Anesthesia E-ssential, July 30, 2012

Anesthesia E-ssential

July 30, 2012


Vital Signs

Colorado Appellate Court Upholds Opt-Out from Federal Anesthesia Rule
On July 19 the Colorado Court of Appeals upheld the previous ruling in favor of the Colorado governor and the Colorado Association of Nurse Anesthetists (CoANA). The appellate court affirmed that Colorado state law does not require Certified Registered Nurse Anesthetists (CRNAs) to be supervised by a physician, and also ruled that former Gov. Bill Ritter acted within his rights by opting out of the federal physician supervision requirement for nurse anesthetists in September 2010.
“We are pleased that the appellate court has upheld the lower court’s decision to continue to allow CRNAs to administer anesthesia without the supervision of a physician, which has always been the scope of practice for Colorado's nurse anesthetists,” said Scott Shaffer, CRNA, president of CoANA.
On March 31, 2011, a district court granted summary judgment in favor of former Gov. Ritter and CoANA, the Colorado Nurses Association and the Colorado Hospital Association, affirming Colorado’s opt-out of the federal supervision requirement. The district court judge stated that in Colorado the administration of anesthesia by CRNAs is an independent nursing function and does not require physician supervision, an important requirement for seeking an opt out from the Centers for Medicare & Medicaid Services (CMS).
Nurse anesthetists provide anesthesia services to 99 percent of the communities with surgical services throughout the state. This ruling is particularly important for Colorado's rural communities, as CRNAs are the sole providers of anesthesia services in over 70 percent of rural hospitals. The court’s ruling dismisses the lawsuit filed in September 2010 by the Colorado Society of Anesthesiologists (CSA) and the Colorado Medical Society (CMS).
Colorado is the 16th of the 17 states to opt out of the federal rule, including Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, California, and Kentucky. For further information about opt-outs, read the Federal Supervision Rule/Opt-Out Information Page on the AANA website.


The Pulse

  • View Proposed Amendments to the Bylaws and Standing Rules on the AANA Website
  • AANA to Broadcast Live Streaming Video of Annual Meeting Session
  • AANA Has New Toll-Free Number
  • Severe Staph Infections Linked to Unsafe Use of Single-Dose/Single-Use Vials
  • HHS Offers Interactive Webinars on the Healthcare Law
  • PTSD Coach Mobile App Available for Free Download
  • See You on August 30
  • Rockin' the Annual Meeting
  • August AANA Journal Features Answers to Journal Course Exam
  • AANA Members Join Tele-Townhalls to Advance the ProtectMyPainCare Campaign
  • Tips on Sending Medicare Your Pain Care Comments
  • ASA and ASIPP Respond to CMS Plan to Restore Direct Reimbursement for CRNA Chronic Pain Services
  • Essential Health Benefits Final Rule Discourages Problematic Anesthesia Survey as Patient Experience Measure
  • House Panel Cuts Nurse, Allied Health Workforce Funds; Next Steps Unclear
  • Party Divide Emerges in Congress over Drug Shortage "Gray Market"
  • Legislation Reintroduced in House to Restore Medicare Rural Hospital CRNA "On Call" Services Reimbursement
  • Medicare Proposes 2013 Hospital Outpatient and ASC Payment

Healthcare Headlines

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
View Proposed Amendments to the Bylaws and Standing Rules on the AANA Website
At the Annual Business Meeting, to be held on Saturday, Aug. 4 at the AANA Annual Meeting, members will vote on amendments to the AANA Bylaws and Standing Rules. For background information on the Business Meeting, including the proposed amendments, visit the AANA Annual Business Meeting Information Page on the AANA website. (AANA member login and password required.)
AANA to Broadcast Live Streaming Video of Annual Meeting Session
The AANA knows that not all of its members are able to attend the AANA Annual Meeting, but all CRNAs need current information to help shape and guide their practice. To provide you with some of the educational content being presented at this year’s meeting, the AANA has arranged to broadcast a two-hour general session live from the Moscone Center in San Francisco on Tuesday, Aug. 7, from 2:30 p.m. to 4:30 p.m. (Pacific Time) / 5:30 p.m. to 7:30 p.m. (Eastern Time). Read more about the session.

AANA Has New Toll-Free Number
The AANA's toll-free number is (855) 526-2262. Fun fact: The last four digits spell "AANA" on your phone.

Severe Staph Infections Linked to Unsafe Use of Single-Dose/Single-Use Vials
New case reports reveal severe staph and methicillin-resistant Staphylococcus aureus (MRSA) infections passed to 10 patients as a result of unsafe injection practices, specifically using single-dose/single-use medication vials for more than one patient. For more information, read the July 13 edition of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

HHS Offers Interactive Webinars on the Healthcare Law
The United States Department of Health and Human Services (HHS) Partnership Center continues to host a series of interactive webinars to discuss the benefits and provisions of the Affordable Care Act. All webinars are open to the public and include a question and answer session where you can ask HHS staff any question you may have about the healthcare law. Submit questions you would like to have answered on the webinar to
To participate in one of the webinars, please select your preferred dates from the list below and submit the necessary information.
National Webinars:
  • July 24, 2:00 pm ET – The Health Care Law 101 (in Spanish)
  • August 21, 2:00 pm ET – Tour of
  • August 28, 2:00 pm ET – The Health Care Law 101 (in Spanish)
Regional Health Care Law 101 Webinars:
  • August 2, 2:30 pm PT – Arizona, California, Hawaii, Nevada, Territories, and Freely Associated States
  • August 7, 2:00 pm ET –New Jersey and New York
  • August 8, 11:00 am ET – Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont
  • August 8, 2:00 pm CT, 1:00 pm MT – Arkansas, Louisiana, New Mexico, Oklahoma, and Texas
PTSD Coach Mobile App Available for Free Download
The Department of Veterans Affairs’ and the Department of Defense’s Post-traumatic Stress Disorder (PTSD) Coach mobile application provides education, symptoms-tracking tools, self-assessment and connections to support individuals with PTSD. Since its public release on April 11, 2011, the app has been downloaded more than 53,000 times in more than 60 countries. It is available for free download for both iPhone and Android devices. For more information visit:

See You on August 30
The Anesthesia E-ssential will not come out on Aug. 15, and it will resume publication on Aug. 30. Before and during the Annual Meeting, watch your inbox for the 2012 AANA Convention Daily. The Daily will once again be distributed via email to all AANA members, not just Annual Meeting attendees. The first preissue debuted on July 24 and is available online at You will receive the next preissue on July 31 and daily issues Aug. 5 through Aug. 7 during the meeting.
Rockin' the Annual Meeting
This year at the AANA Annual Meeting, there are new ways to communicate with your colleagues.
One is the Annual Meeting Community (login required), which allows AANA members to talk about the annual meeting events and the sites of San Francisco in a discussion community in the members section of the AANA website. The community is open from now until September 3.
Also new at the Annual Meeting is the Twitter initiative. AANA has developed hashtags for each of the meeting sessions, so interested students and CRNAs can follow salient points tweeted by attendees. Follow @aanawebupdates to keep up with the latest at the meeting. Find out more about the Twitter initiative here.
For those attending the meeting, keep an eye out for the good old-fashioned message board that will be available in the Moscone West Convention Center. Attendees can post their thoughts about which speakers they enjoyed listening to, what the most interesting session was that they attended, etc. Look for the message board and add your thoughts to what made the San Francisco annual meeting beneficial for you.
August AANA Journal Features Answers to Journal Course Exam
Wondering how well you did on AANA Journal Course Exam #31 (ends July 31 at midnight central time)? Exam answers will be posted online with all Journal content in early August. Journal articles include “Experiences of Military CRNAs with Service Personnel Who Are Emerging from General Anesthesia” and “Infection Control Practices of Laryngoscope Blades: A Review of the Literature.” Part 3 of AANA Journal course #32 discusses “Anesthesia and Safety Considerations for Office-Based Cosmetic Surgery Practice.” Also, look for the AANA Journal Special Research Edition to be available online in early August. View the AANA Journal.

AANA Members Join Tele-Townhalls to Advance the ProtectMyPainCare Campaign
More than 9,700 AANA members joined the AANA’s first-ever tele-townhall meetings the evening of July 17, intended to spur member engagement in the Association’s ProtectMyPainCare campaign and generate comments in favor of the Medicare proposed rule resuming direct Medicare reimbursement for CRNA pain management services.
The call for members in the eastern half of the country was led by AANA President Debra Malina, CRNA, DNSc, MBA, with President-elect Janice Izlar, CRNA, DNP, joining in answering member questions and comments during the call for western members. Though more than two dozen members’ questions were taken and addressed live during the tele-townhall, over 100 members sought to offer questions and comments, and those are being addressed one by one via email and individual conversations. Throughout, nearly a quarter of the entire AANA membership took time on the tele-townhall to learn about this critical CRNA practice issue, and how to be effective writing and generating comments to Medicare via the AANA-backed website.
“At the direction of our united AANA Board of Directors, we are holding this tele-townhall to outline for AANA members the importance of this work to every CRNA practice, and how you as a CRNA can take effective action to support your practice, and to mobilize the support of colleagues, family, patients and other allies,” said President Malina.

Tips on Sending Medicare Your Pain Care Comments
So you’d like to help protect CRNA practice by getting involved in the AANA’s ProtectMyPainCare campaign. What do you do?
  • See the official campaign website, learn about the issue, and use its easy and convenient system to submit a comment on the issue to the Medicare agency and make your voice heard!
  • Your comments should be in your own words. Though form letters are very convenient to send, a large number of identical form letter comments will be received by the Medicare agency as one form letter. Why would restoring Medicare direct reimbursement of CRNA pain management services make a difference to you and your community? Tell that story, and your voice will be heard.
  • Invite your CRNA and health industry colleagues, your family, and friends to get involved! Thoughtful comments from patients, caregivers, nurses, hospital administrators, and physicians are all valuable and important. Be sure to adhere to all rules and laws governing patient and healthcare confidentiality.
  • If you’re attending the AANA Annual Meeting, see the AANA’s Protect My Pain Care advocacy centers near Registration and in the Exhibit Hall to take action.
  • Act on time – comments must be in to Medicare by Sept. 4.
ASA and ASIPP Respond to CMS Plan to Restore Direct Reimbursement for CRNA Chronic Pain Services
On July 10, 2012, the American Society of Anesthesiologists (ASA) released an update to its members regarding the Centers for Medicare & Medicaid Services (CMS) proposed rules on Physician Fee Schedule. The ASA concurs that “under the proposed rule a CRNA will be reimbursed for services related to chronic pain management as long as the CRNA is permitted to perform the service under the state scope of practice law.” The ASA went on to say that it is closely analyzing the full 765-page rule, as AANA is.
Prior to release of the rules, both the ASA and the American Society of Interventional Pain Physicians (ASIPP) weighed in on the potential for a national policy approving direct reimbursement for CRNAs providing pain services. “CRNAs are trained to anesthetize a patient for surgery” cautioned an ASIPP letter circulated to members of Congress. The ASIPP went on to state that “CRNAs are now seeking an unprecedented expansion of their scope of practice to diagnose complex medical conditions, order expensive diagnostic testing, provide unsupervised treatments and to perform complicated and dangerous procedures and surgeries for which they have had no formal training or certification.”
Of course, the ASIPP’s statements are misleading and characteristic of a guild opposing competition. CRNAs are educated to the scope of nurse anesthesia practice, and the Medicare agency which issued the recent proposal resuming direct reimbursement of CRNA pain management services does not govern scope of practice – the profession does, and the states do through adoption of laws and through their Boards of Nursing.

Essential Health Benefits Final Rule Discourages Problematic Anesthesia Survey as Patient Experience Measure
A final rule released by the Department of Health and Human Services on July 20 addresses comments and concerns raised by the AANA regarding state exchanges’ recognition of qualified health plans as part of health reform implementation. In a comment letter signed by AANA President Debra Malina, CRNA, DNSc, MBA (AANA member login and password required), the AANA requested that the agency require qualified health plan (QHP) networks to provide access to non-physician providers to the fullest extent of their training and require QHPs to adhere to state and federal provider nondiscrimination provisions. In the final rule, the agency maintains that QHP networks should be sufficient in the number and types of providers to ensure that all services will be accessible without reasonable delay.
The proposed rule also required the use of patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey as one condition of recognition as an accrediting entity for QHPs. AANA’s comments requested clarification regarding which CAHPS survey would be used to measure patient experience, opposing the use of the CAHPS Surgical Care Survey and the Clinician/ Group CAHPS as proposed measure tools because they fail to recognize the contributions of CRNAs and other nurses and risk collection of data subject to misinterpretation. In the final rule, the agency responded that they are finalizing the requirement that the recognized accrediting entities require accreditation on local performance in patient experience ratings on a standardized CAHPS survey. The agency did not specify which CAHPS surveys that the recognized accrediting entities must use as part of accreditation but expect that the recognized accrediting entities will use health plan CAHPS surveys and will not use the surgical care and/or Clinician/Group CAHPS surveys.

House Panel Cuts Nurse, Allied Health Workforce Funds; Next Steps Unclear
A House Appropriations subcommittee approved on a party-line vote an FY 2013 Labor-HHS-Education budget bill making substantial reductions in nursing and allied health workforce development programs, and level-funding health research initiatives at the National Institutes of Health.
But the fate of the measure pressed by subcommittee chair Rep. Denny Rehberg (R-MT) was just as quickly thrust into doubt as the full Appropriations Committee was unlikely to take it up for further legislative action before Congress goes on recess for August.
In the House subcommittee bill, the Health Professions and Nursing Workforce Development programs (Title 7 & Title 8 of the Public Health Service Act (PHSA)) along with Title 3 of PHSA are provided $623.272 million. While Title 7 and 8 specific funding levels are not available yet, the bill reportedly includes over $100 million in cuts to the health professions, including a 14 percent cut to Title 8, funding the Nursing Workforce Development programs at approximately $197 million. The bill provides $30.6 billion for the National Institutes of Health, including $144.597 million to the National Institute of Nursing Research (both figures represent level funding from FY 2012).
Meanwhile, the Senate measure approved by the full Appropriations Committee June 14 (S 3295, S Rept 112- 176) that level-funds Title 8 programs continues to await full Senate floor consideration.

Party Divide Emerges in Congress over Drug Shortage "Gray Market"
With the ink barely dry on an AANA-backed provision requiring drug companies to issue more advance notice of conditions giving rise to potential shortages, lawmakers are now dividing on party lines over the existence of a “gray market” in drugs in shortage that gives rise to harmful price gouging. House and Senate Democrats have developed a report that they will unveil at a July 25 hearing on price gouging in critical drugs, reported Inside Health Policy on July 24. Meanwhile, in their own new document, House Republicans criticize the Democratic report as focusing on a “significantly limited” list of drugs, says IHP.

Legislation Reintroduced in House to Restore Medicare Rural Hospital CRNA "On Call" Services Reimbursement
Legislation has been reintroduced into the U.S. House of Representatives that would restore Medicare rural hospital CRNA “on call” services reimbursement for qualifying hospitals. The bill, H.R. 6146, was introduced July 18 by Reps. Ruben Hinojosa (D-TX) and Tim Johnson (R-IL), responding to concerns raised by rural hospitals in their congressional districts. It has been referred to the Medicare-writing House Ways and Means Committee for consideration. Similar legislation was introduced in previous Congresses and backed by AANA. The provisions of H.R. 6146 pending in the House are already part of an omnibus rural healthcare bill awaiting Senate consideration, the “Craig Thomas Rural Hospital and Provider Equity Act” (S. 1680, Sec. 23).
Medicare Proposes 2013 Hospital Outpatient and ASC Payment
The Medicare agency July 6 proposed its 2013 hospital outpatient and ambulatory surgery center payment rules, with the public comment period through Sept. 4, 2012. The AANA FGA’s preliminary review has found content related to the following areas of interest to CRNAs: Packaging of drugs, biological and radiologic pharmaceuticals, safe surgery checklists for 2014 and 2015, enforcement instructions for critical access hospitals, small rural hospitals through 2013, and requirements for ambulatory surgical center quality reporting systems. Stay tuned for AANA comments to the Medicare agency once we complete our analysis and review.
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Epidural Analgesia Not to Blame for Fever in Laboring Women, Study Suggests
The results of a study published in the August issue of Anesthesiology challenge prior reports that draw a correlation between fever in laboring women and the use of epidural analgesia. Potential causes of non-infectious maternal intrapartum fever (MIF) changes were explored in 81 cases by researchers from the University of Alabama. All but three of the women received epidural analgesia, with their temperatures recorded both before and after administration; and more than half registered a small rise in temperature. The findings revealed that a significant number of those patients who experienced temperature elevations either were in labor for a markedly longer period of time or had a higher body mass index, both of which are linked to inflammatory processes that can cause temperature to rise. No impact on MIF due to epidural analgesia was observed.
From "Epidural Analgesia Not to Blame for Fever in Laboring Women, Study Suggests" ScienceDaily (07/25/12)

Mechanical Thrombectomy in Acute Stroke: Prospective Pilot Trial of the Solitaire FR Device While Under Conscious Sedation
New research suggests that, for acute ischemic stroke, mechanical thrombectomy with conscious sedation is feasible in many cases and is associated with short procedure delay and good functional outcomes at three months. For the study, French researchers aimed to evaluate the feasibility, safety, and efficacy of mechanical thrombectomy under conscious sedation in patients with acute ischemic stroke. The study used the Solitaire FR device in a prospective, single-center study of 36 patients treated from May 2010 to July 2011. The patients had acute ischemic stroke due to a large artery occlusion and, after intravenous thrombolysis (when no contraindications), they underwent thrombectomy with the Solitaire device under conscious sedation. Successful revascularization was achieved in 77.8 percent of patients. After three months, 61.1 percent of patients showed good functional outcome. Mechanical thrombectomy under conscious sedation was determined to be feasible in 86.1 percent of cases.
From "Mechanical Thrombectomy in Acute Stroke: Prospective Pilot Trial of the Solitaire FR Device While Under Conscious Sedation"
American Journal of Neuroradiology (07/12) Soize, S.; Kadziolka, K.; Estrade, L.; et al.
In a new study, French researchers analyzed data describing the appropriate positioning of the needle tip and pattern of local anesthetic spread in ultrasound-guided peripheral nerve blocks. The investigators sought studies on the optimal procedure for common approaches to block efficacy, performance time, and safety. They noted that large peripheral nerves are surrounded by a gliding layer; a circumneural spread corresponds to adventitial extraneural injection. Deliberate intraneural injection is still controversial and remains inadvisable. For popliteal sciatic nerve blocks, rapid surgical anesthesia comes with positioning the needle in the common nerve sheath between the tibial and peroneal components and obtaining a circumneural spread. Ultrasound-guided perivascular injection aiming at circumferential spread around the artery, with axillary and infraclavicular approaches, may be an alternative to individual targeted nerve injections. When it comes to single-injection interscalene block, injecting into the fascial sheath, far from the plexus, can be as effective as an injection adjacent to the nerve structures. Fascial plane approaches may be alternatives for thin nerves that run between muscles and are not regularly visualized with current ultrasound systems.
From "Where Should the Tip of the Needle Be Located in Ultrasound-Guided Peripheral Nerve Blocks?"
Current Opinion in Anaesthesiology (07/18/2012) Choquet, O.; Morau, D.; Biboulet, P.; et al

PPAHS Releases Safety Checklist That Targets Patient-Controlled Analgesia
More than 700 deaths and tens of thousands more adverse events involving Patient-Controlled Analgesia (PCA) pumps were reported to the Food and Drug Administration between 2005 and 2009. To help decrease these numbers, the Physician-Patient Alliance for Health & Safety (PPAHS) has issued a concise checklist designed to help clinicians cover the proper steps when initiating PCA. "Hospital protocols should call for two professionals to confirm pump settings, and continuous electronically monitoring of all their patients using PCA pumps with pulse oximetry and/or capnography, along with other measures to ensure the safety of patients," remarked Frank Overdyk, MD, an anesthesiology professor at Hofstra University. "The technology and know-how exist to reduce PCA-related incidents and deaths, and more advanced technology is being developed for the future. Designed in collaboration with renowned medical experts—including Peter Pronovost, PhD, MD of Johns Hopkins University—the checklist is available for viewing and download at the PPAHS website at no cost.
From "PPAHS Releases Safety Checklist That Targets Patient-Controlled Analgesia" (07/18/2012) 
What's the Best Way to Sedate Endoscopy Patients?
Endoscopy sedation involves a balance between patient comfort and side effects, which is reflected in a new training curriculum issued by several gastroenterology societies. The American College of Gastroenterology, the American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, and the American Association for the Study of Liver Diseases, and the Society for Gastroenterology Nurses and Associates have issued the Multisociety Sedation Curriculum for Gastrointestinal Endoscopy. The curriculum appears in the July issue of the journal Gastroenterology and comprises 11 training sections for safe delivery of sedation during endoscopy. These sections include the levels of sedation; instances when anesthesia providers should be involved; training in specific agents for moderating sedation; airway rescue techniques; and intraprocedure monitoring requirements. The curriculum is intended to ensure a standardized approach to endoscopy sedation training.
From "What's the Best Way to Sedate Endoscopy Patients?"
Outpatient Surgery (07/17/12) Cook, Daniel
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Study: Use BMI to Calculate Pediatric Propofol Doses
Basing the amount of propofol needed exclusively on a patient's weight can cause overdosing in children, researchers have discovered. The study, which involved obese patients aged three to 17, found that heavy children need a lower weight-based dose of propofol for anesthesia induction than do their normal-weight counterparts. The researchers, who reported their results in Anesthesia & Analgesia, concluded that body mass index should be used instead to calculate propofol dosages for children.

From "Study: Use BMI to Calculate Pediatric Propofol Doses"
Becker's Hospital Review (07/13/12) 

Updated CDC Recommendations Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students
The Centers for Disease Control and Prevention (CDC) has updated its 1991 recommendations for the management of hepatitis B virus (HBV)–infected healthcare providers and students to reduce the risk of transmitting HBV
to patients. The updates reflect changes in the epidemiology of U.S. HBV infection and advances in the medical management of chronic HBV infection. Percutaneous injuries that healthcare personnel may receive during certain procedures could lead to HBV transmission to patients as well as providers. CDC researchers found that many interventions—such as the adoption of Standard Precautions, the use of double-gloving during invasive surgical procedures, and vaccination of healthcare providers—nearly eliminated the very low risk for HBV transmission during exposure-prone procedures. The updates reaffirm that HBV infection alone should not disqualify someone from practicing surgery, dentistry, or medicine. CDC recommendations now include: no prenotification of patients of a healthcare provider's or student's HBV status and the use of HBV DNA serum levels instead of hepatitis B e-antigen status to monitor infectivity. The updates also include, for healthcare professionals who require oversight, specific suggestions for composing expert review panels and the threshold value of serum HBV DNA considered "safe" for practice. Most medical and dental students who are discovered to have chronic HBV infection do not need to curtail their practices or learning experiences if they conform to current standards for infection control.
From "Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students"
Morbidity and Mortality Weekly Report (07/06/12) Vol. 61, No. 3, P. 1 Holmberg, Scott D.; Suryaprasad, Anil; Ward, John W.
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