Anesthesia E-ssential, November 15, 2012

Anesthesia E-ssential

November 15, 2012 

Vital Signs

Medicare Agency rules in Favor of Patient Access to CRNA Care 
The AANA applauded the Centers for Medicare & Medicaid Services and the administration for ruling on Nov. 1 to preserve patient access to chronic pain management services administered by CRNAs – in fact, access to all services within the full scope of CRNA practice.
Going into effect on January 1, 2013, the highlights of the agency ruling include:
  • Expanding Medicare coverage of services within CRNA scope of practice by stating that “Anesthesia and related care means those services that a certified registered nurse anesthetist is legally authorized to perform in that state in which the services are furnished”;
  • Agreeing with the AANA and those who submitted comments through the Protect My Pain Care Campaign, whose overarching message was that the primary responsibility for establishing the scope of services CRNAs are trained for and authorized to furnish resides with the states; and
  • Defining the Medicare benefit category for CRNAs as including any services CRNAs are permitted to furnish under their state scope of practice.
Read more about the ruling and what it will mean to CRNAs here, and in the lead story in the Federal Government Affairs section of this issue of the E-ssential.


The Pulse

Inside the Association
  • Hurricane Resources
  • Nurse Anesthesia Featured in USA Today "Thanking Our Troops" Insert
  • See the Patient Care Extraordinaire Video on the AANA Website
  • Check out the Revamped Patients Section of the AANA Website
  • AANA Supplier Directory Debuts
  • Introducing AchieveLinks the AANA's newest Affinity Program Partner!
  • Nurse Anesthesia Week Promotional Materials Available Now
  • Attention Fall Assembly Leadership Academy Attendees: Please join Us...
  • Voluntary Recall of All Ameridose Drug Products
  • What's In CMS' Pain Care Final Rule? And What's Next?
  • Medicare Projects 26 Percent Anesthesia Cut in 2013 Physician Fee Schedule - Unless Congress Acts to Reverse It
  • Medicare OKs Use of Surgery Checklist Measure for the Outpatient, ASC Reporting Programs 
  • CRNA-PAC Wins 94 Percent of Contests Where It Made a Contribution - Keeping CRNAs Voice Strong in Washington
  • Join CRNA-PAC for "Pints & Politics" at AANA Fall Assembly Leadership Academy
  • Reduction of Outpatient Therapeutic Services Supervision will Improve Healthcare, Says AANA and Nursing Community 
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

Hot Topics

Hurricane Resources
In light of the destruction and devastation caused by Hurricane Sandy, the AANA would like to extend its sympathy to those who have lost friends, family members, and property in this natural disaster. The Current Events and Health and Wellness areas of the AANA website provide helpful information and links to resources for helping to deal with this and other disasters.
Nurse Anesthesia Featured in USA Today "Thanking Our Troops" Insert
The “Thanking Our Troops” special section in the Nov. 9, 2012, issue of USA Today featured a two-page spread on the role of nurse anesthetists in the U.S. Military. The timing of this wonderful insert, which included a full-page advertisement and a full page of editorial content from your AANA, coincided with Veterans Day on Nov. 11.
Nurses first provided anesthesia to soldiers on the battlefields of the Civil War, and ever since have been the primary anesthesia professionals caring for U.S. service personnel and veterans at home and abroad. To all of our CRNA colleagues who have devoted their lives to preserving and protecting the freedoms we enjoy in this great country of ours, thank you so much on behalf of your friends and colleagues at the AANA. Our participation in the USA Today special section “Thanking Our Troops” is but a small token of our appreciation for all you do.
See the Patient Care Extraordinaire Video on the AANA Website
Introduce your patients and colleagues to the updated “For Patients” section of the AANA website with this fast-paced new teaser video at ges/ Patient-Care-Extraordinaire.aspx. You can also access the video via the QR code on Nurse Anesthetists Week promotional materials.
Check out the Revamped For Patients Section of the AANA Website
To help you inform your patients about anesthesia and answer their questions, be sure to direct them to the AANA’s comprehensive “For Patients” section of the AANA website at The newly revamped section provides a broad range of patient education resources, including brochures, fact sheets, and more.
AANA Supplier Directory Debuts
The AANA is proud to announce that the AANA Supplier Directory is now available and can be accessed at The Association’s online directory is a comprehensive resource of product and service providers critical to the anesthesia community. The AANA Supplier Directory is designed to help our members – key decision makers in the nurse anesthesia profession – make informed purchasing decisions, and it will be a consistently expanding, updated resource. Refer to it often!
Introducing AchieveLinks, AANA's New Affinity Program Partner!
AchieveLinks is a unique Internet shopping rewards program developed exclusively for members of the American Association of Nurse Anesthetists. Membership in the program is absolutely free, and with every purchase you make a portion of the proceeds goes to the AANA. Sign up now!
Nurse Anesthetists Week Promotional Materials Available Now
CRNAs all across the country are gearing up for the 14th annual National Nurse Anesthetists Week, to be celebrated Jan. 20-26, 2013. Promotional items, including posters, buttons, ink pens, table tents, and the ever-popular Nurse Anesthetists Week logo merchandise, including T-shirts and mugs, are available now for purchase at beginning in November. Please note: Ordering is now online-only. Phone, fax, or mail orders will not be accepted.


AANA Foundation and Research

Attention Fall Assembly Leadership Academy Attendees:
Please Join Us...
The AANA Foundation is partnering with PharMEDium in hosting a hospitality suite on Friday, Nov. 16, 2012, from 6 to 10 p.m. at The Broadmoor’s Lake Terrace Dining Room at the Fall Assembly Leadership Academy.
There will be food, fun, and a unique opportunity for hands-on demonstrations and interactions that will help you learn more about increasing efficiency and enhancing patient safety.
View the invitation and plan to attend! We look forward to seeing you in Colorado.


Professional Practice

Voluntary Recall of all Ameridose Drug Products
Ameridose, LLC, is voluntarily recalling all of its unexpired products in circulation. Ameridose is the sister company of New England Compounding Center (NECC), the firm associated with compounded drugs linked to the ongoing fungal meningitis outbreak. The FDA is conducting an inspection of Ameridose’s facility and recommended this recall out of caution. This recall is not based on reports of patients with infections associated with any of Ameridose’s products. More information about this recall can be accessed here.
This recall affects products that are already on the FDA’s critical drug shortage list, including anesthesia-related drugs. More information about the impact of this recall on drug shortages can be accessed here. If you, your practice, or your pharmacy are experiencing any drug shortages, difficulties obtaining products, or have any questions, please contact the FDA’s Drug Shortage Program at
Additional information regarding the ongoing fungal meningitis outbreak can be found on AANA’s fungal meningitis outbreak webpage.

What's In CMS's Pain Care Final Rule?  And What's Next?
Now that the Medicare agency has published its final rule authorizing Medicare direct reimbursement of CRNA chronic pain management services and other services within CRNA scope of practice in a state, what else is there to know? And what’s next?
  • As AANA President Janice Izlar, CRNA, DNAP, noted in her Nov. 1 message to members, the final rule states that, “Anesthesia and related care means those services that a certified registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished.” The agency also said in its descriptive preamble, “In addition, we agree with commenters that the primary responsibility for establishing the scope of services CRNAs are sufficiently trained and, thus, should be authorized to furnish, resides with the states.”
  • The final rule is effective Jan. 1, 2013; the agency is not applying this new rule to claims retroactively.
Several of the next steps will be outlined for AANA members at the Fall Assembly Leadership Academy in Colorado Springs. They include actions in Washington to protect the final rule from attacks during the post-election “lame duck” session of Congress, actions in states in anticipation of Medicare Administrative Contractors querying states about CRNA scope of practice, and actions in states in advance of 2013 legislative sessions.
Read the ASA response to the final rule.
Medicare Projects 26 Percent Anesthesia Cut in 2013 Physician Fee Schedule Unless Congress Acts to Reverse It
Medicare Part B anesthesia payment will be reduced 26 percent on Jan. 1, 2013, unless Congress acts to reverse the “sustainable growth rate” formula funding cuts, the Medicare agency announced Nov. 1 in its 2013 physician fee schedule (PFS) final rule.
If Congress fails this fall to reverse the cuts, the mean Medicare anesthesia conversion will drop to $15.93 per unit for services beginning Jan. 1, 2013. The regular physician conversion factor, applicable to CRNA services such as chronic pain management and line insertions that are not anesthesia services, would fall to $25.0008 per unit for services beginning Jan. 1, 2013.

Other provisions of the final rule that the AANA is reviewing closely include:
  • The agency estimates CRNA allowed charges of $1.104 billion in 2013, about 1 percent over 2012 levels.
  • The agency has clarified the patient charge when a screening colonoscopy becomes a surgical service, such as when the screening discovers a polyp that can be removed. Under the new policy, Medicare waives the deductible when a screening colonoscopy becomes a surgical procedure. (starting on p. 1230 of the preview)
  • In a section relating to payment modifiers, the agency declined to modify medical direction payment in the final rule, as a comment from the American Society of Anesthesiologists suggested, saying it was “not appropriate to modify the medical direction figure.” The agency further stated “we would welcome any independently verifiable data that could inform the accuracy of our assumption regarding duplicative time units.” (starting on p. 39 of the preview)
The AANA continues reviewing the final rule.
This link will last approximately until Dec. 1, 2012, or until the rule appears in the print edition of the Federal Register. Read a fact sheet about the rule.
Medicare OKs Use of Safe Surgery Checklist Measure for Outpatient, ASC Reporting Programs
According to a Nov. 1 final rule issued for 2013 hospital and outpatient prospective payment systems (OPPS), and following a recommendation from the AANA, the Medicare Agency is retaining a previously adopted measure for a safe surgery checklist for the CY 2014, CY 2015, and subsequent years payment determinations under the Hospital Outpatient Quality Reporting (OQR) Program. The Medicare agency has added the measure for the CY 2015 payment determination for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program.
In other matters in the OPPS rule, the agency approved an additional one-year delay of rules regarding supervision of outpatient therapeutic services – a list of services that does not include surgical or diagnostic services requiring anesthesia. The extension was likely to last just one more year, though, through Dec. 31, 2013, with further decision-making on the topic to be undertaken by the CMS Advisory Panel on Hospital Outpatient Payment. Also, the agency did not address whether to establish a task force including CRNAs to evaluate quality measures affecting anesthesia services, as the AANA had recommended.
The AANA continues reviewing the final rule.

CRNA-PAC Supports Winners in 94 Percent of Contests Where It Made a Contribution - Keeping CRNAs' Voice Strong in Washington
As the dust settles from Election Day, the CRNA-PAC Committee is pleased to provide members with the CRNA-PAC Election Report highlighting CRNA-PAC election successes as well as the candidates, party committees and other federal PACs supported by the CRNA-PAC this election cycle. The report is found at (requires AANA member login and password).
Thanks to the generous support of thousands of AANA members leading up to the elections, the CRNA-PAC maintained its status as the largest federal nursing political action committee in the healthcare industry, collecting more than twice as many contributions than any other federal nursing political action committee. Ninety-four percent of campaigns receiving CRNA-PAC funding won their elections, helping keep CRNA voices strong in Washington. And the nonpartisan CRNA-PAC split its outlays nearly equally among the parties representing the divided Congress, with 52 percent going to Democratic campaigns and 48 percent to Republicans.
By making more than $1.1 million in campaign contributions during the 2011-2012 election cycle, CRNA-PAC built relationships with lawmakers and kept issues like Medicare coverage of CRNA pain care and all CRNA services within our state scope of practice, reversing Medicare cuts, advancing CRNA interests in health reform implementation, combating drug shortages, securing educational funding, and driving patient access to the care provided by CRNAs at the forefront of healthcare debate in Congress.
“Together, CRNAs have built one of the largest PACs in the nation,” said Ruth Ann Morris, CRNA, MS, chair of the CRNA-PAC Committee. “On behalf of the entire CRNA-PAC Committee, I sincerely thank all members who were a part of this important effort. We hope you will contact us with any questions, comments, and/or suggestions and continue to support these important efforts in the future.
Reduction of Outpatient Therapeutic Services Supervision will Improve
Healthcare, Says AANA and Nursing Community
The Medicare agency’s proposal to reduce physician supervision requirements for several outpatient therapeutic services is “one additional step in the process of improving health care by expanding access and reducing cost while ensuring quality, (that) further recognizes the ability of RNs to provide these services without the supervision of a physician,” according to an Oct. 24 comment letter signed by AANA and 45 nursing organizations.
The list approved by the Medicare agency represented about two-thirds of a list recommended by its Hospital Outpatient Payment Panel that focused primarily on minor primary care services such as vaccinations. The list was restricted to outpatient therapeutic services and did not include the issue of physician supervision of nurse anesthetists or the opt-out process, which relates to surgical services. But the nursing groups urged the Medicare agency in the future to consider broadening the list of services not requiring supervision, saying “more must continue to be done” to implement the Institute of Medicine recommendation for nurses to “practice to the full extent of their education and training.”
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.

Capnography Training Video by BMC Published in New England Journal of Medicine
A new training video from Boston Medical Center (BMC) provides instruction on the use of capnography to monitor ventilation and carbon dioxide levels in patients who are under anesthesia or conscious sedation. The tutorial employs real and simulated patients in different clinical situations to demonstrate how to use and manage the technology, which graphically tracks CO2 concentration and measures respiration and ventilation. The video release comes as capnography is gaining popularity for its ability to show that a patient is breathing properly and as it is being used more often in tandem with pulse oximeters, which monitor blood oxygen levels, in order to get a better snapshot of respiratory status. "Using capnography and pulse oximetry technologies together is a powerful approach to monitor the ventilation and gas exchange of patients," says BMC's Rafael Ortega, MD. "This video provides best practices for healthcare providers on how to accurately utilize this technology in a variety of clinical settings."
From "Capnography Training Video by BMC Published in New England Journal of Medicine"
EurekAlert (11/08/12)
Study Shows How Local Anesthetics Can Improve Motor Skills of Patients After Stroke

A new study, published in the Journal of Neuroscience, found that anesthesia drugs can be useful in therapies for stroke patients. Researchers at the Friedrich Schiller University Jena and the University Hospital Jena in Germany found that a local anesthetic can improve the motor skills of stroke patients. Using the 'Constraint-Induced Movement Therapy,' patients are asked to carry out small tasks such as stacking toy blocks and washing their hands. While the therapy is beneficial by itself, the impact of the activity was enhanced greatly when the sensitivity of the affected limbs was lowered by an anesthetic. The researchers studied 36 patients, half of whom received a local anesthetic and the remainder of whom received a placebo. While participating in the therapy after receiving one of the options, the researchers found that patients who received the anesthetic were more successful in the tasks.
From "Study Shows How Local Anesthetics Can Improve Motor Skills of Patients After Stroke" (11/06/2012)
General Anesthesia May Disrupt Communication Between Brain Areas
Researchers from Harvard University and Massachusetts General Hospital have identified a new component of brain activity, dubbed "slow oscillation," that could deepen clinical understanding of anesthesia. The study, published in the Proceedings of the National Academy of Sciences, involved just three patients—all of whom were undergoing surgery to remove electrodes placed on the cerebral cortex to monitor their epilepsy. Just prior to procedure, the researchers used the electrodes to capture brain activity as the patient slipped unconscious after being given propofol. When the test subjects went "under," as signaled by the lack of response to a spoken command, slow oscillation began at once. The brain waves—in which neuron firing graduates from very little simultaneous activity at the bottom to much activity at the top—occurred fewer than one time per second as opposed to multiple times per second during normal, "awake" brain function. Moreover, the oscillations appeared to occur at slightly different times in different parts of the brain. The implication is that propofol prevents those areas of the brain from working together, even though the individual areas appear to be functioning normally. With these findings and better comprehension of the exact mechanisms of anesthetics, researchers could be on their way to developing more targeted anesthesia drugs with fewer side effects.
From "General Anesthesia May Disrupt Communication Between Brain Areas"
Los Angeles Times (11/05/12) Bardin, Jon
Simulations Raise Concerns About Managing Cardiac Arrest in Pregnant Patients
While cardiac arrest rarely occurs during labor, new research suggests that anesthesiology residents may lack the necessary knowledge and skills to save their pregnant patients under these circumstances. Investigators at Sheba Medical Center in Israel conducted a small stimulation study involving about two dozen senior anesthesiology residents. Working with life-size and lifelike computerized mannequins, the participants overwhelmingly carried out general resuscitation steps properly; but only 68 percent moved the "patient" into the recommended position for a pregnant woman, and just 40 percent prepared to deliver the baby via emergency C-section in the event that the mother died. Debriefing sessions held after the simulations to discuss performance showed, however, that most participants know the proper steps to take—even though most did not take those steps during the simulations. Lead researcher Dr. Haim Berkenstadt believes that the format used at Sheba, simulation followed by debriefing, is particularly useful in identifying gaps in what anesthesia residents know and their ability to perform the recommended steps when a situation arises. Improving maternal resuscitation skills is integral to efforts to lower the rate of pregnancy-related mortality, the researchers write in the November issue of Anesthesia & Analgesia.
From "Simulations Raise Concerns About Managing Cardiac Arrest in Pregnant Patients"
Newswise (11/05/12)
Anesthesia experts agree that extubation failure remains a significant problem, with about 20 percent of patients at increased risk for morbidity and mortality because an airway tube must be reinserted after a procedure. Now, a team in Washington State says it has developed an algorithm that can accurately predict extubation failures 70 percent of the time. Dr. Miriam Treggiari and colleagues at the University of Washington School of Medicine analyzed data from more than 2,000 intensive care unit patients who were intubated in 2007, comparing variables between successful extubations and failed ones. Regression modeling narrowed down four factors that together predicted about 70 percent of reintubations within 24 hours of extubation. The algorithm "is meant to be incorporated into a more comprehensive checklist that allows screening for extubation readiness, stratification of patients based on their risk for extubation failure and implementation of a specific extubation plan," said Treggiari, who presented preliminary data at the 2012 annual meeting of the American Society of Anesthesiologists (ASA). She and her team have gathered six months of pre-algorithm baseline data and will compare it against data currently being recorded with the algorithm in place. They will present those findings at the 2013 ASA meeting.
From "Seeking Solutions to Failed Extubation"
Anesthesiology News (11/01/12) Vol. 38, No. 11 Wild, David
Regional Anesthesia Reduces Transfusion Risk in Knee Replacement Surgery
New research suggests that patients who are having bilateral total knee replacement and who are administered regional anesthesia, rather than general anesthesia, need blood transfusions less often. Of 15,687 patients who underwent the procedure, 6.8 percent were given neuraxial anesthesia, while 80.1 percent received general anesthesia and 13.1 percent received a combination of the two. Stavros Memtsoudis, of the Hospital for Special Surgery in New York, and his team found that just 28.5 percent of patients who received regional anesthesia required a blood transfusion versus 44.7 percent of those who received general anesthesia only and 38 percent of those who were given a combination of both. The researchers also identified a slight trend toward a reduction in major complications including pulmonary embolism and mechanical ventilation with the use of neuraxial anesthesia. "You have to take into account comorbidities, patient preferences and other other practice specific factors, such as the choice for anticoagulation," Memtsoudis remarked in a statement, "but neuraxial anesthesia should at the very least be considered in every patient."
From "Regional Anesthesia Reduces Transfusion Risk in Knee Replacement Surgery"
News-Medical (10/31/12) Mahendra, Piriya
Significant Pain Relief for Abdominal, Pelvic Surgeries Provided by Dicolfenac
Researchers in Boston report in Anesthesia-Analgesia that low-dose injections of solubilized diclofenac sodium produces favorable pain outcomes in patients after abdominal or pelvic surgery. The team, from the anesthesiology department at Tufts Medical Center, followed 331 patients who received small doses of diclofenac or a placebo after their procedures. The results indicated that, compared to the placebo, repeated lower doses of solubilized diclofenac significantly calmed the acute moderate and severe pain patients experienced following a surgical procedure on the abdomen or pelvis. A decreased need for opioid pain relief also was documented in patients who received the diclofenac.
From "Significant Pain Relief for Abdominal, Pelvic Surgeries Provided by Dicolfenac"
Becker's Hospital Review (10/31/12) Linder, Heather
Video Reduces Children's Anxiety Prior to Surgery
Children who watch a video immediately before surgery experience less anxiety when receiving anesthesia, research suggests. About half of children who receive surgery display significant distress during inhaled induction. This anxiety may be due to separation from parents, fear of the procedure, or exposure to a foreign environment. Children with high levels of distress at anesthesia induction may have more painful recoveries, longer hospital stays, and more negative behavior changes after surgery. The new research was conducted at the IWK Health Center in Halifax, Nova Scotia. The researchers sought to determine whether anesthesia professionals could use video distraction to help reduce anxiety in 97 pediatric patients. Participants randomized to the video-distraction group were given a choice of age-appropriate videos, and clips were played via YouTube for the child during anesthesia induction. "Enabling the participant to choose a video allowed for parental approval of the video and gave the child the opportunity to become familiar with the content, thus becoming engaged with the distractor and possibly avoiding anticipatory anxiety," said Dalhousie University's Dr. Jill Chorney.
From "Video Reduces Children's Anxiety Prior to Surgery"
Newswise (10/30/12)
Doctors Advocate Greater Use of Pain Relievers for Children in the ER
A study published in the journal Pediatrics has found that the use of topical pain medications and mild narcotics often does not result in misdiagnoses, despite the beliefs of many emergency room doctors to the contrary. As a result, the study said, topical pain medications and mild narcotics could be used to treat pain in children who are experiencing medical emergencies before they reach emergency rooms. In addition, topical pain medications and mild narcotics could be used to reduce the pain that children experience in emergency rooms during procedures such as the placement of IV lines and the drawing of blood, the study found. Meanwhile, the American Academy of Pediatrics has announced that it has created new guidelines for reducing pain and stress in children during visits to emergency rooms.
From "Doctors Advocate Greater Use of Pain Relievers for Children in the ER"
RTTNews (10/29/12)
Same Neurons at Work in Sleep and Under Anesthesia
While the introduction of an anesthetic agent tends to quiet most neurons in the brain, an experiment at the University of Pennsylvania reveals that at least two drugs—isoflurane and halothane—directly stimulate neurons that induce sleep. Mice given the anesthetics became sleepy, and nerve cell activity in the ventrolateral preoptic nucleus (VLPO) area of the brain increased. The drugs had an impact only on those VLPO neurons that promote sleep, while others were unaffected. Additionally, when the researchers destroyed VLPO neurons, bigger doses of isoflurane and halothane were required to make the test subjects groggy, implying that this part of the brain is key for anesthetic effects. The two anesthetics used in the research are not common in the United States but are much like propofol and others that are; and the new insight into how the brain responds to these drugs is invaluable as scientists look to create improved anesthetics with fewer side effects. The study was published in the Oct. 25 issue of Current Biology.
From "Same Neurons at Work in Sleep and Under Anesthesia"
Science News (10/25/12) Sanders, Laura
Clostridium difficile infections are increasing in prevalence and severity among hospitalized children, according to the Mayo Clinic. The bacterium can cause infections with symptoms ranging from diarrhea to life-threatening colon inflammation, and it has been associated with 14,000 U.S. deaths each year. Researchers found that, out of about 13.7 million hospitalized children, 46,176 had C. difficile infections. Those with C. difficile had significantly longer hospital stays, more instances of colectomy, increased admission to other care facilities, and higher mortality. The increased severity of C. difficile is partly due to widespread antibiotic use. Recurrent C. difficile is also a problem, with the risk of recurrence 20 percent after a first infection and up to 60 percent after multiple infections. Prevention measures include frequent hand washing with soap and warm water, quarantine of patients hospitalized with C. difficile, thoroughly cleaning surfaces with chlorine bleach, and limiting unnecessary use of antibiotics. The researchers reported their findings at the American College of Gastroenterology annual meeting.
From "C. Diff Infections Becoming More Common, Severe"
Mayo Clinic (10/22/12) 
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