fingertips. Fitted with headsets that delivered simple melodies and tones, the volunteers were instructed to signal when the melodies strayed from what was expected. The researchers found that those absorbed in and engaging with the music were distracted from the sensation in their fingertips. "Pain has a psychological component," remarked Carlene Brown, director of the music therapy program at Seattle Pacific University. "Anything that can interrupt that [decreases] pain," Brown added.
From "Utah Study: Music Helps Take the Sting Out of Pain"
Salt Lake Tribune (UT) (04/11/12) Burger, David