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VA Final Rule Granting Full Practice Authority to APRNs Excludes CRNAs

On Dec. 14, 2016, the Department of Veterans Affairs (VA) published its final rule that grants full practice authority to advanced practice nurses but excludes CRNAs. The final rule, which approves full practice authority for nurse practitioners, certified nurse-midwives, and clinical nurse specialists states, "Certified Registered Nurse Anesthetists (CRNA) will not be included in VA's full practice authority under this rule, but comment is requested on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking."

The final rule will take effect 30 days after publication in the Federal Register. The rule is available online. Comments on full practice authority for CRNAs must be received by the VA within 30 days of publication of the rule (Jan. 13, 2017).


VA Comment Period Reopened, Take Action Today!
Deadline January 13, 2017
Over the last several months, AANA members have sent tens of thousands of letters to the VA, members of Congress, and others in support of CRNA Full Practice Authority—but our work is not yet done. During this last 30-day comment period, your efforts are more important than ever if we want to reverse this irresponsible decision. Visit CRNA-PAC for instructions on submitting a comment to the VA. (Member login and password required.)


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Hot Topics

Happy Holidays—And See You Next Year!

Due to the holidays, Anesthesia E-ssential will not come out on Dec. 30, 2016, and will resume publication with the Jan. 13, 2017, issue. The E-ssential staff wishes all of our readers a joyous holiday season, and we look forward to serving you in 2017.
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Order Your CRNA Week Promo Items Soon!

Here are some important deadlines you need to know as 2017 approaches! 1) The AANA offices, including the bookstore, will be closed for the holidays, Dec. 24-Jan. 2. Orders received by close of business on Monday, Dec. 19, will be guaranteed to ship before Dec. 24. 2) National CRNA Week will be celebrated Jan. 22-28, 2017. The last orders for remaining promotional items will be accepted on Wednesday, Jan. 16. Please note: Inventory does start to run out after the first week in January, so if there are pens, buttons, posters, or other items you simply must have to complete your promotional plans, visit the bookstore page to order today.
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MACRA Quality Payment Program Launches January 1, 2017

The new Quality Payment Program established under MACRA will begin with the 2017 performance year and will be replacing PQRS. Most CRNAs will have to participate in the Merit-based Incentive Payment System (MIPS) track to avoid the -4 percent Medicare reimbursement penalty and possibly earn an incentive in 2019. The AANA Research and Quality Division has created a MACRA video as well as other MACRA resources including FAQ and fact sheets, which are all available on the AANA Quality-Reimbursement website.
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Nomination Deadline for Daniel D. Vigness Federal Political Director Award is Jan. 15

Is your state's Federal Political Director (FPD) awesome? Then nominate him or her for the Daniel D. Vigness Federal Political Director Award, which is presented during AANA Mid-Year Assembly in April 2017. Named for the late Dan Vigness, CRNA, of South Dakota, the first AANA FPD of the Year, this honor recognizes a CRNA who has been involved in federal political campaigns, developed close working relationships with federal officials, led successful CRNA advocacy efforts, helped contribute and raise funds for the CRNA-PAC, and helped recruit CRNAs to participate in political campaigns. Learn more and to submit a nomination
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2016 PQRS Reporting—the Clock Is Ticking!

Remember, if you do not report to PQRS for the 2016 performance year (which ends Dec. 31), you will automatically receive a -2 percent penalty on your 2018 Medicare reimbursement. CRNAs now qualify for the Value-Based Modifier program, and will receive an additional -2 percent to -4 percent penalty for not reporting. Most Qualified Registries and Qualified Clinical Data Registries are still accepting quality data for submission to CMS. Visit the AANA Quality-Reimbursement website or log into the myAANA Quality Reporting Tool Kit to learn more about how to successfully report to PQRS for 2016.
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Important Information about Mid-Year Assembly Travel and Hotel Accommodations

Before you make your travel and hotel arrangements for the AANA Mid-Year Assembly, please note that special hotel group rates are available April 5-10 at AANA's official conference hotel, the Renaissance Downtown Hotel (located at 999 9th Street NW) by reserving rooms through AANA's website. Dates outside of these dates are not guaranteed, as the Cherry Blossom festival attracts tens of thousands of tourists from around the world. Also, there is a large city-wide convention taking place prior to the AANA Mid-Year Assembly, and hotel availability is extremely scarce for those planning to arrive before April 5. (Please note: Special hotel rates are through April 10.) Haven't registered yet? Get the preparation you need to advance CRNA policy interests on Capitol Hill and to effectively advocate for your profession. Then apply a broader knowledge of policy and reimbursement issues at meetings with state representatives and Congressional staff.
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New Sponsored Courses on AANA Learn: Complimentary CE for AANA Members

Be sure to take advantage of two new complimentary AANA Learn CE courses available to AANA members through an educational grant by Merck.

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Nomination Deadline for Service on the 2017-18 CRNA-PAC is Jan. 31

If you or a colleague would like to serve on the CRNA-PAC Committee, Jan. 31 is the deadline for submitting an application online. In September 2017, the nine-member committee will have two CRNA vacancies, each for three-year terms. One student registered nurse anesthetist vacancy will also open for a one-year term. Two members of the AANA Board of Directors serve on the CRNA-PAC Committee, each for a one-year term that may be renewed for one additional year while the member also serves on the Board. To learn more about the CRNA-PAC Committee and access applications for both the CRNA and student positions, visit the Federal Government Affairs page (AANA login required).
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Consider Nominating a Colleague for an AANA Award!

Do you work with an outstanding program director, didactic instructor, or clinical instructor? Do you know someone who has spent a lifetime advancing the practice of nurse anesthesia as a practitioner, educator, clinician, or advocate? Consider nominating your colleague for one of the national AANA Recognition Awards. Visit AANA Awards for details on the Agatha Hodgins Award for Outstanding Accomplishment, Helen Lamb Outstanding Educator Award, Alice Magaw Outstanding Clinical Practitioner Award, Ira P. Gunn Award for Outstanding Professional Advocacy, Clinical Instructor of the Year Award, Didactic Instructor of the Year Award, and Program director of the Year Award.
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State Government Affairs

Top Ten Suggestions on Establishing a Proactive Government Relations Committee

The AANA Government Relations Committee, in collaboration with the AANA Government Relations Division staff, created Top Ten Suggestions on Establishing a Proactive Government Relations Committee, a helpful tool to assist state associations with structuring the Government Relations Committee. For additional resources on State Government Relations Advocacy please visit the SGA page or contact the SGA Division at sga@aana.com.
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Nomination Deadline for Award for Excellence in State Government Relations Advocacy is Feb. 15

Nominate your state association for the AANA's Award for Excellence in State Government Relations Advocacy! State associations are encouraged to describe their significant efforts in state government affairs advocacy and enter by Feb. 15, 2017, to win this award, which will be presented at the AANA Mid-Year Assembly in April 2017. This annual award is not tied to a specific "victory" in the state legislative or regulatory arena, but will be given based on the quality of the undertaken effort. Examples of state association efforts include successful lobby days, legislative/regulatory efforts, or increased member participation in grassroots or other efforts. For more information and to submit your state's application, go to Recognition Awards.
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Meetings and Workshops

2022 is Closer than You Think

Students starting programs Jan. 1, 2022, must graduate with doctoral degrees: Is your program ready? Program administrators, faculty, and deans are encouraged to attend "2022 is Closer than You Think: Transitioning to the Doctoral Degree." The joint 1.5-day COA/AANA Education Committee workshop is designed to assist programs in their successful transition to entry-level doctoral degrees.
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Registration Open for these Popular Hands-On Workshops

Register now—space is limited for the following spring hands-on workshops: Upper and lower Extremity Nerve Block, the Essentials of Obstetric Analgesia/Anesthesia, Spinal and Epidural, and Jack Neary Advanced Pain Management Workshop Part I. Visit meetings for further information and to register!

Upper and Lower Extremity Nerve Block Workshop
AANA Foundation Learning Center
March 18-19, 2017
The Upper and Lower Extremity Nerve Block Workshop is designed to enhance the practitioner's knowledge in the clinical sciences related to upper and lower block anesthesia. The program will include case studies and hands-on demonstration.

Essentials of Obstetric Analgesia/Anesthesia Workshop
AANA Foundation Learning Center
May 10, 2017
Refresh your knowledge of clinical applications of spinal and epidural anesthesia procedures at the three-day intensive Spinal and Epidural Workshop. An excellent complement to the Essentials of Obstetric Analgesia/Anesthesia Workshop, this workshop combines expert lecture with a guided hands-on approach to learning.

Spinal and Epidural Workshop

AANA Foundation Learning Center
April 21-23, 2016
Refresh your knowledge of clinical applications of spinal and epidural anesthesia procedures at the three-day intensive Spinal and Epidural Workshop. An excellent complement to the Essentials of Obstetric Analgesia/Anesthesia Workshop, this workshop combines expert lecture with a guided hands-on approach to learning.

Jack Neary Pain Management Workshop Part 1
Rosemont, IL
June 3-5-2017
This workshop will expand your knowledge of interventional pain management through scientific and theoretical bases of pain, pharmacology, and pain management considerations.
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Visit www.crnacareers.com to view or place job postings
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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.

'Enhanced Recovery' Protocol Superior for Colon Cancer Surgery

New evidence supports the use of enhanced recovery after surgery (ERAS)—an approach emphasizing minimally invasive techniques, anesthesia/analgesia, prevention of nausea and ileus, nutrition, and early mobilization, among other components. The findings come from a prospective, multi-site study of 320 patients who had colon cancer surgery from April 2011 to January 2014. About half received standard care, while the other half underwent ERAS. A comparison of outcomes revealed less blood loss, shorter operation times, and reduced intraoperative fluid administration among the ERAS patients, whose hospital stays were also shorter in duration compared to those receiving conventional care. ERAS treatment also helped participants achieve discharge criteria, including normal food consumption and adequate pain relief with nonopioid oral analgesia, sooner. Meanwhile, complications—both surgical and nonsurgical—were no worse with ERAS than with normal care. "The present series of 320 patients represents one of the largest ERAS trials," the researchers report in Surgery Today. "Our results suggest that the ERAS protocol is superior to conventional postoperative management after elective colonic resection for colon cancer. These results may encourage medical staff, surgeons and anesthetists to implement and support adherence to an ERAS protocol."

From "'Enhanced Recovery' Protocol Superior for Colon Cancer Surgery"
Clinical Oncology (12/16) Brown, Tina Demarcantonio

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Researchers Study Injections as PTSD Treatment

Several hundred soldiers with post-traumatic stress disorder (PTSD) have had local anesthetic injected into nerve tissue in the neck in an effort to treat their anxiety, but researchers are still chasing solid scientific proof that stellate ganglion block actually works. The procedure has effectively alleviated certain types of pain in the face, neck, arms, and upper torso; and scientists suspect it also could relieve PTSD, although it is unclear how. In hopes of producing that evidence, the U.S. Army is bankrolling a $2 million study on active-duty troops in North Carolina, Hawaii, and Germany. The goal is to enroll 240 patients and randomize them to receive either a real or sham injection. Participants who are assigned to placebo as part of the study, which should be completed in 2018, will later be offered the actual treatment.

From "Researchers Study Injections as PTSD Treatment"
WUNC.org (NC) (12/13/16) Price, Jay

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Can IV Acetaminophen Offer an Option for Surgical Patients?

New findings suggest intravenous acetaminophen may be a viable and cost-effective strategy for pain management. Duke University and University of Washington School of Pharmacy researchers studied 190,691 patients who underwent total knee arthroscopy between 2012 and 2015. Those who received IV acetaminophen to help manage postoperative pain—representing about 30 percent of the participants—remained hospitalized for 2.8 days, compared with 3.0 days for those who received oral analgesic. In addition to shorter hospital stays, the IV acetaminophen patients were more likely to be discharged home and less likely to be discharged to a nursing facility. Their overall health care expenses were generally lower, as well. The research results were presented recently at the 28th annual National Forum of the Institute for Healthcare Improvement.

From "Can IV Acetaminophen Offer an Option for Surgical Patients?"
American Journal of Managed Care (12/12/2016) Caffrey, Mary

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Survey: Pain Patients Reveal How Chronic Opioid Use Begins

According to a poll of chronic pain patients, more than a quarter became long-term opioid users after taking the pills for short-term relief following an operation or injury. Based on feedback from 115 respondents, researchers with Penn Pain Medicine Center at the University of Pennsylvania found that opioid therapy was often extended because corrective surgery was eventually needed for many of the patients with injury-related pain. Almost 25 percent of poll participants, however, reporting taking painkillers for a reason other than that for which they were initially prescribed. The study findings offer further insight on how chronic opioid therapy begins and, the investigators report in The Journal of Pain, may point to "opportunities for improved patient selection for opioid therapy."

From "Survey: Pain Patients Reveal How Chronic Opioid Use Begins"
Monthly Prescribing Reference (12/16) Han, Da Hee

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Anesthetic Cream Best for Relieving Vaccination Pain in Infants

According to a new study out of Canada, the optimal approach to minimizing vaccination pain in babies involves applying topical analgesic, administering an oral sugar solution, and showing parents a video on soothing techniques. The researchers randomly assigned 352 healthy infants younger than one year old to one of four different cohorts during routine immunizations. "We found that only liposomal lidocaine combined with parental video instruction and orally administered sucrose showed a benefit on acute pain when compared with placebo, video alone, and video and sucrose together," the researchers report in Canadian Medical Association Journal. "The effects of consistent pain management on the development of preprocedural anxiety (fear), hypersensitivity to pain and compliance with future vaccination warrant future investigations."

From "Anesthetic Cream Best for Relieving Vaccination Pain in Infants"
Medicalxpress (12/12/2016)

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Preloading Alkalinized Lidocaine in ETT Cuff Reduces Emergence Cough After General Anesthesia

Canadian researchers have found that filling the endotracheal tube (ETT) cuff with alkalinized lidocaine ahead of short surgeries quells emergence cough when patients awaken from general anesthesia. Although alkalinized lidocaine is already recognized for this ability, it was unclear if the benefit was limited to longer procedures since the analgesic typically takes 90 to 120 minutes to diffuse out of the ETT cuff. The University of Montreal investigators tested the idea of pre-loading the cuff at least 90 minutes prior to operations expected to last one hour or less. Participants in the study were randomly assigned to an ETT cuff that was inflated either with alkalinized lidocaine or with saline. Just 12 percent of the lidocaine patients experienced emergence cough, compared to 22 percent of the saline patients. "So we can confidently say that preloading alkalinized lidocaine in the ETT cuff significantly diminishes cough in surgeries shorter than 90 minutes," said pediatric anesthesiologist Papu Nath, MD, who reported the research at the 2016 annual meeting of the Canadian Anesthesiologists' Society.

From "Preloading Alkalinized Lidocaine in ETT Cuff Reduces Emergence Cough After General Anesthesia"
Anesthesiology News (12/09/16) Vlessides, Michael

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For Breast Cancer Surgery, To Block or Not to Block?

There are arguments both for and against performing paravertebral block (PVB) during breast cancer surgery, according to experts who spoke at the 2016 International Symposium of Ultrasound for Regional Anesthesia. University of Toronto assistant anesthesia professor Faraj Abdallah, MD, pointed to research showing that 94 percent of PVB recipients remained metastasis-free two and three years post-surgery. By comparison, only 82 percent of women given general anesthesia only had no disease progression a year later—a share that slipped to 77 percent by the second year. While acknowledging that there is not enough evidence yet to support a change in practice, Abdallah said there is sufficient data demonstrating PVB's contribution to improved short-term outcomes. A meta-analysis of two dozen randomized controlled trials involving nearly 2,000 patients showed that block lowered pain scores and curtailed opioid requirements. University of Alberta Hospital's Ban Tsui, MD, countered Abdallah's assertions, finding fault with both the study designs and results of the research Abdallah cited. He also pointed to his own investigation—which observed no disparity in opioid use, length of stay in the post-anesthesia care unit, rates of nausea and vomiting, or degree of chronic pain in mastectomy patients who received either a PVB or a sham block as part of a multimodal anesthesia protocol. Tsui suggested the regional technique may not be as safe as believed, noting that some data have indicated a high rate of complications.

From "For Breast Cancer Surgery, To Block or Not to Block?"
General Surgery News (12/09/16) Wild, David

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Scoring System Predicts Difficult Airways in Obese Patients

The possibility of airway problems presents a challenge among the morbidly obese, prompting a literature review to identify independent predictors of the complication in this population. Based on the data culled from the review, University of Ottawa researchers designed a new scoring system. Under it, patients are assigned one point each for certain characteristics—including age between 40 and 60 years, female gender, and neck circumference between 40 and 60 centimeters. They rack up two points each, meanwhile, if they are older than 60 years, male, or have a neck circumference greater than 60 cm, among other traits. Anyone whose total score falls below 5 should undergo anesthesia induction with controlled ventilation and direct laryngoscopy, according to the system, while induction with spontaneous ventilation and video laryngoscopy is recommended for those scoring between 5 and 10. A point total exceeding 10, however, warrants an awake look or fiber-optic intubation.

From "Scoring System Predicts Difficult Airways in Obese Patients"
Anesthesiology News (12/05/16) Vlessides, Michael

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Long-Acting Liposomal Bupivacaine Decreases Inpatient Narcotic Requirements in Men Undergoing Penile Prosthesis Implantation

Researchers questioned whether the benefits of a new long-acting form of liposomal bupivacaine, already demonstrated in some patient groups, were evident in a urologic surgery setting. They studied pain scores and morphine consumption over the course of 23 hours in 37 patients who had penile prothesis implantation performed by the same surgeon. Thirteen study participants received extended-release suspension bupivacaine (ERSB), while 24 underwent standard care or no local anesthesia at all. The results of the chart review revealed that ERSB use among patients getting penile prothesis implants curtailed narcotic requirements while achieving similar pain relief as the control group. However, the researchers report in the Turkish Journal of Urology, the cost of ERSB may be cost-prohibitive at $285 per dose compared with $5.16 per dose for standard care.

From "Long-Acting Liposomal Bupivacaine Decreases Inpatient Narcotic Requirements in Men Undergoing Penile Prosthesis Implantation"
Uro Today (12/05/16)

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Acupuncture Improves Postoperative Symptoms in Women Undergoing Surgery for Breast Cancer

Abbott Northwestern Hospital compared outcomes in breast cancer patients who received acupuncture versus standard care to manage postoperative symptoms. Oncology Nursing Forum reported the results of the study, which randomized 30 mastectomy patients to undergo two acupuncture treatments or usual care following surgery. Patients' perception of pain, anxiety, and nausea declined by about 1.5 units with the nonpharmacologic approach, roughly comparable to a reduction of 1.9 units in women treated with opioids. Despite the favorable findings, the researchers emphasize that additional study is warranted before incorporating acupuncture into the standard of care.

From "Acupuncture Improves Postoperative Symptoms in Women Undergoing Surgery for Breast Cancer"
Oncology Nurse Advisor (12/05/16) Pagan, Joyce

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TSRI Scientists Discover Potential Drug Candidate to Suppress Pain and Itch

A team from The Scripps Research Institute (TSRI) has introduced a kappa opioid receptor (KOR) agonist that promises to relieve pain and itch while avoiding the undesirable properties of similar agents. Drugs that target KORs tend to sap the body's supply of the neurotransmitter dopamine, subsequently triggering side effects like sedation and anxiety. Researchers at TSRI's Florida campus, however, have developed a "biased" KOR agonist that can preferentially activate certain pathways over others. Comparing triazole 1.1 and a conventional, selective KOR agonist in rodent models, they demonstrated that triazole 1.1 was able to suppress pain and itch while avoiding unwanted adverse effects. "This adds to the mounting evidence that shows analgesic effects can be separated from the sedative and dysphoric effects by altering how the agonist engages the receptor," explained first study author Tarsis Brust. KORs also do not produce a "high" or elevated risk for overdose, making a biased KOR agonist a good candidate for treating pain and itch without the risk of abuse.

From "TSRI Scientists Discover Potential Drug Candidate to Suppress Pain and Itch"
News-Medical.net (12/01/2016)

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Femoral Nerve Blockade Using Various Concentrations of Local Anesthetic for Knee Arthroscopy in the Pediatric Population

While femoral nerve blockade (FNB) is known to alleviate pain in children following arthroscopic knee surgery, it is unclear whether boosting the concentration of local anesthesia in extremity blocks is also beneficial—as has been demonstrated in adults. A retrospective analysis assessed the efficacy of FNB with different doses of ropivacaine and bupivacaine in nearly 270 children and adolescents who underwent arthroscopic knee surgery from January 2010 to December 2013. The researchers determined that FNB using ropivacaine 0.5% provided more effective postoperative pain control than FNB using ropivacaine 0.2% or bupivacaine 0.25%. The 75 patients who received it experienced lower opioid needs after the procedure and were released sooner from the post-anesthesia care unit and from the hospital.

From "Femoral Nerve Blockade Using Various Concentrations of Local Anesthetic for Knee Arthroscopy in the Pediatric Population"
Journal of Pain Research (11/16) Vol. 2016, No. 9, P. 1073 Veneziano, Giorgio; Tripi, Jennifer; Tumin, Dmitry; et al.

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Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed bimonthly to AANA members.

Anesthesia E-ssential is for informational purposes, and its contents should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

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December 15, 2016
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