AANA Anesthesia E-ssential

Vital Signs

#AANA2015: Come for the Education...

And Stay for the experience! Come join us in Salt Lake City on August 29 – September 1: The 2015 Nurse Anesthesia Annual Congress will offer more education and more opportunities to earn up to 27.5 CE credits. New this year, educational tracks will help you identify sessions relevant to your specialty and interests, including: The Essentials, Clinical, Practice Management, Research in Action, History and Archives, Health and Wellness, and Special Interest. Learn more about #AANA2015 at www.aana.com/naac on the AANA website. Check out the choices available to you in the Program, now available online.        
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CPC Pulse

Meeting the Class B Requirement

Are you active in your national or state nurse anesthesia association? Do you participate in committee work, review boards, or task forces at your facility or institution? Volunteer or elected service is a great way to meet your Class B requirement. One year of service for a seated or elected role provides 5 Class B credits. University or college committee work (admissions, program evaluation, or university senate, for example) would qualify for Class B credit, as would participating on AANA, Council on Accreditation of Nurse Anesthesia Educational Programs (COA), National Board of Certification and Recertification of Nurse Anesthetists (NBCRNA), or state nurse anesthetist committees. Just keep a copy of a document that provides evidence of your role, like a published copy of the committee listing, and contact information for someone to verify your role and how long you were in the position. 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

Your Membership Matters!

Enrollment is now open for the membership period of September 1, 2015, through August 31, 2016. Renew today at www.aana.com/renewal and continue to be part of the more than 48,000 members-strong voice of the American Association of Nurse Anesthetists. Installment payments and automatic renewals now available!
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PQRS: Mid-Year Checkpoint

Have you started reporting to the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS)? Group practices and individual eligible professionals (EPs) now have less than six months left to report measures to PQRS. As the June 30 deadline for the PQRS Group Practice Reporting Option (GPRO) registration has already expired, individual EPs (i.e., solo practitioners) can participate in the PQRS program by selecting one of the following reporting mechanisms:
  • Claims based reporting;
  • Qualified PQRS Registry (log in to myAANA to find out how the AANA Member Advantage Program has partnered with PQRSwizard);
  • Qualified Clinical Data Registry (QCDR); or
  • Electronic Health Record (EHR) using Certified EHR Technology (CEHRT)
For more information, please visit our Quality-Reimbursement page under the AANA website resources tab.
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AANA Foundation Presents... One Night - Twice the Fun

Sunday, August 30, in Salt Lake City, plan to attend a fabulous and fun event that offers something for everyone. One Night – Twice the Fun features fabulous live entertainment by Hollywood Revisited, followed by an awesome dance party. This event has two parts – twice the fun – at two different ticket prices.

Star-Studded Main Event and Shake It for a Cause Dance Party

Registration fee is $250
7:00 – 11:45 pm
Ticket includes dinner, drinks, entertainment featuring Hollywood Revisited, and the dance party.

Shake It for a Cause Dance Party
Registration fee is $50 for CRNAs and $25 for SRNAs
9:30 pm – 11:45 pm
Ticket includes the dance party only.

Hollywood Revisited is a tribute to the golden age of Hollywood in costume and song. Concert pianist and well-known collector of movie costumes, Greg Schreiner, provides movie and scene anecdotes and musical accompaniment while acclaimed vocalists sing and dance while wearing the actual costumes worn by Hollywood legends such as Marilyn Monroe, Elizabeth Taylor, Gene Kelly, Bob Hope, Judy Garland, and many more.

Shake It for a Cause Dance Party will feature a DJ playing all your favorite songs. Nurse anesthetists love to go all out on the dance floor – so plan to boogie, kick up your heels, and groove the night away.

Please register today! Not only will you have a fun time, but a portion of your donation is tax deductible and will support the AANA Foundation and our grand profession.

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AANA for SRNAs Facebook Page is Now Available!

It's here! We're excited to announce the launch of our new Facebook page designed for SRNAs to enjoy a dedicated space to connect with peers and keep up on the latest in the profession from your association. “Like” the page, select “get notifications”, and reply to our welcome message with what program you’re in for a chance to win a $50 gift card! This limited offer is restricted to SRNAs currently enrolled in Nurse Anesthesia Programs. One winner will be randomly selected and notified on August 3, 2015. https://www.facebook.com/aana4srnas
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Proposed Bylaw Amendments and Resolutions to be Published Online

Due to the changed submission deadline that took effect this year, proposed AANA Bylaw Amendments and Resolutions will be published online instead of in the July issue of AANA NewsBulletin because of a conflict with printing deadlines. The proposed Bylaw Amendments and Resolutions to be debated at the August 30, 2015, AANA Business Meeting will be posted online by July 15 at: http://www.aana.com/myaana/AANABusiness/governance/Pages/AANA-Annual-Business-Meeting-Agenda-and-Information.aspx. In the event a member does not have online access, you may request that a hard copy be mailed to you via a message to mscheuermann@aana.com or phone (847) 655-1101.
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Opening for New COA Director

The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is seeking nominations for a Healthcare Administrator representative to serve on the COA Board. Candidates must meet the following requirements.
  • Holds one or more graduate degrees from an institution or institutions of higher education accredited by a regional accrediting agency.

  • Shows evidence of current involvement in a healthcare administration setting and direct interaction with a nurse anesthesia program.

For more information and the application form please refer to the COA website.
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Upcoming Accreditation Reviews

The COA provides a list on the COA website of nurse anesthesia educational programs scheduled to be reviewed by the COA during the fiscal year of September 1, 2015 to August 31, 2016. Third parties wishing to present an oral or written statement must notify the Council at least 60 days prior to the COA meeting at which the program will be reviewed. The Council’s 2015 meeting date is October 14 - 16. The Council’s 2016 meeting dates are January 20-22, June 1-3 and October 19-21.
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AANA PR Committee Recognizes MYA Student Mentoring Program Participants

On April 20, 2015, at the AANA Mid-Year Assembly (MYA) in Washington, D.C., 35 student registered nurse anesthetists (SRNAs) from around the country spent the day being mentored by practicing CRNAs as part of the Student Mentoring Program, coordinated by the AANA Public Relations Committee. Each year, SRNAs who demonstrate leadership qualities and skills are recommended by their educational program administrators to participate in this popular program. We congratulate the students and their CRNA mentors who made this year’s mentoring program a resounding success. See a complete list of the mentors and students who participated in the program here.
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Webinar Explores Student Loan Best Practices for Nurse Anesthetists

Did you know that you can refinance a student loan just like a home mortgage? Did you know that there are also federal repayment assistance programs, which are dedicated to nurses? Chances are, there is money to be saved on your loans. On August 4, 7 PM ET, DRB Student Loan is hosting a “Student Loan Best Practices” presentation for AANA members, which will cover all available opportunities for nurse anesthetists. The salient questions to be addressed are:
  • How can I lower my interest rate?
  • Will the government help me repayment my loans if I work in a rural or underserved area?
  • Is there any way my loans will ever be forgiven?
  • How will the proposed legislative changes to federal repayment programs affect me?
  • How much money do I stand to save my refinancing?
Click here to register. Webinar ID: 109-138-115.
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Meetings and Workshops

Save! Travel and Hotel Discounts Available for AANA Annual Congress

Going to the AANA Annual Congress in majestic Salt Lake City? Be sure to book your hotel room by July 25th to take advantage of special group rates! Also, if you haven’t booked your flight, take advantage of our special airline and car rental discounts promo codes. Visit the travel discounts page.
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2015 AANA Fall Leadership Academy Registration is Open

Find out why past attendees rave about the 2-day Fall Leadership Academy conference in Rosemont, IL. You’ll rub shoulders with the “movers and the shakers” in the world of nurse anesthesia and enjoy five leadership tracks including interactive sessions designed to help you implement change, motivate others, and build relationships. Register today at save 10 percent! www.aana.com/meetings
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Coming This Fall: Popular Hands-On Workshops

Check out the Meetings and Workshops webpage on the AANA website and future issues of the AANA NewsBulletin and Anesthesia E-ssential for further information.
  • Essentials of Obstetric Analgesia/Anesthesia Workshop: October 21, 2015, Park Ridge, Ill.

  • Spinal and Epidural Workshop: October 22-24, 2015, Park Ridge, Ill.

  • Jack Neary Advanced Pain Management Workshop Part II, October 10-11, 2015, Rosemont, Ill.

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Foundation and Research

AANA Foundation to Host 18th Annual Golf Tournament at Eaglewood Golf Course in North Salt Lake, Utah

The AANA Foundation will host its 18th Annual Golf Tournament on Friday, August 28, 2015 at Eaglewood Golf Course with tee off at 1:30 p.m.

Click here to visit the AANA Foundation 18th Annual Golf Tournament webpage for more details including information on club rental, sponsorship, contests, and photos from past AANA Foundation golf tournaments.

The golf registration fee is $250. To register, click here to be directed to the AANA Annual Congress Registration Page.

Please plan to participate in this fun event and experience Eaglewood Golf Course with CRNAs and SRNAs from across the country while benefiting the AANA Foundation and its mission to advance the science of anesthesia through education and research.

If you have any questions, please contact Luanne Irvin, AANA Foundation Development Officer, at (847) 655-1173 or lirvin@aana.com.
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Art on Canvas Silent Auction and Contest Deadline July 31, 2015

The AANA Foundation is hosting an Art on Canvas silent auction at the upcoming Annual Congress. It’s going to be a crowd pleaser—who doesn’t love looking at beautiful photos and artwork?

We are inviting CRNAs and SRNAs to print a favorite photo or paint a picture on canvas, and donate it to the AANA Foundation to be entered in the auction. Artwork will be on display in the AANA Foundation Poster room at the 2015 AANA Nurse Anesthesia Annual Congress in Salt Lake City, Utah.

If you have a special photo or piece of artwork you’d like to submit, contact Luanne Irvin at (847) 655-1173 or lirvin@aana.com. This opportunity is limited to the first 20 participants. Please respond no later than July 31, 2015. Please name your artwork and include any other details such as where the photo was taken or what type of paint was used.

Participants may enter any original photo or painting, but are asked to adhere to the following guidelines:

  • Photographs/artwork should be printed/created on canvas
  • Gallery wrap
  • No larger than 20" X 28"
A few options for printing photos on canvas include Canvas World, Snapfish, and Adorama (links below).

Visitors to the AANA Foundation Poster Room will have an opportunity to vote for their favorite photo or painting. All donors will receive a gift-in-kind letter and the artist with the most votes will win a prize.

Proceeds benefit the AANA Foundation and its mission to advance the science of anesthesia through education and research. Thank you in advance for participating!
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Federal Government Affairs

AANA and APRN Organizations Support 21st Century Cures Initiative, which Passed U.S. House July 10

On June 29, the AANA and 10 APRN organizations submitted a letter of support to party leadership for the “21st Century Cures Act” (H.R. 6). In the letter, the APRN workgroup commended Congress’ “focus on healthcare innovations and infrastructure development in order to accelerate new scientific understanding into treatments and cures. We would like to specifically thank you for the increase in funding to the National Institutes of Health (NIH), and that the bill respects all healthcare professionals equally.” The AANA and APRN organizations previously commented on an earlier version of this legislation to advise against language excluding CRNAs and other APRNs. The U.S. House subsequently adopted H.R. 6 on July 10 with a bipartisan 344-77 vote. 

The Senate Health Education Labor and Pensions (HELP) Committee is considering developing a related bill early in 2016. Read the APRN Workgroup letter on H.R. 6 here. See how your U.S. Representatives voted here.

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Medicare Updates 2015 Anesthesia Conversion Factor – Instead of Cuts, a $200 Boost This Year for the Average CRNA

The Medicare Part B mean anesthesia conversion factor for services effective July 1 is $22.6083 per unit, a 0.5 percent positive update, as directed by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), according to information posted by the Medicare agency.

 The AANA-backed MACRA legislation, enacted this past spring, permanently repealed Medicare Sustainable Growth Rate (SGR) cuts and reforms Medicare payment. Medicare calculates fee-for-service anesthesia payment according to the formula of “base units plus time units” times “dollar value conversion factor.” For an average CRNA billing 300 nonmedically directed Medicare cases per year of 12 base and time units each, the update increases Medicare payments by about $200 over the last six months of 2015 relative to what would have been provided with no funding increase – and well above what Medicare would have paid had the April 1 SGR cuts taken effect. This new rate is valid until December 31, 2015.

Rather than another round of 20-25 percent SGR cuts to CRNA and physician payment next January as has happened in the past, the new rate will be updated by an additional positive 0.5 percent update on January 1, 2016. Anesthesia conversion factors vary by locality following agency analysis of local healthcare costs, from a low of $20.26 per unit in Puerto Rico to a high of $31.08 per unit in Alaska. Growth from 2014-2015 also varied by locality, from a minus 3.09 percent in Detroit, MI to plus 2.52 percent for New York suburbs and Long Island, NY.

See the Medicare 2015 anesthesia conversion factor list by locality here (requires AANA member login and password).

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Medicare Publishes Major Proposal for Patient-Centered Care in Joint Replacement Procedures

The Medicare agency published on July 9 a preview of a major new pilot for care coordination of joint replacement procedures in hospitals, among the most common services for which CRNAs provide anesthesia. The AANA is reviewing the proposal closely to inform public comments due Sept. 8.

Intended to promote coordinated, patient-centered care, the agency describes its “Comprehensive Care for Joint Replacement” proposal as follows: “Under this proposed model, the hospital in which the hip or knee replacement takes place would be accountable for the costs and quality of care from the time of the surgery through 90 days after—what’s called an ‘episode’ of care.” Affecting hospitals in 75 geographic regions, the proposal may also renew a modernizing healthcare industry’s focus on securing patient access to high-quality, cost-effective anesthesia and pain care delivery models such as those offered by CRNAs.

See the agency fact sheet and the proposed rule in preview (expires shortly and then will be posted in the Federal Register).

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U.S. Supreme Court Ruling Preserves Federal Subsidies in States that have Federally-Facilitated Marketplaces: What’s the CRNA Impact?

The U.S. Supreme Court issued a ruling on the King v. Burwell case on June 25 that preserves the federal subsidies for 6.4 million Americans in the 34 states that choose to have their health insurance marketplaces run by the federal government instead of by the state. The decision was received with applause from the Obama Administration, with supportive statements from health industry leaders that had averted disruption if the decision had gone the other way, and with objections from congressional Republicans opposed to the Affordable Care Act (ACA).

In a statement summarizing the ruling’s impact on CRNAs, AANA President Sharon Pearce, CRNA, MSN, said, “For CRNAs, the Supreme Court’s ruling upholding Affordable Care Act subsidies … means simply that ACA implementation continues. The Court has left to Congress and the President whether to further reform the Act. And it has left states to decide whether to accept ACA funding for Medicaid expansion…. But access to insurance is not the same as access to healthcare. For patients to have access to excellent care they can afford, health plans and new payment systems must continue to recognize and fully cover the services of CRNAs and other Advanced Practice Registered Nurses. That’s what we’re working to help them do.”

See the final ruling here. To learn more about this case, see http://www.scotusblog.com/case-files/cases/king-v-burwell/.
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Senate Veterans’ Affairs Committee Postpones Action Legislation that Excludes CRNAs from VHA APRN Full Practice Authority

The Senate Veterans Affairs Committee postponed July 14 action on healthcare legislation on July 14, including one bill, S. 297 (Kirk, R-IL), that would extend Full Practice Authority to APRNs in the Veterans Health Administration but not to CRNAs. According to committee sources, action may be delayed a week or more, and was not directly related to S. 297. The AANA and CRNAs have expressed concerns that the provision must be addressed before it can set a dangerous precedent against recognition of the full scope of CRNA services in the VHA and elsewhere. AANA members residing in states represented by a Senator serving on the Veterans Affairs’ Committee are urged to write their Senator right away here.

The AANA is requesting that Senators refrain from supporting legislation that impairs Veterans access to care by failing to recognize CRNAs and all APRNs with Full Practice Authority. Over 10,000 messages from AANA members have been sent to Senators urging that S. 297 include CRNAs, and the AANA and 12 APRN organizations have submitted testimony and a letter to the committee expressing concern for this legislation as written. The AANA will be present as the committee meets and will provide additional details as they are made available. Take action here (AANA member login required).

View the AANA testimony on S. 297 here. (AANA member login required) and see the AANA and APRN letter here (AANA member login required).

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Medicare Revises Infection Control Surveyor Worksheet for Ambulatory Surgical Centers

The Centers for Medicare & Medicaid Services (CMS) in late June posted an advance copy of its revised ambulatory surgical center (ASC) infection control surveyor worksheet, which includes updates on ASC survey procedures relating to hand hygiene, injection practices, single use devices, sterilization, and high-level disinfection, among other factors.

The new worksheet and its changes are important for ASC CRNAs to know. The worksheet guides how surveyors for Medicare and state agencies oversee ASC compliance with the Medicare Conditions for Coverage (CfCs), federal regulations with which healthcare facilities must comply in order to participate in the Medicare program. The agency noted that this is an advance copy; a final version published at a later date might differ slightly.

The AANA and expert CRNAs are reviewing the worksheet in depth and will share any concerns with CMS and with membership. CRNAs should also familiarize themselves with the AANA Infection Control Guide for Certified Registered Nurse Anesthetists and should be aware of the ASC infection control worksheet. The AANA also has several infection control-related materials in the Professional Practice area of the AANA website. Read the Advance Copy of the ASC Infection Control Worksheet here.

For further information, read the AANA Infection Control Guide for Certified Registered Nurse Anesthetists and the infection control-related materials .

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Update on AANA’s Efforts to Ensure Veterans Access to Quality Care

The AANA and its members continue to advocate for legislation and a Veterans Health Administration (VHA) proposal that would authorize all advanced practice registered nurses (APRNs), including CRNAs, to practice as Full Practice Providers in the VHA and help improve access to quality healthcare for all Veterans. Here is a status update:
  • The AANA is supporting legislation in the House, H.R. 1247, the “Improving Veterans Access to Quality Care Act,” sponsored by Reps. Sam Graves (R-MO) and Jan Schakowsky (D-IL). The bill has 31 bipartisan cosponsors. The AANA encourages members whose U.S. Representative has cosponsored this legislation to send a thank you note (here). Please continue to contact your U.S. Representative and encourage co-sponsorship of this bill (here). View the AANA and APRN Workgroup letter of support here and also view the Nursing Community letter here.
  • The AANA has expressed strong concerns about legislation in the Senate, S. 297, the “Frontlines to Lifelines Act,” sponsored by Sen. Mark Kirk (R-IL), which the Senate Veterans Affairs Committee expects to act upon this summer at a date to be named later. AANA members who reside in a state represented on the Senate Veterans Affairs Committee are encouraged to contact their Senator here Unlike the House bill (H.R. 1247), S. 297 recognizes only three of the four APRN specialties for Full Practice Authority in the VHA, omitting CRNAs. The AANA encourages CRNAs to contact their U.S. Senators with similar concerns about S. 297. Please do so here. See AANA’s letter on S. 297 here.
  • The AANA continues to strongly support the VHA’s efforts to update its Nursing Handbook to recognize CRNAs and other APRNs to their full practice authority, consistent with the recommendations of the Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health. According to the VHA, the agency intends to publish regulatory rulemaking later this year recognizing CRNAs and other APRNs to their full practice authority in the VHA. Thousands of AANA members have already contacted the VHA in support of this work; AANA members are currently being requested to focus on contacting Congress.
  • Dr. David Shulkin was sworn in as VA Under Secretary for Health on Monday, July 6. Dr. Shulkin was confirmed by the U.S. Senate on June 23 and replaces Dr. Carolyn Clancy who served in the post in an acting role. The AANA looks forward to continuing to work with all VA leadership including Dr. Shulkin in support of improving Veterans access to quality care through recognizing VHA APRNs to their Full Practice Authority.
Since mid-February, AANA members have sent more than 13,500 messages to their federal legislators expressing support for H.R. 1247 and concern for S. 297 as written.
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Update on U.S. Senate and House Actions on Fiscal Year 2016 Healthcare Funding Bills

Both the House and Senate moved health funding bills quickly the week of June 22, but their prospects for enactment later this summer remain challenging.

Within these Labor-HHS-Education appropriations bills, the AANA works to support nurse workforce development funding and health research, and to oppose attacks on CRNAs. The Senate Appropriations Committee approved the Labor, Health and Human Services, and Education appropriations bill with a $10.99 million cut to Title 8 Nursing Workforce Development Program funding in FY 2016, with Sens. Jeff Merkley (D-OR) and Barbara Mikulski (D-MD) supporting an unsuccessful effort to reverse the Title 8 cut.

The Nursing Workforce Development Program funding covers loan repayment programs, nurse anesthesia traineeships, and other workforce programs for which nurse anesthesia educational programs apply competitively. The Senate legislation reduces but does not eliminate funding for the Agency for Healthcare Research and Quality (AHRQ) as the House bill does, and its accompanying report asks Medicare to explain why it demands patient copays for colonoscopies that result in polyp removal. The AANA has supported legislation to cover such services without copays. As previously reported, the House version maintains level funding for Title 8 Nursing Workforce Development programs at $231.6 million for FY 2016. The legislation includes a $1.1 billion increase in funding for the National Institutes of Health, which is over the amount that the Administration requested.

The AANA has supported full funding for Title 8 and AHRQ and will keep you informed as additional details emerge. Read more here about this legislation, and read the AANA’s comment on removing barriers to colorectal cancer screening here.

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AANA Members in Key Districts Urged to Oppose ASA-backed Rural Anesthesia Legislation

An American Society of Anesthesiologists-backed piece of legislation would increase rural healthcare costs without improving quality, and the AANA is urging members residing in districts represented on the Senate Finance Committee and House Ways and Means Committee to contact their members of Congress in opposition to this legislation. The problematic bill, the “Medicare Access to Rural Anesthesiology Act of 2015” (HR 2138) introduced by Rep. Lynn Jenkins (R-KS), seeks to establish “parity between anesthesiologists and certified registered nurse anesthetists (CRNAs) by allowing anesthesiologists to receive pass-through payments in the same fashion CRNAs receive pass-through payments.” In a letter from President Sharon Pearce, CRNA, MSN, the AANA said, “As proposed, HR 2138 will increase the overall cost of anesthesia delivery in rural America without improving outcomes or access for rural Americans, placing additional financial burdens upon rural hospitals already facing financial challenges.” Similar legislation was introduced in past Congresses, but efforts by the AANA halted the legislation from moving.

If you reside in a district or state whose legislator serves on the Senate Finance or House Ways & Means committee, please take action here. You should also have received a CRNAdvocacy Alert message you can use to take action. See the AANA’s letter (requires AANA member login and password) here. Read H.R. 2138 at here

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Medicare Proposes 2016 Schedule for CRNA and Physician Payment, Implementation of Medicare Payment Reforms

The Centers for Medicare & Medicaid Services (CMS) released a preview of the CY 2016 Physician Fee Schedule proposed rule on July 8 directing CRNA and physician payment in 2016 and implementing major Medicare payment reforms enacted by Congress this past spring. The AANA is reviewing the proposed rule in detail to protect and advance the profession of nurse anesthesia through public comments due Sept 8. In the physician fee schedule proposal, CMS estimates that the CY 2016 national anesthesia conversion factor will be $22.6296 per unit and the regular physician CF for CY 2016 is estimated to be $36.1096 per unit. Both are slight increase from current CY 2015 levels — as opposed to the huge “sustainable growth rate” (SGR) cuts that would have otherwise applied without Congress have passed the AANA-backed SGR repeal legislation in April. Allowed charges for anesthesia professionals in 2016 charges for anesthesia professionals total about $3 billion out of $88.4 billion for all Part B services. In addition, the agency is proposing to:
  • Implement certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), including the new Merit-based Incentive payment system (MIPS). CRNAs are identified as eligible professionals under this program;
  • Change methodology for the malpractice premium for anesthesia service;
  • Identify certain anesthesia services furnished in conjunction with lower GI procedures as misvalued;
  • Include CRNAs as practitioners who can furnish Medicare telehealth services; and,
  • Make a technical correction in regulations to ensure that both surgical or anesthesia services furnished in connection with, as a result of, and in the same clinical encounter as a colorectal cancer screening test will be exempt from the deductible requirement when furnished on the same date as a planned colorectal cancer screening test as described in Medicare regulation.
The preview is posted here through July 15, after which it will be posted in the Federal Register. The agency fact sheet posted here.
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AANA Comments on Pain Care Related Proposal to Medicare Contractor WPS Medicare

Promoting Medicare coverage of CRNA services in six Midwestern states (Wisconsin, Indiana, Iowa, Kansas, Michigan, and Missouri) was the objective of comments that AANA submitted on June 26 to Medicare administrative contractor (MAC) Wisconsin Physicians Service Insurance Corporation (WPS), concerning a draft local coverage determinations (LCD) document on facet joint injections. This draft LCD is nearly identical to one issued by National Government Services (NGS) to which the AANA commented back in July 2014.

The AANA letter signed by President Sharon Pearce, CRNA, MSN, stated, “The Provider Qualifications section of this draft LCD states, ‘The following training requirement applies only to those providers who have not provided these specific interventional pain management services on a regular basis (at least two times per month) during the 10 years prior to the effective date of this LCD…. A basic requirement of payment is training and/or credentialing by a formal residency/fellowship program and/or other training program that is accredited by a nationally-recognized body….’ We understand this section to clearly state that on behalf of the Centers for Medicare & Medicaid Services (CMS), Wisconsin Physicians Service Insurance Corporation (WPS) covers all Medicare CRNA services within their state scope of practice, including the services described in this LCD…. All CRNAs are certified and recertified to practice by an accredited nationally recognized organization, the National Board for Certification and Recertification of Nurse Anesthetists (NBCRNA).”

Read the AANA comment letter here.
Read the draft LCD here.
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Medicare Proposes 2016 Hospital Outpatient Prospective Payment and ASC Payment Rule

The Centers for Medicare & Medicaid Services on July 1 released a preview of the CY 2016 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment (HOPPS) proposed rule. Of specific interest to CRNAs, the proposed rule includes a request for comment on a quality measure of note. For the Ambulatory Surgical Center Quality Reporting (ASCQR) Program, CMS is requesting comment on one anesthesia-related outcome measure for future consideration: the Normothermia Outcome, which assesses the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in the post-anesthesia care unit. The AANA is reviewing this proposal closely for possible impacts on or opportunities for CRNA practice and reimbursement, and to inform the profession’s response during the public comment period ending August 31, 2015. Read the proposed rule here and the fact sheet on the proposed rule provided by CMS here.
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  • Both the House and Senate are in session during July. If you see your legislators or their staff at home on the weekend, let us know how your visits went by logging your visit on the CRNA-PAC website at https://www.crna-pac.com/legisreport.aspx (AANA login required) and sending us pictures to info@aanadc.com. To see when Congress is in Washington or at home, go to House scheduleHouse schedule, Senate schedule.
  • New training materials were released by the federal government for health professionals who provide care to patients living with multiple chronic conditions. These materials were released by the Office of the Assistant Secretary for Health, in collaboration with the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services. The resources are availablehere. HHS will also host a webinar to discuss the new materials Wednesday, July 8, from 12:00-1:00pm ET. To get more information on the webinar and to RSVP, click here.
  • The AANA is supporting efforts to restore funding for a federal agency focused on healthcare quality. A Senate Appropriations Committee proposal to reduce funding for the Agency for Healthcare Quality and Research (AHRQ) by more than 30 percent in the FY 2016 Labor, HHS and Education Appropriations bill has drawn opposition from the AANA, which has signed onto a letter circulated by the Friends of AHRQ in support of restoring the funding. Once the letter is finalized, it will be posted online for membership to see. Previously, the AANA joined Friends of AHRQ in objecting to a House committee proposal to eliminate AHRQ funding entirely in FY 2016.
  • News reports July 3 said that Aetna plans buy its insurance competitor, Humana, for $37 billion, merging the third and fourth largest U.S. health plan systems. The plan is under review at the U.S. Department of Justice, specifically focusing on the merger’s potential effect on competition and prices. Read the ModernHealthcare article on the Aetna announcement here.
  • The U.S. Supreme Court released a ruling on the Glossip v Gross case, stating the use of a three-drug protocol is constitutional and does not violate the Eighth Amendment’s protection against cruel and unusual punishments. Some of the drugs at issue are used in anesthesia care. While the AANA does not have a formal position on capital punishment or the administration of anesthesia related to it, the AANA Code of Ethics recognizes the right of individual CRNAs to refuse to participate in providing patient care in situations they object to on moral grounds.
  • The Department of Justice (DOJ) is gearing up to investigate whether mergers of some of the nation’s largest health insurance companies could suppress competition and violate antitrust laws. The potential for DOJ investigations comes after news that Anthem Inc. has bid on Cigna Corp and Aetna has made a proposal to takeover Humana. Read the Wall Street Journal article here
  • On Tuesday, June 23, the U.S. House passed legislation repealing an Affordable Care Act provision that created an Independent Payment Advisory Board (IPAB) by a vote of 244-154. This Board, if it is filled and funded, would be charged with helping to reign in Medicare costs without additional legislative approvals. This legislation is one of several bills that congressional Republicans are promoting to repeal various aspects of the ACA. The legislation is now headed to the Senate for consideration. See how your U.S. Representative voted at http://clerk.house.gov/evs/2015/roll376.xml
FEC Required Legal Notice

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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.

Analgesic Combination Therapy Shows Promise for Acute Pain

In the pursuit of more effective treatments for acute pain, analgesics have been paired with a similar drug—paracetamol, for example, with codeine or with oxycodone—instead of administered alone. Recently, the results from tests of previously untried combinations of dexketoprofen trometamol and tramadol hydrochloride were reported in The Journal of Headache and Pain. The study population included 606 healthy patients who suffered severe pain after undergoing tooth extraction under local anesthesia. Four different fixed combinations of the analgesics were administered, and the findings indicated that all combinations outperformed the placebo—400 mg of ibuprofen—over the next 24 hours. In particular, researchers were excited by the combination of 25 mg of dexketoprofen trometamol with 75 mg of tramadol hydrochloride, which provided rapid initial pain relief that was maintained for a long duration with only a small number of patients needing additional medication. The results cannot be translated into clinical practice just yet, the investigators say, as patients in each group received each combination of different analgesics at different dosages. Still, they believe the combination warrants additional study.

From "Analgesic Combination Therapy Shows Promise for Acute Pain"
HCPLive (07/13/15) Schu, Bill

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FDA Strengthens Warning That Non-Aspirin NSAIDs Can Cause Heart Attacks or Strokes

The Food and Drug Administration (FDA) announced on July 9 that it is strengthening an existing label warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) raise the risk of heart attack or stroke. Following a comprehensive review of new safety information, the agency is requiring the drug labels of all prescription NSAIDs to be updated to reflect the higher risk. The Drug Fact labels for prescription and OTC non-aspirin NSAIDs already include information about heart attack and stroke risk, and FDA said it would request updates to the OTC non-aspirin NSAID Drug Facts labels. While the risk of heart attack and stroke with NSAIDs has been included on the prescription drug labels since 2005, FDA said the prescription NSAID labels will be revised to reflect several factors, including that the risk of heart attack or stroke can occur as early as the first weeks of using an NSAID, and the risk may increase with longer use of the drug. In addition, the risk appears greater at higher doses, and NSAIDs can increase the heart risks in patients with or without heart disease or risk factors for heart disease. FDA warned that patients and health providers should be alert to potential heart-related adverse events for the entire duration of NSAID use.

From "FDA Strengthens Warning That Non-Aspirin NSAIDs Can Cause Heart Attacks or Strokes"
FDA Drug Safety and Availability (07/09/2015)

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Back Pain Patients With Psychiatric Disorders May Not Benefit From Opioids Prescribed to Them

Patients who are prescribed opioid medications for chronic lower back pain tend to experience significantly less relief and are more likely to abuse their medication if they also suffer from a psychiatric disorder, such as anxiety or depression. Chronic lower back pain affects about 50 million U.S. adults, and high levels of depression and anxiety are common in this population. In a new study published in Anesthesiology, researchers used data from 55 patients with chronic lower back pain and symptoms of depression or anxiety that ranged in severity from low to high. Patients were assigned to receive either morphine, oxycodone, or a placebo for six months, and they were asked to record their daily doses and pain levels. Patients with the highest level of depression and anxiety symptoms experienced 50 percent less improvement in back pain and 75 percent more opioid abuse compared with patients who had low-to-moderate symptom severity. Physicians are advised to identify psychiatric disorders before deciding to prescribe opioids for chronic back pain, and try to treat these conditions early, before the pain becomes chronic.

From "Back Pain Patients With Psychiatric Disorders May Not Benefit From Opioids Prescribed to Them"
Medical Daily (07/09/15) Venosa, Ali

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Creating a New Paradigm in Pain Care for the Elderly

Prescription-drug abuse has become a national problem, and it can create particular risks among the elderly, writes Kenneth Thorpe, MD, chairman of the Partnership to Fight Chronic Disease and chair of the Department of Health Policy & Management in the Rollins School of Public Health at Emory University in Atlanta. Medications that may be safe and manageable for the general population may create significant health crises among older adults. According to the National Safety Council, patients over age 65 years who take opioids are 68 percent more likely to be hospitalized than those who take over-the-counter remedies, and they are 87 percent more likely to die. Seniors who take prescription opioids have a greater risk of fractures from falling, impairment, or gastrointestinal or respiratory issues. Pain-treatment options for seniors should not be limited to medications that carry a higher risk of death and disability, Thorpe says. Alternative, non-opioid methods for pain relief in surgical patients include preoperative cocktails of analgesic medications, local anesthetics, or nerve blocks. Intravenous acetaminophen sometimes provides the same pain relief as opioids. Thorpe notes that the White House Conference on Aging is a good place to launch discussion of pain management in older adults.

From "Creating a New Paradigm in Pain Care for the Elderly"
The Hill (07/09/15) Thorpe, Kenneth

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MIT Researchers Reveal Key Brainwave Changes Among Patients Receiving Nitrous Oxide

MIT researchers have uncovered new information on how the centuries-old anesthetic known as laughing gas alters brainwave patterns. The mechanisms behind what is more formally known as nitrous oxide are not well understood; but the recent findings reveal waves of electrical firing passing the front of the brain as slowly as every 10 seconds after the agent is administered at anesthetic doses. While similar to brainwave changes that occur during the deepest natural sleep, the waves created by nitrous oxide are double the size and apparently more powerful than the ones produced during slumber. The phenomenon lasts only about three minutes—even though nitrous oxide administration is ongoing—but MIT medical engineering professor and Massachusetts General Hospital anesthesia provider Emery Brown wonders what might happen if it could be maintained at a steady state. In that case, he suggests, nitrous oxide might possibly serve as a potent anesthetic whose effect could quickly be reversed. Brown and his team, who reported their findings in Clinical Neurophysiology, are continuing their research, which involves recording electroencephalogram (EEG) readings from anesthesiology patients.

From "MIT Researchers Reveal Key Brainwave Changes Among Patients Receiving Nitrous Oxide"
News-Medical (07/07/15)

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Antimicrobial Stewardship Cuts Antibiotic Use in Half

Infections caused by antibiotic-resistant bacteria kill an estimated 23,000 people annually, according to Centers for Disease Control and Prevention statistics, but new research suggests that antimicrobial stewardship programs that foster correct use of antibiotics are helpful. Led by Olivia Jackson, RN, a trial program at the Elizabeth Seton Pediatric Center curbed the use of mupirocin by more than 50 percent after finding that certain antibiotics were being prescribed for a prolonged period and for rashes and other noninfectious indications. In addition, by performing audits of all antibiotics ordered each month, placement of orders without proper documentation were practically eliminated. "Before we transitioned to an electronic medical records system, our providers often failed to document a reason for antibiotic prescriptions or failed to discontinue treatment when an appropriate duration had been completed," Jackson said. "With a new barrier built into the electronic medical records, providers are required to document the specific condition that dictates the need for the antibiotic they want to order. Once this was in place, there was a sharp decline in prescription numbers." The findings were presented at the Association for Professionals in Infection Control and Epidemiology annual meeting in Nashville.

From "Antimicrobial Stewardship Cuts Antibiotic Use in Half"
Medscape (07/06/15) Lowry, Fran

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High Customizability Increases Risk for PCA Errors

Researchers in Philadelphia say their single-site analysis shows that patient-controlled analgesia (PCA) devices compromise patient safety by allowing customized drug delivery. While most of the 300 PCA prescriptions studied by the team from Thomas Jefferson University Hospitals called for standard programming and opioid concentrations, a significant share of patients who used custom settings were at risk from misprogramming and drug errors. Moreover, the rate of errors—about 400 per 10,000 uses—has not declined even with the introduction of smart pumps. The study concluded that simpler PCA technology with standardized settings might benefit the general patient population and help bring down the number of errors.

From "High Customizability Increases Risk for PCA Errors"
Anesthesiology News (07/01/15) Vol. 41, No. 7 Leung, Martin

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Incidence and Risk Factors for Progression From Short-Term to Episodic or Long-Term Opioid Prescribing

Researchers examined prescription records for 293 patients in Olmsted County, Minn., over a one-year period to determine the progression to episodic or long-term patterns of opioid prescribing. The patients received a total of 515 new prescriptions for opioid analgesics in 2009. Opioid prescribing was categorized as short-term, episodic, or long-term. Of the patients, 21 percent progressed to an episodic prescribing pattern, and 6 percent progressed to a long-term pattern. The most common indication for the first prescription was a painful procedure, such as surgery. Most patients received one prescription, but 16 percent received two prescriptions, and 16 percent received three or more. Substance abuse was associated with a long-term prescribing pattern compared with a short-term pattern. Nicotine use and substance abuse were significantly associated with an episodic or long-term prescribing pattern. These findings could help identify at-risk patients and contribute to the development of targeted clinical interventions.

From "Incidence and Risk Factors for Progression From Short-Term to Episodic or Long-Term Opioid Prescribing"
Mayo Clinic Proceedings (07/15) Vol. 90, No. 7, P. 850 Hooten, W. Michael; St Sauver, Jennifer L.; McGree, Michaela E.; et al.

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FDA Studying Potential Risk of Serious Adverse Events in Codeine Cough Medicines for Children

Codeine-containing cough and cold medicines for children carry possible risks of serious adverse events, according to the Food and Drug Administration (FDA). The potential risks include slowed or difficult breathing. The agency is studying the safety of the drugs—noting that children, particularly those who already have breathing issues, may be more susceptible to the adverse events. FDA warned two years ago that codeine should not be used for children who recently had surgery to remove their tonsils or adenoids. The European Medicines Agency (EMA) also said earlier this year that codeine should not be used to treat cough and cold in children aged 12 years or younger, and that codeine is not recommended for individuals aged 12 to 18 years who have breathing problems. FDA will investigate the safety of codeine-containing cold and cough medicines for children aged 18 years and younger, and will issue final conclusions and recommendations when the review is complete.

From "FDA Studying Potential Risk of Serious Adverse Events in Codeine Cough Medicines for Children"
FDA MedWatch (07/01/15)

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High Morbidity and Mortality Rates in Children With Multiple Intubation Attempts

A review of information in the PeDI (Pediatric Difficult Intubation) database has uncovered an alarming trend of morbidity and mortality in children who undergo multiple intubation attempts because of difficult airways. The analysis looked at 900 cases over a roughly two-year period, revealing a cardiac arrest rate of one in 75 for kids with airway issues compared to a rate of about 1.4 per 10,000 for other pediatric patients while under general anesthesia. The research indicated that cardiac arrest and other "severe" complications—including aspiration, severe airway trauma, and even death—were more common in children who had unanticipated difficult airways, who underwent airway management outside of the operating room, and who required four or more intubation attempts. To address the problem, researcher John Fiadjoe, MD, of Children's Hospital of Philadelphia said educational outreach is needed. For one, the assistant professor of anesthesiology and critical care noted, clinicians too frequently are using direct laryngoscopy to try to intubate kids who present with difficult airways. "It's important that we move away from direct laryngoscopy if it fails after the first couple of attempts," he stressed. "We should quickly move to something else that gives us a higher success rate."

From "High Morbidity and Mortality Rates in Children With Multiple Intubation Attempts"
Anesthesiology News (07/01/15) Vol. 41, No. 7 Vlessides, Michael

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States Snub Execution Drug Approved by Supreme Court

Several states that continue to scramble for limited supplies of execution drugs showed no signs of adopting the drug that was upheld by the Supreme Court in late June and that had a role in three apparently painful executions last year, lawyers and opponents of capital punishment said Tuesday. In Texas, the state prison system has a supply of the chemical—midazolam—on hand, but appeared to have no plans to start using it. Prison officials planned to instead use the sedative pentobarbital for the state's next scheduled execution on July 16. On June 29, Ohio issued a new lethal-injection protocol that no longer calls for midazolam. Experts in lethal injection law said some states were reluctant to turn to midazolam in part because of its involvement in high profile executions last year in Oklahoma, Ohio, and Arizona in which prisoners appeared to suffer. Of the nation's 31 states that have the death penalty, only a handful use midazolam or include it as an option in their official protocols, including Florida, Virginia, Alabama, Oklahoma, Louisiana, and Arizona. The other states use other chemicals, including pentobarbital, or do not specify the chemicals they use.

From "States Snub Execution Drug Approved by Supreme Court"
New York Times (07/01/15) Fernandez, Manny

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Accreditation Statements 
The 2015 Nurse Anesthesia Annual Congress has been prior approved by the American Association of Nurse Anesthetists for a maximum of 27.5 (CE) credits; AANA Code Number 1030986; Expiration date 09/01/2015.
The AANA designates the Pharmacology lectures as meeting the criteria for 3 CE credits in Pharmacology/Therapeutics.
The American Association of Nurse Anesthetists is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Provider approved by the California Board of Registered Nursing, Provider #10862, for 27.5 Contact Hours.
This educational activity is being presented without bias or conflict of interest from the planners and the presenters.





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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.

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Pain Ease Continuing Education for the CRNA Earn Your DNAP Discovery Continues Within

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