Anesthesia E-ssential

AANA Anesthesia E-ssential, January 31, 2019
 
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CRNAdvocacy Alert: Join our Grassroots Efforts on HHS Pain Management Task Force

On Tuesday, Jan. 14, AANA President Garry Brydges, DNP, MBA, CRNA, ACNP-BC, FAAN, sent an email to members asking for your help with our grassroots efforts.

The Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force recently released a draft version of its report "Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations.”

The AANA supports the draft report’s recommendation to expand the availability of non-physician pain specialists. However, we are gravely concerned that another recommendation in the report for credentialing and training requirements limits the pathways available for non-physician practitioners, such as CRNAs, to provide interventional pain procedures.

The draft report, which is available online, is available for open comment until April 1, 2019. We urge you, your friends, and even patients to submit a comment asking HHS not to adopt these recommendations as drafted and request that the credentialing and training requirements be amended to be inclusive of all types of practitioners and their educational pathways.

Please follow these instructions to contact HHS today:
  1. Login to https://crna-pac.com/composeletters/2883 with your AANA username and password.
  2. You will be directed to a sample letter that you can personalize and send.
  3. Click “send letter” to have your letter posted to the comment site. Please note that all comments are public.

Non-AANA members can submit comments here through regulations.gov website. If you have any questions, please don’t hesitate to contact AANA Federal Government Affairs at info@aanadc.com or 202-484-8400.
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In Appreciation

It's been a tough weather week for those in the nation's middle and northern states due to the polar vortex, but this appreciation extends to all of our members who go into work and keep our patients safe every day. You may or may not hear an appreciation from your employer, co-workers or facility, but you are hearing it from the American Association of Nurse Anesthetists today.

Thank you!

To all of our CRNAs and SRNAs who brave weather challenges, natural disasters, war, rural and urban environments, and third-world countries - for all you do, for all you are, we thank you. #WeAreThere
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Hot Topics


AANA Submits Comments to FDA Regarding Anesthesia Drug Shortages

Correction: The date of submission was incorrectly reported in a previous issue of Anesthesia E-ssential. We are re-running the item with the correct submission date below:

On Jan. 11, 2019, the AANA submitted a comment letter to the FDA regarding drug shortages' impact on anesthesia care and proposed solutions. The letter describes CRNAs' experience with drug shortages, including clinical impacts on patients. These impacts include, but are not limited to, drug rationing and less effective care, increased risk of medication error due to new medication protocols, and increased side effects, complications and mortality due to drug substitutions. The letter also addressed economic impacts of the drug shortage crisis, methods CRNAs use to mitigate drug shortages, and potential strategies and policies to help alleviate the persistent drug shortage problem. The letter also emphasized the AANA’s commitment to collaborating with the FDA, other healthcare associations, and industry to mitigate and resolve this complex problem that undermines patient safety.
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The Joint Commission Issues Safety Alert on De-escalation in Health Care

The Joint Commission’s Quick Safety 47: De-escalation in health care describes de-escalation models and interventions for managing aggressive and agitated patients in inpatient settings, noting that there is no guidance on the gold standard for practice. De-escalation strategies include communication, self-regulation, assessment, actions, and safety maintenance in order to decrease risk of harm to patients and caregivers and the use of restraints or seclusion. The Quick Safety lists tools to assess the aggressive patient, models to de-escalate aggression, and resources on workplace violence. Interventions to de-escalate aggression include:
  • Educate staff about de-escalation techniques
  • Practice de-escalation skills and techniques with staff
  • Use risk assessment tools for early detection and intervention
  • Verbally communicate calmly and clearly with the patient
  • Use nonconfrontational language
  • Avoid abbreviations or health-care terms
  • Use non-threatening body language
  • Approach the patient with respect and support
  • Respond to the patient’s expressed problems or conditions, which will help build trust
  • Set clear limits for the patient to follow
  • Implement environmental controls, including minimizing lighting, noise and loud conversations

The Quick Safety also lists actions that healthcare organization leadership can take to support staff de-escalation efforts and refers to Sentinel Event Alert 59, “Physical and verbal violence against health care workers,” for actions to take if violence occurs.
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AANA Member Benefits


Nationwide
How to Lower Your Bills

Here's how to lower your monthly bills to help you save money.


January Lower Bills
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Jobs


Assistant Director, Certified Registered Nurse Anesthetist Program: Marian University, Indianapolis, Indiana

The Leighton School of Nursing at Marian University in Indianapolis seeks a dynamic and innovative leader to serve as the Assistant Program Director for the Certified Registered Nurse Anesthesia Program. The Assistant Program Director assists the Program Director in the daily operations of the Doctoral of Nursing Practice in Nurse Anesthesia Program and assists in assuring compliance with the Council on Accreditation of Nurse Anesthesia Educational Program’s Standards and Guidelines. 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. The new mantra for the AANA is "experiment, fail, learn, and repeat," and we'll need someone comfortable working in that kind of environment. Learn more.
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CRNACareers

Kick-start the new year and give your career a reboot with updates and new resources via the AANA official career center, CRNA Careers. Here are the top three features to check out:

  1. Career Resources: The turn of the year is the perfect time to catch up on industry news or read tips about advancing your career. The AANA Career Center is a great resource, whether you're looking for industry updates or available positions.
  2. Location Radius Job Search: Searching for a job can be time-consuming. Now when entering a job search location, you will be presented with matching locations to autocomplete your search. You can also choose a specified mile radius from which to pull open jobs.
  3. Job Alert Quick Create: When searching for a job on CRNA Careers, you can also create a job alert. In one easy step, you can search for a job and be alerted when a job you're interested in becomes available.


Wishing you career success and a happy 2019! Get started today!


 

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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.

Balancing the Risks and Benefits of Opioids for Children

Parents fear their child could become addicted to opioids after an injury or surgery, yet they still believe that narcotic analgesics are the best pain relief under these circumstances, according to a new survey. The American Society of Anesthesiologists polled more than 1,000 parents, more than half of whom expressed anxiety about the potential for dependency but nearly two-thirds of whom thought opioids were the most effective option. Experts in pediatric pain acknowledge the benefits of opioid pain management and say that, when used appropriately, the drugs do not pose a threat of addiction. However, parents should know that alternatives are available, including local or regional anesthesia, if the child is not in unbearable pain. In the case of kids who are seriously ill or suffering from terrible pain, specialists say opioids should be used to deliver relief; but then the patient should be stepped down to a different pain management approach as soon as feasible. Parents should discuss their options with doctors and, when opioids are part of the care plan, understand how to safely store the medications and dispose of any leftover doses.

From "Balancing the Risks and Benefits of Opioids for Children"
New York Times (01/28/19) Klass, Perri

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Protocol Reduces Opioid Use in Spinal Surgery Patients

Researchers at Penn Medicine are lauding the opioid-sparing benefits of "Enhanced Recovery After Surgery" (ERAS), after conducting a prospective study of the approach in spine operations. The trial compared outcomes in 74 patients who received standard surgical care for a spine or peripheral nerve surgery in late 2016 with those of 201 patients who underwent the ERAS protocol for their procedures the following spring. While more than 50 percent of the control patients needed intravenous opioids, delivered via a pain pump, patient-controlled analgesia (PCA) use was nearly eliminated in the ERAS group. One month post-surgery, meanwhile, only 38 percent of ERAS patients were still taking opioids versus 53 percent of controls. Because pain scores between the two cohorts were comparable, the researchers determined that PCA was not needed in this setting and that the ERAS protocol—which uses both opioid and non-narcotic medications—provided sufficient pain management. The findings represent the first successful use of ERAS in neurology, although the regimen has been effective for orthopedic, urologic, and colorectal procedures. "This approach may have profound implications in limiting the risk of chronic opioid dependency in patients following spine surgery," says lead investigator and study author Zarina Ali, MD. The study report appears in the Journal of Neurosurgery: Spine.

From "Protocol Reduces Opioid Use in Spinal Surgery Patients"
ScienceDaily (01/25/19)

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Comparable Analgesia With Low-Dose IV Ketamine, Morphine for Acute Pain

The results of a systematic review suggest that low-dose intravenous ketamine may relieve acute pain more quickly than IV morphine in the emergency department (ED) setting. Researchers analyzed results from three relevant randomized trials and a collective 261 enrollees presenting to the ED with acute pain lasting at least one week. Based on the difference in mean pain score 10 minutes after treatment, low-dose ketamine infusion was just as effective as a single dose of IV morphine. "It is unclear how ketamine compares with titrated opioids or whether it can be effectively redosed or titrated," explained the researchers, who reported the findings in the Annals of Emergency Medicine. "Further inquiry is needed to answer these questions, as well as to explore the utility of ketamine as an adjunct to opioids."

From "Comparable Analgesia With Low-Dose IV Ketamine, Morphine for Acute Pain"
Clinical Pain Advisor (01/23/19) Dellabella, Hannah

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Continuous Interscalene Block Superior to Single-Shot Block With Periarticular Local Infiltration

Single-shot interscalene block with periarticular injection is growing as an alternative to opioid pain control after shoulder surgery, leading researchers to wonder how the technique compares with continuous interscalene block. They conducted a single-site retrospective review of shoulder arthroplasty patients between January 2014 and October 2016. During that time, 53 of the patients received a single-shot interscalene block followed by a periarticular injection that included a local anesthetic, a vasoconstrictor, an opioid, and a nonsteroidal anti-inflammatory drug. Outcomes were compared with 63 patients who received a continuous interscalene block, which uses an indwelling catheter to deliver a steady flow of analgesia after surgery. Based on review of patients' charts on postoperative days 0 and 1, continuous interscalene blocks substantially reduced opioid consumption versus single-shot interscalene block with periarticular injection. The evidence suggests that the technique could potentially eliminate opioid requirements in the immediate postoperative period, according to the study authors, who presented their findings at the 2018 annual congress of the European Society of Anaesthesiology. Study researcher and Mayo Clinic anesthesia provider Elird Bojaxhi, MD, said at the time, "We hope that the result of the study will encourage the use of continuous nerve block as an alternative to reduce the need for opioids after a surgery."

From "Continuous Interscalene Block Superior to Single-Shot Block With Periarticular Local Infiltration"
Anesthesiology News (01/28/19) Doyle, Chase

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Intravenous Acetaminophen Versus Saline in Perioperative Analgesia With Laparoscopic Hysterectomy

Researchers explored intravenous acetaminophen as an alternative to opioids for post-surgical pain, without the accompanying nausea and risk of addiction. The prospective trial randomized 183 patients undergoing laparoscopic hysterectomy to either IV acetaminophen or placebo at anesthesia induction, followed by another dose after six hours. All participants self reported pain and nausea levels before pre-procedure and at 2, 4, 6, 12, and 24 hours afterward; however, no meaningful between-group difference was documented at any interval. Opioid requirements and satisfaction scores were also comparable between the IV acetaminophen patients and the controls. Considering the relatively high cost of IV acetaminophen—and given its lack of strong benefit and the availability of oral options—the researchers do not support its routine use during hysterectomy.

From "Intravenous Acetaminophen Versus Saline in Perioperative Analgesia With Laparoscopic Hysterectomy"
American Journal of Obstetrics and Gynecology (01/22/2019) Rindos, Noah B.; Mansuria, Suketu M.; Ecker, Amanda M.; et al.

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Ketamine Reduced Opioid Need in Severely Injured Subgroup

There is evidence to suggest that ketamine infusions may be a beneficial adjunct treatment for patients sustaining acute traumatic pain, although researchers agree that more study is needed. Their own experiment involved 91 adults suffering from three or more rib fractures, which are known to factor heavily into the morbidity and mortality associated with polytrauma. An acute thoracic pain management protocol was administered to all participants, along with rib blocks and epidural catheters as needed; but half were also randomized to ketamine infusion, with the remainder given an equivalent dose of saline. Low-dose ketamine did not significantly reduce 24-hour numerical pain scores or oral opioid use at 24 and 48 hours in the overall cohort. It did, however, lower opioid demand among the 45 participants with Injury Severity Scores above 15. The effect was maintained for the duration of the patients' hospital stay even though infusion was terminated at 48 hours. In reporting the findings at the 2018 annual meeting of the American Association for the Surgery of Trauma, study lead Nathan Kugler, MD, of the Medical College of Wisconsin noted that unfavorable outcomes, including respiratory events, were no worse with ketamine. "The side effect of hallucination is a major obstacle to ketamine's utilization, so it's important to note that no differences were seen between groups with respect to Confusion Assessment Method–positive events or incidence of hallucination and disturbing dreams," he added.


From "Ketamine Reduced Opioid Need in Severely Injured Subgroup"
General Surgery News (01/22/19) Doyle, Chase

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Infection Control Guidelines Improves Anesthesia Hand-Washing Compliance: 3 Research Insights

Anesthesia providers are more likely to adhere to infection control protocols when exposed to education and visual reminders, researchers report. Compliance with patient care hand hygiene was tracked before implementation of infection control guidelines, three weeks after adoption, and three months later. After 95 observations, the investigators determined that the number of anesthesia providers separating clean items in the workspace from contaminated ones surged nearly 72 percent after the infection control guidance was put in place. Additionally, 26.2 percent more providers practiced appropriate hand hygiene after airway instrumentation. "Education, visual reminders and standardized infection control guidelines were shown to improve compliance with infection control best practices in a group of nurse anesthetists," wrote the researchers, who published their findings in the American Journal of Infection Control.

From "Infection Control Guidelines Improves Anesthesia Hand-Washing Compliance: 3 Research Insights"
Becker's Clinical Leadership & Infection Control (01/22/19) Popa, Rachel

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News summaries © copyright 2019 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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Attn: Cathy Hodson
E–ssential Editor
chodson@aana.com
January 31, 2019