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Vital Signs


AANA Election Slate Announced

The AANA Nominating Committee, after reviewing the nominations for elected positions for the upcoming election at its February meeting, has announced the slate of candidates for the 2016 election of the AANA Board of Directors and Nominating and Resolutions Committee members. Click here for the complete slate of candidates and further information about the upcoming elections. (Member login and password required.) The order of names was determined randomly on the ballot by the Nominating Committee. Those elected will begin their fiscal year 2017 terms of office at the conclusion of the AANA 2016 Nurse Anesthesia Annual Congress in Washington, D.C.
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CPC Facts


Two New Live Webinars: One for CRNAs on Feb. 16 and one for Program Administrators and Students on Feb. 17

Due to popular demand, a second Continued Professional Certification (CPC) Program webinar for CRNAs has been scheduled for Feb. 16 at 7 p.m. CST. Join the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA), along with panelist AANA Senior Director, Education and Professional Development Bruce Schoneboom, PhD, CRNA, FAAN, COL (Ret), USA, for this one-hour LIVE webinar to provide an overview of the CPC Program, identify what's new and what stays the same, as well as next steps for even-year, odd-year, and newly certified professionals. The session, which will include a Q&A session, will be recorded. (Open to the first 1,000 participants.) Register TODAY!

The previous live webinar for CRNAs, held Jan. 28, was recorded and can be watched at your convenience.

Another live Webinar for Program Administrators and Students will be presented on Feb. 17 at 11 a.m. CST. Program administrators are invited to register for that live webinar, which will also be recorded.

For more information about the NBCRNA's Continued Professional Certification (CPC) Program, which will launch on Aug. 1, 2016, go to the cpc-facts.aana.com and NBCRNA websites.
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Hot Topics


Members Welcome at Open Session of Upcoming AANA Board Meeting

The Board of Directors of the American Association of Nurse Anesthetists will be meeting in Open Session on Wednesday, Feb. 24, 2016, at Hyatt Regency San Antonio River Walk in San Antonio, Texas. The Board invites AANA members to audit the Open Session starting at 1 p.m.

The Open Session will be live audio streamed. Register to receive the audio information at the link below. All members are welcome either in person or listening to the audio stream. The preliminary agenda and background material are available on the members’ side of the website at
www.aana.com/myaana/AANABusiness/governance/Pages/Open-Sessi
on-Board-Meeting-Agendas.aspx
(member login required). Please contact mscheuermann@aana.com if you have any questions.
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Coming Soon: Online Video Chat with President Quintana

On Tuesday, Feb. 23, President Juan Quintana, DNP, MHS, CRNA, will be joined by AANA Senior Director, Federal Government Affairs, Frank Purcell, for "30 minutes with the President," the AANA’s 21st Century answer to Franklin Delano Roosevelt’s “Fireside Chats.” A maximum of 300 participants will be able access the online video chat session at

This session will focus on federal government-related issues, including full practice authority for CRNAS in the Veterans Health Administration, and implementation of Medicare Access & CHIP Reauthorization Act (MACRA) payment system changes. As in previous sessions, this "Fireside Chat" will feature two-way communication: Participants will be able to ask questions.

To participate, mark your calendar and make sure to visit the Fireside Chat webpage on Tuesday, the 23rd, at 7 p.m. CST.
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CRNA Recalls Operation to Save Dr. Martin Luther King, Jr., After Near-Fatal Stabbing

Most people of a certain age have vivid memories of the terrible day when Dr. Martin Luther King, Jr., was assassinated in Memphis on April 4, 1968. Few may remember that there was another attack on King’s life nearly 10 years earlier in New York City, where a mentally unstable woman stabbed him with a letter opener as he sat autographing copies of his first book, Stride Toward Freedom. AANA Past President Goldie Brangman, CRNA, who was on staff at Harlem Hospital where King was rushed for surgery on September 20, 1958, recalls the harrowing events of that day in a recent issue of the AANA Journal. To learn more, read the Imagining in Time column, “Goldie Brangman Remembers the Operation to Save Dr King,”co-written by nurse anesthesia historian Evan Koch, MSN, CRNA, and the AANA Press Release​ 
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Research and Quality Division Presents Health Services Research Webinar Series

The AANA Research and Quality Division has developed an educational series of live and prerecorded webinars in an effort to encourage more interest in both research development and aid in the proposal writing process. The next topic in the series will cover “what reviewers are looking for” in a grant proposal and will specifically address the AANA Foundation criteria. This webinar will be recorded and made available on the HSR Webinar Series webpage on Tuesday, Feb. 23, 2016. Previous recordings on “Conceptualizing a Study Design” and “Writing a Grant Proposal” are also available here (member login required).
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PQRSwizard to Present Four Webinars in February

To help AANA members become more familiar with the many features of PQRSwizard, CECity, the company that makes the software, is producing four webcast presentations in February. Registration links for all webcasts are available through the support page of your PQRSwizard website, and a live Q&A will accompany each session.It is a pivotal time to begin PQRSwizard registration. The end of the year will come quickly, and the penalties for non-participation are up to 6 percent. AANA members should be aware that CECity has extended data submission deadlines from Feb. 26 to March 18 at 5 p.m. ET.
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Nominations Sought for AANA Recognition Awards: Deadline March 15

The AANA is seeking nominations for the following recognition awards, to be presented at the Nurse Anesthesia Annual Congress: 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. Visit www.aana.com/awards for further information and to download a nomination form. The deadline for receipt of nomination is: March 15, 2016.
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Professional Practice


Joint Commission Releases 2015 Sentinel Event Data

In 2015, sentinel events reviewed by The Joint Commission increased to 936 from 764 in 2014. These sentinel events occurred in hospitals, ambulatory care, and other settings. The top 10 sentinel events included 111 wrong-patient, wrong-site, or wrong-procedure events (67 in 2014), 95 fall events (91 in 2014), 76 operative/postoperative complications (52 in 2014), and 42 perinatal death/injury events (32 in 2014). Anesthesia-related events decreased from six to five from 2014 to 2015. The most common root causes for anesthesia-related events from 2004 through 2015 included communication, assessment, human factors, anesthesia care, and leadership. For more detailed data analysis, read Summary Data of Sentinel Events Reviewed by The Joint Commission, Sentinel Event Data - Root Causes by Event Type 2004-15, Sentinel Event Data General Information 1995-2015, and Sentinel Event Data Event Type by Year 1995-2015.
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Joint Commission and CDC Partner on Ambulatory Infection Prevention

The Joint Commission and Centers for Disease Control and Prevention (CDC) are collaborating to create model infection control plans for ambulatory settings. This collaborative, which aims to enhance current infection prevention and control guidance for outpatient facilities, will also involve 12 ambulatory care-focused professional organizations and 10 ambulatory healthcare systems. This initiative is supported by the CDC Safety and Healthcare Epidemiology Prevention Research Development contract.
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Joint Commission releases 2016 National Patient Safety Goals

These 2016 goals, which The Joint Commission enforces, apply to Joint Commission-accredited hospitals, critical access hospitals, and ambulatory care and office-based surgery organizations. While there are no major substantive changes in the goals, it is helpful to review them every year. Goals that impact surgery and anesthesia include medication labeling, hand hygiene, prevention of surgical site infections, and the universal protocol for preventing wrong site, wrong procedure, and wrong patient surgery. Additional goals that specifically apply in hospital and critical access hospitals include measures to prevent central line-associated bloodstream infections and to improve the safety of clinical alarm systems.
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AAAHC 2015 Quality Report Lists Safe Injection Practices as a Common Deficiency

Accreditation Association for Ambulatory Health Care (AAAHC) released its Quality Roadmap 2015 – Accreditation Survey Results, which identifies and analyzes common accreditation deficiencies across various AAAHC-accredited facility types (ambulatory surgery centers, Medicare deemed status ASCs, office-based surgery facilities, and primary care settings). This report describes overall findings, including high compliance rates for treating patients with respect, consideration and dignity, and most common deficiencies, including safe injection practices, credentialing, privileging and peer review, quality improvement, and documentation. Like the AANA, AAAHC partners with the Centers for Disease Control and Prevention (CDC) in the One and Only Campaign to promote safe injection practices. Download AAAHC’s report here.
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State Government Affairs


Updated Background Resources Regarding Anesthesiologist Assistants

Are you looking for information about the current status of anesthesiologist assistant practice in the U.S.? For the latest information on anesthesiologist assistants, please visit the State Government Affairs’ Anesthesiologist Assistant information page to see the updated “Fact Sheet Regarding Anesthesiologist Assistants” and “CRNA-AA Comparison Table.”
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Meetings and Workshops


Register Now for Business of Anesthesia Conference

On June 24-25, join the AANA for a two-day conference on Chicago’s Magnificent Mile that will arm you with critical tools for navigating the business aspects of anesthesia practice. Get real-world advice from expert speakers with experience in building and maintaining a successful practice. Get the details and register here.
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Save the Dates for These Popular Hands-On Workshops

Visit www.aana.com/meetings for further information and to register!

Jack Neary Pain Management Workshop
  • Rosemont, IL
  • April 23-25, 2016
Jack Neary Pain Management Workshop II
  • Rosemont, IL
  • October 29-30, 2016
Upper and Lower Extremity Nerve Block Workshop
  • AANA Foundation Learning Center
  • March 19-20, 2016
  • September 24-25, 2016
Essentials of Obstetric Analgesia/Anesthesia Workshop
  • AANA Foundation Learning Center
  • April 20, 2016
  • November 2, 2016
Spinal and Epidural Workshop
  • AANA Foundation Learning Center
  • April 21-23, 2016
  • November 3-5, 2016
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Foundation and Research


Register Today for Foundation ASF Opportunities

If you’re planning to attend the AANA Assembly of School Faculty (ASF) meeting in February, you won’t want to miss the AANA Foundation events:

February Fiesta on the Riverwalk
Thursday, February 25, 7 p.m.
LaPaloma Riverwalk

Research Forum titled “Impactful Research – Are you in? (2 CEs)
Friday, February 26, 12:15 p.m.
Morton’s Steakhouse

Visit the AANA ASF registration page to learn more and purchase tickets for these events when you register for the meeting. If you’ve already registered for ASF and would like to purchase tickets, please contact Margaret Brennan, AANA Registrar, at (847) 655-1180.

If you have any questions, please contact Luanne Irvin, AANA Foundation Development Officer, at (847) 655-1173. Thank you.
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Student Advocate Opportunity Applications Due March 1

In 2015 the AANA Foundation piloted the Student Advocate program with 10 students representing 10 nurse anesthesia programs across the country. We are now expanding the program and looking for one Student Advocate per state.

Benefits of the Student Advocate program include networking opportunities with CRNAs and students outside of those in your current program, professional involvement, leadership, Foundation board mentors at Annual Congress, special recognition at AANA meetings, invitations to special receptions, and tickets to Foundation events to help out when needed.

Student Advocate responsibilities include making a Foundation presentation to your fellow students with materials provided, attending AANA meetings (when possible), and acting as a liaison in communicating information between the Foundation and your classmates.

Learn more and access the application at www.aanafoundation.com. Contact Luanne Irvin at (847) 655-1173 or lirvin@aana.com if you have any questions.
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Student Scholarship Applications Due March 1

Applications for nurse anesthesia student scholarships are available online and range from $1,000 to $3,000 each. In order to apply for a scholarship, you must be enrolled in a program for at least six months prior to March 1, 2016. Click here to access the Student Scholarship Application webpage on the AANA Foundation website at www.aanafoundation.com. Please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com if you have any questions.
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“State of the Science” Oral and General Poster Presentation Applications Now Available

“State of the Science” offers an opportunity for CRNAs and SRNAs to present their research findings and innovative educational approaches at the AANA Nurse Anesthesia Annual Congress in Washington, D.C., Sept. 9-13, 2016. Research, literature reviews, and innovative, creative techniques in anesthesia are appropriate topics. Click here to access the applications which are currently available on the AANA Foundation website at www.aanafoundation.com.
  • Oral Poster Presentation – April 1 Deadline – An award of up to $1,000 accompanies oral presentation
  • General Poster Presentation – May 1 Deadline
If you have any questions, please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.
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Federal Government Affairs


VHA Full Practice Authority Issue Rundown

Here is the current update on our issue of expanding veterans access to care through full practice authority for VHA CRNAs and APRNs:
  • On Jan. 8 the Secretary of Veterans Affairs submitted a proposed rule to the White House Office of Management and Budget (OMB) for review and publication in the Federal Register. The OMB has 90 days to either publish it in the Federal Register, triggering a 60-day public comment period, or return it to the VHA for more work. The AANA is encouraging members to make their voice heard and pre-submit a comment in favor of expanding veterans access to care through CRNA and APRN full practice authority, click here (requires AANA member login and password). To encourage colleagues, family, friends and veterans to support veterans access to care, click www.Veterans-Access-To-Care.com.
  • Bipartisan legislation is pending in Congress supporting expanding veterans access to care through full practice authority for CRNAs and other APRNs in the VHA. In the U.S. House of Representatives, HR 1247 (Graves-Schakowsky) has 45 cosponsors. In the Senate, S 2279 (Merkley-Rounds) has eight cosponsors. After pre-submitting a comment, AANA members should use this link (requires AANA member login and password) to follow up and contact their members of Congress.
  • Our advocacy plans include engaging our state associations of nurse anesthetists to take action. Federal Political Directors and State Presidents should have our detailed action packet.
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VHA Full Practice Issue 101: What Do These Key Terms Mean?

The procedural issues involved in the VHA expanding veterans access to care by granting full practice authority to CRNAs and other APRNs can be confusing. The Secretary of veterans Affairs has proposed a rule now under review at the White House Office of Management and Budget. Legislation is pending in Congress. How does it all fit together?

If Congress passes the laws, what gives agencies the authority to issue regulations? Laws (statutes) enacted by Congress give agencies like VHA their authority to issue regulations. In some cases, the president may delegate existing presidential authority to an agency. An agency must not take action that goes beyond its statutory authority or violates the Constitution. Agencies must follow an open public process when they issue regulations. This process, the Administrative Procedure Act (APA), includes publishing a statement of rulemaking authority in the Federal Register for all proposed and final rules.

Why does the VHA full practice authority issue need sign-off from the OMB? Currently, the proposal to grant APRNs in the VHA with full practice authority is under review by the White House Office of Management and Budget (OMB). This step allows administration officials to analyze draft proposed rules to ensure their consistency with the law and administration policy before they are published in the Federal Register.

So what’s the next step after the OMB? Once OMB clears the proposal, the VHA publishes it in the Federal Register as a Notice of Proposed Rulemaking (NPRM), an official document that announces and explains the agency’s plan to address a problem or accomplish a goal. All proposed rules must be published in the Federal Register, a daily publication of the U.S. government, to notify the public and provide an opportunity to submit comments.

And my input is needed during a “comment period?” Yes, your voice has a very important role in this process! An NPRM published in the Federal Register specifies a period during which it will accept comments from the public. Comments provide the agency additional information on the public’s views and how the policy will impact various stakeholders.

What happens when the comment period is over? The agency will evaluate the public comments and any other information accumulated during the pre?rule and proposed rule stages. To move forward with a final rule, the agency must conclude that its proposed solution will help accomplish the goals or solve the problems identified. It must also consider whether alternative solutions would be more effective or cost less. If the rulemaking record contains persuasive new data or policy arguments, or poses difficult questions or criticisms, the agency may decide to delay or terminate the rulemaking. But if after this analysis period the agency decides to finalize the rule, it is published in the Federal Register as a final rule—a law with an effective date that is usually 30-60 days after its publication.

Why is there also legislation pending in Congress on this issue? Members of Congress concerned with promoting solutions that improve veterans access to healthcare have introduced S 2279 and HR 1247 with the support of AANA. The VHA has the authority it needs to propose and finalize a regulation expanding veterans access to care through full practice authority for CRNAs and other APRNs. In Congress, the legislation demonstrates support for the overall policy of APRN full practice authority in the VHA and provides legislators a platform to communicate that support on Capitol Hill.
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Administration Releases 2017 Budget Proposal

The administration released its 2017 federal budget proposal on Feb. 9, calling for continued implementation of the Affordable Care Act and level funding for the healthcare workforce programs that include Title 8, of interest to CRNAs and educators.

A $1.1 billion initiative to address the opioid abuse epidemic was also included in the budget proposal.

Overall, the budget was greeted skeptically by Republican congressional leaders. They are making plans to move a 2017 budget resolution that hews to the 2015 two-year budget agreement, rendering further funding increases unlikely.

Additional information will be provided shortly as the AANA’s analysis continues. To see the budget proposal, go to www.whitehouse.gov/omb/. To see information about the administration’s opioid epidemic proposal, see
https://www.whitehouse.gov/blog/2016/02/01/preventing-epidem
ic-opioid-abuse-and-heroin-use
.
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Medicare Releases Draft Quality Measure Development Plan Affecting Future CRNA Payments; AANA Developing Comments

Medicare in December released a draft quality measure development plan that will serve as a strategic framework for the future of clinician quality measure development—including measures and payment incentives for CRNAs. The AANA has been reviewing the proposal and developing a response in advance of a March 1 deadline.

The plan will support the development of the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Adopted last spring, MACRA establishes new quality measure and reporting systems and sunsets the Physician Quality Reporting System (PQRS); Value-based Payment Modifier (VBM); and Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals.

The new CMS Quality Measure Development Plan outlines how existing measurement strategies, policies, and principles will guide the agency’s efforts in building measure portfolios for MIPS and APMs. According to CMS, future measure development will prioritize person- and caregiver-centered experience of care, patient-reported outcomes and patient health outcomes, communication and care coordination, and appropriate use of resources across six quality domains. Those six domains are clinical care, safety, care coordination, patient and caregiver experience, population health and prevention and efficiency and cost reduction. The agency will review and consider all comments as it develops its final Measure Development Plan, by May 1, 2016.

View the draft CMS Quality Measure Development Plan here.
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Novitas Medicare Issues Problematic Draft Local Coverage Determination on Lumbar Epidural Injections

The Medicare Administrative Contractor (MAC) Novitas Solutions has issued a draft local coverage determination (LCD) that would limit coverage of CRNA lumbar epidural injection pain management services in 12 states where Novitas administers the Medicare program. The AANA is reviewing the proposals and preparing a response to protect patient access to care provided by CRNAs.

Novitas’ draft LCD affects Medicare coverage in the following states: Arkansas, Colorado, Delaware, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, Texas, and the District of Columbia. Comments to Novitas are due on March 10. Members with any questions or comments regarding this LCD are invited to contact AANA DC at info@aanadc.com and include the words “Novitas LCD” in the subject line.

To read the Novitas Medicare draft LCD on lumbar epidural injections, see here.
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Renew Your Commitment to Keeping the CRNA Voice Strong

With the goal of raising $1.8 million this 2015-16 election cycle to keep the voice of CRNAs strong in Washington, protect and advance CRNA practice, and fight off anti-CRNA attacks, the CRNA-PAC is reaching out to past donors to the PAC in hopes of renewing their support this year.

Chaired by Angela Mund, DNP, CRNA, the CRNA-PAC Committee is working to increase contributions to the PAC, encourage past contributors to continue support, and to boost the number of members who are giving to the CRNA-PAC—the only PAC that supports CRNA patients and practice 24/7 in Washington, D.C. In the past two-year election cycle, the CRNA-PAC had a $1.6 million impact on the national elections, and 90 percent of the candidates the PAC supported won their 2014 elections. However, in that same cycle the ASA PAC raised and spent $5 million. To approach that level, the CRNA-PAC must renew its existing donors and reach out to AANA members to be new donors.

Learn more and donate today by clicking www.CRNA-PAC.com (requires AANA member login and password).
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We Want to Hear from CRNAs Active in Early Voting States

The AANA encourages CRNAs to vote and to be active in primary elections this winter and spring in support of candidates of their choice. If you are involved in one of the following early primary or caucus campaigns below, AANA D.C. would be delighted to hear from you. Tell your story or send your pictures to info@aanadc.com with “CRNAs in Campaigns” in the subject line.
  • Feb. 20, Nevada Democratic presidential caucus, South Carolina Republican presidential primary, and Washington state Republican presidential caucus.
  • Feb. 23, Nevada Republican presidential caucus.
  • Feb. 27, South Carolina Democratic presidential primary.
  • March 1, presidential primaries in Alabama, Arkansas, Georgia, Oklahoma, Tennessee, Texas, Vermont and Virginia. Presidential caucuses in Alaska (Republicans only), American Samoa (Democrats only), Colorado and Minnesota. Congressional primaries in Arkansas, Alabama, and Texas.
For an up-to-date list of all U.S. 2016 election dates by state and by date, see this.
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Book Your Meeting, Hotel and Travel Now for Mid-Year Assembly 2016 in Downtown Washington, D.C.

The AANA Mid-Year Assembly, to be held April 2-6, 2016, returns to downtown Washington, D.C.! But because our site and our dates coincide with additional major events in the nation’s capital—namely the 2016 Cherry Blossom Festival and parade—AANA members are encouraged to register and book their lodgings and air travel as early as possible.

Everything you need to register for Mid-Year Assembly 2016 is here.
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What a CRNA Week!

As AANA members recognized National CRNA Week Jan. 23-29, the profession of nurse anesthesia drew national recognition.


USNews
recognized our profession as the No. 3 healthcare job in the U.S. for 2016, and No. 4 among all jobs in the U.S., citing CRNA quality and cost-effectiveness – and an estimated 19 percent job growth by 2024. See http://money.usnews.com/careers/best-jobs/nurse-anesthetist.



StatInitiative, a project of influential U.S. Rep. Michael Burgess MD (R-TX) to bring attention to critical health policy issues, recognized CRNA week online.
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Amendments

  • The Veterans Affairs Commission on Care met Feb. 8-9, in Washington, to continue considering options for the agency’s future. To learn more, see https://commissiononcare.sites.usa.gov/ and see its December 2015 interim report to the president here.
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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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Jobs


Visit www.crnacareers.com to view or place job postings
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Featured Career Opportunity

CRNA Faculty Positions – University of Pittsburgh – School of Nursing Pittsburgh, PA

Join the top-ranked Nurse Anesthesia Program at the University of Pittsburgh School of Nursing. We’re looking to fill a full-time, tenure-stream position with research and teaching responsibilities.

Read more about this position
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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.

New Study Highlights Risks of Combining Benzodiazepines and Opioids

The risk of overdose from taking narcotic painkillers at the same time as benzodiazepines is four times the risk from taking opioids by themselves, according to new research. The study used VA documentation and the National Death Index to identify 422,786 veterans prescribed opioids for nonterminal cancer pain, about a quarter of whom also were on benzodiazepines. Approximately 2,400 people in the study sample suffered a fatal overdose, and about half of them were patients taking both drugs. "If you are going to prescribe benzodiazepines [to people on analgesic opioids], you should understand that there may be an increased risk of overdose, and you should consider what disorder you are attempting to treat," said co-investigator Tae Woo Park, MD. "Typically, benzodiazepines are prescribed for anxiety disorders and insomnia, and these are pretty common in patients with pain problems. You want to ensure that you are prescribing in an evidence-based manner, and carefully weigh the risks and benefits of treatment." Park also identified high opioid doses, a history of mental health and/or substance abuse problems, and having more than one doctor prescribing opioids or more than one pharmacy filling them as other warning signs of high risk for overdose.

From "New Study Highlights Risks of Combining Benzodiazepines and Opioids"
Pain Medicine News (02/10/2016) Holzman, David C.

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New Study Proposes Strategies for Pain Control After Total Knee Replacement

Patient-controlled analgesia (PCA), the standard of care following total knee replacement, has been improved upon with multimodal pain management strategies. While PCA can trigger constipation, nausea, vomiting, low blood pressure, and other side effects, the new approach is more effective and causes fewer adverse events. Practitioners use a combination of medications before and after the operation, regional anesthesia with preoperative nerve block, and intraoperative pain injections to achieve optimal patient outcomes. According to a literature review, reported in the Journal of the American Academy of Orthopaedic Surgeons, the modern protocol reduces pain severity in the first few days after surgery, curtails postoperative opioid consumption, mitigates negative outcomes common with traditional pain regimens, gets patients moving sooner, and enhances patient satisfaction.

From "New Study Proposes Strategies for Pain Control After Total Knee Replacement"
Monthly Prescribing Reference (02/16)

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Restricting Ketamine Would Have 'Dire Consequences' for Surgery in Low-Resource Countries, Anesthesiologists Warn

Although ketamine poses a risk for dependency and has earned a reputation as an illegal recreational drug, the United Nations Commission on Narcotic Drugs rejected a proposal to reclassify it under Schedule I. Writing in Anesthesia & Analgesia, several doctors warned that such a move would have deeply and negatively affected low- to middle-income countries. Because it is affordable, readily available, and requires little equipment and training to administer, they noted, ketamine is critically important in areas of the world where modern technology is scarce or nonexistent. Indeed, it often is the only general anesthesia drug in resource-poor markets; and reducing its availability by labeling it as a Schedule I substance would have seriously jeopardized the ability to perform surgery in those countries. Many in the medical community are relieved that regulators declined to reclassify ketamine, but they remain on alert for future campaigns along the same vein.

From "Restricting Ketamine Would Have 'Dire Consequences' for Surgery in Low-Resource Countries, Anesthesiologists Warn"
Newswise (02/08/16)

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U.S. Veterans: Meditation May Help With Chronic Pain Management

New research demonstrates the benefits of mindfulness meditation for the millions of Iraq and Afghanistan veterans suffering from musculoskeletal and other types of pain. The pilot study involved nine male subjects, all of whom returned from combat duty with chronic pain and traumatic brain injury. Four of the men received Integrative Restoration Yoga Nidra, or iRest, first attending institutional sessions and then ultimately continuing the practice on their own. By the end of eight weeks, they had built skills allowing them to use meditation to manage their pain. Pain intensity declined by 20 percent; and pain had less effect on their quality of life—including mood, sleep, and activity level. "Meditation allows a person to accept pain and to respond to pain with less stress and emotional reactivity," explained Thomas Nassif, PhD, a researcher at the Veterans Affairs Medical Center in Washington, D.C. "Our theory is that this process increases coping skills, which in turn can help veterans to self-manage their pain." He added that meditation is promising as an alternative to opioids, which many veterans consider only a short-term solution. The study is reported in Military Behavioral Health.

From "U.S. Veterans: Meditation May Help With Chronic Pain Management"
Science World Report (02/06/16) Lees, Kathleen

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New Opioid Use High Among Older Adults With COPD

Canadian researchers have documented a disturbing trend of new opioid use—and, potentially, overuse—among patients with chronic obstructive pulmonary disease (COPD) living in elder care settings. From 2003 to 2012, they tracked 107,109 community-dwelling residents and 16,207 long-term-care residents with the respiratory condition. More than 68 percent of the former and more than 54 percent of the latter were given an incident opioid drug over the study time frame. Patterns of new opioid use raised concerns about the potential for multiple opioid dispensing, use for longer than 30 days, second dispensing, and refilling prescriptions early. Although health care providers might be prescribing narcotic painkillers as part of multimodal analgesic therapy to treat chronic musculoskeletal pain—a common complication in COPD patients—the investigators say the literature offers little evidence to support including opioids in this approach. They conclude that more study is needed to evaluate potential respiratory-related health problems associated with opioid use among seniors with COPD.

From "New Opioid Use High Among Older Adults With COPD"
AJMC.com (02/05/16) Syrop, Jackie

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Tiny Doses of Opioid Could Be First Fast Anti-Suicide Drug

With millions of Americans either committing suicide each year or contemplating it, there are high hopes for what could become the first rapid-onset anti-suicide drug. Early evidence suggests that buprenorphine, an opioid analgesic, can curb suicidal thoughts in as little as a week. "Converging lines of evidence point to a connection between mental pain, depression, suicidal ideation and the body's natural opioids," notes Washington State University's Jaak Panksepp, who spearheaded a study of severely suicidal individuals. Participants took either very low doses of buprenorphine or a placebo. Scoring 20 on average on a psychiatric questionnaire at the start of the trial—which categorized suicidal thoughts as severe enough to warrant hospitalization—readings fell by 6 points on average after a week for the buprenorphine patients. At the conclusion of the study after a month, their scores were down nearly 10 points on average, to a level that might not necessarily call for hospitalization. Panksepp believes the fast-acting effect could be accelerated with higher doses; and, although there are risks associated with increasing the dosage, buprenorphine is not as problematic as other opioid analgesics. Ketamine, for example, has been effective in treating depression; but it can trigger hallucinations and its effects can quickly fade.

From "Tiny Doses of Opioid Could Be First Fast Anti-Suicide Drug"
New Scientist (02/04/16) Locklear, Mallory

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Califf, FDA Top Officials Call for Sweeping Review of Agency Opioids Policies

In response to the opioid abuse epidemic, Robert Califf, MD, FDA’s Deputy Commissioner for Medical Products and Tobacco, along with other FDA leaders, has called for a far-reaching action plan to reassess the agency’s approach to opioid medications. The plan will focus on policies aimed at reversing the epidemic, while still providing patients in pain access to effective relief. The FDA will re-examine the risk-benefit paradigm for opioids and ensure that the agency considers their wider public health effects. The agency will also convene an expert advisory committee before approving any new drug application for an opioid that does not have abuse-deterrent properties. It will assemble and consult with the Pediatric Advisory Committee regarding a framework for pediatric opioid labeling before any new labeling is approved. FDA will also develop changes to immediate-release opioid labeling, including additional warnings and safety information that incorporate elements similar to the extended-release/long-acting opioid analgesics labeling that is currently required. Additionally, it plans to improve access to naloxone and medication-assisted treatment options for patients with opioid use disorders. "We are determined to help defeat this epidemic through a science-based and continuously evolving approach," said Califf. "This plan contains real measures this agency can take to make a difference in the lives of so many people who are struggling under the weight of this terrible crisis."

From "Califf, FDA Top Officials Call for Sweeping Review of Agency Opioids Policies"
FDA News Release (02/04/16)

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Safety Scale Spotlights Oversedation and Respiratory Depression

The newly created Michigan Opioid Safety Score (MOSS) can guide nurses toward better analgesic choices, bolstering patient safety in the process, report researchers who analyzed it. The tool measures health risk and respiratory rate, producing a point total that is categorized as safe, concern, or caution to help dictate the next clinical step. A third gauge, the modified Pasero Opioid-Induced Sedation Scale, is a fail-safe that stipulates no additional narcotic analgesic for patients who are in overly sedated state or cannot be woken up. More opioids could trigger adverse events, such as respiratory depression, for these individuals. A total of 53 orthopedic surgical floor nurses completed an online assessment of MOSS, with favorable results. "We found with regard to reception that neutral-to-favorable responses were above 75 percent for ease of use, efficiency of time, impact on patient safety and improved confidence in opioid therapy," said researcher Brandon Yaldou, MD. He noted that using pain scales alone for evaluation can cause oversedation but they do still have a role. For example, "the VAS [visual analog scale] would still be used to determine the patient's level of pain," he explained, "[and] the MOSS would be utilized to determine what to do thereafter."

From "Safety Scale Spotlights Oversedation and Respiratory Depression"
Anesthesiology News (02/03/16) Vlessides, Michael

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Onetime Party Drug Hailed as Miracle for Treating Severe Depression

Ketamine—commonly stocked in emergency rooms for anesthetic purposes but also abused as a club "party favor" and date rape drug—is raising hope for people with severe depression. Research confirms its strong antidepressant effect as well as its ability to dissolve suicidal thoughts in minutes or hours, compared with the weeks or months needed for traditional mood stabilizers and antidepressants to kick in. The relief only lasts about a week after patients receive a single infusion. Even so, experts are hailing ketamine's newfound role in treating depression as the top mental health finding in decades. The American Psychiatric Association expects to support ketamine treatment for severe depression this year and has commissioned a task force to codify the protocol for how and when to administer the drug. In the meantime, ketamine clinics are arriving in big cities to provide booster infusions that help patients avoid relapse. They typically are run by anesthesia providers or psychiatrists, creating somewhat of a gray area. "Most anesthesiologists don't do mental health," concedes Portland anesthesia provider Enrique Abreu, who has been using ketamine to treat depression since 2012, "and there's no way a psychiatrist feels comfortable putting an IV in someone's arm."

From "Onetime Party Drug Hailed as Miracle for Treating Severe Depression"
Washington Post (02/01/16) Solovitch, Sara

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New Tool for Predicting Respiratory Adverse Events in the PACU

Pulse oximetry is typically used to detect respiratory distress in the post-anesthesia care unit (PACU), but researchers say providers should also check for end-tidal carbon dioxide (CO2). Led by Hiroshi Morimatsu, MD, PhD, of Okayama University Hospital in Japan, the study recommends using the Integrated Pulmonary Index (IPI) to monitor patients after surgery. Morimatsu and colleagues used the 10-point scale—which combines end-tidal CO2, respiratory rate, and pulse rate—to predict apnea, hypoxia, and other problems. A total of 163 patients at elevated risk for hypoventilation were included, 11 of whom experienced a respiratory adverse event (RAE). The report noted that those patients had lower initial IPI scores and oxygen saturation readings from pulse oximetry than those who did not suffer an RAE; and they also spent almost twice as long in the PACU. According to Morimatsu, the IPI is more effective than pulse oximetry by itself because it is more sensitive and more specific. Although more research is needed, he says a close eye should be kept any patient with an IPI score below seven.

From "New Tool for Predicting Respiratory Adverse Events in the PACU"
Anesthesiology News (01/28/16)

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Health Brief: Propofol Appears Safe for Procedural Sedation in Older Teens

Emergency department personnel often administer ketamine for procedural sedation of young patients, but analysis suggests that children older than 13 years are more likely to experience adverse respiratory and airway events with this anesthetic agent. New research published in Pediatric Emergency Care indicates that propofol, which works faster and also wears off more quickly than ketamine, is a safe option for older teenagers in this setting. The retrospective study looked at more than 4,000 patients, comparing rates of hypotension and hypoxia in those 16–19 years old against those in the 20–65 age range and those older than 65 years. The investigators support the use of propofol in patients older than 16 years, finding that they can tolerate larger doses of the anesthetic than adults yet experience fewer negative outcomes.

From "Health Brief: Propofol Appears Safe for Procedural Sedation in Older Teens"
AAP News (01/16) Kemp, Carla

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Pain Sufferers Risking Overdoses, National Survey Finds

As many as 100 million Americans suffer from chronic pain, by one estimate, but recent survey results show that many face additional health problems because they misuse over-the-counter drugs. Failure to take medication as directed can lead to overdose—which subsequently can cause internal bleeding, organ damage, and even death. The finding comes from the American Gastroenterological Association (AGA), which commissioned the Harris Poll online query of about 250 doctors within the specialty and about 1,000 adults aged 30 years or older. The "Gut Check: Know Your Medicine" responses indicate that too many people with chronic pain deliberately take more of an OTC drug than recommended, and for a longer duration. Many dismiss warning labels as mere guidelines; and many also do not realize the potentially serious consequences from combining two or more NSAIDs or two or more acetaminophen products when taking OTC pain medications. AGA advises OTC drug users to adhere to medicine labels, take only one product at a time with the same kind of ingredient, and disclose all medications to health care providers.

From "Pain Sufferers Risking Overdoses, National Survey Finds"
American Gastroenterological Association (01/25/16)

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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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