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Vital Signs


Following AANA Response to VA Secretary and Under Secretary Statements about CRNAs, AANA Urges CRNAs to Take Action

With the AANA having responded strongly to a March 2 statement in Congress by Veterans Affairs Secretary Bob McDonald that he feels “least comfortable” with CRNAs having full practice authority in the Veterans Health Administration (VHA), the AANA is once again urging members to take action.

Citing the Institute of Medicine and the Veterans Administration Independent Assessment, AANA President Juan Quintana, DNP, MHS, CRNA, wrote, “Together with many veterans, veterans organizations, the AARP, nursing groups and members of Congress, we continue to request that the VHA publish in the Federal Register for public comment a proposed rule expanding veterans access to care by CRNAs and other APRNs at the earliest possible date, so that our veterans may benefit from improved access to quality healthcare.”

To take action, click www.VeteransAccessToCare.com, and share the site with your colleagues, family and friends—especially those who are themselves veterans. To read the AANA letter, click here. To read what the VA Secretary said, click here.

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CPC Facts


CPC Program: The Two-Year Check In, Just as You’ve Been Doing

The myth is that there is a new “interim” check-in under the Continued Professional Certification (CPC) Program. Though the continuing education periods in the CPC Program are divided into two four-year cycles, you will still check in every two years, just as you are used to doing now. The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) wants to be respectful of the two-year timing that CRNAs have become accustomed to, and so will continue to follow that even after the CPC Program begins. At these two-year check-ins (at the midpoint of your four-year cycle), certificants will still pay the same fee, at the same time as they do now.

For instance, a CRNA certifying in 2016 will pay $110, just as they've been doing all along, as part of their recertification requirements in the existing program. Two years later, in 2018, that CRNA will come back to the NBCRNA and pay another $110, just as they always have. At that time they will complete a brief validation of their state license and continued nurse anesthesia practice, as well as verify (or update) their contact information. Also at that time, they will be able to review their progress toward CPC Program compliance (still two years away in their first four-year cycle) and make plans for the last two years of their current cycle. In 2020, another two years later, they will come back and pay their $110 fee, fill out their CPC application, and verify their Class A and Class B credits as presented by the AANA (or they will present their Class A and B credits for review if they are not an AANA member). Finally, just like the current program, they will be authorized for continued nurse anesthesia practice once all of the necessary information is submitted and verified.

For more information about the NBCRNA's 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


AANA Celebrates NPSF’s United for Patient Safety Campaign

Healthcare is a joint effort between healthcare providers and patients. “United for Patient Safety,” this year’s theme for National Patient safety Foundation’s Patient Safety Awareness Week, held March 13-19, 2016, focuses on the patient’s role in their own health. The campaign highlights patient engagement and the importance of building relationships among clinicians, patients, and family members to promote patient safety and optimize health. AANA encourages all clinicians, patients, and others involved in the delivery of healthcare to unite and collaborate in the promotion of patient safety. Download resources and view ways to engage with the United for Patient Safety Campaign at www.unitedforpatientsafety.org and www.aana.com/PSAW
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AANA Partners with MHAUS to Educate Patients and Clinicians About Malignant Hyperthermia

March is Malignant Hyperthermia (MH) Awareness and Training Month and the AANA has joined the Malignant Hyperthermia Association of the United States (MHAUS) in educating patients and healthcare professionals about the resources and guidance available for scientific understanding and optimum treatment of MH and related disorders.

MH is a rare, inherited syndrome that can affect patients who are receiving anesthesia for surgery or other procedures. It presents suddenly as an extreme metabolic reaction to various anesthetic gases and drugs. The signs of MH include muscle rigidity, rapid heart rate, high body temperature, muscle breakdown and increased acid content. Early recognition of an impending MH crisis and prompt emergency response are critical for a patient’s survival.

“As an anesthesia or healthcare provider, knowing about MH is important to saving the lives of our patients,” said Debra Merritt, MSN, CRNA, who is a member of the MHAUS Board of Directors. “MH raises many questions for patients and their families, so it’s important for anesthesia professionals to be knowledgeable about the syndrome and be able to serve as a resource. Patient safety has always been the first priority for CRNAs.” In April 2015, the AANA Board of Directors adopted the position statement titled Malignant Hyperthermia Crisis Preparedness and Treatment, which contains the AANA’s position on stocking dantrolene and considerations for MH policy development. Dantrolene is currently the only clinically accepted drug treatment for MH and is available in two formulations.

Anesthesia professionals may be the first to recognize the onset of an MH crisis, but a coordinated team response is vital in the effective treatment and management of MH. For emergencies only, call the MHAUS 24-hour MH Hotline at 1-800-644-9737.

For detailed information on MH crisis preparation, patient assessment, management, and transfer of care visit www.mhaus.org and the AANA’s MH clinical resource webpage at www.aana.com/MH to access the position statement, articles, and other resources.

The preceding news story is adapted from the AANA Press Release dated March 3, 2016.
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COA Revises Eligibility for Accreditation Policy

At its January 2016 meeting, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) reviewed proposed revisions to the COA’s “Eligibility for Accreditation” policy. Revisions to the policy relate to eligibility requirements for applicant programs seeking initial accreditation by the COA. The revised policy introduction now states that applicant programs’ degree-granting institutions must be accredited by a regional accrediting agency officially recognized by the U.S. Secretary of Education to accredit institutions prior to seeking Council accreditation. A Call for Comments survey on this policy is open and will be available on the COA website until March 18, 2016. A mark-up of the revised policy is also available on the website.
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Want to Serve on an AANA Committee?

Positions are available on AANA Committees for CRNAs and student registered nurse anesthetists. Check out the committee page on the AANA website to read about the various opportunities. Deadline for submission of a committee request is May 15, 2016. Please note: If you currently serve on a fiscal year 2016 committee, you must reapply for fiscal year 2017.
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Professional Practice


Health IT Safety Collaborative Issues Recommendations on the Safe use of Copy and Paste

In the recently released, publicly-available toolkit, Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste, the Partnership for Health IT Patient Safety presents the four safe practice recommendations, along with actionable resources to facilitate the implementation of these recommended safe practices. The Partnership identified the following Safe Practice Recommendations for the use of copy and paste. They encourage stakeholders to:
  • Provide a mechanism to make copy and paste material easily identifiable.
  • Ensure that the provenance of copy and paste material is readily available.
  • Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
  • Ensure that copy and paste practices are regularly monitored, measured, and assessed.
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ICD-10 Next Steps Toolkit for Providers

The Centers for Medicare & Medicaid Services (CMS) has released the Next Steps Toolkit to help providers track and improve ICD-10 progress. This new, in-depth toolkit includes information and resources on how to:
  • Assess ICD-10 progress using key performance indicators to identify potential productivity or cash flow issues
  • Address opportunities for improvement
  • Maintain progress and keep up-to-date on ICD-10
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Protect Patients from Antibiotic Resistance

The CDC’s latest Vital Signs report urges healthcare workers to use a combination of infection control recommendations to better protect patients from healthcare-associated infections (HAIs) and antibiotic resistance. CDC is calling on doctors, nurses, health care facility administrators, and state and local health departments to continue to do their part to prevent HAIs. The report recommends doctors and nurses combine three critical efforts to accomplish this:
  • Prevent the spread of bacteria between patients;
  • Prevent infections related to surgery and/or placement of a catheter; and
  • Improve antibiotic use through stewardship.
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Meetings and Workshops


SAVE THE DATE for #AANA2016!

The 83rd AANA Annual Congress will be held Sept. 9-13, 2016, in Washington, D.C. Washington, D.C. Look for the Preliminary Program with your copy of the April issue of the AANA Journal.
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Register Now for Business of Anesthesia Conference

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

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

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


AANA Foundation 2016 Award Nominations Due March 31

Each year the AANA Foundation presents awards at the AANA Annual Congress to individuals who have made a difference in the nurse anesthetist community. Take the time to recognize someone you appreciate. The deadline for Award nominations is March 31, 2016. Click here to access the nomination/application forms for:
  • Advocate of the Year—Presented to an advocate committed to supporting the AANA Foundation and encouraging others to do the same.
  • John F. Garde Researcher of the Year—Presented to an individual who has made a significant contribution to the practice of anesthesia through clinical research.
  • Rita L. LeBlanc Philanthropist of the Year—Presented to an individual who has donated time, talent and direct financial support to the AANA Foundation and other deserving organizations.
  • Janice Drake CRNA Humanitarian Award— Presented to a CRNA who wishes to volunteer and provide anesthesia, education and training in underserved areas.
Forward the completed form to the AANA Foundation – email to foundation@aana.com or mail to 222 S. Prospect Avenue, Park Ridge, IL 60068.

Thank you in advance for recognizing a member of the nurse anesthesia community. If you have any questions, please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.
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AANA Foundation Research Grant Applications Due May 1

The mission of the AANA Foundation is to advance the science of anesthesia through education and research. As the philanthropic arm of the AANA, the Foundation raises funds and invests in projects that directly support the AANA Foundation and AANA priorities. One of the goals of the AANA Foundation is to support new and seasoned investigators in nurse anesthesia through grants and fellowships. The AANA Foundation sets a broad research agenda that includes the following areas:
  • Healthcare policy
  • Science of anesthesia
  • Education
  • Practice/Clinical
  • Leadership
Spring Research Grant applications are currently available on the AANA Foundation website at www.aanafoundation.com. General research grants are awarded to AANA member CRNAs in good standing. Research funding priorities change annually. Click here to access the 2016 research agenda and link to the application page. If you have any questions, please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.
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AANA Foundation “State of the Science” Oral and General Poster Presentations


“State of the Science” offers an opportunity for CRNAs and SRNAs to present their research findings and innovative educational approaches at the AANA Nurse Anesthesia Annual Congress in Washington, D.C., Sept. 9-13, 2016. Research, literature reviews, and innovative, creative techniques in anesthesia are appropriate topics. Click here to access the applications which are currently available on the AANA Foundation website at www.aanafoundation.com.

Oral Poster Presentation – April 1 Deadline – An award of up to $1,000 accompanies oral presentation

General Poster Presentation – May 1 Deadline

If you have any questions, please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.

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Federal Government Affairs


Member Update: Expanding Veterans Access to Care through Full Practice Authority for VHA CRNAs, APRNs

With the AANA working with a broad coalition in support of improving veterans access to care through full practice authority for CRNAs and other APRNs, here is a brief rundown to keep members apprised of current actions:
  • On the regulatory process front, the White House Office of Management and Budget (OMB) continues evaluating a proposed rule on APRN full practice authority submitted by Veterans Affairs Secretary Robert McDonald in early January. The OMB has until early April to publish the rule in the Federal Register and trigger a 60-day public comment period, or return it to the Veterans Administration for more work. AANA is urging all members to use www.Veterans-Access-To-Care.com to submit regulatory comments ahead of time in support of improving veterans access to quality healthcare through CRNA and APRN full practice authority. AANA members can also share the site with colleagues, friends and family—especially veterans—to take action.
  • In the legislative arena, the AANA-backed HR 1247 continues gathering cosponsors and is now up to 46 bipartisan cosponsors in the House of Representatives. In the Senate, the AANA-supported S 2279 now has eight bipartisan cosponsors. These cosponsorships help demonstrate support for the full practice authority proposed rule now making its way through the regulatory process.
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Senate Approves Legislation to Combat Opioid Abuse, Diversion

The U.S. Senate on March 10 approved on a 94-1 vote a major bill authorizing new grants and programs intended to combat opioid abuse and diversion. Issues relating to opioid abuse and diversion are relevant to CRNAs clinically as persons with addictions arrive in the operating room, and in professional practice as CRNAs administer or in some circumstances prescribe opioids. CRNAs also provide comprehensive pain management services that may help reduce pain patients’ need for opioid painkilling medications.

The bipartisan “Comprehensive Addiction and Recovery Act,” (S 524) authorizes about $78 billion annually through 2020 for grants from the Departments of Health and Human Services and the Justice Department to expand the availability of naloxone to law enforcement agencies and first responders, boost prescription drug monitoring programs, increase drug treatment for incarcerated persons, and prohibit the Education Department from including questions on the federal financial aid application about possession or sale of illegal drugs. The next step for the bill is action in the U.S. House of Representatives.

See how your Senators voted here.
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Recent Fraud Cases Underscore Importance of Accurate Documentations, Claims

Two recent Medicare fraud convictions underscore the importance CRNAs should ascribe to accurate documentation and to accurate Medicare claims.

In one case, a jury in Dallas on March 3 convicted anesthesiologist Dr. Richard Toussaint, Jr., a co-founder of Forest Park Medical Center, for filing false claims to Blue Cross Blue Shield of Texas, United Healthcare, the federal employee health benefits program, and others, according to Becker’s Hospital Review. According to Becker’s, Dr. Toussaint filed claims for some $10 million in fraudulent payments, including claims for being present for procedures when he was out of state – and one when he himself was the patient. He faces a prison sentence of up to 10 years and a maximum fine of $250,000 for each of seven counts, plus restitution and property forfeiture.

In another case, a Chicago internal medicine physician, Dr. Venkateswara Kuchipudi, was convicted by an Illinois jury on March 3 for accepting kickbacks for referring patients to Sacred Heart Hospital where he practiced. According to Law 360, he accepted free labor from nursing staff in exchange for his referring patients to the hospital.

See the Becker’s article here. See an AANA NewsBulletin article on CRNAs and the False Claims Act here.
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Medicare Delays Implementation for Certain Network Adequacy Provisions; States Given Responsibility to Take Action

In a final rule published the week of March 7, Medicare said that it will delay implementation of certain network adequacy provisions in order to give time to states to take action on the issue. Late last year, in response to the Department of Health and Human Services’ (HHS) Notice of Benefit and Payment Parameters for 2017 proposed rule, which solicited comments regarding provider network adequacy, the AANA and nine APRN organizations asked that APRNs be included in the networks of qualified health plans participating in federally facilitated marketplaces. The AANA and APRN groups also recommended that qualified health plans design their network participating provider selection criteria so as not to discriminate against qualified licensed healthcare providers acting within their state scope of practice laws and regulations.

The final rule stated that the agency is “not implementing additional network adequacy related provisions at this time. Our intention is to give states time to adopt the NAIC Network Adequacy Model Act provisions and potentially reconsider this area in the future." Consistent with a recommendation from AANA, in December 2015, the National Association of Insurance Commissioners (NAIC) has included in its latest model law new language expanding recognition of healthcare providers like CRNAs in plan networks, and expressly recognizing the federal AANA-backed Provider Nondiscrimination law.

View the AANA’s comments here. View the APRN organization’s comments here. View the final rule here. View the NAIC Network Adequacy Model Act here.
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AANA Urges Novitas Medicare to Correct LCD and Cover CRNA Services Fully

On Feb. 26, AANA submitted to Medicare administrative contractor (MAC) Novitas Solutions comments on its draft local coverage determination (LCD) affecting coverage of CRNA pain management services in 11 states and the District of Columbia where Novitas administers the Medicare program. The Novitas’ draft LCD affects Medicare coverage in the following states: Arkansas, Colorado, Delaware, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, Texas, and Washington, DC.

In the comment letter, the AANA stated that CRNAs are appropriately educated and certified to deliver pain management services; requested clarification on how Novitas arrived at its decision to grandfather the training requirement at 10 years; urged Novitas to remove a proposed requirement for CRNAs regarding radiologic imaging; requested clarification on a requirement that a practitioner be credentialed in the hospital and outpatient and office settings; urged Novitas to amend training requirements to be the same across healthcare professionals; and requested that Novitas allow for a transforaminal or interlaminal injection in conjunction with a caudal injection when medically necessary.

The AANA letter signed by President Juan Quintana, DNP, MHS, CRNA, stated, “The AANA strongly objects to the Provider Specialty Section of this draft LCD. To exempt physician specialties from training requirements, but not to do so for all types of healthcare professionals who currently provide these services, is arbitrary and discriminatory…. We urge Novitas to amend this training requirement so that it is the same across healthcare professionals and does not discriminate on the basis of licensure in violation of Medicare policy.”

Read the AANA comment letter here. Read the Novitas draft LCD here.
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AANA Requests that CMS Involve CRNAs, APRNs in Measure Development Process for MIPS and APMs

In response to Medicare’s release of a draft quality measure development plan, the AANA requested that CRNAs be included in a transparent and consensus-driven quality measure development process for the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) prior to releasing new measures.

The draft Measure Development Plan (MDP) supports the development of the MIPS program authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The MDP outlines how existing measurement strategies, policies, and principles will guide the agency’s efforts in building measure portfolios for MIPS and APMs. According to CMS, future measure development will prioritize person- and caregiver-centered experience of care, patient-reported outcomes and patient health outcomes, communication and care coordination, and appropriate use of resources across six quality domains. Those six domains are clinical care, safety, care coordination, patient and caregiver experience, population health and prevention, and efficiency and cost reduction.

The letter signed by AANA President Juan Quintana, DNP, MHS, CRNA, requests that CRNAs not be excluded from development of non-consensus endorsed quality measures for MIPS and APMs, and that CRNAs and APRNs should not be forced to participate in a physician specialty association’s qualified clinical data registry. The letter also emphasizes that the most cost-effective, safe anesthesia care delivery model is CRNA services and recommended that CMS arrange the components within the MIPS system and APMs to promote their use.

View AANA’s comments, here. View the draft Quality Measure Development Plan here.
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Medicare and Health Plans Unite on Quality Measures Plan; No Direct Application to Anesthesia

After a thorough review of the quality measures listed under the seven core sets of clinical quality measures that support multi-payer alignment for reporting to physician quality programs released by the Core Quality Measure Collaborative, the AANA has determined that none of the current quality measures directly apply to anesthesia. Furthermore, the quality measures in these seven core sets will not directly impact CRNAs because compliance will be determined at the hospital or facility level.

On Feb. 16, the Core Quality Measure Collaborative, led by America’s Health Insurance Plans (AHIP), leaders from the Centers for Medicare & Medicaid Services (CMS) and the National Quality Forum (NQF), and other healthcare stakeholders, released seven sets of clinical quality measures that support multi-payer alignment for reporting to physician quality programs. The guiding principles used by the collaborative in developing the core measure sets are that they be meaningful to patients, consumers, and physicians while reducing variability in measure selection, collection burden, and cost. CMS and AHIP have identified future measures which they plan to consider but have not yet developed. The AANA will closely monitor any future measures for impacts on CRNA practice.

To view the CMS press release on release of the seven sets of measures, click here. To view the Core Measures, click here.
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CRNA-PAC Potpourri

The CRNA-PAC, the only PAC devoted to protecting and advancing CRNA issues in Washington, is under way with several activities engaging AANA membership this spring:
  • The PAC’s spring development campaign is under way now! If you get a call, letter or email from your CRNA-PAC, answer the call and support the PAC’s efforts to raise $1.8 million this 2015-16 election cycle and ensure that the voice of nurse anesthesia is heard on Capitol Hill.
  • As part of AANA Mid-Year Assembly, the CRNA-PAC is hosting a “Bootlegger’s Ball” Sunday evening on the Georgetown Potomac waterfront. Contributors at the Presidential or Diplomat Club levels—over $1,000 during AANA Fiscal Year 2016—gain access to a “Smugglers’ Cruise” by the monuments after the ball. To RSVP for the cruise, email info@aanadc.com and include “Smugglers’ Cruise” in the subject line.
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Upcoming Presidential and Congressional Elections

The AANA encourages CRNAs to vote and be active in primary elections this winter and spring in support of candidates of their choice. If you are involved in one of the following early primary or caucus campaigns below, AANA DC would be delighted to hear from you. Tell your story or send your pictures to info@aanadc.com with “CRNAs in Campaigns” in the subject line.
  • March 15, presidential primaries in Florida, Illinois, Missouri, North Carolina and Ohio; Republican caucus in the Northern Marianas Islands; congressional primaries in Illinois, North Carolina (U.S. Senate), and Ohio
  • March 19, Republican caucus in the Virgin Islands
  • March 22, presidential primary in Arizona; Republican and Democratic caucuses in Utah; Democratic caucus in Idaho; Republican caucus in American Samoa
  • March 26, Democratic caucuses in Alaska, Hawaii, and Washington

For an up-to-date list of 2016 election dates by state and by date, see here.
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Amendments

  • The Senate Finance Committee approved the nomination of Mary Wakefield, PhD, RN, FAAN, as Deputy Secretary of Health and Human Services on March 2, 2016. The AANA strongly supports her confirmation by the full Senate later this year.
  • In support of VA Medical and Prosthetic Research, the AANA has endorsed the Friends of VA Medical Research and Health Care Coalition’s (FOVA) FY 2017 budget request.
  • The Veterans Affairs Office of Inspector General (VA OIG) this month released several “administrative summaries of investigation regarding wait time,” outlining specific instances where care for veterans was delayed. The AANA is reviewing the 21 reports regarding care delays in seven states. You can find the reports here.
  • With changes coming to Medicare quality reporting systems, a new study published in Health Affairs says healthcare practices spend $15.4 billion each year to report quality measures. See the abstract here.
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The following is an FEC required legal notification for CRNA-PAC

Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. Each contributor must be a U.S. Citizen.
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Jobs


Visit www.crnacareers.com to view or place job postings
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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.

Isoflurane Noninferior to Sevoflurane for Cardiac Surgery

Canadian researchers say isoflurane is just as safe and effective as sevoflurane for cardiac surgery, despite the common perception that it is inferior. For their study, 464 patients were randomized to receive one or the other anesthetic agent. The primary outcome—a stay of 48 hours or longer in the ICU or death for any reason within 30 days of the operation—was not statistically different for the two groups, at 25 percent for sevoflurane patients and 30 percent for isoflurane patients. The team also noted no meaningful difference between the cohorts in terms of surgical duration, time to ICU discharge, and time to hospital discharge. Absent any clear benefit of one agent over the other, researcher Philip Jones, MD, of the University of Western Ontario, concluded that anesthesia providers should choose the anesthetic that is least expensive—in this case, isoflurane.

From "Isoflurane Noninferior to Sevoflurane for Cardiac Surgery"
Anesthesiology News (03/07/16) Vlessides, Michael

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Presurgical Opioids Heighten Addiction Risk, Complications

Research cites preoperative opioid use as a risk factor for postsurgical consumption in patients undergoing total knee arthroplasty (TKA). Led by Robert Westermann, MD, of the University of Iowa, the study identified 112,569 TKA patients based on opioid history. At one month post-procedure, 83.2 percent of previous opioid users had filled a prescription for narcotic painkillers versus 52.1 percent of patients who had never used them before. One year after TKA, just 2.7 percent of nonusers were taking opioids, compared to 24 percent of previous users. Westermann and colleagues also discovered that presurgery opioid users were more likely than nonusers to experience postoperative complications such as respiratory failure, deep vein thrombosis, and acute renal failure within 90 days of surgery. The findings were presented at the American Academy of Orthopaedic Surgeons 2016 annual meeting—where Westermann noted that America accounts for 99 percent and 83 percent, respectively, of global hydrocodone and oxycodone consumption. "In other countries," he remarked, "people go home on Tylenol 3."

From "Presurgical Opioids Heighten Addiction Risk, Complications"
Medscape (03/04/16) Hein, Ingrid

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Pupillometry Accurately Predicts Postoperative Nausea and Vomiting, Allows Earlier Intervention

Building on earlier research demonstrating pupillometry as an effective tool to gauge analgesic needs in noncommunicative patients, investigators explored whether the approach also could identify patients likely to develop postoperative nausea and vomiting (PONV). The investigators included 47 patients in the study—which recorded changes in pupil diameter and constriction velocity before, during, and after elective surgery. Patient feedback on nausea symptoms was collected 15 minutes after admission to the post-anesthesia care unit and then again at 60 minutes. The data indicated that constriction velocity at 15 minutes is indeed a reliable predictor of PONV. "We suspect that patients with impaired pupillary light reflex measurements may have impaired autonomic balance upon discharge, which may result in increased rates of hospital readmission associated with [PONV]," said research Eric Yang, who presented the findings at the 2015 New York State Society of Anesthesiologists PostGraduate Assembly. Simon Lee, MD, of Atlanta's Emory University Hospital Midtown—where the research was conducted—expressed optimism that pupillometry ultimately will help shape an anesthetic and administration of medication for PONV prevention. "I'm hoping this will help us better prepare the patient for recovery, rather than just treat anesthetic-related symptoms," he said.

From "Pupillometry Accurately Predicts Postoperative Nausea and Vomiting, Allows Earlier Intervention"
Anesthesiology News (03/04/16) Duffy, Brigid

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Different Opioids Provide Similar Control of Cancer Pain

A Phase IV study revealed that four different opioids yielded similar analgesic efficacy, response rates, and safety profiles in patients with moderate to severe cancer pain. The 520 trial participants were randomized to receive oral morphine, oxycodone, transdermal fentanyl, or buprenorphine over a period of 28 days. During that time, worst and average pain intensity weakened by about the same margin for the different cohorts. Nonresponse rates were closely aligned as well, ranging from 11.5 percent for patients taking morphine to 14.4 percent for those taking buprenorphine. Adverse events also were similar, although neurotoxicity was a bigger factor with morphine—which also produced the highest rate of drug switches as well as the highest rate of adjuvant analgesic consumption. And while all patients needed their daily dose of drug to be upped, the increase was smallest with morphine—at 32.7 percent, compared to 121.2 percent with transdermal fentanyl. The researchers reported the findings in the Annals of Oncology.

From "Different Opioids Provide Similar Control of Cancer Pain"
Oncology Nurse Advisor (03/03/16) Hoffman, Jason

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Weak in the Knees? New Pain Relief Technique for ACL Surgery Preserves Muscle Strength

Anesthesia providers increasingly favor adductor canal block over conventional femoral block for ACL knee surgery, as evidence of its superiority grows. Additional proof comes from a Canadian study showing the technique, which blocks pain by numbing nerves in the mid-thigh, better maintains muscle strength, and improves patient safety while providing similar analgesia as femoral block, which numbs nerves in the groin. Based on a sample population of 100 patients, the researchers calculated that loss of strength in the quad muscles surrounding the knee was 71 percent for those who received femoral block but only 22 percent for the other patients. A total of three falls or near-falls were reported after femoral block, while none occurred after adductor canal block. Also, release from the recovery room—predicated on adequate pain relief and weight-bearing ability—came 18 minutes earlier on average for adductor canal block patients. The findings are reported online in Anesthesiology.

From "Weak in the Knees? New Pain Relief Technique for ACL Surgery Preserves Muscle Strength"
HealthCanal.com (03/03/16) Stephenson, Kendra

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Propofol Could Provide Benefits in Open Heart Surgery

Research reported in the Canadian Journal of Anesthesia highlights the protective role of propofol during open heart surgery. The 137 study participants were randomized to receive either propofol or isoflurane during cardiopulmonary bypass. The results revealed that patients in the propofol group experienced a higher increase in 15-F2t-isoprostane levels in the coronary sinus but a lower incidence of low cardiac output syndrome (LCOS). The benefits of propofol appear to be compounded in open-heart surgery patients who have diabetes mellitus, as LCOS occurrence in this subgroup was significantly lower than in a subgroup of non-diabetic isoflurane patients. Overall, meanwhile, fewer heart failure events took place under the propofol regimen. "Originally we thought we're protecting the heart by soaking up free radicals, but the reality is that propofol and how we administer it is actually changing the biology of the heart to a more favorable profile that protects mitochondria, keeping cell tissue alive," explained lead study author David Ansley, MD, of the University of British Columbia.

From "Propofol Could Provide Benefits in Open Heart Surgery"
HospiMedica (03/02/16)

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Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk

A new study confirms that preterm and former preterm children are almost twice as likely to experience adverse events, especially airway problems and respiratory distress, when sedated or anesthetized for diagnostic and therapeutic reasons. The Pediatric Sedation Research Consortium's study included 57,227 patients aged 0 to 22 years old. Findings revealed an adverse event rate of 14.7 percent in children born before 37 weeks, compared with 8.5 percent in full-term children. Moreover, the results indicated that this vulnerability to adverse events could linger into early adulthood. The investigators recommend that caregivers determine birth history before setting up an anesthetic/sedation plan, keeping in mind that preterm and former preterm children may have an elevated risk of complications.

From "Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk"
Pediatrics (03/01/16) Havidich, Jeana E.; Beach, Michael; Dierdorf, Stephen F.; et al.

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Evaluation of 2-Stage Injection Technique in Children

Limiting pain during local anesthetic injections is an important aspect of pediatric dentistry practice, leading researchers to explore new strategies toward this end. In India, investigators looked at pain scores in 100 patients aged seven to 13 who needed inferior alveolar nerve block, posterior superior alveolar nerve block, or maxillary and mandibular buccal infiltrations for a dental procedure. The children were randomized either for conventional technique or for a two-stage injection process. Use of the alternative approach was associated with substantially lower pain scores. Based on the finding, the researchers support the two-stage injection technique as an easy and effective way to curb injection pain in pediatric dental patients.

From "Evaluation of 2-Stage Injection Technique in Children"
Anesthesia Progress (Winter 2016) Vol. 63, No. 1, P. 3 Sandeep, Valasingam; Kumar, Manikya; Duggi, Vijay; et al.

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Intrathecal Analgesia Allows for Lowered Risk for Side Effects in Elderly With Metastatic Malignancies

Researchers have found success using intrathecal analgesia to treat pain in the elderly and in patients with end-stage malignancies. Their study entailed using intrathecal catheters to deliver a cocktail of five different drugs. Lead researcher Sadegh Abdolmohamamdi, MD, of the Universite de Montreal, who reported the results at the 2015 annual meeting of the Canadian Anesthesiologists' Society, explained why his team used multiple analgesics at once. "These were end-stage cases in whom we tried other options without success," he said. "Secondly, we didn't really want to try one medication, have it fail and then try another. Finally—and most importantly—the mechanism of pain is complex. So with just one medication—which affects one receptor and one pathway—we would never control it adequately." Although the mix of bupivacaine, naloxone, ketamine, morphine, and clonidine was potent, the small doses of individual medications reduced potential side effects. No major complications, like cognitive dysfunction or muscle weakness of the lower limbs, were reported in any of the three patients; and pain was successfully controlled.

From "Intrathecal Analgesia Allows for Lowered Risk for Side Effects in Elderly With Metastatic Malignancies"
Pain Medicine News (02/29/2016) Vlessides, Michael

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Capnographic Monitoring Fails to Reduce Hypoxemia in Routine Upper Endoscopy, Colonoscopy

New research suggests that using capnography to monitor oxygen saturation levels during moderate sedation for endoscopic procedures does not impact likelihood of hypoxemia. The study included 452 healthy patients undergoing routine esophagogastroduodenoscopy or colonoscopy with moderate sedation administered through an opioid/benzodiazepine formula. "We found for both the upper endoscopy and the colonoscopy arms of the trial, there was no difference in the incidence of hypoxemia with or without capnography," said John J. Vargo of the Cleveland Clinic's Digestive Disease Institute. "This study very much clarifies the use of capnography in this patient subset, and that capnography does not appear to have a safety advantage." The findings, reported in the American Journal of Gastroenterology, challenge institutional guidelines that endorse capnographic monitoring for endoscopies with moderate sedation.

From "Capnographic Monitoring Fails to Reduce Hypoxemia in Routine Upper Endoscopy, Colonoscopy"
Healio (02/29/2016) Leitenberger, Adam

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Positive Long-Term Results for Back Pain Procedure

Based on a year's worth of data from patients undergoing intradiscal biacuplasty (IDB), researchers believe the treatment offers significant relief and better quality of life for people with chronic low back pain. The technique involves precise placement of thermal probes to deactivate sensory nerves in the lumbar disc. The final phase of a prospective study documented significant drops in pain scores, which fell month after month. Patients also performed increasingly well on the 36-item short-form physical functioning scale. "This is the only study I know of that shows that the results are improving over time, so at 12 months, patients actually did better than after 1 month," said Canadian researcher Michael Gofeld, MD, who presented the findings at the 2016 annual meeting of the American Academy of Pain Medicine. He and colleagues concluded that IDB is a viable course of action for patients with level 1 to level 2 degenerative disc disease, disc thickness of more than 50 percent, and no sciatica who have not responded to conventional medical management. "The degenerated disc will not get better, but patients can restore their functional status and can get back to work and a normal active life," according to Gofeld.

From "Positive Long-Term Results for Back Pain Procedure"
Medscape (02/23/16) Anderson, Pauline

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Cognitive Functioning After Surgery in Middle-Aged and Elderly Danish Twins

The question of whether surgical anesthesia causes long-term cognitive harm remains unanswered. In Denmark, a large-scale study of thousands of twins explored this possible correlation but turned up little evidence to support it. Researchers compared cognitive scores in twins who had various operations—major and minor—against a control group that had none. Intrapair analysis was also conducted on more than 200 sets of twins, with just one of the siblings having a history of major surgery. In that case, the twin who had surgery also had the lower cognitive score about half of the time. In the overall study population of more than 8,500 twins, however, there was a slight drop in cognitive score in twins who had a least one major operation. From a clinical perspective, the association between major surgery and postoperative cognitive dysfunction (POCD) was not significant. The researchers concluded that factors aside from surgery and anesthesia are more important contributors to POCD.

From "Cognitive Functioning After Surgery in Middle-Aged and Elderly Danish Twins"
Anesthesiology (02/16) Vol. 124, No. 2, P. 312 Dokkedal, Unni; Hansen, Tom G.; Rasmussen, Lars S.; et al.

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Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed bimonthly to AANA members.

Anesthesia E-ssential is for informational purposes, and its contents should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

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March 15, 2016
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