Anesthesia E-ssential Sept. 30, 2013

Anesthesia E-ssential

Sept. 30, 2013


Vital Signs

AANA Report Provides Comprehensive Data on CRNA Compensation and Benefits
Arm yourself with knowledge about your value in the marketplace and employment trends affecting your profession. Order the 2013 CRNA Compensation and Benefits Survey Report, available through the AANA Marketplace. Using 2012 data, collected in March-April 2013, this 126-page report provides employers, as well as CRNAs, with comprehensive information on CRNA compensation and benefits that cannot be found elsewhere. Order your copy today.
Member Price: $100
Nonmember Price: $200
For AANA Members Only: Free Summary
The AANA offers a free 13-page summary of the 126-page 2013 Compensation and Benefits Survey Report exclusively for members here on the AANA website. (Member login and password required.)


The Pulse

  • Renew Your Membership Online: It's Easy!
  • AANA Business of Anesthesia Conference: Register by Oct. 4 and Save!
  • Pain Management Training Offered in Rosemont, Ill.
  • Fall Leadership Academy to Educate Future Leaders
  • AANA Foundation Kicks Off FY14 Annual Campaign
  • The AANA Research Abstract Repository
  • The AANA Research Discussion Forum
  • Hospitals Still Far From Being Highly Reliable
  • FDA Requiring Color Changes to Duragesic (Fentanyl) Pain Patches to Aid Safety
  • AANA Submits Comments to FDA Regarding REMS
  • National Conference Of State Legislatures Legislative Summit: AANA's 21st Successful Year as Exhibitor
  • Washington Risks Oct. 1 Shutdown: How Would CRNAs Be Affected?
  • Proposed Medicare Fix Costs $175 Billion; How Will Congress Pay for It?
  • AANA Supports Veterans Health System Recognizing APRNs as Licensed Independent Practitioners, Corrects ASA Statements about CRNA Practice
  • ASA Complaints on VHA Nursing Handbook Reach Industry Press
  • Noridian Releases Draft Local Coverage Determinations on Facet and Epidural Injections; Requests Comments
  • Working for Your Reimbursement: How You Can Avoid a 1.5 Percent Medicare Cut in 2015
  • Past AANA President Rowles Named to Federal Advisory Workgroup on Pain Research
  • Affordable Care Act Health Coverage Countdown: On Oct. 1, People Start Enrolling for Coverage through State or Federal Marketplaces
  • AANA Comments on Medicare 2014 Fee Schedule
  • AANA Submits Comments on CMS Hospital Outpatient Payment Proposal
  • With Appreciation to Christine Zambricki, CRNA, DNAP, FAAN
  • Amendments

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
Renew Yor Membership Online: It's Easy!
Renewing your AANA membership for the fiscal year Sept. 1, 2013, through Aug. 31, 2014, is more convenient than ever. Just click here (AANA member login and password required) and complete the online process using your credit card. You can also renew your membership using the paper forms sent to you through the mail. See the AANA website for further information about membership and its benefits. 

AANA Business of Anesthesia Conference: Register by Oct. 4 and Save!
Today’s healthcare environment, including reform, impacts the business of anesthesia. Learn how to navigate these changes by attending the AANA Business of Anesthesia Conference, Nov. 2 , at the Renaissance Hotel in Pittsburgh, Pa. This meeting is designed to help you achieve the content expertise needed to meet the economic and quality requirements of your nurse anesthesia business. Learn the best business principles and practices of your profession from successful CRNA business owners and other experts. Here’s what previous attendees are saying about the AANA Business of Anesthesia Conference:
  • This was one of the best educational meetings of my career … from ANY source!”
  • "It’s the best AANA meeting that I have attended in my 38 plus years as a CRNA."

Register before Friday, Oct. 4, and save $75 on the registration fee.

Pain Management Training Offered in Rosemont, Ill.
The AANA is offering one of the most comprehensive pain management training programs for CRNAs interested in a pain management practice. While course can be taken individually, the biggest benefit comes from taking all the content together. 
Friday, Oct. 11, 2013
  • Advanced Physical Assessment for Pain Practice – 8 CEs
    A hands-on workshop for differential diagnosis in pain practice designed for CRNAs. Pain assessment is critical to optimal pain management interventions.
Saturday and Sunday, Oct. 12-13, 2013
  • Jack Neary Advanced Pain Management Workshop I – 16 CEs
    If you have limited experience in interventional pain management, this workshop will expand your knowledge in interventional pain management through scientific and theoretical bases of pain, pharmacology, and pain management practice considerations.
Monday and Tuesday, Oct. 14-15, 2013
  • Jack Neary Advanced Pain Management Workshop II – 16 CEs
    For CRNAs with practical experience in interventional pain management, this workshop provides you with an opportunity to learn and practice pain management techniques on human cadavers and state-of-the-art pain procedure simulators.

Wednesday, Oct. 16, 2013

  • Neuroanatomy Prosection Lab – 7 CEs
    If you are interested in expanding your knowledge of the anatomy associated with chronic and acute pain, this workshop will provide didactic and hands-on training for interventional pain management.
Click here to register for one or all of these programs in interventional pain management.

Fall Leadership Academy to Educate Future Leaders
Get the nuts and bolts you need to run an effective state association at The Fall Leadership Academy, Nov. 8-10 in Miami Beach, Fla. At the Fall Leadership Academy you can register for the track that is most meaningful to you. Choose from the following:  Federal Political Director; State President-elect; State Government Relations; State Reimbursement Specialist; Foundation Advocate or general leadership. Tracks are filling quickly. Here’s what past attendees have said:
  • “Of all the national meetings, the Fall Leadership Academy is focused on the development of leadership at the state level.”
  • “My term as president was strengthened by the information acquired at the Fall Leadership Academy. I highly encourage all states to send as many people as possible to FLA.”
 Register by Oct. 18 and receive a $50 discount. Click here to register.

AANA Foundation Kicks Off FY14 Annual Campaign
The AANA Foundation officially kicked off FY14, and program and fundraising efforts are well underway. For a quick recap:
Program application deadlines are as follows:
  • Oct. 31, 2013 – Merck Fellowship
  • Nov. 1, 2013 – Research Grants
  • Jan. 1, 2014 – Student Scholarship Donors
  • Feb. 1, 2014 – Award Nominations
  • March 1, 2014 – Student Scholarships
  • April 1, 2014 – State of the Science Oral Poster Presentation; Fellowships
  • May 1, 2014 – State of the Science General Poster Presentation; Research Grants
  • June 15, 2014 – Friends for Life
Please be a part of our success, and support nurse anesthesia research and education today! It’s easy to make your tax-deductible donation:
  • Online at
  • Mail it to AANA Foundation at 222 S. Prospect Avenue, Park Ridge, IL 60068
  • Call the Foundation at (847) 655-1170
Thank you in advance for your continued support of our profession!
The AANA Research Abstract Repository
The AANA Research Department has created the Research Abstract Repository for the purpose of posting and viewing research abstracts produced by AANA members. At no cost to members, all students and CRNAs are encouraged to enter published or unpublished abstracts to the Research Abstract Repository. This is great way to highlight the importance of your research, thesis, capstone, or dissertation, and assist both students and researchers with similar research interests assess potential research questions and trends in anesthesia research. You will need your user name and password to access this site.
The AANA Research Discussion Forum
In an effort to engage members in research, the AANA Research Department has created the Research Discussion Forum which will be monitored by research content moderators. The purpose of the Research Discussion Forum is to provide a platform for those individuals interested in research to delve more deeply into research-related topics and methodology as it applies to the art and science of anesthesia, health policy, health service, and evidenced-based practice. If you are interested in becoming a research moderator, please visit the Research Discussion Forum and fill out the AANA Research Discussion Forum Commitment Form for research moderators. You will need your user name and password to access this site.

Hospitals Still Far from Being Highly Reliable
“High-Reliability Health Care: Getting There from Here," written by Mark Chassin, MD, FACP, MPP, MPH, and Jerod Loeb, PhD, from the Joint Commission, urges hospitals to make the substantial changes that will be needed to achieve the ultimate goal of zero patient harm by adapting lessons from high-risk industries. Access the full article here.
FDA Requiring Color Changes to Duragesic (Fentanyl) Pain Patches to Aid Safety
In an effort to minimize the risk of accidental exposure to fentanyl patches, the FDA is requiring the manufacturer of Duragesic to print the name and strength of the drug on the patch in long-lasting ink and in a color that is clearly visible to patients and caregivers. Read the FDA Safety Communication here.
AANA Submits Comments to FDA Regarding REMS
The AANA has submitted comments to the FDA regarding the standardization and assessment of risk evaluation mitigation strategies (REMS) for drug and biological products. The AANA asked the FDA to ensure that REMS are available and accessible to all healthcare providers, including CRNAs, and to engage professional organizations, such as AANA, to ensure that all stakeholders’ needs are considered in the development of any standardized REMS resource tools. Read the letter here.

National Conference Of State Legislatures Legislative Summit: AANA’s 21st Successful Year as Exhibitor
The AANA welcomed more than 5,000 state legislators, legislative and executive agency staff, and representatives from trade and professional associations to its booth at the National Conference of State Legislatures (NCSL) Legislative Summit in Atlanta, Ga., Aug. 13-15. The 2013 meeting was an invaluable opportunity for local nurse anesthetists, student nurse anesthetists, and AANA State Government Affairs staff to visit informally with legislators and their staff from all 50 states. An estimated 20 percent of all state legislators attend the NCSL’s Legislative Summit.  
The AANA exhibit booth was staffed by Jo Sinneath, CRNA, Tiara McCaskill, RN, Malorie Brewer, RN, and Taylor Hosner, RN. Anna Polyak, RN, JD, Senior Director of State Government Affairs, and Sarah Chacko, JD, Assistant Director of State Government Affairs, also represented the AANA at the exhibit booth. The State Government Affairs Division would like to thank the Georgia Association of Nurse Anesthetists for coordinating local volunteers and to thank all of our local volunteers for making this a successful event. 

Washington Risks Oct. 1 Shutdown: How Would CRNAs Be Affected?
The federal government may shut down on Tue., Oct. 1, unless the Republican-majority House and the Democratic-majority Senate can agree on legislation continuing funding for the U.S. government beyond Sept. 30.  Healthcare is caught in the conflict, since the House passed “continuing resolution” (CR) legislation on Sept. 19 (H.J.Res. 59) to keep Uncle Sam’s doors open through Dec. 15, 2013, but on the condition of defunding the Affordable Care Act, which is unacceptable to the Senate majority and to President Obama.  Senate votes scheduled for Sept. 25 or thereabouts might not yield a solution on time.  What can a CRNA expect if a federal government shutdown occurs?
In general, most CRNAs will not see impacts on their practices right away, but the federal government has not yet provided details about what would be affected by a shutdown and what would remain operational and unaffected.  CRNAs can expect that Medicare claims payment may be delayed by agency or contractor furloughs, though most likely not substantially until after Nov. 1, and that they would be restored retroactively once the budget situation is resolved.  Funding for Title 8 nurse workforce development programs is usually not paid until late in a federal fiscal year, and is likely to be relatively unaffected by a temporary shutdown.  Enrollment in health plans through Affordable Care Act healthcare marketplaces is likely to begin as scheduled Oct. 1, but some challenges may occur behind the scenes.  Federal agencies that have indirect or longer-term impacts on CRNA practice, such as the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Drug Enforcement Administration, might have staff subject to furloughs, impairing customer service and backlogging work while a shutdown is in place.
The most direct impacts of a federal government shutdown may fall upon CRNAs who are federal employees.  Though government shutdowns expressly are not supposed to affect services critical to human life and safety, such as many healthcare services, some healthcare providers and administrative personnel may be subject to furlough and may have their paychecks replaced by IOUs so long as Uncle Sam is closed.  Federal CRNAs should pay close attention to information from their supervisors and human resources departments.
Your AANA will continue monitoring the situation closely and keeping CRNAs informed through postings on the AANA Facebook page and
For further information, see how your U.S. Representatives voted on H.J.Res 59, read the legislation, and see this news report about federal government shutdown impacts. 
Proposed Medicare Fix Costs $175 Billion; How Will Congress Pay for It?
Legislation passed by the House Energy and Commerce Committee to repeal Medicare “sustainable growth rate” (SGR) payment cuts to CRNAs and other Part B providers and reform Medicare payment would cost the U.S. Treasury $175 billion over 10 years, reported the Congressional Budget Office (CBO) Sept. 13. That figure is about $40 billion more than a straight repeal of the Medicare SGR cuts, which threatens 24 percent reductions to CRNA and physician payment this January.
But that cost figure presents a problem: Six weeks after the committee passed its bill (HR 2810) on a 51-0 vote, with the backing of AANA and several APRN organizations, no plan has yet emerged to finance the bill’s cost.
The CBO attributed most of the bill’s costs above the straight SGR repeal to its 0.5 percent boost to Medicare CRNA and physician payment each of the next four years, and to authorizing provider groups to develop alternative payment methodologies. Compared with Medicare’s existing alternative payment development program offered through the Centers for Medicare & Medicaid Innovation (CMMI), CBO said the House bill was likely to cost more.
The next step for HR 2810 is to be considered in the House Ways and Means Committee, which has offered Medicare reforms affecting beneficiaries, such as increasing out-of-pocket costs for wealthier Medicare beneficiaries and a new copay requirement for the Medicare home health benefit. On a parallel track, the Senate Finance Committee continues to consider its own Medicare fix legislation, but has not yet released a draft bill or scheduled committee action.
Read the CBO budget estimate
AANA Supports Veterans Health System Recognizing APRNs as Licensed Independent Practitioners, Corrects ASA Statements about CRNA Practice
CRNAs and other APRNs should be recognized by the Veterans Health Administration (VHA) as licensed independent practitioners (LIPs), said the AANA and the Association of Veterans Affairs Nurse Anesthetists (AVANA) in an Aug. 30 letter in support of an agency proposal. The letter also corrected several statements that the American Society of Anesthesiologists (ASA) had made to the VHA about CRNA practice. AANA members are encouraged to contact their U.S. Representatives and Senators about the issue.
“We write to express our strong support for modernizing the VHA Nursing Handbook, which has undergone extensive VA Central Office concurrence procedures in accordance with agency policy, and to update you about the safe and effective practice of nurse anesthesia in the VHA,” wrote AANA President Dennis Bless, CRNA, MS, and AVANA President Sherry Swearngin, CRNA, MHS. “(T)he VHA’s proposed update to its Nursing Handbook, based on recommendations of the Institute of Medicine, honors our commitment to our nation’s veterans through quality healthcare services delivery and evidence-based practice.”
Several corrections to statements that ASA made to the VHA July 2 were also provided in the AANA-AVANA joint letter:
  • ASA said CRNA LIPs would be “required” to function without physician oversight. In response, the AANA-AVANA letter stated that “the truth is that neither the VHA draft Nursing Handbook nor the term ‘Licensed Independent Practitioner’ suggest that CRNAs and other APRNs would be ‘required’ to function without physician involvement should the VHA designate APRNs as LIP.”
  • ASA said the Nursing Handbook would result in “effectively eliminating physician-nurse team-based coordinated care.” In response, the AANA-AVANA letter stated, “The ASA statement is false. While the VA Anesthesia Handbook supports care provided in teams, it does not require anesthesiologist supervision of CRNAs. Consistent with the Anesthesia Handbook, several VHAs are staffed solely by CRNAs working without anesthesiologist supervision … Overall care of the patient remains a collaborative effort among physicians, APRNs, nurses and other healthcare professionals, as it should.”
  • Finally, ASA cited its long-discredited “Silber” study as justification for concluding “anesthesia care is improved with the involvement of a physician anesthesiologist in a team.” In response, the AANA-AVANA letter stated that, “This ASA statement misrepresents the findings of a claims-data based study, the results of which have not been replicated and have been disregarded by Medicare.”
AANA members should go to and communicate with their members of Congress in support of the VHA recognizing CRNAs to their full scope.
For further information, see the AANA-AVANA letter, the ASA’s July 2 letter,  and the VHA Anesthesia Handbook.
ASA Complaints on VHA Nursing Handbook Reach Industry Press
Complaints by the American Society of Anesthesiologists (ASA) that the Veterans Health Administration (VHA) updates to its Nursing Handbook would be “dangerous” and would prohibit certain APRNs from providing care in teams with physicians reached some health industry press the week of Sept. 10. AANA spokespersons were contacted by reporters from Anesthesiology News, Medscape and most recently the Wall Street Journal to comment on the issue. The AANA and the Association of Veterans Affairs Nurse Anesthetists (AVANA) had already objected to and corrected the ASA’s misstatements about CRNA practice in an Aug. 30 letter to the VHA. 
Among other updates, the draft VHA Nursing Handbook authorizes all APRNs in the VA health system to be licensed independent practitioners (LIPs). According to Anesthesiology News, ASA President-elect Jane Fitch, MD, hosted a conference call with reporters during which she termed the update a “significant” concern for the safety of patients who are veterans. Anesthesiology News added, “Some people familiar with the issue said the ASA’s aggressive response to what could be considered a matter of worst-case interpretation of an ambiguous policy indicated Dr. Fitch’s desire to assert her bona fides as incoming president of the society on the eve of her ascension to the position.”
The AANA and CRNAs will continue working to ensure that agency officials, legislators, and health policy leaders get the truth and the evidence supporting CRNA professional practice. AANA members should go to and communicate with their members of Congress in support of the VHA recognizing CRNAs to their full scope.
For further information, see the at AANA-AVANA joint VHA letter (requires AANA member login and password). 
Noridian Releases Draft Local Coverage Determinations on Facet and Epidural Injections; Requests Comments
Medicare’s administrative contractor serving Western states has posted draft Local Coverage Determinations (LCDs) for public comment through Nov. 6 regarding Medicare coverage of certain pain management services provided by CRNAs. The AANA is reviewing the draft LCDs, circulating them among pain CRNAs nationwide and State Reimbursement Specialists (SRSs) in states served by Noridian, and developing comments in response to the LCDs.
The draft LCDs relate to Medicare coverage of epidural steroid injections, and facet joint injections, medial branch blocks, and facet joint radiofrequency neurotomy. The contractor, Noridian Medicare, administers Medicare Part B in the Jurisdiction F states of Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, and Wyoming, and the Jurisdiction E states of California, Hawaii, and Nevada plus American Samoa, Guam and the Northern Marianas Islands. If Noridian Medicare adopts the LCDs, they will be effective for CRNAs serving Medicare patients in those jurisdictions, and may be adopted and put to use by other Medicare administrative contractors (MACs) serving other states.
Your views on these draft LCDs are welcome. Please send your observations about them to, with “NORIDIAN PAIN LCD” in the subject line.
Working for Your Reimbursement: How You Can Avoid a 1.5 Percent Medicare Cut in 2015
How can a CRNA avoid having all Medicare services cut by up to 1.5 percent in 2015? By reporting one Medicare Physician Quality Reporting System (PQRS) code on one Medicare claim this year (2013), according to representatives of the Medicare agency.
Because Medicare’s continued rollout of its PQRS quality incentive payment system affects CRNAs nationwide, AANA staff secured a meeting with Medicare agency representatives the week of Sept. 9 to discuss how CRNAs can learn more about the PQRS, ensure eligibility for incentives, and avoid penalties. A reduction of 1.5 percent of Medicare payment in 2015 might not seem like much now, but come 2015, no CRNA would be happy with a pay cut of up to 1.5 percent because he or she provided care to Medicare patients and did not ensure that Medicare’s PQRS participation requirement was met in 2013. CRNAs should report all of the quality measures they can in their Medicare claims, because reporting or failing to report will affect Medicare CRNA reimbursement in 2014 and following years. Successfully completing these reports in 50 percent or more of your Medicare cases in 2013 may make a positive 0.5 percent difference in your Medicare revenues paid in 2014. However, failing to complete these reports in 2013 may reduce your 2015 payments by up to 1.5 percent, says Medicare.
The Medicare representatives also said:
  • CRNAs and other healthcare providers have until Oct.15 to enroll in a Medicare computer database (IACS) that tracks participation in the PQRS online, and provides estimates of providers’ eligibility for incentive payments. To learn more, click here.
  • A tip sheet is available from CMS to help CRNAs and other healthcare professionals avoid PQRS-related payment cuts in 2015. 
Many CRNAs are already participating in the PQRS. According to Medicare Chief Medical Officer Dr. Patrick Conway, 17,166 CRNAs were eligible participants in the PQRS in 2011, and 38.9 percent of eligible CRNAs participated in the program that year. According to a separate CMS report, the most common measures reported by CRNAs are these five, in order of their use:
  • 30. Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
  • 193. Perioperative Temperature Management
  • 76. Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol
  • 20: Perioperative Care: Timing of Antibiotic Prophylaxis-Ordering Physician
  • 145: Radiology: Exposure Time Reported for Procedures Using Fluoroscopy
Every CRNA should become familiar with PQRS reporting instructions and guidelines. This incentive represents future earnings for an individual CRNA or for his or her employers. Please refer to the CMS website for details. 
Past AANA President Rowles Named to Federal Advisory Workgroup on Pain Research
A federal agency workgroup on pain research and public health has named to its membership AANA Past President Jackie Rowles, CRNA, MBA, MA, FAAPM, ANP, DPNAP, having been nominated by the AANA to the post.
In response to the findings of the Institute of Medicine (IOM) “Relieving Pain in America” report, the Department of Health and Human Services charged the Inter Agency Pain Research Coordinating Committee (IPRCC) of the National Institute of Health (NIH) with creating a comprehensive population health-level strategy for pain prevention, treatment, management and research. Rowles has been named to the “Public Health: Care, Prevention and Disparities” working panel to plan implementation of that aspect of the IOM report. There are five panels altogether. Rowles is the second CRNA named to an IPRCC panel, as Margaret Faut-Callahan, CRNA, PhD, FAAN, was called earlier to serve on the “Professional Education and Training” working panel as part of the same overall project.
The AANA continues to encourage government agencies and others to engage CRNAs as full partners in redesigning healthcare in the United States, consistent with the recommendations of the IOM report “The Future of Nursing.”
Learn more about the IPRCC at
Affordable Care Act Health Coverage Countdown: On Oct. 1, People Start Enrolling for Coverage through State or Federal Marketplaces
Patient enrollment opens Oct. 1 for health plans marketed through Affordable Care Act (ACA) marketplaces and exchanges, and that take effect Jan. 1, 2014. Though the political environment around the ACA remains contentious—nationally, Democrats tend to support it while Republicans tend to oppose it—its implementation carries important ramifications for CRNAs and the patients they care for.
Information available at provides patients a breadcrumb trail for new health insurance options that may be available to them, help with healthcare and health coverage costs, and apples-to-apples comparisons of health plans so patients can make wise decisions. If you would like to help promote patient enrollment in the health insurance marketplace serving your community, please see for a wide variety of publications, articles, research, and online tools in English, Spanish and other languages.
AANA Comments on Medicare 2014 Fee Schedule
Medicare should ensure that standards used in seeking measures for public reporting on the Physician Compare website protect the public and other healthcare professionals who may be market competitors, said the AANA in a comment letter submitted to the agency Aug. 28 in response to its Physician Fee Schedule CY 2014 proposed rule.
As stated in a letter signed by AANA President Dennis Bless, CRNA, MS, “The AANA is concerned that CMS is considering expanding reporting on the Physician Compare website with measures that have been developed and collected by physician specialty societies and not necessarily subject to a transparent interdisciplinary consensus evaluation process. The AANA supports the use of quality measures that are transparent, actionable, evidence-based, patient-centered and consensus-driven, taking into account all stakeholders, including CRNAs. For this reason, the AANA supports measures that are endorsed by the National Quality Forum (NQF), which includes a wide variety of healthcare stakeholders and employs a rigorous process of accountability to assure validity and reliability. CRNAs commonly report measures that are NQF-endorsed.”
The AANA also recommended the agency require that surveys used for the Physician Compare website capture patient care experience with CRNAs as APRNs. It asked the agency to keep claims reporting as an option available for Physician Quality Reporting System (PQRS) measures groups. Finally, the agency had claimed that the most common code reported with ultrasound guidance is CPT Code 20610 (drain/inject major joint or bursa). The AANA responded that CRNAs are more likely to report the code for ultrasound guidance with injection services other than CPT Code 20610. 
For futher information, read the AANA’s comments and the 252-page proposed rule (both links require AANA login and password).
AANA Submits Comments on CMS Hospital Outpatient Payment Proposal
Medicare should continue its moratorium against enforcing on-site supervision of outpatient therapeutic services in Critical Access Hospitals (CAH) and small rural hospitals, said the AANA in a comment letter submitted to the agency Aug. 29 in response to its Hospital Outpatient Prospective Payment (HOPPS) CY 2014 proposed rule.
In the letter signed by AANA President Dennis Bless, CRNA, MS, the AANA stated that it “opposes superfluous Medicare requirements for physician supervision or on-site general oversight that are not linked to demonstrated patient safety benefits, because they impose costs and opportunity costs that waste scarce healthcare resources and impair patient access to quality care. If a regulatory requirement is meaningless in practice, contributes to greater healthcare costs, and is contrary to existing evidence regarding patient safety and access to care, it is obsolete and unnecessary and should be eliminated. The AANA recommends that the agency reconsider its decision to end this moratorium on the supervision policy for outpatient therapeutic services provided in CAHs and rural hospitals, and instead extend the moratorium.”
The AANA also recommended that the agency specify the anesthesia-related quality measures to be proposed for future rulemaking for the ASC Quality Reporting Program and to convene a task force of anesthesia professionals to develop and evaluate the use of these measures. AANA also commended the agency for seeking to develop a comprehensive set of quality measures in the Hospital Outpatient Quality Reporting Program (OQR) through future rulemaking and supported the agency’s proposed measure domains which include clinical quality of care, care coordination, patient safety, patient and caregiver experience of care, population/community health, and efficiency.
For further information, read the AANA’s comments (requires AANA login and password) and the proposed rule
With Appreciation to Christine Zambricki, CRNA, DNAP, FAAN
Our AANA FGA friend and colleague Christine Zambricki, AANA Senior Director of Federal Affairs Strategy, is departing the AANA staff to serve as CEO of America’s Blood Centers (ABC). Christine’s last day as a member of the AANA staff will be Oct. 11. Based in Washington, D.C., ABC is a membership organization consisting of North America’s largest network of nonprofit community blood centers. The network provides more than half the blood supply to more than 3,500 hospitals and other healthcare facilities in the United States.
During her distinguished career, Christine has served as AANA president, chair of the Michigan Board of Nursing, nurse anesthesia educational program director at Oakland University, and administrator of one of the largest hospitals in Michigan before joining the AANA Washington, D.C., office. She has fulfilled strategic roles on many important initiatives, including the Protect My Pain Care campaign which led to CMS confirming that CRNAs are qualified to provide all Medicare services within their state scope of practice, including pain management; implementing the new State Reimbursement Specialist (SRS) program; and helping to secure CRNA postings to federal advisory panels and workgroups at the National Academy of Science and the Interagency Pain Research Coordinating Committee. Christine recently received her DNAP from Virginia Commonwealth University, Richmond, Va., and was elected Organizational Affiliates representative to the American Nurses Association board of directors. In 2001, Christine was honored with the Agatha Hodgins Award for Outstanding Accomplishment, the AANA’s highest honor. There is no doubt that the AANA benefitted greatly from Christine’s more than 20 years of healthcare executive experience. 
Please join us in wishing Christine Zambricki, our friend and colleague, best wishes in her new endeavor.
  • ​With support from the CRNA-PAC, AANA members from Maryland met House Majority Whip Steny Hoyer (D-MD) and several other lawmakers from the House Democratic leadership at a reception benefiting the Democratic Congressional Campaign Committee on Sept. 10. Pictured, from left, are Gregory Taylor, CRNA, Rep. Hoyer, and Kelly Petz, CRNA. To contribute to CRNA-PAC today, click, enter your AANA member login and password, and click the big “Contribute” button!
  • The CRNA-PAC unveiled a new video in which AANA members share how their own experiences in advocacy and support of the CRNA-PAC have made a positive difference to their practice and the nurse anesthesia profession. See (AANA member login and password required) and click “WATCH our new CRNA-PAC video.”
  • AANA’s Fall Leadership Academy Nov. 8-10 will offer an educational track for Federal Political Directors and the first dedicated track for State Reimbursement Specialist (SRS) development. Every participant will leave the FLA educated and energized and well-prepared to coordinate grassroots and reimbursement advocacy in their states. To learn more or register online, click here.
About This Document
The AANA Federal Government Affairs Hotline is published for the nurse anesthetist members of AANA Mondays when Congress is in session by the AANA Office of Federal Government Affairs, Washington DC, (202) 484-8400,, Frank Purcell, Senior Director. © 2013 American Association of Nurse Anesthetists. The following is an FEC required legal notification for CRNA-PAC: 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 its 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. Each contributor must be a US Citizen.


Questioning Steroid Shots for Back Pain
A review of 43 studies, published online in Anesthesiology, found that an epidural involving the injection of any liquid—even a plain saline solution—into the area around the spinal cord alleviates back pain just as effectively as an injection of steroids. While the researchers expected to uncover some evidence that epidural steroid injections provide more relief for back pain than intramuscular steroid injections, they also detected little difference between the amount of pain relief provided by steroidal and nonsteroidal epidural injections. This discovery lead them to suggest that any liquid injected epidurally can help reduce nerve inflammation—the cause of pain—and possibly even enhance blood flow to the nerves and clean out scar tissue. The study's senior author, Johns Hopkins anesthesiology professor Dr. Steven Cohen, said that while "epidural steroid injections may provide modest relief," they also have side effects; and "most of the short-term benefit seems to be not from the steroids, but from the local anesthetic and saline, which may 'calm' inflamed nerves that send pain signals." He recommended that for patients at high risk, "doctors should consider significantly reducing the steroid dose, or even not using steroids."
From "Questioning Steroid Shots for Back Pain"
New York Times (09/24/13) P. D4 Bakalar, Nicholas
Breakthrough Propofol Study May Lead to Better Anesthetics
In a groundbreaking discovery, U.S. and U.K. researchers have pinpointed the exact place on the brain where propofol binds to receptors to create an anesthetic effect. "For many years, the mechanisms by which anesthetics act have remained elusive," noted Dr. Alex Evers, head of Washington University's anesthesiology department. "We knew that intravenous anesthetics, like propofol, act on an important receptor on brain cells called the [gamma-aminobutyric acid type A] GABAA receptor, but we didn't really know exactly where they bound to that receptor." To find out, investigators built a molecule that mimicked the structure and function of propofol. They added a chemical element to permanently bind the drug on the GABAA receptor—which was then removed and cut up to reveal the location on the protein where the propofol model was attached. The researchers say their work may help identify the binding sites for other anesthetics and facilitate the development of new drugs. "Whilst propofol is the best anesthetic we have today, it is important for patient safety that we come up with new versions of the drug that work just as well or better as anesthetics, but have fewer or less dangerous side effects," wrote study author Nicholas Franks, PhD, of Imperial College London, in a report published in Nature Chemical Biology. Propofol, while less likely to trigger nausea than other anesthetic agents, runs the risk of reducing blood pressure and disrupting breathing, among other complications.
From "Breakthrough Propofol Study May Lead to Better Anesthetics"
RedOrbit (09/23/13) Smith, Brett
Imbalancing Act: Study Shoots for Optimal Spinal Anesthetic, But Misses Mark
A new study out of the Hospital for Special Surgery in New York City suggests that researchers still have not discovered the ideal combination of drugs that will deliver both reliable spinal anesthesia and fast recovery. Since transient neurologic symptoms dethroned lidocaine as the standard for knee surgery, a combination of isobaric mepivacaine and fentanyl has emerged as a popular alternative. Hoping to improve the performance of the drug blend by optimizing the dose, the New York researchers evaluated 56 patients who were randomized to receive one of four anesthetic regimens. Following their outpatient knee surgeries, study participants received either 37.5 mg of mepivacaine; 30 mg of mepivacaine plus 10 mcg of fentanyl; 27 mg of mepivacaine plus 10 mcg of fentanyl; or 24 mg of mepivacaine plus 10 mcg of fentanyl. Ultimately, it was found that patients who received the lower doses of mepivacaine in tandem with the fentanyl experienced shorter recovery times and faster discharge. The downside, however, is that the effectiveness of the anesthetic was compromised. "With such low doses of mepivacaine, we're pushing the limit of where we can reliably achieve a good anesthetic," explains the hospital's Richard Khan, MD. "The recovery might be a little bit faster, but you might also have an incomplete block. The challenge here is to find something that will give complete anesthesia but resolve relatively quickly, so the patient doesn't have to sit in the recovery room for an hour and a half after an ambulatory procedure." The study findings were reported at the 2013 annual meeting of the American Society of Regional Anesthesia and Pain Medicine.
From "Imbalancing Act: Study Shoots for Optimal Spinal Anesthetic, But Misses Mark"
Anesthesiology News (09/01/13) Vol. 39, No. 9 Vlessides, Michael
Smartphones and Tablets Could Provide Universal Access to Medical Monitoring
According to Dr. J. Mark Ansermino of the University of British Columbia, Vancouver, smartphones and tablet computers may herald the future of mobile medical monitoring. In the October issue of Anesthesia & Analgesia, he writes that their widespread adoption would allow clinicians to monitor vital signs anywhere—and at a lower cost than standard equipment. In particular, the devices could expand the use of pulse oximetry—which tracks blood oxygen levels—in developing countries. Ansermino notes that "the inherent computing power of these devices and their everyday availability offer the opportunity to create a stand-alone device that can be used in the home by patients, yet which can also communicate with clinicians in real time." While mobile pulse oximetry is already in use in some ways, the technology needs to be refined. Smartphones and tablets could be used, for example, to improve contact with healthcare providers, as an educational tool, and as an information resource. Ansermino concludes, "The widespread availability of pulse oximetry on mobile devices will realize the potential of pulse oximetry as both a monitoring and diagnostic tool in a wide range of clinical settings," and could allow oxygen saturation to "truly become recognized as one of the vital signs."
From "Smartphones and Tablets Could Provide Universal Access to Medical Monitoring"
Medical Xpress (09/23/13)
Oral or IV? Both Forms of APAP Avoid Opioids, Study Finds
New research suggests that intravenous acetaminophen may reduce postoperative morphine requirements after pediatric surgery, but the opioid-sparing effects are not superior to those of the oral drug. The study of 17 children undergoing cleft-palate repair found that children receiving IV acetaminophen (APAP) used significantly less morphine after surgery compared to children who received placebo. Both oral and IV APAP, however, had similar effects. Patients were randomized to receive both oral and IV agents at specified times in the following combinations: IV APAP/oral placebo, oral APAP/IV placebo, or oral placebo/IV placebo, and the children received intraoperative opioids as needed. Intraoperative administration of fentanyl in the post-anesthesia care unit was comparable among the three groups, but morphine consumption on the ward was lower in the two study groups compared to controls. Twenty-four-hour opioid use, measured in morphine equivalents, was lower in IV patients than in those who had received either oral APAP or placebo, though this was not statistically significant. The researchers presented their results at the 2013 annual meeting of the International Anesthesia Research Society.
From "Oral or IV? Both Forms of APAP Avoid Opioids, Study Finds"
Anesthesiology News (09/01/13) Vol. 39, No. 9 Vlessides, Michael
Fentanyl Patch Can Be Deadly to Children
Accidental exposure to a skin patch containing the pain reliever fentanyl has caused serious illness and even death in some children, prompting the Food and Drug Administration (FDA) to issue a Drug Safety Communication to warn about the dangers of accidental exposure and improper storage of the patches. The fentanyl transdermal system is marketed under the brand name Duragesic and is available generically to treat chronic-pain patients. An overdose of fentanyl can occur if the child puts the patch in his or her mouth or applies it to the skin. The drug can cause death by slowing breathing and increasing the levels of carbon dioxide in the blood. The agency has recorded 32 cases of accidental exposure to fentanyl since 1997, most of them involving children under age two. Twelve cases have led to death, while another 12 have required hospitalization. "The best thing a patient can do is to follow the instructions on the medicine label and talk to a health care professional about how to prevent anyone else from coming in contact with the fentanyl patch," says Dr. Douglas Throckmorton, deputy director of FDA's Center for Drug Evaluation and Research. On Sept. 23, the FDA approved changes to the Duragesic patch so that the drug's name and strength will be printed clearly on the patch, making it easier to find patches that need to be removed from patients' bodies or have fallen off. A partially detached patch could be transferred from adult to child if the child is being held by the adult, for example, and toddlers may find lost, discarded, or improperly stored patches. The FDA recommends that used patches be discarded by folding them in half with the sticky sides together, and then flushing them down the toilet; they should not be placed in household trash where children or pets could find them.
From "Fentanyl Patch Can Be Deadly to Children"
FDA Consumer Updates (09/23/2013)
The Sound of Music and Other Techniques to Help Kids Deal With Pain at the Doctor’s Office
Research shows that listening to certain types of music can help distract young children who are undergoing painful medical procedures. A research team in Canada monitored pain and distress in 42 children, ages three to 11, before and after they received an intravenous line. Half of the children received standard emergency room care, while the other half listened to musical selections over room speakers. All of the children experienced distress during the IV insertion, but there were twice as many signs of distress in those kids not exposed to music compared to those who were. Other useful distraction techniques include storytelling, guided imagery, blowing soap bubbles, tablet games, sipping sugar water, or deep breathing. William Zempsky, head of pain medicine at Connecticut Children's Medical Center, is part of a group of physicians and researchers trying to change how providers manage pediatric pain. Zempsky co-authored a clinical report for the American Academy of Pediatrics that offered strategies for reducing pain during childhood immunizations, such as consuming sugar solutions. Distraction techniques may be used in conjunction with regular pain medications, and clinicians may ask parents to help with some of these solutions. Parents are encouraged to be more direct and advocate for pain management at the pediatrician's office or in the emergency room.
From "The Sound of Music and Other Techniques to Help Kids Deal With Pain at the Doctor’s Office"
Washington Post (09/16/13) Adams, Jill U.
Patients Love a Gentler Approach to Surgery, But Surgeons Balk
An enhanced recovery approach protocol pioneered in Europe about 10 years ago dispenses with many of the standard steps for patient care before, during, and after surgery that have no evidence to support their benefits. A Mayo Clinic study found that women who had major abdominal surgery and were treated with this approach—which includes forgoing abdominal drains, nasogastric tubes, and prolonged fasting, among other protocols—felt less pain and were able to recover faster than those who received conventional care. Not only are patients allowed to eat until midnight the day before surgery and drink water up until four hours prior, the regimen also changes anesthesia and pain management by making intravenous opioids a pain relief of last resort. The Mayo doctors instead administered non-narcotic painkillers first and found that, overall, patients' use of opioids fell 80 percent in the first two days following surgery. Dr. Sean Dowdy, a professor in obstetrics and gynecology at Mayo who led the study, noted, "Whether it's the early feeding or the lack of bowel preps or the change in anesthesia delivery, [...] patients are happier." The Mayo doctors also looked at the health of patients who had the enhanced recovery approach and discovered that they had shorter hospital stays and substantially lower costs. Following the study, which was published in Obstetrics & Gynecology, Mayo began using the enhanced recovery pathway for all inpatient gynecological surgery and adopted the approach for colorectal surgery, too. Dowdy notes that while the protocol has been discussed and studied for at least 10 years, few hospitals offer it, as many surgeons are "just not willing to accept that this is a better way to manage patients."
From "Patients Love a Gentler Approach to Surgery, But Surgeons Balk"
Boise State Public Radio (08/27/2013) Shute, Nancy
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