Anesthesia E-ssential

AANA Anesthesia E-ssential, June 21, 2018

Vital Signs

Large U.S. CRNA Contingent Heads to Budapest for IFNA World Congress

The International Federation of Nurse Anesthetists' (IFNA) World Congress convened in Budapest June 18-20, 2018, with more than 700 attendees. Approximately one-fifth of the attendees were from the United States.

Former AANA President Jackie Rowles, DNP, MBA, MA, CRNA, ANP, DAAPM, FAAPM, FAAN, was elected to her third two-year term (2018-2020) as IFNA president. She is the sixth president in the history of the federation. Other American CRNAs to serve before her were the late IFNA co-founder and former AANA President Ronald Caulk, CRNA, FAAN, and Sandra Ouellette, MEd, CRNA, FAAN, also a former AANA president.

View photos from the World Congress on AANA's Facebook page.

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AANA to VHA: Now is the Time to Grant CRNAs Full-Practice Authority

OIG report reveals 22 percent anesthesiology provider shortage in VA, contradicting VA final rule’s findings that excluded CRNA full practice authority

Park Ridge, Illinois – The American Association of Nurse Anesthetists (AANA) is urging the VA to reopen its final rule to grant Certified Registered Nurse Anesthetists (CRNAs) the authority to practice to the full scope of their education, training, certification and licensure. The AANA’s request comes in light of a report from the Department of Veterans Affairs’ (VA) Office of the Inspector General (OIG), released June 14, that reveals the VA has a rampant anesthesia provider shortage, limiting access to care for veterans.

In the just-released OIG report,* anesthesiology was listed as having a provider shortage at 31 of 141 surveyed facilities throughout the VHA, meaning 22 percent of these facilities have an identified shortage of anesthesia providers, in direct contrast to the VA final rule that denied nurse anesthetists full practice authority. The December 2016 final rule stated the denial was not due to any lack of capability on nurse anesthetists, saying “[t]he safety of CRNA services has long been recognized by the VHA and underscored by peer-reviewed scientific studies, including a major study published in Health Affairs which found that anesthesia care by CRNAs was equally safe with or without physician supervision,” but because there is “no shortage of physician anesthesiologists in VA and the current system allows for sufficient flexibility to address the needs of all VA hospitals.”

The VA final rule also stated that if the agency learns “of access problems in the area of anesthesia care in specific facilities or more generally that would benefit from advanced practice authority, now or in the future, or if other relevant circumstances change, we will consider a follow-up rulemaking to address granting full practice authority to CRNAs."

“Improving the VA’s ability to provide better, faster care to our veterans doesn’t require increasing budgets or staff,” said AANA President Bruce Weiner, DNP, MSNA, CRNA. “One solution has been there all along, and is as simple as removing barriers to CRNAs’ ability to practice to the full extent of their education, training, certification and licensure.”

With roughly 900 CRNAs in the VHA system, CRNA full practice authority would greatly increase the access to surgical and anesthesia care the VHA could provide for its veterans.

“Veterans are still waiting entirely too long to receive the quality healthcare they deserve and have earned in service to our country. The AANA strongly urges the VA to solve this problem by using readily available healthcare resources – such as CRNAs – to the full extent of their practice authority,” said Weiner.

* Large file, may be slow to load.

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Hot Topics

National Post-Traumatic Stress Awareness Month: Identify, Manage Symptoms

June is National Post-traumatic Stress (PTSD) Awareness month; June 27 is PTSD Awareness Day. Take this opportunity to share supportive resources with friends and family to help identify and manage symptoms. Helpful links:

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New User-Friendly URL for COA Website

The Council on Accreditation of Nurse Anesthesia Educational Programs’ (COA) website has a new, user-friendly URL. You will still be able to access all the pertinent content that you currently do, with the same login that you use today. Be sure to update your bookmarks for quicker access. Visit today!

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A Malpractice Insurance Policy Designed Specifically for Employed CRNAs

Did you know that your employer can settle a claim on your behalf without your consent? Ensure you have protection when you need it with a policy that supplements the coverage provided by your employer. Learn more: Employed CRNA Toolkit.

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Professional Practice

American Nurses Association Call for Committee Nominations

The American Nurses Association’s (ANA) annual call for nominations for appointed positions to committees and subsidiary boards is open until 5:00 p.m. ET on Friday, June 29, 2018. Information about available positions can be found on ANA’s website. Please note, most of these positions require ANA membership.

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FDA Approves First Generic Versions of Suboxone

The U.S. Food and Drug Administration (FDA) has approved the first generic versions of Suboxone (buprenorphine and naloxone) sublingual film for the treatment of opioid dependence. “The FDA is taking new steps to advance the development of improved treatments for opioid use disorder, and to make sure these medicines are accessible to the patients who need them. That includes promoting the development of better drugs, and also facilitating market entry of generic versions of approved drugs to help ensure broader access,” said FDA Commissioner Scott Gottlieb, MD. Learn more in FDA’s news release.

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Debriefing After Surgery

During National Time Out Day on June 13, The Joint Commission and the Association of periOperative Registered Nurses (AORN) partnered again this year to raise awareness of the value of a surgical/procedural time out for patient safety. This year the two organizations placed special emphasis on the post-operative debriefing as an important component of the surgical safety checklist. The debrief happens after the surgery/procedure and before the patient leaves the room.

Debriefing after surgery:

  • Promotes collaborative information sharing, which supports the patient’s postoperative recovery.
  • Provides time to identify defects or system barriers during the surgery and enhances team learning.

AORN recommends all perioperative team members evaluate their postprocedure debrief. In particular, teams should evaluate barriers to performing an effective debrief. AORN recommends a standardized debriefing process, which can be customized for your facility and team from the AORN’s Comprehensive Surgical Checklist. Read additional information on patient procedural and surgical safety from The Joint Commission and AORN, including The Joint Commission’s Universal Protocol resources.

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The Joint Commission Implements Survey Process Improvements to Assess Safety Culture

Beginning in June 2018 for hospitals and critical access hospitals (CAHs) and October 2018 for all other programs, The Joint Commission will implement changes to the survey process to assess the organization’s patient safety culture. Survey improvements include requiring the organization to:

  • Provide the organization’s completed Safety Culture Survey for review by Joint Commission surveyors early in the Joint Commission survey process.
  • View the video Leading the Way to Zero during the Leadership Session of The Joint Commission survey.
  • Undergo a safety culture tracer during The Joint Commission survey. Surveyors will trace safety culture as part of survey activities and ask questions during the survey to assess safety culture.

For specific details about these survey improvements, read "Safety Culture Assessment: Improving the Survey Process".

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Foundation and Research

Enhanced Features to CMS Quality Payment Program MIPS and APM Look-Up Tools Now Available

The Centers for Medicare & Medicaid Services (CMS) just updated its Quality Payment Program Look-Up Tool to allow clinicians to view 2018 Merit-based Incentive Payment System (MIPS) eligibility and Alternative Payment Model (APM) Qualifying APM Participant (QP) data—in one place. With the enhanced tool, using your National Provider Identifier (NPI), clinicians can now review their MIPS participation status and/or their Predictive Qualifying APM Participant (QP) status based on calculations from 1/1/17 to 8/31/17. CMS also has created the ability for group practices to download a list of all NPIs associated with the TIN to view eligibility status of every clinician in the group. To obtain the detailed group list you must use your EIDM credentials and log into the CMS Quality Payment Program portal. If you have questions about these tools and how to access them, please email or call 1-866-288-8292 to speak with a QPP service representative.

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AANA Member Benefits

New AANALearn Courses Just for Members!

Take advantage of two complimentary new courses to help you advance patient safety and improve outcomes. Earn Class A Credits as you learn the latest technology offerings and best practices for monitoring patients undergoing anesthesia for potential complications related to brain health and respiratory compromise. Login to your AANA account is required. The following courses are supported by Medtronic:

  1. What's New with Neurological Monitoring for Patients Undergoing General Anesthesia
  2. Respiratory Compromise: Can Innovation in Monitoring Improve Patient Care and Outcomes?

Get Started Today!

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5-Minute Financial Risk Assessment

One Advisory PartnersLearn about risk assessment from Member Advantage Partner ONE Advisory Partners. Every day talented CRNAs perform pre-anesthesia evaluations on their patients. In essence, CRNAs perform indispensable patient risk assessments before administering anesthesia. But how many CRNAs have taken the time to evaluate the risk in their own financial lives? Now CRNAs can get an assessment in merely 5-minutes. 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.

Clonidine Effect on Pain After Cesarean Delivery

Researchers in Brazil questioned whether adding clonidine to spinal anesthesia would increase pain relief following elective cesarean childbirth. Over the course of one year, April 2016 to April 2017, they enrolled 78 women who were scheduled for C-section under spinal anesthesia in their double-blind trial. Each participant was randomly assigned to intrathecal clonidine, intravenous clonidine, or placebo on top of usual care. The final analysis included 64 women, who were rated for pain on movement using the Numerical Verbal Scale and measured for sedation using the Richmond Agitation and Sedation Scale. Although clonidine deepened sedation in patients compared with placebo, regardless of the administration route, it had no effect on 24-hour postoperative pain.

From "Clonidine Effect on Pain After Cesarean Delivery"
Anesthesia & Analgesia (07/18) Vol. 127, No. 1, P. 165 Fernandes, Hermann S.; Bliacheriene, Fernando; Vago, Thúlio M.; et al.

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Short Periods of Hyperoxia Associated with Worse Outcomes for Mechanically Ventilated Patients

While prolonged exposure to overly high oxygen levels has already been linked to worse outcomes, researchers wondered if shorter exposures—like after emergency department (ED) intubation—have an equally unfavorable effect. A team from Washington University in St. Louis undertook an observational cohort study that aimed to "assess the association between hyperoxia after intubation in the ED and clinical outcomes in patients who were subsequently normoxic while in the ICU," explains lead study author Brian Fuller. The investigators considered 688 cases, with about 51 percent of the patients experiencing normoxia and more than 43 percent sustaining exposure to hyperoxia. According to the evidence, hyperoxia was associated with higher mortality risk, prolonged duration of mechanical ventilation, and extended length of stay in the hospital. The findings indicate that even fairly short bouts of hyperoxia may be harmful for critically ill patients, says Fuller, adding that the immediate focus after mechanical ventilation should be normoxia. "There is no downside to targeting normoxia, so given the association between hyperoxia and harm, excessive oxygen administration should be avoided," he adds, noting that this could be easily accomplished just by "turning a dial on the ventilator."

From "Short Periods of Hyperoxia Associated with Worse Outcomes for Mechanically Ventilated Patients"
Anesthesiology News (06/18/18) Rosenthal, Thomas

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Intravenous Acetaminophen Has Limited Benefit for Colectomy Patients, Study Finds

Acetaminophen administered orally controls pain after colorectal procedures just as well as much more expensive intravenous delivery, according to a first-of-its-kind study. Researchers at New York-based Mount Sinai reviewed data on 181,640 patients nationwide who underwent colectomy between 2011 and 2016. IV acetaminophen was used in approximately a quarter of the surgeries; but the approach did not significantly lower postoperative opioid use. In fact, acetaminophen taken by mouth appeared to be equivalent or superior to IV administration, particularly in cases where patients received multiple doses on the day of surgery. The investigators believe IV acetaminophen may be an option for patients who cannot tolerate oral medication, but the findings do not support its routine use. Reporting in Anesthesiology, they recommend more research to pinpoint the optimal dosing regimen and appropriate types of procedures. While the current study demonstrates limited effects of IV acetaminophen after colectomy, the benefits could be more pronounced in other surgeries with a different patient population.

From "Intravenous Acetaminophen Has Limited Benefit for Colectomy Patients, Study Finds"
Medicalxpress (06/18/2018)

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Study with Implications for Opioid Crisis Finds Opioids Raise Risk of Fracture Nonunion

Findings from a new study tie chronic opioid use to poor healing after bone fracture. The researchers looked at more than 300,000 common bone fractures, along with patients' medication use. They discovered that, as a class, opioids like tramadol, hydromorphone, and meperidine raised the risk of fracture nonunion compared with non-opioid analgesics. "Chronic opioid use roughly doubled the risk of nonunion among all patients, and this effect was fairly consistent across all ages and both genders," according to Robert Zura, MD, of LSU Health New Orleans School of Medicine. Based on the results, he and his colleagues emphasize the importance of multimodal, non-opioid analgesic techniques at fracture.

From "Study with Implications for Opioid Crisis Finds Opioids Raise Risk of Fracture Nonunion"
ScienceDaily (06/15/18)

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Corticosteroid Plus Lidocaine Injections Do Not Alleviate Pain in Central Lumbar Spinal Stenosis

Researchers designed a randomized trial to explore the effect of supplementing local anesthetic epidural injections with corticosteroids in the setting of central lumbar spinal stenosis. A total of 400 patients aged 50 years or older who had never undergone lumbar surgery were recruited for the University of Washington study, with 89 percent of them completing the 12-month protocol. Patients were randomly and blindly assigned in a 1:1 ratio to receive lidocaine epidural injection with or without corticosteroid. One to two injections were administered for six weeks, with zero to two additional injections between weeks six and 12. Study participants were permitted to cross over to the alternate treatment at six weeks, which 45 percent of the lidocaine-only group elected to do versus 30 percent of the lidocaine-corticosteroid group. At 12 months, there was no between-group difference in change in disability or leg pain intensity scores from baseline. Writing in an accompanying editorial in the Journal of Bone & Joint Surgery, Vanderbilt University Medical Center's Nitin Jain, MD, noted that lidocaine and corticosteroids alike would be expected to deliver optimal relief in the first few weeks after an injection, owing to their half-life. "Therefore," Jain speculated, "corticosteroid spinal injections could have a role in clinical practice, even if they do not lead to better outcomes at one year of follow-up, if they can provide better symptomatic relief at six weeks."

From "Corticosteroid Plus Lidocaine Injections Do Not Alleviate Pain in Central Lumbar Spinal Stenosis"
Clinical Pain Advisor (06/13/18) Morr, Madeline

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New Algorithm Can Predict Low Blood Pressure Risk During Surgery

A newly developed algorithm predicts the onset of dangerously low blood pressure in surgical patients up to 15 minutes before it actually happens, allowing the problem to be addressed proactively rather than reactively. The team led by anesthesiology professor Maxime Cannesson, MD, PhD, of UCLA Medical Center collected data on more than 1,300 patients—records of arterial pressure waveform activity and episodes of hypotension, specifically. They extracted more than 3,000 individual features for each heartbeat which, when combined, generated an estimated 2.6 million bits of information that helped to build the algorithm. "We are using machine learning to identify which of these individual features, when they happen together and at the same time, predict hypotension," explains Cannesson. "By finding a way to predict hypotension, we can avoid its complications, which can include postoperative heart attack and acute kidney injury, that can lead to death in some cases." The study appears in Anesthesiology.

From "New Algorithm Can Predict Low Blood Pressure Risk During Surgery"
R&D Magazine (06/11/18) Walter, Kenny

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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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June 21, 2018
VCU United Anesthesia