Anesthesia E-ssential

AANA Anesthesia E-ssential, July 12, 2018

Vital Signs

Novitas Releases Final Draft Local Coverage Determination with Limited Payment for CRNAs

Dear Colleagues,

It appears that the Medicare Administrative Contractor (MAC) Novitas Solutions is at it again.

You may recall that in 2017, after nearly nine months of advocacy and legal work, the AANA successfully fended off a local coverage determination (LCD) issued by Novitas that would have limited payment to CRNAs for epidural injections for pain management in 11 states and the District of Columbia. In follow-up to that situation, the AANA has continuously lobbied Congress for legislation to prevent MACs from promulgating rules.

Today I’m writing to inform you that barely a year after achieving that favorable result for our members, the AANA is faced with a similar situation. On June 29, 2018, Novitas released a final draft LCD which, if implemented on August 16 as scheduled, will negatively impact CRNA reimbursement for facet joint injections. AANA’s comments on the prior draft version of the LCD requested provider neutrality and recognition by Novitas of the nonsurgical pain management subspecialty certification (NSPM) as sufficient training to qualify for reimbursement; however, Novitas chose to ignore the evidence provided by the AANA and denied both requests.

As a result, the AANA’s federal advocacy efforts will strive to ensure that the prejudicial decision against CRNAs made by Novitas is changed prior to the August 16 implementation. As with the 2017 matter, your AANA Board of Directors and staff will explore every avenue to ensure a positive result for our members.

I will keep you informed of further developments regarding the Novitas LCD as they occur.


Bruce Weiner, DNP, MSNA, CRNA
AANA President
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AANA Journal Inducted Into Nursing Journal Hall of Fame

The AANA Journal is being inducted into the Nursing Journal Hall of Fame by the International Academy of Nursing Editors (INANE).

The International Academy of Nursing Editors (INANE) has established the Nursing Journal Hall of Fame to recognize scholarly nursing journals that have 50 or more years of continuous publication and sustained contributions to nursing knowledge.

The AANA Journal is the scholarly journal of the American Association of Nurse Anesthetists and began publication in 1933. It is published six times per year.

The inaugural cohort of 13 journals will be inducted at the 37th Annual Meeting of INANE on Tuesday, August 7th at 1:30 p.m. 

Journals honored, with founding dates, include: 
  1. American Journal of Nursing (1900);
  2. The Canadian Nurse (1905);
  3. Nursing Times (1905);
  4. AANA Journal (1933);
  5. Workplace Health & Safety (1943);
  6. Nursing Research (1952);
  7. Nursing Outlook (1953);
  8. International Nursing Review (1954);
  9. Journal of Midwifery & Women’s Health (1955);
  10. Journal of Nursing Education (1962);
  11. Journal of Psychosocial Nursing (1963);
  12. AORN Journal (1963);
  13. Journal of Nursing Scholarship (1966).
The International Academy of Nursing Editors, established in 1982, is an all-volunteer organization whose members include editors, publishers, and others involved in the dissemination of nursing knowledge through the scholarly literature.

Congratulations to the AANA Journal Editor in Chief, Chuck Biddle, PhD, CRNA; the AANA Journal Editorial Committee; and AANA Journal staff.
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Hot Topics

CDC Health Alert Update: Rising Deaths Due to Opioids

2017 data finds rising overdose deaths due to fentanyl and fentanyl analog, carfentanil, and opioid/non-opioid mixing. Alert includes list of actions by sector to participate in prevention efforts. See Opioid Crisis Resources.
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2019 MIPS Payment Adjustment Now Available - Request a Targeted Review

Eligible clinicians and groups have until September 30, 2018, to submit their request for a Targeted Review of their 2019 Merit-based Incentive Payment System (MIPS) payment adjustment factor through the Quality Payment Program website. Clinicians must use their Enterprise Identity Management (EIDM) credentials that were used to submit their MIPS data.

The information in the Targeted Review is based on 2017 MIPS performance year data which affects the 2019 payment period. To be granted a Targeted Review eligible clinicians/groups must meet certain criteria which include but are not limited to:
  1. Errors or data quality issues on measures and activities submitted;
  2. Eligibility issues (e.g. you did not meet the low-volume threshold);
  3. Being erroneously excluded from an alternative payment model (APM) participation list; and
  4. Not being automatically reweighted even though you qualify for automatic performance category reweighting.
Clinicians/groups are urged to be prepared to provide additional supporting documentation if the Targeted Review is granted. CMS cautions clinicians that all decisions made during the Targeted Review will be considered final and not appealable. For more details please refer to the 2019 MIPS Targeted Review Fact Sheet and User Guide. 
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Securing Malpractice Insurance Coverage – Simplified

We know securing malpractice insurance can be a tedious process. AANA Insurance Services has eliminated the hassle with our new Get a Quote option, which allows you to quickly and easily request a quote* or get in contact with a knowledgeable representative who specializes in the state or states that you plan to practice in. Get a Quote.

*This is a request for a non-binding premium indication. An application will need to be completed in order to obtain a formal quote
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NewsMakers: Three CRNAs To Be Inducted as Fellows into American Academy of Nursing

AANA and its membership congratulate Sass Elisha, EdD, CRNA; Garry Brydges, DNP, MBA, CRNA, ACNP-BC; and J. Dru Riddle, PhD, DNP, CRNA, who will be inducted as fellows in the American Academy of Nursing later this year. The CRNAs are among 195 distinguished nurse leaders as the 2018 class of academy fellows. The inductees will be honored at a ceremony to be held during the AAN's annual policy conference, which will take place November 1-3, 2018, in Washington, D.C.

The fellows, with the addition of the new class, represent all 50 states, the District of Columbia and 29 countries. The academy is currently comprised of more than 2,500 nurse leaders in education, management, practice, policy, and research. The fellows include hospital and government administrators, college deans, and renowned scientific researchers.

New fellows will be eligible to use the FAAN credential (fellow of the American Academy of Nursing) after the induction ceremony takes place in November.
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NewsMaker: CRNA Henry Talley Receives ABNF Award in England

Florida A&M University School of Nursing Dean Henry Talley, PhD, CRNA, APRN, LTC(ret), has been awarded the Association of Black Nursing Faculty (ABNF) Award for Excellence in Community Service and Community Engagement.

The award was presented at an awards luncheon on June 8 during the 31st ABNF Annual Meeting and Scientific Conference in London, England. The association highlighted Talley’s “exceptional contributions that you make on a daily basis to improve the lives of underserved populations in Florida.”

Read more in the Tallahassee Democrat.
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NewsMaker: CRNA Leo Le Bel Named One of 65 Nurses Over 65 Years of Age in State Celebration

The Connecticut League for Nursing (CLN) recently celebrated 65 years of serving nursing and nurse education within the state of Connecticut. To mark this milestone, CLN recognized the contributions of 65 nurses over the age of 65 who have left a lasting impact on nursing in Connecticut and beyond.

Leo Le Bel, JD, MEd, CRNA, APRNLeo Le Bel, JD, MEd, CRNA, APRN, is one of the recognized nurses. He is affiliated with the CT Nurses Association and Le Bel Consulting LLC during his practice in Connecticut.

Leo was the 22nd out of 65 nurses honored in the CLN campaign. The campaign launched in March 2017 and for the next 64 weeks, one nurse was highlighted each week through email, social media, and the monthly CLN News Brief.

Congratulations to Leo on this accomplishment!

Learn more about Leo and the award.

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NewsMaker: CRNA Bobby Finch Joins International Nurses Association

Colonel Bobby J. Finch, CRNA, joined the International Nurses Association in March, effective with her publication in Worldwide Leaders in Healthcare.

Now retired, Finch began her career as a CRNA in 1969. She resides in North Carolina, and was affiliated with Duke University Medical Center, Watts Hospital, and WakeMed Hospital. She has expertise in emergency room nursing and medical military care.
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Professional Practice

Fagron Sterile Services Recalls Two Lots of Neostigmine Methylsulfate

Fagron Sterile Services is voluntarily recalling two lots of Neostigmine Methylsulfate 5mL syringes, Lot Number C274-000004690 and C274-000004678. The specified product lots are being recalled because of a confirmed customer complaint that some syringe units containing Neostigmine Methylsulfate 1mg/mL, 5mg per 5mL are incorrectly labelled as Neostigmine Methylsulfate 1mg/mL, 3mg per 3mL. Secondary packages are properly labelled as Neostigmine Methylsulfate 1mg/mL, 5mg per 5mL. Learn more on the Recall Announcement.
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The Joint Commission Adopts Newborn Identification Requirement

To reduce newborn identification errors, which sometimes lead to wrong patient/wrong procedure and other harms to newborns, The Joint Commission has instituted this new requirement, effective January 1, 2019, for all hospitals and critical access hospitals with labor and delivery services. The risk of identification error is high for newborns because they cannot talk, sometimes look similar, and may share a similar naming convention with other newborns. The goal of the new standard, found at National Patient Safety Goal .01.01.01, Element of Performance 3, is to require “more distinguishable naming methods for this vulnerable population.” Read The Joint Commission’s R3 Report describing the standards, rationale, and references.
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Joint Commission Reports Explain New and Revised Pain Management Standards

Effective January 1, 2019, The Joint Commission will enforce new and revised pain assessment and management standards in critical access hospitals, ambulatory care organizations, and office-based surgery organizations. The Joint Commission has issued R3 Reportsexplaining these standards, including rationales and references.  Read the reports to familiarize yourself with these new accreditation standards.
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The Joint Commission and OSHA Join to Provide Free Workplace Violence Prevention Webinar on July 25

On Wednesday, July 25, The Joint Commission and the Occupational Safety and Health Administration (OSHA) will provide the webinar, “Workplace Violence Prevention: Implementing Strategies for Safer Healthcare Organizations,” from:
  • 11:30 a.m.-12:30 p.m. (PT)
  • 12:30 p.m.-1:30 p.m. (MT)
  • 1:30 p.m.-2:30 p.m. (CT)
  • 2:30 p.m.-3:30 p.m. (ET).
The webinar will review OSHA 2015 Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, as well as The Joint Commission’s standards related to Workplace Violence (WPV) prevention. Judith Arnetz, PhD, MPH, PT, Department of Family Medicine, Michigan State University, will then discuss a multi-hospital, tailored intervention study which reduced violent events and describe how to apply this approach to your organization.

The Joint Commission and OSHA do not have specific standards that apply to WPV at this time, but OSHA is in the rule development stages and has released WPV guidance documents in the last few years. The April 2018 Joint Commission Sentinel Event Alerton WPV focused on physical and verbal violence against healthcare workers. Read more about The Joint Commission and OSHA’s resources on this topic and register for the free webinar.
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Meetings and Workshops

AANA 2018 Annual Congress: Tap into the Power of Technology

The 85th AANA Annual Congress will be held September 21 - 25, 2018, at the Hynes Convention Center in Boston, Massachusetts.
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Upper and Lower Extremity Nerve Block Workshop

Expand your knowledge and skills in peripheral nerve blocks with didactic and hands-on training. The workshop is held August 18-19, 2018, in Park Ridge, Illinois.                      
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NEW! Practice Leadership Assembly Debuts

November 9-11, 2019, Rosemont, Illinois. Current and aspiring business owners, as well as practice and facility leaders, will gain insight and confidence to lead the way in a rapidly changing healthcare environment. Register today!

See all upcoming events on our AANA Meetings & Workshops page.
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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 Access to Appropriate Treatment for Chronic and End-of-life Pain with Need to Stem Misuse and Abuse of Opioids

As the agency considers new ways to tackle the country's opioid crisis, FDA Commissioner Scott Gottlieb says the aim is to strike "the right balance" between curtailing exposure to opioids and maintaining access for patients who truly need them. FDA's goal is to "support more rational prescribing practices, as well as identify and encourage development of new treatment options that don't have the addictive features of opioids," according to Gottlieb. "In this way, we'll help ensure that we're not unnecessarily putting patients as risk of addiction by overprescribing opioids, while also maintaining appropriate access to care for patients with serious pain." FDA recently held a Patient-Focused Drug Develop meeting seeking input from adults and children living with chronic pain. "We want to better understand the challenges or barriers patients face accessing various treatments for pain," adds Gottlieb, who hopes the meeting provided insight to help inform opioid policies and further efforts to create new treatments.

From "Balancing Access to Appropriate Treatment for Chronic and End-of-life Pain with Need to Stem Misuse and Abuse of Opioids"
FDA News Release (07/09/18) Gottlieb, Scott

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Rapid-Acting Sublingual Sufentanil Effective for Short-Duration Acute Pain

Sufentanil delivered via the sublingual route, instead of intravenously, is looking more and more like a viable short-term option for moderate to severe acute pain. University of Minnesota assistant anesthesiology professor Jacob Hutchins, MD, spearheaded a review of four late-phase studies on the investigational product with more than 400 patients in all. The findings indicated that the intervention is effective and well-tolerated after short-stay surgeries, including bunionectomy and abdominal procedures, as well as in the emergency room setting. The appeal of sublingual sufentanil, Hutchins says, is that it works quickly without the need for an I.V., is non-invasive, and has a more prolonged effect than the intravenous formulation. "What's nice about the sublingual tablet is that it's small and dissolves in just a few minutes when placed underneath the tongue using the applicator," he adds. "It maintains effective drug levels for up to three hours and minimizes saliva production, so there's less likelihood of a patient accidentally swallowing it. Also, you don't have to worry about setting up a [patient-controlled analgesia pump] or drawing up the medication in a syringe."

From "Rapid-Acting Sublingual Sufentanil Effective for Short-Duration Acute Pain"
Anesthesiology News (07/06/18) Vlessides, Michael

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You May Be Partly Conscious Under General Anesthesia

Even anesthesia professionals may be surprised to learn that, according to new findings, consciousness persists on some level even when people are anesthetized. Finnish and Swedish researchers worked with 47 healthy volunteers for the study, which randomized them to receive propofol or dexmedetomidine gradually until becoming nonresponsive. The participants were played congruent and incongruent sentences while under general anesthesia and also exposed to different sounds. At some point, though, investigators tried to return the volunteers to a state of responsiveness without stopping or adjusting the drug infusion, all while monitoring their brain activity. The readouts suggest that, once emerging from anesthesia, the brain recognized sounds that were played for the first time while the individual was supposedly unconscious. "In other words, the brain can process sounds and words even though the subject did not recall it afterwards," explains study co-author Katja Valli of the University of Skövde. "Against common belief, anesthesia does not require full loss of consciousness, as it is sufficient to just disconnect the patient from the environment." The researchers say their evidence, reported in Anesthesiology, is especially impactful because they used constant infusion both during a state of semi-wakefulness and while under anesthesia. Doing so allowed the team to distinguish between drug-related effects from other potential confounders.

From "You May Be Partly Conscious Under General Anesthesia"
Medical News Today (07/06/18) Sandoiu, Ana

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Recovery Characteristics of Total Intravenous Anesthesia with Propofol Versus Sevoflurane Anesthesia

To gain more insight into emergence delirium (ED)—behavioral disturbances that may affect children after anesthesia exposure—researchers in Turkey recruited more than 100 pediatric dental patients for a study. Enrollees were randomized to undergo full-mouth dental rehabilitation with either sevoflurane anesthesia or propofol-based total intravenous anesthesia (TIVA). Based on postoperative pain measurements taken every five minutes, as well as extubation time and other characteristics, ED occurred less often with the TIVA approach, which also was associated with a higher level of parental satisfaction and lower levels of postsurgical pain.

From "Recovery Characteristics of Total Intravenous Anesthesia with Propofol Versus Sevoflurane Anesthesia"
Journal of Pain Research (07/18) Vol. 11, P. 1289 Kocaturk, Ozlem; Keles, Sultan

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Popliteal Sciatic Nerve Block May Increase Time to First Opioid Request in Diabetic Peripheral Neuropathy

New evidence suggests that ultrasound-guided popliteal sciatic nerve block may benefit surgical patients with type 2 diabetes in ways that do not apply to nondiabetics. The study involved 56 participants who underwent the block, with lidocaine and bupivacaine, as part of a foot operation. Among them, 33 had type 2 disease and diabetic peripheral neuropathy and 23 did not. The primary outcome was time to first opioid request after the block procedure, which took the diabetic patients twice as long to reach, at a median 1,440 minutes, as the nondiabetic participants, who needed relief after about 710 minutes. Secondary endpoints included time to sensory blockade and at-rest pain on postoperative day 1, both of which also favored the diabetic group. Onset of sensory blockade occurred 59 percent faster among patients with diabetic peripheral neuropathy, who also scored their pain lower on the first day after surgery than did the control patients. "These results should help physicians in adjusting peripheral regional anaesthesia in this population," the researchers write in Anaesthesia.

From "Popliteal Sciatic Nerve Block May Increase Time to First Opioid Request in Diabetic Peripheral Neuropathy"
Clinical Pain Advisor (07/05/18) Dellabella, Hannah

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Philly Anesthesiologist Charged in Opioid, Health Care Fraud Bust

The U.S. Justice Department executed what it billed as the "largest health care fraud and opioid enforcement action ever taken," resulting in the late-June arrests of a Philadelphia anesthesiologist and eight other locals. Anthony Pepe III and two others were nabbed for selling more than 1,100 oxycodone pills. They each face a $1 million fine and up to 20 years of jail time. Two other suspects are charged with insurance fraud in connection with chiropractic services never rendered, and three more were taken in for their participation in a phony compounded medication scheme. The arrests were part of a nationwide sting targeting hundreds of perpetrators—many of them medical professionals, including 76 doctors whose prescribing of opioids and other narcotics is being called into question. In addition to the Justice Department campaign, the Department of Health and Human Services has been steadily making its own moves against shady activity. Over the past year, it has kicked approximately 2,700 individuals out of the Medicare, Medicaid, and other federal health care programs—including 587 providers who were blocked because of conduct related to opioid abuse and diversion.

From "Philly Anesthesiologist Charged in Opioid, Health Care Fraud Bust"
Philadelphia Patch (06/28/18) Bennett, Max

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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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