Anesthesia E-ssential

AANA Anesthesia E-ssential, December 6, 2018

Vital Signs

AANA Applauds HHS Report Calling for Removal of Practice Barriers for Non-physician Providers

Dear Colleagues,

In a positive move for CRNAs and other non-physician healthcare professionals, and especially for the millions of patients served by these qualified providers, the Department of Health and Human Services (HHS) yesterday released its new report titled “Reforming America’s Healthcare System through Choice and Competition.” The AANA applauds the impressive message the report sends to policymakers, the medical profession, allied health professionals, and the public about the need to fully utilize all healthcare professionals to ensure patient access to the widest possible spectrum of safe, affordable healthcare options.

The report strongly encourages state governments to remove barriers to practice and allow all healthcare providers to practice to the top of their license and skill set. While the report doesn’t deliver a specific action plan, it makes many recommendations for improving healthcare public policy in the areas of healthcare workforce and labor markets, healthcare provider markets, healthcare insurance markets and consumer-driven healthcare. Officials from HHS and the Centers for Medicare & Medicaid Services (CMS) were open to many of the AANA’s recommendations during the report’s development. AANA leadership and staff will continue meeting with HHS and CMS representatives to provide input on next steps.

Checking in at 114 pages, the extensive report states that “Even when some form of collaboration or supervision might be desirable, particular requirements might be unnecessary, over-rigid, and costly barriers to the efficient delivery of healthcare services. Extremely rigid collaborative practice agreements and other burdensome forms of physician and dentist supervision are generally not justified by legitimate health and safety concerns.”

The report makes the following recommendations to broaden scope of practice:
  • States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.
  • The federal government and states should consider accompanying legislative and administrative proposals to allow non-physician and non-dentist providers to be paid directly for their services where evidence supports that the provider can safely and effectively provide that care.
  • States should consider eliminating requirements for rigid collaborative practice and supervision agreements between physicians and dentists and their care extenders (e.g., physician assistants, hygienists) that are not justified by legitimate health and safety concerns.
In addition, the report recommends streamlining federal funding of medical education, continuing the work being done by the Health Resources and Services Administration’s National Center for Health Workforce Analysis, and ensuring flexible network adequacy standards for Medicare Advantage and other federally sponsored programs.

As always, the AANA will keep you apprised of new developments with regard to the work of HHS and CMS to ensure healthcare provider competition that allows patients to receive care from the providers of their choice.


Garry Brydges, DNP, MBA, ACNP-BC, CRNA, FAAN
American Association of Nurse Anesthetists
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Practice Document for Open Comment: Standards for Nurse Anesthesia Practice

An updated practice document is available for open comment:
  • Standards for Nurse Anesthesia Practice.
We appreciate your time, expertise, and feedback in the review of this document. Please complete a survey that contains the new proposed standards by January 7, 2019. You can download the draft document at
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CRNA Spotlight on Ketamine

According to a New York Times article, suicide is the 10th leading cause of death in the U.S. A relatively new ketamine treatment can help patients with depression or anxiety. Find out how CRNAs are helping to curb severe depression with ketamine infusion therapy:
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Hot Topics

The Joint Commission Issues Advisory on Flu Vaccinations for Healthcare Workers

The advisory, Quick Safety 46: Protecting Patients and Others from Influenza in the Health Care Setting, asks healthcare facilities to help their workers understand their responsibility to protect themselves and their patients from the flu. The advisory notes that healthcare workers who skip the flu vaccination may be harming their patients and coworkers the most. Hospitalization rates for all age groups during the 2017-2018 flu season were the highest recorded. Flu prevention is the best way to protect healthcare workers, patients, and visitors. Joint Commission-accredited organizations must offer flu vaccination to staff (see Infection Prevention and Control standard IC.02.04.01). The advisory recommendations include:

For facilities:
  • Establish and implement supportive, nonpunitive time-off policies to encourage sick employees to stay home from work.
  • Make flu vaccines available to employees working all shifts to encourage compliance.
  • At all facility entrances, place tissues, masks and hand sanitizer, along with cover your cough signs.

For healthcare workers:
  • Get vaccinated every year.
  • Clean hands frequently with soap and water or alcohol-based hand rub.
  • Avoid touching eyes, nose and mouth.
  • Frequently clean and disinfect surfaces.
  • Stay home from work if sick.
  • When coughing or sneezing, cover mouth and nose and clean hands after handling tissues.
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Check Final MIPS Eligibility Status for 2018

CMS updated the final eligibility status for 2018 for the Merit-based Incentive Payment System (MIPS), based on review of Medicare Part B claims and Provider Enrollment, Chain and Ownership System (PECOS) data from September 1, 2017 to August 31, 2018. CRNAs can check their eligibility status using the Quality Payment Program Participation Status Tool. Please be aware that a CRNA’s status could have changed by joining a new practice (under a new or different TIN) between September 1, 2017 and August 31, 2018. CRNAs who joined a practice after August 31st are not eligible for MIPS as an individual but could receive a MIPS payment adjustment based on the new group’s participation, if it chose to participate in MIPS as a group.
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CMS Approves AAAASF for Continued Recognition

The Centers for Medicare & Medicaid Services (CMS) has approved the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) for continued recognition as a national accrediting organization for ambulatory surgical centers (ASCs) that wish to participate in the Medicare or Medicaid programs effective November 27, 2018 through November 27, 2024. Read AAAASF's announcement.
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Physician Compare Preview Period Opens

The Physician Compare Preview period opened on November 30, 2018. CRNAs can review their 2017 Quality Payment Program (QPP) performance information through the Quality Payment Program website for 30 days before it appears on the Physician Compare profile pages, and in the Downloadable Database. CMS provided a Preview Period User Guide to help providers review their information, along with specific resources for Individual Providers and Groups. The preview period closes on December 31, 2018.
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CRNA-PAC Reaches New Heights in 2018

For the first time in history, CRNA-PAC has raised $1 million in the 2018 calendar year. A huge thank you goes out to the more than 6,300 AANA members who have contributed and helped us to achieve this significant milestone.
As the political arm of the AANA, the nonpartisan CRNA-PAC helps the AANA and CRNAs across the country to educate and build relationships with federal lawmakers, and to elect and re-elect CRNA champions to the U.S. House and Senate. In the 2018 election cycle (January 1, 2017 – December 31, 2018), CRNA-PAC raised a total of $1.8 million – an all-time high—and disbursed more than $1.1 million to candidates for federal office. Of these disbursements, 51.5 percent went to Democrats and 48.5 percent went to Republicans; 92 percent of CRNA-PAC supported candidates won their elections in 2018. See a list of disbursements by state.

CRNA-PAC relies on the personal financial support of AANA members to achieve its goals of amplifying the voice of CRNAs on Capitol Hill. If you have not already done so, please make your one-time or recurring contribution today!

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 U.S. Citizen.
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Add Your Signature to PBS Letter Expressing Dissatisfaction with Ken Burns Mayo Documentary

Acclaimed filmmaker Ken Burns’s latest documentary, “The Mayo Clinic: Faith, Hope and Science,” recently aired on the Public Broadcasting System (PBS), and much to the chagrin of CRNAs and SRNAs across the country, there was nary a mention about nurse anesthesia in the entire program. Of course, it is well known that nurse anesthetists—especially Alice Magaw—were instrumental to the Mayo brothers’ advancement of surgical safety.

Evan Koch, CRNA, and a nurse anesthesia historian, has written a letter to PBS to express strong concerns about the filmmaker’s glaring oversight. If you would like to add your name to Evan’s letter, please write to with your name, credentials, and member number, and we will work with Evan to have your name added. Numerous CRNAs have already signed on. The deadline for requesting to have your name added is 4 p.m. CST, Wednesday, Dec. 12. ( NOTE: Only your name and CRNA credential will be used on the letter.) View the letter on the member side of the AANA website. Reminder: This letter will not be sent to PBS until after Dec. 12.
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SRNAs and CRNA Educators: Sign Up for the Student Mentoring Program at ADCE

SRNAs, are you interested in becoming a nurse anesthesia educator? CRNA educators, are you interested in mentoring students with an interest in education? Sign up for the Student Mentoring Program at the February 2019 Assembly of Didactic and Clinical Educators (ADCE).  

The program consists of a Student/Mentor Meet and Greet from 6:00 - 6:30 p.m., on Wednesday, February 13th, for the mentor/mentee pairs to meet each other. Students are paired with an educator from a program other than their own. Thursday, February 14th, is the one-day mentoring experience. Wherever the mentor goes throughout the day, the student will follow. The mentor introduces their mentee to their colleagues, involves them in their discussions, and takes them to lunch.

SRNAs: One student who has been nominated by their program director is accepted from each nurse anesthesia program, and a student may participate in the mentoring program only once. Let your program director know now if you would like your name submitted!

CRNA Educators: Volunteers are needed to serve as mentors.

Please refer to the brochure for complete details about the program. Simply email the Education department at to nominate a student and/or sign up as a mentor by December 10, 2018.
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Certified Registered Nurse Anesthetist: Anesthesia Associates of Lancaster – Lancaster, Pennsylvania

Anesthesia Associates of Lancaster, an independent medical practice, has openings for nurse anesthetists to join our clinical team at a surgery center in Lancaster, PA and an orthopedic specialty hospital and ambulatory surgery center in York, PA. The schedule is Monday - Friday, no call, no weekends, plus a $10,000 signing bonus. Learn more.
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BANNER UNIVERSITY MEDICAL GROUP (BUMG) is seeking a CRNA to join our team at Banner University Medical Center – Tucson (BUMC-T). You’ll be involved in clinical management of patients, performance of therapeutic and diagnostic procedures, interpretation of diagnostic tests, prescribing medications, patient education, consultation, and research. Must be able to work autonomously as well as part of an integral team of clinicians and physicians. Learn more.
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New CRNA Openings: $230,000 Base: Envision Physician Services – Tulsa, Oklahoma

Envision Physician Services is seeking CRNAs for this unique opportunity with Hillcrest Healthcare System. Learn more.
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Professor/Associate Professor of Anesthesiology: Barry University – Hollywood, Florida

Barry University, College of Nursing and Health Sciences, Anesthesiology Program is seeking a full-time faculty member for the Hollywood classroom with travel to four (4) other geographical classroom sites for the entry level DNP in Anesthesiology. This position would also involve teaching didactic courses in the Post-Master’s Doctor of Nursing Practice (DNP) with a Specialization in Anesthesiology. Learn more.
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CRNA Opportunity at Level I Trauma Center and Regional Referral Center: HSHS Medical Group – Springfield, Illinois

HSHS Medical Group is actively recruiting Certified Registered Nurse Anesthetists to join an existing team of 40 CRNAs at St. John’s Hospital in Springfield, IL. Practice in a setting that offers a wide variety of cases and procedures to include: General, Cardio-Thoracic, OB/ Pediatric/ NICU, Regional, Spinal, Epidurals, IV Regionals, CVP, PA Invasive Monitors and A-lines. 100% Medically Directed. Learn more.
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Chief Learning Officer: AANA – Park Ridge, Illinois

The AANA is recruiting for a gifted Chief Learning Officer. To be successful in this role, you must be chameleon-like with the ability to lead our Learning, Workforce and Practice Management programs and staff. This person must have an entrepreneurial spirit, and he/she will be empowered to be disruptive and visionary. Learn more.
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Certified Registered Nurse Anesthetists: Sanford Health – Fargo, North Dakota

Sanford Health Fargo Anesthesia Department is currently seeking Certified Registered Nurse Anesthetists (CRNA) to join its current group of 21 anesthesiologists and 72 CRNAs. Learn more.
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Check out the new AANA Career Center, CRNA Careers! Whether you’re a seasoned CRNA or just getting started, the new Career Center can connect you to the best opportunities.

Plus, there are robust search tools to help narrow your search, as well as tips for resume writing and salary negotiating. Add your resume and know that you can remain anonymous if you choose. Take advantage today!

Visit 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.

Thoracic Epidural Found Best for Analgesia Post-VATS Lobectomy

Although the search for a viable alternative continues, U.S. researchers say that, for now, thoracic epidural analgesia remains the gold standard for managing pain after thoracic surgery. The technique is effective but also comes with a risk of hypotension, urinary retention, and bleeding. A study out of the University of California, San Diego, had high hopes for liposomal bupivacaine as a substitute. Researchers manually extracted data for patients undergoing video-assisted thorascopic surgery (VATS) for lobectomy at the school's medical center between January 2014 and November 2017. A total of 31 people in the sample received thoracic epidural analgesia and 14 received surgical site infiltration with liposomal bupivacaine, each at the discretion of the surgeon who performed all 45 procedures. The results indicated significantly less opioid use during the first two days after surgery among patients who received thoracic epidural analgesia versus those who received surgical site infiltration. "In an effort to minimize unwanted side effects and complex management of thoracic epidurals, surgical site infiltration of liposomal bupivacaine has been suggested as a safe and effective alternative," said UC San Diego's Jacklynn Sztain, MD. "In this retrospective analysis, however, the patients consumed 43.4 percent less opioids on postoperative days 0 to 2 with a thoracic epidural compared to surgical site infiltration." Presenting the findings at the 2018 Joint World Congress on Regional Anesthesia and Pain Medicine and annual meeting of the American Society of Regional Anesthesia and Pain Medicine, Sztain said additional prospective, randomized studies are needed to validate her team's findings.

From "Thoracic Epidural Found Best for Analgesia Post-VATS Lobectomy"
Anesthesiology News (12/01/18) Vlessides, Michael

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Reversal of Deep Pipecuronium-Induced Neuromuscular Block With Moderate Versus Standard Dose of Sugammadex

Although 4 mg/kg of sugammadex is recommended for reversal of deep neuromuscular block induced with rocuronium or vecuronium, researchers believed half that amount would be effective for antagonism of deep block with pipecuronium. To investigate, they performed a single-site noninferiority study involving 50 participants randomly allocated to either 4 mg/kg or 2 mg/kg of sugammadex for recovery after general anesthesia with propofol, sevoflurane, fentanyl, and pipecuronium. The primary endpoint was reversal time, as defined by a normalized train-of-four (TOF) ratio of 0.9. Patients in the moderate-dose sugammadex group took 0.31 minutes longer to achieve the TOF target than did those in the standard-dose group; however, that was below the prespecified noninferiority threshold of 1 minute. Based on the results, the investigators from Hungary believe 2 mg/kg of sugammadex is effective for reversal of deep pipecuronium block.

From "Reversal of Deep Pipecuronium-Induced Neuromuscular Block With Moderate Versus Standard Dose of Sugammadex"
Anesthesia & Analgesia (12/18) Vol. 127, No. 6, P. 1344 Tassonyi, Edömér; Asztalos, László; Szabó-Maák, Zoltán; et al.

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Analgesic Efficacy and Safety of Morphine in the Procedural Pain in Premature Infants Study

A study out of the University of Oxford evaluated the safety and efficacy of oral morphine as analgesia for non-ventilated premature babies as they undergo acutely painful procedures. The analysis involved 30 infants at a single hospital who were subjected to heel pricks and retinopathy of prematurity screening examination. Half of the newborns were randomized to oral morphine sulfate before the procedures, which were carried out during the same session, and the other half were assigned to placebo. The primary outcomes were magnitude of noxious-evoked brain activity after heel lancing and Premature Infant Pain Profile-Revised (PIPP-R) score after retinopathy of prematurity screening. While the co-outcomes were not meaningfully different between groups, the investigators terminated trial recruitment due to serious adverse effects of a respiratory nature from the morphine. Given its potential for harm and seeming lack of analgesic efficacy, they recommend against oral morphine for the two procedures studies and call for extreme caution if the drug is considered for other acute painful procedures in non-ventilated premature neonates.

From "Analgesic Efficacy and Safety of Morphine in the Procedural Pain in Premature Infants Study"
The Lancet — The Lancet (11/30/18) Hartley, Caroline; Moultrie, Fiona; Hoskin, Amy; et al.

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Development and Validation of a Predictive Risk Factor Model for Epidural Re-siting in Women Undergoing Labour Epidural Analgesia

Investigators in Singapore built a predictive model for risk of epidural catheter re-siting during labor analgesia, a process that puts patients at higher risk for complications. They applied multivariate logistic regression analysis to 2014-2015 data from more than 7,400 epidural recipients at one women's hospital, 93 of whom needed to have their epidural catheter re-sited. The model identified increasing age, an increased incidence of breakthrough pain, a higher pain score after epidural catheter insertion, and setbacks such as venous puncture as risk factors for epidural re-siting. At the same time, spontaneous onset of labor was shown to protect against re-siting. The research team validated the predictive model internally with nearly 3,200 additional patients from 2014-2015, and then validated it externally with data gathered from more than 10,100 patients who underwent epidural analgesia at the same hospital in 2012 and 2013.

From "Development and Validation of a Predictive Risk Factor Model for Epidural Re-siting in Women Undergoing Labour Epidural Analgesia"
BMC Anesthesiology (11/29/18) Vol. 18, No. 176 Lee, John Song En; Sultana, Rehena; Han, Nian Lin Reena; et al.

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Audiovisual Distraction May Reduce Need for Supplemental Sedation

High levels of anxiety often require awake patients to be sedated during regional anesthesia, but new evidence suggests that using audiovisual devices as a distraction may curtail the need. The finding comes out of New York City, where investigators recruited 26 participants scheduled for ambulatory knee surgery under spinal anesthesia. The entire sample received minimal sedation with midazolam and, after randomization, 13 were also provided with video goggles and headphones so that they could watch content they had pre-selected. Patients were permitted to request more sedation at any time during the procedure. The results revealed no between-group difference in postoperative pain scores or satisfaction, anxiety levels, or demand for opioids or other analgesics. More patients in the control group requested additional sedatives, but the difference compared to goggle users was not meaningful. "We demonstrated that performing ambulatory knee surgery under regional anesthesia in awake patients is feasible both with and without the use of audiovisual devices," remarked study lead Luke Pichler, a research fellow at the Hospital for Special Surgery and NewYork-Presbyterian/Weill Cornell Medicine. "Then again, this was a pilot study, and it was not designed to demonstrate the superiority of audiovisual distraction. Therefore, future studies should use greater sample sizes to determine if audiovisual distraction can reduce the requirement for sedatives and improve postoperative outcomes." The findings were presented at the 2018 Joint World Congress on Regional Anesthesia and Pain Medicine and annual meeting of the American Society of Regional Anesthesia and Pain Medicine.

From "Audiovisual Distraction May Reduce Need for Supplemental Sedation"
Anesthesiology News (11/27/18) Vlessides, Michael

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Intranasal Ketamine Reduces Pain of Digital Nerve Block

Researchers in Iran say low-dose ketamine provides safe and effective analgesia for acute pain management in the emergency department (ED). The randomized trial included 100 patients at least 15 years of age who required digital nerve block (DNB). Patients were randomized to receive intranasal ketamine five minutes prior to block administration or placebo. While participants had similar visual analogue (VAS) scores at baseline, those who received ketamine experienced less pain after DNB and 45 minutes post-procedure, compared with those in the placebo group. Median block pain VAS scores were 28.5 and 47.5, respectively, for the ketamine and control groups, while median procedural pain VAS scores were 21.5 and 43.5, respectively. Adverse events, meanwhile, were few overall. The investigators say their results indicate that intranasal ketamine can curtail acute pain in ED patients without exposing them to serious side effects.

From "Intranasal Ketamine Reduces Pain of Digital Nerve Block"
The American Journal of Emergency Medicine (11/17/2018) Nejati, Amir; Jalili, Mohammad; Abbasi, Saeed; et al.

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News summaries © copyright 2018 SmithBucklin

Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed weekly 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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For more information on AANA and Anesthesia E-ssential, contact:

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Attn: Cathy Hodson
E–ssential Editor
December 6, 2018