Anesthesia E-ssential, June 17, 2013

Anesthesia E-ssential

June 17, 2013 

Vital Signs

Medicare Clarifies AAs Cannot Bill “QZ” Nonmedically Directed Services as CRNAs Can
The Centers for Medicare & Medicaid Services (CMS) has now clarified and confirmed that anesthesiologist assistants (AAs) may not bill Medicare for nonmedically directed (billing code QZ) anesthesia services as CRNAs are educated and authorized to do.
In a policy transmittal dated May 30, 2013, the agency clarified the distinctions between CRNAs, who may practice autonomously and bill Medicare for their services, and AAs, whose services are covered by Medicare when they are medically directed by an anesthesiologist. Transmittal 2716 amends Chapter 12 of the Medicare Claims Processing Manual governing Medicare Part B coverage of anesthesia care.
Though Medicare Administrative Contractors (MACs) long held that AAs may not bill Medicare QZ, the Palmetto GBA MAC serving the states of California, Hawaii, Nevada, North Carolina, South Carolina, Virginia, and West Virginia published an email on April 24 stating, "Palmetto GBA has received guidance that the QZ HCPCS modifier is also to be used for an Anesthesiologist Assistant (AA) service performed without medical direction.” Noting that the Palmetto GBA action was inconsistent with Medicare regulations and payment manuals that say an AA is a “person who works under the direction of an anesthesiologist,” AANA addressed the issue directly with Palmetto GBA and the Centers for Medicare & Medicaid Services (CMS).
The action taken by CMS represents an important development in anesthesia services coverage, clarifying what we already know: that CRNA and AA educational preparation and services are not the same, and that the Medicare program recognizes them differently. While Medicare recognizes CRNA services provided autonomously and with anesthesiologist medical direction, in contrast, the agency only recognizes AA services under anesthesiologist medical direction. Many public and commercial health plans covering CRNA services follow Medicare's lead.
In updating the AANA membership, President Janice Izlar, CRNA, DNAP, stated, “We commend the Medicare agency for having an open ear to AANA's concerns, following and appropriately clarifying the law, and promoting patient access to safe and cost-effective anesthesia care.”


The Pulse

  • Iowa Supreme Court Decision Protects Nursing Practice, Ensures Patient Access to Care
  • Don't Miss the Annual Meeting
  • Don't Wait to Register for the Las Vegas Annual Meeting 2013 Walk/Run
  • Mid-Year Assembly Student Mentoring Program Provides Valuable Insight to Future CRNAs
  • Plan Now to Attend the Upper and Lower Extremity Block Workshop
  • Let there be Golf!
  • Register Now for "Vegas - The Stars Come Out at Night"
  • CDC Releases Toolkit to Assist With Patient Notification Events After Unsafe Medical Practice
  • Preventing Unsafe Injection Practices
  • Get Your Six FREE CE Credits!
  • Call for Entries: AANA Public Relations Recognition Awards
  • If You Can't Be There, You Can Still Be There!
  • Tweeting in Las Vegas: #aanamtg
  • SGR Fix Should Recognize CRNA and APRN Roles, AANA Tells Congress
  • House Panel Unveils SGR Fix Bill, Holds June 5 Hearing
  • Tavenner Confirmed to Lead Medicare Agency
  • New York Times Examines Colonoscopy Payment as an Example of a Healthcare Cost Growth Driver; AANA Responds
  • Senate Panel OKs Compounding Reform Bill
  • Medicaid Hospital Payments Proposed to Be Cut as Scheduled
  • Hospitals Invited to Participate in Bundled Payment Initiative
  • Medicare Trustees Say Healthcare Cost Growth Slowdown Extends Solvency of Medicare Trust Fund
  • Interagency Pain Research Coordinating Committee (IPRCC) Leads Implementation of National Pain Strategy
  • Join Your CRNA Rat PAC Friends at the AANA Annual Meeting

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
Iowa Supreme Court Decision Protects Nursing Practice, Ensures Patient Access to Care
Iowa patients and the CRNAs who care for them were the big winners when the Iowa Supreme Court affirmed on May 31 that the supervision of fluoroscopy, a type of X-ray imaging used in healthcare procedures such as pain management, is within the scope of practice for the state’s advanced registered nurse practitioners (ARNPs), including nurse anesthetists. Read the full story here.
Don’t Miss the Annual Meeting!
Earn valuable continuing education (CE) Credits and network with your fellow CRNAs during the 2013 AANA Annual Meeting at The Mirage in Las Vegas, Nev., Aug. 10-13! Register for the Annual Meeting plus one of the exciting Preconvention Workshops to receive additional CE credit and a $50 discount on the combined registration. Don’t miss this opportunity to earn up to half your recertification CE credits all in one place. Register today!
Don't Wait to Register for the Las Vegas Annual Meeting 2013 Walk/Run
See our video invitation to the eighth annual Fun 5K Walk/Run to be held on Monday, Aug. 12, 2013. Yes, it will be hot, but it’s only “dry heat,” and the shirts are a cool blue color. Plus, we’re planning super soaker stations! Besides, what’s a little heat when your participation benefits Lifebox’s global patient safety mission? Walk/run sign-up is separate from meeting registration – to take your spot among your colleagues register here. To ensure shirt size, register this week. Onsite registration will be available if the event is not sold out; a limited number of shirts will be available while supplies last.
Mid-Year Assembly Student Mentoring Program Provides Valuable Insight to Future CRNAs
On April 15, 2013, at the AANA Mid-Year Assembly, a group of student registered nurse anesthetists from around the country spent the day being mentored by practicing CRNAs as part of the Student Mentoring Program, coordinated by the AANA Public Relations Committee. Nurse Anesthesia educational program administrators nominate students who actively and consistently demonstrate leadership qualities and skills. Click here for a firsthand account from the 2012-2013 student representative to the AANA Public Relations Committee, Elizabeth Broome, RN, and here for a list of participants.
Plan Now to Attend the Upper and Lower Extremity Block Workshop
Mark your calendars and plan to attend the Upper and Lower Extremity Block Workshop on Sept. 28-29, 2013, at the AANA Foundation Learning Center, Park Ridge, Ill. This popular workshop will include discussion on anatomy, pharmacology, and techniques. Between the lectures you can put into practice what you’ve learned in the “hands-on” sessions.
This popular program fills up quickly so register today!
Let there be Golf!
When news got out that the AANA Foundation would not be hosting a golf outing at this year’s Annual Meeting in Las Vegas—a favorite event for many meeting regulars—a group of CRNAs spearheaded by David Schwytzer, CRNA, of Kentucky, took action. If you are interested in playing 18 with other golf-minded members, please contact Dave in June at A portion of the proceeds from this event will go to the AANA Foundation.

Register Now for “Vegas – The Stars Come Out at Night”
If you’re planning to attend the Annual Meeting in Las Vegas and are looking to have a great time, watch fellow CRNAs and student registered nurse anesthetists compete in a talent competition with Kenan Thompson as emcee, and support a great cause, register today for …
Vegas – The Stars Come Out At Night
Monday, Aug. 12, 2013, at 7:30 p.m.
Treasure Island Ballroom
To register, visit the AANA 2013 Annual Meeting Web page and register online, via email, or fax your registration to AANA. On your registration form, be sure to complete section 5 – Ticketed Events and register for the Monday Evening – AANA Foundation Fundraiser. Thank you in advance for your support. A portion of your registration fee for this event is tax-deductible and will support nurse anesthesia education and research. See you in Vegas!

CDC Releases Toolkit to Assist With Patient Notification Events After Unsafe Medical Practice
The Centers for Disease Control and Prevention (CDC) released a new online Patient Notification Toolkit to assist health departments and healthcare facilities with notifying patients after an infection control lapse or potential disease transmission during medical care. The toolkit includes the key steps a healthcare facility or public health department should take to initiate a patient notification and provides resources to assist with creating notification documents, planning media and communication strategies, establishing communication resources to support patient notification, and releasing notification letters.
Preventing Unsafe Injection Practices
The May 31 issue of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report highlights prevention of unsafe injection practices in the U.S. healthcare system.

Get Your Six FREE CE Credits!
AANA members can earn six free CE credits by taking the AANA Journal Course exam online now through July 31.
Call for Entries: AANA Public Relations Recognition Awards
Deadline: July 15, 2013
The AANA Public Relations Committee is seeking entries for the 2013 Public Relations Recognition Awards. Visit the AANA website for more information about the awards criteria and guidelines and an electronic entry form.
If You Can’t Be There, You Can Still Be There!
If you absolutely cannot attend the AANA Annual Meeting Aug. 10-13 in Las Vegas in person, you don’t have to miss out completely. The AANA Convention Daily will be arriving in every member’s email on Sunday, Monday, and Tuesday during the meeting, plus you’ll receive two Annual Meeting newswires during the two weeks leading up to the meeting. The Daily is filled with news and information about and from the meeting—stuff you won’t want to miss. Coming soon to an e-mailbox near you!
Tweeting in Las Vegas: #aanamtg
The AANA has made it easy to communicate what's going on at the Las Vegas Annual Meeting with one simple hashtag (#aanamtg) that can be added to tweets. Those interested in what's being said about the Annual Meeting Aug. 10-13 can search for this hashtag through Twitter's search function, and follow the news and conversations. Twitter provides an instantaneous way to convey news to members and non-members alike from meeting. To learn how to use Twitter, see this article on the Twitter website.

SGR Fix Should Recognize CRNA and APRN Roles, AANA Tells Congress
Congress should recognize the value and importance of CRNAs and other advanced practice registered nurses (APRNs) as part of legislation replacing the Medicare Part B “sustainable growth rate” (SGR) funding formula and reforming future Medicare payment, said the AANA and a coalition of APRN groups in comment letters to the Senate Finance Committee May 31.
In a letter signed by President Janice Izlar, CRNA, DNAP, the AANA outlined the characteristics of Medicare anesthesia payment and made recommendations for reforms and improvements based on the evidence. “Congress should direct Medicare and urge states to promote delivery systems that reward patient safety, access to care and cost-efficiency, and to discourage those systems that shift costs onto the rest of the health system and its payors, and that divert critical resources from other healthcare needs,” the letter said.  In the interest of promoting Medicare and healthcare system cost savings as well as healthcare delivery efficiency, the AANA also recommended that “Congress direct the Government Accountability Office to evaluate the cost to the Medicare program of waiting to accommodate anesthesiologists wishing to claim medical direction Medicare payments.”
The letter, cosigned by AANA and eight other APRN and nursing organizations, provided the Finance Committee four recommendations: that RNs and APRNs be made full partners in the development, evaluation, and use of quality measures, including those for payment incentives; to ensure that measures evaluate the work being done by the provider who is performing the service; that infrastructure for quality reporting be open and transparent; and that payment reforms involve and recognize APRNs in the same way that physicians are recognized.
Read the AANA letter here, and the APRN letter here. (Letters require AANA member login and password.)  Note the ASA response here.
House Panel Unveils SGR Fix Bill, Holds June 5 Hearing
During the week of Memorial Day, the House Energy & Commerce Committee Republican majority unveiled draft legislative language to repeal the Medicare SGR formula and reform Medicare payment, and held a June 5 hearing to examine the proposal, with a June 10 deadline for public comments.
Of interest to CRNAs, the bill would repeal the SGR formula and replace it with a “period of stability” of indeterminate length to be succeeded by a pay-for-quality or pay-for-value system in which providers receive a base payment and then a bonus on top of that for meeting or exceeding certain quality benchmarks. Providers can opt out of the pay-for-quality system if they agree to be reimbursed by some other mechanism such as accountable care organizations, medical homes, or bundled payments, according to the draft bill. 
However, the bill does not yet describe key provisions important to CRNAs and other healthcare providers, such as the source of funding to offset its yet-to-be-estimated costs, the amount of the base payment relative to current payment, the amount of the bonus payment, the systems of quality measures and “core competency categories,” and the means by which providers might become eligible for the bonus payment. Some of these, such as the funding source, are to be supplied later in the legislative process. Others, such as the precise systems of quality measures and the benchmarks for bonus payments, may be deferred to the Secretary of Health and Human Services to decide, according to the bill.
The committee may take up SGR repeal and Medicare reform legislation later this summer. The AANA continues meeting with key committee members and presenting comments to SGR and Medicare payment proposals and was preparing a comment for the committee by its deadline. Unless Congress acts by Dec. 31, Part B cuts of approximately 25 percent will hit CRNAs and physicians Jan. 1, 2014. 
Read the hearing backgrounder here and the proposed legislative language here.
Tavenner Confirmed to Lead Medicare Agency
The U.S. Senate voted May 15 to confirm Marilyn Tavenner, RN, MHA, FACHE, as the Administrator of the Centers for Medicare & Medicaid Services.
Tavenner, whose nomination was supported by the AANA, is the first registered nurse to serve in this post and the first person to be confirmed for it since 2006.
See how your Senators voted here.
New York Times Examines Colonoscopy Payment as an Example of a Healthcare Cost Growth Driver; AANA Responds
A major article in the New York Times June 2 examined Medicare and commercial insurance coverage of colonoscopies as an example of why healthcare costs in the U.S. are so much higher than in other countries. Among the factors the article pointed to is coverage of services provided by anesthesiologists.
In “The $2.7 Trillion Medical Bill,” author Elisabeth Rosenthal outlined costs associated with anesthesiologists. She pointed to a study sponsored by Johnson & Johnson, developer of the Sedasys™ automated propofol sedation device, to make a point about anesthesia and colonoscopy, saying “many medical experts question why anesthesiologists are involved at all. Colonoscopies do not require general anesthesia—a deep sleep that suppresses breathing and often requires a breathing tube. Instead, they require only ‘moderate sedation,’ generally with a Valium-like drug or a low dose of propofol, an intravenous medicine that takes effect quickly and wears off within minutes. In other countries, such sedative mixes are administered in offices and hospitals by a wide range of doctors and nurses for countless minor procedures, including colonoscopies. Nonetheless, between 2003 and 2009, the use of an anesthesiologist for colonoscopies in the United States doubled, according to a RAND Corporation study published last year. Payments to anesthesiologists for colonoscopies per patient quadrupled during that period, the researchers found, estimating that ending the practice for healthy patients could save $1.1 billion a year because ‘studies have shown no benefit’ for them, Dr. Mattke said.”
The AANA’s response by President Janice Izlar, CRNA, DNAP, said, “So why are healthcare costs so high in the United States? A big reason is because ossified healthcare policy impairs competition, access and choice. Barriers to the use of CRNAs as well as other advanced practice registered nurses (APRNs) include unnecessary ‘physician supervision’ requirements, prohibitions against delivery of services they are educated to provide, and reimbursement rules that hinder cost- and life-saving care coordination. Noting that the safety and everyday excellence of CRNAs and other APRNs is well established, the Federal Trade Commission has red-flagged several state legislative and regulatory attempts to protect physician guilds at the expense of patients and the public. Yet, such barriers contribute to the huge overcharges the Times described.”
To read the Times article, click this link, read the referenced RAND Corporation study  here, and the AANA’s response  here.
Senate Panel OKs Compounding Reform Bill
The Senate Health, Education, Labor and Pensions (HELP) Committee approved legislation May 24, the Pharmaceutical Compounding Quality and Accountability Act (S. 959), which intends to address safety issues associated with oversight, production, distribution and administration of compounded drugs. The safety and oversight of compounded drugs is a vital issue for CRNA practice.
Among other provisions, the bill creates a new definition for a “compounding manufacturer” that repackages and combines drugs and other compounds for administration to people or animals. It exempts hospitals and other healthcare facilities from that new definition, continuing to define them as a type of “traditional compounder” under the law.
The AANA is continuing to review and monitor legislative progress on this measuring, mindful of the importance of safe medications for CRNA practice. The measure awaits action by the full Senate.
Medicaid Hospital Payments Proposed to be Cut as Scheduled
The Centers for Medicare & Medicaid Services proposed May 15 to reduce on schedule the Medicaid “disproportionate share hospital” (DSH) payments for facilities serving larger numbers of indigent patients, consistent with the provisions of the Affordable Care Act. For states that have chosen to accept the federal Medicaid eligibility expansion, the reduction is anticipated to be offset by income from persons bringing Medicaid coverage. But for states rejecting the Medicaid expansion, the proposal leaves hospitals in a bind because their DSH funding will be cut and not backfilled by other Medicaid dollars.
States have broad discretion to distribute Medicaid DSH payments to hospitals, subject to hospital-specific payment limits and statewide DSH allotments. DSH allotments vary greatly among states, and the ACA directs that there be greater targeting of this funding. This proposed rule delineates a methodology to implement the annual DSH reductions for FY 2014 and FY 2015. The rule also proposes to add additional DSH reporting requirements for use in implementing the DSH health reform methodology.
Although the proposed rule does not affect CRNA practice directly, members should be aware of its possible effects on hospitals that rely on CRNA services.  
Read the proposed rule here and the CMS fact sheet here. See the status of Medicaid expansion by state here.
Hospitals Invited to Participate in Bundled Payment Initiative
The Center for Medicare & Medicaid Innovation (CMMI) within the Centers for Medicare & Medicaid Services (CMS) announced May 10 an open period for acute care hospitals to participate in Model 1 of CMMI’s Bundled Payments for Care Improvement initiative. Under Model 1, Medicare will pay the hospital a discounted amount on an inpatient hospital stay based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare will continue to pay practitioners separately for their services under the Medicare Physician Fee Schedule. Under certain circumstances, hospitals and practitioners will be permitted to share gains arising from the providers’ care redesign efforts. Acute care hospitals have until July 31, 2013, to apply.  The start of the performance period may be as early as the first quarter of CY 2014. CRNAs should be aware of this program and if their hospital is participating in it.   
Read the notice from the Federal Register here and additional information about the CMMI Bundled Payment Initiative  here.
Medicare Trustees Say Healthcare Cost Growth Slowdown Extends Solvency of Medicare Trust Fund
Trustees for the Medicare program reported May 31 that the recent slowdown in healthcare cost growth is extending the solvency of the Medicare trust fund through the year 2026, two years longer than it was anticipated to last a year ago. 
Further, Medicare anticipates spending less per beneficiary in 2013 than in the previous year, the first time ever that per-beneficiary Medicare spending is falling. The trustees credit lower outlays for skilled nursing facilities and the 2013 budget sequestration process for the per-beneficiary spending reduction. Sequestration reduced Medicare spending 2 percent beginning earlier this spring. 
Read more about the report of the Medicare trustees  here and the report itself here.
Interagency Pain Research Coordinating Committee (IPRCC) Leads Implementation of National Pain Strategy
The AANA was represented this week at the IPRCC meeting at the National Institutes of Health (NIH). The IPRCC is close to finalizing a structure for implementing the charge by the Office of the Assistant Secretary for Health to create a comprehensive population health level strategy for pain prevention, treatment, management, and research, a significant interest to CRNAs.
This strategy is a core recommendation of the 2011 IOM Report: Relieving Pain in America (Recommendation 2-2): “The Secretary of the Department of Health and Human Services should develop a comprehensive, population health-level strategy for pain prevention, treatment, management, education, reimbursement, and research that includes specific goals, actions, time frames, and resources.” The AANA strongly advocates for the inclusion of CRNAs in this strategic initiative.
Of additional interest to CRNAs, particularly educators, is the ongoing support of Centers of Excellence in Pain Education selected by the NIH Pain Consortium, which are charged with building pain curricula across several of their health professional schools. CRNAs working in these facilities, particularly in nurse anesthesia educational programs, are encouraged to reach out and become involved in these initiatives. The Centers of Excellence selected by the NIH include: the University of Washington, Seattle; the University of Pennsylvania Perelman School of Medicine, Philadelphia; Southern Illinois University, Edwardsville; the University of Rochester, N.Y.; the University of New Mexico, Albuquerque; the Harvard School of Dental Medicine, Boston; the University of Alabama at Birmingham; the Thomas Jefferson University School of Medicine, Philadelphia; the University of California, San Francisco; the University of Maryland, Baltimore; and the University of Pittsburgh. 
Learn more about IPRCC at, and about the NIH Pain Consortium Centers of Excellence in Pain Education at
Join Your CRNA Rat PAC Friends at the AANA Annual Meeting
While you’re at the AANA Annual Meeting in Las Vegas, embark on a one-of-a-kind experience with the CRNA-PAC at the Cleveland Clinic Lou Ruvo Center for Brain Health on Sat., Aug. 10, from 6:30-8:30 p.m.
Starting from our convention hotel, guests will be transported a short drive off the Vegas Strip and back to a different decade as the CRNA-PAC celebrates with a “RETRO RAT PACK” reception and silent auction. Designed by world-renowned architect Frank Gehry, the Lou Ruvo Center is an iconic architectural landmark that includes a Wolfgang Puck-inspired kitchen, 199 unique windows, and a surrounding stainless steel trellis canopy, creating a truly magical experience.
With a venue mantra of “Keep Memory Alive,” the evening will surely be one to remember for years to come. Get your tickets today when you register for the AANA Annual Meeting. Tickets can also be purchased and/or picked up on-site at the PAC booth located near meeting registration. Please visit for additional information. Proceeds to benefit the AANA’s CRNA-PAC, the only PAC in the U.S. devoted 100 percent to keeping the voice of nurse anesthesia strong in Washington, D.C.


A Tennessee compounding pharmacy has issued a voluntary nationwide recall for all lots of sterile products that it compounds. The Food and Drug Administration (FDA) said that unopened vials of a steroid injection from the company, preservative-free methylprednisolone acetate, contained bacterial and fungal growth. According to the FDA, samples in two different batches from Main Street Family Pharmacy showed evidence of microbial growth. Products subject to the recall have a use-by date on or before Nov. 20, 2013. "At this point in FDA's investigation, the sterility of all sterile products produced by Main Street is of significant concern and the products should not be used," the FDA stated. The Centers for Disease Control and Prevention has recorded 24 cases of infection from four states—Arkansas, Florida, Illinois, and North Carolina—with most cases involving skin and soft tissue infections following intramuscular injections of the steroid. The FDA said it is still evaluating other samples of the steroid as well as other products from Main Street. An outbreak of fungal meningitis last year was connected to methylprednisolone acetate from a compounding pharmacy in Massachusetts; however, the FDA said that it is not aware of any cases of meningitis linked to steroid injections from Main Street.
From "Fungal, Bacterial Growth Found in Steroid Injections"
CNN (06/10/13) Landau, Elizabeth
Lumbar epidural steroid injection (LESI) is one option for treating back pain, but new research has found that repeated treatments raise the risk of the patient suffering a vertebral fracture. The retrospective study compared outcomes in 3,000 LESI recipients against a like number of spine patients who had never had the treatment. They discovered that each successive injection increased the risk of a spinal fracture by 21 percent and that the treatment may make bones more fragile over time. While LESI is still considered viable, the researchers believe the technique should be used cautiously with older women, anyone who has ever had a previous fracture, smokers, and underweight patients. "In the appropriate setting, and for the right patient, LESI provides effective symptomatic relief and improved level of function," according to Shiomo Mandel, MD, lead author of the study. "Through careful screening and monitoring steroid exposure, the risk of a fracture can be minimized. ... we know there is a role for injection therapy, but the challenge is to make sure it is administered safely and still provide long-term benefits." The findings were published in the June 5 issue of the Journal of Bone and Joint Surgery.
From "Epidural Steroid Injection Is Associated With Increased Spinal Fracture"
News-Medical (06/07/13)
A study out of Emory University supports other recent research suggesting that pain-relieving drugs may block the development of post-traumatic stress disorder (PTSD), raising the promise of new avenues for battling the condition. Discussing the findings in Science, the investigators report that a gene called Oprl1, which encodes the receptor for the opioid nociceptin, is more active in mice placed under extreme stress than in control mice. Working in cooperation with another group of researchers, the Emory team also discovered that a compound targeting the opioid receptor, SR-8993, blocked the formation of fear memories in the mouse amygdala—an area of the brain stimulated by fear and stress. Researchers are unsure whether the approach could work in humans; but they do know that of 1,800 people who have experienced severe violence and trauma, more aggressive PTSD has been observed in those who carry a particular variant of Oprl1. "While many hurdles remain for SR-8993 or a related compound to become a drug used to prevent PTSD, these results are important first steps in understanding how such treatments may be effective," according to a press release from study co-author Thomas Bannister of the Scripps Research Institute.
From "Opioid Receptors Implicated in PTSD"
The Scientist (06/07/13) Cossins, Dan
Researchers say healthcare institutions can lower the risk of post-operative pneumonia and unplanned intubation by adopting the standardized I COUGH program—which stresses patient education, early mobilization, and pulmonary interventions. The study, led by Michael Cassidy, MD, encompassed all general or vascular surgery patients at Boston University Medical Center over the course of one year. The investigators compared the National Surgical Quality Improvement Program risk-adjusted pulmonary outcomes before and after putting I COUGH in place. The rate of post-operative pneumonia shrank to 1.6 percent from 2.6 percent after adopting I COUGH, while the incidence of unplanned intubations declined to 1.2 percent from 2.0 percent. "We are stimulated by the possibility that postoperative complications may be diminished by adherence to simple, inexpensive, easily performed patient care strategies," declared the researchers, whose work was published online June 5 in the journal JAMA Surgery.
From "Patient-Care Program Associated With Reduction of Common Post-Operative Complications"
Infection Control Today (06/05/13)
A recent study presented June 2 at Euroanaesthesia, the annual congress of the European Society of Anaesthesiology, suggests that receiving general anesthesia may increase dementia risk. The research, led by Francois Sztark, MD, PhD, of the University of Bordeaux in France, has yet to be published in a peer-reviewed journal and should be considered preliminary. The goal was to identify whether elderly patients who receive general anesthesia are at greater risk of developing dementia. Over a period of 10 years, the researchers tracked more than 9,000 participants aged 65 and up who did not have dementia when starting the study between 1999 and 2001. After adjusting for factors that might have influenced risk of dementia—including race/ethnicity, gender, socioeconomic status, education level, cardiovascular risk factors, depression symptoms, disabilities, disease histories, lifestyle habits, and weight—the researchers determined that patients who had received general anesthesia at least once over the 10-year followup period were at a 35 percent higher risk of dementia compared to patients who did not receive anesthesia. The research had at least one limitation: failing to identify what surgeries participants had that required them to undergo general anesthesia. It should be considered that the conditions that warranted the surgeries and the administration of general anesthesia could have been tied to the dementia.
From "Another Risk Factor for Dementia?"
DailyRx (06/01/13) Haelle, Tara
Studies over the past 10 years have tied the use of anesthetics to brain cell death in developing animals, raising concern about the impact of pediatric surgery. New research, however, suggests that it is not the age of the subject undergoing anesthesia, but rather the age of brain neurons, that is the primary risk factor for cell death. Investigators from Cincinnati Children's Hospital Medical Center exposed newborn, juvenile, and young adult mice to doses of isoflurane typical for surgery. While the newborns presented widespread neuronal loss in forebrain regions—similar to earlier studies—with no significant impact in the dentate gyrus area of the brain that helps control learning and memory, the opposite was true in juvenile test mice. In them, there was minimal impact to the forebrain but major cell death in the dentate gyrus. "We demonstrate that anesthesia-induced cell death in neurons is not limited to the immature brain, as previously believed," said Andreas Loepke, MD, PhD, of the research, which appeared in the June 5 issue of the Annals of Neurology. "Instead, vulnerability seems to target neurons of a certain age and maturational stage. This finding brings us a step closer to understanding the phenomenon's underlying mechanism."
From "Study Expands Concerns About Anesthesia's Impact on the Brain"
Science Codex (06/05/13)
According to new study published in the New England Journal of Medicine, the most effective way to reduce deadly hospital bloodstream infections is to wash the sickest patients with a cloth soaked in chlorhexidine soap and apply mupirocin ointment inside their nose each day. The study has broad implications for practical use, as it reveals that this simple strategy can reduce the incidence of bloodstream infections by up to 44 percent and can significantly reduce the presence of methicillin-resistant Staphylococcus aureus (MRSA). Susan Huang, an infectious disease specialist at the University of California at Irvine and the lead author of the study, notes that the research answers the question of how to target the superbug: by screening patients and treating those who already have it, or by treating all of those considered to be at a high risk of contracting it. She notes, "This study is the first to answer the question—it's the high-risk patient. Stop screening. Treat them all." The study found that, in addition to being effective at halting the spread of MRSA in intensive-care units, the use of chlorhexidine soap and mupirocin ointment for all ICU patients prevented infections from other germs. Huang adds that "everything we did was rolled out by the hospitals' own systems," which suggests that the protocol would be easy for other hospitals to adopt and implement. Hospital Corporation of America—which took part in the research along with the University of California at Irvine, Harvard Pilgrim Health Care Institute, and the U.S. Centers for Disease Control and Prevention—said it would be adopting this care protocol in around 450 adult intensive-care units at its 162 hospitals. CDC Director Tom Frieden commented that the agency is evaluating the findings and may include them in the CDC's infection prevention recommendations.
From "Simple Strategy Works Best to Reduce Infections, Study Finds"
Washington Post (05/29/13) Sun, Lena H.
A "walking" epidural effectively manages pain during labor while reducing the rate of Cesarean deliveries, according to researchers at the University of Medicine and Dentistry of New Jersey. The standard non-ambulatory regimen for epidural anesthesia is patient-controlled analgesia (PCA) consisting of ropivacaine 0.1%, 1 mcg/mL of sufentanil, and 2 mcg/mL of epinephrine. The researchers randomized 420 patients to receive this PCA and 420 others to receive the same dose of ephinephrine and sufentanil but less of the third drug. Patients receiving ropivacaine 0.04 percent also were permitted to walk as long as they had a modified Bromage score of mobility below 6. The researchers documented fewer cases of hypotension, bladder catheterization, motor block, and C-section in the ambulatory group compared to the non-ambulatory group. Patients who had walking epidurals were more inclined to suffer pruritus and needed more PCA and rescue doses of ropivacaine; however, patient satisfaction with analgesia was about the same for both sets of women. "Some patients may be willing to tolerate a greater amount of discomfort if it means enhanced ability to ambulate, while others will desire more pain relief at the expense of increased motor block," noted David Wlody, MD, chief of anesthesiology at the State University of New York-Downstate Medical Center, who was not involved in the research.
From "'Walking' Epidural Reduces Rate of Cesareans With No Loss of Pain Relief"
Anesthesiology News (05/01/13) Vol. 39, No. 5 Dunleavy, Brian P.
According to research conducted by Ohio State University researchers, music therapy offers a number of benefits—including reduced anxiety—for intensive care unit (ICU) patients on acute ventilatory support. These patients typically receive intravenous sedative and analgesic medications to reduce anxiety and improve comfort; however, the drugs tend to be administered at high doses for prolonged periods, have been linked to adverse side effects, and often do not adequately alleviate patient anxiety. The multi-site study led by Linda Chlan, PhD, RN, compared outcomes from three sets of patients: 126 who underwent patient-directed music (PDM) therapy, 122 who used noise-cancelling headphones, and 125 who received standard care. The results indicated that patients in the PDM group experienced reduced anxiety, reduced frequency of sedation, and reduced sedation intensity compared to standard care patients—but not compared to the headphone group. The authors wrote, "[Music] is an inexpensive, easily implemented non-pharmacological intervention that can reduce anxiety, reduce sedative medication exposure, and potentially associated adverse effects." In an accompanying editorial, Elie Azoulay, MD, PhD, of the Universite Paris-Diderot, Sorbonne Paris-Cite wrote, "The trial by Chlan et al provides preliminary data that create new possibilities for improving the well-being of ICU patients. Further studies are needed to better understand how music therapy might improve the ICU experience for critically ill patients."
From "Listening to Music May Reduce Anxiety and Medication for Hospital Patients Using Ventilators"
Medical Daily (05/20/13) Scutti, Susan
Children who receive opioid infusions often experience potentially critical incidents, but a team of Canadian researchers has found that these adverse events usually involve minor errors in the drug administration. Most incidents occurred in children being treated by clinicians for acute pain. An analysis of patient safety and pharmacy data, including 166 potential incidents, found 31 root causes. The most frequent and significant involved defective preprinted order sheets for opioid infusions, lack of nursing guidelines for infusion adjustment and weaning off medication, and inadequate guidelines for monitoring and recording pain and vital signs. One problem found in the study was the transfer of patients between units, which increased the chances of an incident due to a lack of procedures for opioid infusions and standardized opioid concentrations. The researchers recommend uniform, hospital-wide monitoring, documentation, and policies for opioid administration, weaning and conversion in children; enhanced education for healthcare professionals in pediatric acute pain management; and timely involvement of the acute pain service.
From "Researchers Probe Causes of Opioid Infusion Errors in Peds"
Anesthesiology News (05/01/13) Vol. 39, No. 5 Vlessides, Michael
Based on a survey by the International Anesthesia Research Society (IARS), the pulse oximetry sensors currently on the market seem to have limitations that make them unreliable. Nearly 94 percent of poll participants said they have had to try multiple devices during surgery before they can get a reading. IARS President Andrew Kersey said, "Pulse oximetry is a critical tool for patient safety, but the limitations of fingertip sensors compromise their effectiveness, putting patients at risk. Our preliminary survey of IARS participants clearly shows how fingertip sensors are a weak link in patient safety monitoring. We plan to expand this research over the coming months."
From "Anesthesiologist Survey Suggests Existing Pulse Oximetry Sensors Unreliable"
Sacramento Bee (05/28/13)
Infants who are circumcised without anesthesia do not appear to experience more pain or a greater likelihood of sleep disturbances than those who were not circumcised, according to an analysis of neonatal breathing rates. The study included 17 circumcised boys, four uncircumcised boys, and 23 girls. Researchers reported at the annual meeting of the Associated Professional Sleep Societies that they observed an increase in breaths-per-minute on the Quiet Sleep Respiration Rate across all babies in the sample. Further research will look at motion and other factors to determine if sleep disturbances occur among circumcised infants.
From "Study: Circumcision Pain Not Severe"
MedPage Today (06/05/13) Susman, Ed
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