Anesthesia E-ssential

AANA Anesthesia E-ssential, March 19, 2020
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AANA CEO Attends White House Meeting to Discuss COVID-19 Response


Dear Colleagues,

Yesterday our collective voice was heard at the White House. In a meeting with President Donald Trump, Vice President Mike Pence, and members of the White House Coronavirus Task Force, I conveyed the top priorities critical to sustaining our profession in this time of emergency. Along with leaders of other national nursing organizations, I requested that federal agencies:

  • Remove all regulatory barriers for CRNAs and enable all advanced practice providers to practice at the top of our education and training;
  • Ensure that all healthcare providers immediately have appropriate Personal Protective Equipment (PPE) to protect themselves and their families; and
  • Ensure a sufficient number of ventilators and other medical equipment to accommodate the anticipated surge of patients in respiratory failure.

This is an all-hands-on-deck situation. CRNAs, NPs, PAs, and others are on the frontlines of care, saving lives.

Your message was delivered to the U.S. Administration. With the support of others, I described the importance and urgency of moving forward an executive order to protect and improve Medicare, which serves as a strong step toward ensuring access to high-quality anesthesia care and enabling nurse anesthetists to practice at the top of their license.

I will continue to spend my time and energy in Washington, D.C., participating in high-level meetings with the HHS, the Centers for Medicare & Medicaid Services, and Congress, to ensure the health and safety of providers, patients, and the communities we serve.

Randy

Randall D. Moore, DNP, MBA, CRNA
Chief Executive Officer

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Professional Practice Answers Members' Questions About COVID-19

The American Association of Nurse Anesthetists (AANA) continues to monitor the impact of COVID-19 and compile relevant clinical practice resources to help keep CRNAs and their colleagues and patients safe. We have received many questions related to patient care.

In response to questions from members, we are issuing the following updated guidance, which is consistent with the Anesthesia Patient Safety Foundation, the American Society of Anesthesiologists, and the Centers for Disease Control and Prevention: https://www.aana.com/practice/covid-19

See additional information at:

Other common questions we've received are:

Should elective surgeries be cancelled?
In light of the anticipated needs of critically ill patients and if your facility does not have sufficient supplies to protect healthcare providers, AANA agrees with the recent American College of Surgeons Recommendations for Management of Elective Surgical Procedures to "thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures."

How can my facility prepare for COVID-19?
According to the Centers for Disease Control and Prevention (CDC), all U.S. hospitals should be prepared for the possible arrival of patients with Coronavirus Disease 2019 (COVID-19). All hospitals should ensure their staff is trained, equipped and capable of practices needed to:

  • Prevent the spread of respiratory diseases including COVID-19 within the facility
  • Promptly identify and isolate patients with possible COVID-19 and inform the correct facility staff and public health authorities
  • Care for a limited number of patients with confirmed or suspected COVID-19 as part of routine operations
  • Potentially care for a larger number of patients in the context of an escalating outbreak
  • Monitor and manage any healthcare personnel who might be exposed to COVID-19
  • Communicate effectively within the facility and plan for appropriate external communication related to COVID-19

See additional information at:

Since materials are added daily, we want to highlight several of the new resources posted this week:

We will continue to communicate with our membership as new resources are posted. Visit www.aana.com/COVID-19 at any time to review anesthesia care consideration and resources. The AANA will continue to monitor the situation and support CRNAs as we work together to safely deliver patient care and keep ourselves and the communities we serve healthy.

For questions and concerns, please contact the AANA Professional Practice Division at practice@aana.com or 847-655-8870.

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CRNAs: Assuming Roles Different From Traditional Anesthesia Roles


There is no question that during times of emergency and crisis, CRNAs are well prepared to fulfill a multitude of healthcare-related and leadership roles including expert intubation team, ventilation management, and intensivist. Due to the extraordinary nature of the COVID-19 pandemic and the fact that CRNAs are licensed as RNs, healthcare facilities may ask CRNAs to assume responsibilities that are different from their traditional anesthesia roles.

Please read the AANA position statement CRNAs Asked to Assume Critical Care Responsibilities During the COVID-19 Pandemic for guidance in situations where CRNAs may be asked to assume responsibilities traditionally performed by critical care nurses. Ultimately, the decision to assume new responsibilities is based on an array of considerations unique to the individual CRNA, facility, and state.

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CRNAs, SRNAs: Safeguard Your Health and Wellness During COVID-19 Pandemic


The AANA reminds you to care for yourself in this stressful and scary time. Simple tips: exercise, go for a walk outside, talk or video chat with friends and family, hydrate with H2O, and laugh to reduce your anxiety and improve your immunity! AANA features resources to help you find what you need to maintain a healthy work-life balance.

Here is a collection of URLs taking you directly to each topic area:

Need help?

Alcohol or other drugs:

Suicidal ideation:


Outpatient Facility Considerations

  • Contains info on Emergency Preparedness and Equipment Requirements for Ambulatory Surgical Centers (ASCs) and Office-Based Anesthesia Settings (OBSs)
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CMS and Accrediting Organizations Limit Survey Activities Due to COVID-19


In response to the escalating pandemic, the Centers for Medicare & Medicaid Services (CMS) announced that it has suspended certain non-emergency survey activities and is limiting other survey activities indefinitely. These actions will allow CMS to focus on the spread of COVID-19 and facilities to focus on preparing for treating patients with COVID-19. CMS is coordinating with State and local health departments, accrediting organizations, and the Centers for Disease Control and Prevention (CDC) to minimize impact to providers while retaining the ability to direct resources to areas of concern.

CMS has issued and will frequently update FAQs for State Survey Agencies and Accrediting Organizations - COVID-19 Survey Suspension to respond to specific questions.

Limited survey activities are prioritized in the following order:

  1. Immediate jeopardy complaints and allegations of abuse and neglect.
  2. Complaints alleging infection control concerns, including facilities with potential COVID-19 and other respiratory illnesses.
  3. Statutorily required recertification surveys (these do not apply to hospitals or ambulatory surgery centers).
  4. Any revisits needed to resolve enforcement actions.
  5. Initial certifications.
  6. Surveys of facilities/hospitals with infection control deficiency history at the immediate jeopardy level in the last three years.
  7. Surveys of facilities/hospitals that have infection control deficiency history at lower levels than immediate jeopardy.

CMS is not suspending the requirement for unannounced surveys, but validation surveys are suspended. In addition to the FAQs, see Suspension of Survey Activities and Survey Planning in Facilities with Active or Suspected Cases of COVID-19.

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Press Release: AANA Updates COVID-19 Resources for Anesthesia Professions


As the Coronavirus Disease 2019 (COVID-19) pandemic unfolds, healthcare professionals such as Certified Registered Nurse Anesthetists (CRNAs) are facing an unprecedented, ever-evolving crisis. The American Association of Nurse Anesthetists (AANA) has focused its resources on ensuring that its members have the latest information and practice considerations needed to keep themselves, their colleagues, and their patients safe and healthy.

The AANA is monitoring the crisis and serves as a clearinghouse of recommendations and guidelines from government agencies as well as top national and international healthcare organizations. The online resource page devoted to Anesthesia Care of the Patient with Coronavirus Disease 2019 (COVID-19) is being updated daily as information becomes available from sources such as the Centers for Disease Control and Prevention, World Health Organization, Anesthesia Patient Safety Foundation, Centers for Medicare & Medicaid Services, the National Institute of Occupational Safety and Health, and many others. Learn more.

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Jobs



CRNACareers

CRNACareers.com - What are your next steps?

Whether you’re graduating soon and researching employers, are a seasoned professional interested in advancing your career or looking to supplement your work with locum tenens options, CRNACareers.com is the place to help get you started:

  • Search and apply to locum tenens or permanent positions at industry-leading facilities.
  • Upload your resume anonymously and allow employers to contact you.
  • Set up job alerts to receive notifications on new openings.
  • Access free career resources to assist with resume and interview preparation.

Learn more today!

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CRNA: Beth Israel Lahey Health, Massachusetts


Lahey Hospital & Medical Center is part of a vibrant and growing health care system, recognized as a trailblazer in medicine and a standard bearer in patient experience. It includes an award-winning academic medical center, a superb constellation of community hospitals, home care services, rehabilitation facilities and more.

We are committed to attracting, developing and retaining top talent in a market long recognized and revered as a global leader in health. With a team approach to care, we encourage learning and growth at all levels, and we offer competitive salaries and benefits. We adhere to the principles of a just and fair work environment for all colleagues, where respect is foundational, and performance is rewarded. Learn more.

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Seeking CRNAs: University of Rochester Health System, New York


Looking for an exciting career w/ excellent work-life balance and supportive mentors/colleagues? Come and join our expanding team of CRNAs at the University of Rochester! We offer competitive salary, generous benefits including retention/loan forgiveness, opportunities for continuing education or participating in Grand Rounds, and excellent work-life balance w/ no weekends and no call requirements!

Our CRNAs see a broad spectrum of patient cases - including Orthopedics, OB/GYN, Ambulatory Surgery, GI, General Surgery, Neurosurgery, and more — enjoy supportive, respectful working relationships w/ Anesthesiology providers.
Other Highlights:

  • Flexible shift length (dependent on OR cases for the shift).
  • Large team of Anesthesia MDs, CRNA providers, and Anesthesia Techs.
  • Optional afternoon/evening or weekend shifts available, if desired.

Learn more.

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Certified Registered Nurse Anesthetist: Anesthesia Associates of Lancaster, Pennsylvania


Anesthesia Associates of Lancaster, an independent medical practice, has immediate career opportunities for full-time nurse anesthetists to join our clinical team at a surgery center in Lancaster, PA and an orthopedic specialty hospital and ambulatory surgery center in York, PA. The no-call schedule is Monday – Friday. We are currently offering a $35,000 signing bonus. Great opportunity for New Grads or experienced CRNAs.

We are looking for motivated, team-oriented nurse anesthetists to work in a care team model that emphasizes the best possible care for our patients.

General Summary of Duties:

  • Administers anesthesia and anesthesia-related care to patients of all ages.
  • Under the medical direction of an anesthesiologist, CRNAs will perform pre-anesthetic preparation and evaluation; anesthesia induction, maintenance and emergence; and post anesthesia care.

Competitive salary and benefits, which include:

  • Signing Bonus.
  • 5 weeks of paid vacation.
  • 10 PTO days.
  • Business/CEC allowance.
  • Health Insurance.
  • Disability Insurance.
  • Malpractice Insurance.
  • 401k/Profit Sharing.

Learn more.

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CRNA: Banner Health, California


Banner Health, a Top 5 Large Health System and one of the country's premier non-profit health care networks is expanding its team of advanced practice providers and is seeking an experienced CRNA to join our highly trained surgical team where you’ll enjoy a smaller hospital setting and become part of the fabric of the community.

Banner Lassen Medical Center (BLMC), built in 2004, in Susanville, California, has a growing younger population with four seasons and a short winter and is located just 90 minutes from Reno, Nevada. Proximity to Eagle Lake and the mountains, the area offers many outdoor recreational opportunities, including hiking, biking, golfing, fishing and hunting. Susanville and Lassen County is an outdoor paradise where the beautiful Sierra Nevada and Cascade mountains meet the desert of the Great Basin. The unique and diverse terrain offers something for everyone with an ideal year-round climate with an average summer high of 89 degrees and daytime temps of 40 degrees during the winter months.

This represents an excellent opportunity for a passionate and energetic CRNA to join a well-respected surgical team providing Orthopaedic, General Surgery and Scopes.

  • CRNA-only practice model.
  • Responsible for performing general, regional, and monitored anesthesia services including Ultrasound-guided block, and OB.
  • 3 years’ experience preferred.
  • 2 weeks on, 1 week off.
  • SIGN-ON BONUS.

Banner Health offers a competitive salary and recruitment incentives along with an industry leading benefits package that provides security for you and your family:

  • Comprehensive medical, dental, vision and pharmacy plans.
  • Paid time off plans.
  • Eligible for benefits coverage within 30 days.
  • Financial savings resources.
  • Career advancement and optimal work/life balance.
  • Employee Discounts.

Learn more.

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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.


Supporting the Health Care Workforce During the COVID-19 Global Epidemic

The rapid spread of COVID-19 is putting pressure on health care professionals (HCPs), who are faced not only with managing the growing number of cases but also with preventing cross-infection to themselves or family members. James G. Adams, MD, of Northwestern University Feinberg School of Medicine and Ron M. Walls, MD, of Harvard Medical School note the many precautions that HCPs can take to protect themselves—starting with the use of masks, gloves, gowns, and goggles when treating any patient exhibiting respiratory symptoms. Strict adherence is especially necessary in the emergency room, where crowding adds another layer of concern. The authors also emphasize the importance of enhanced hand hygiene and surface contamination—which, if ignored, will only undermine the benefits of personal protective gear. Besides hand washing, it is critical for HCPs to disinfect their workstations and personal items including stethoscopes, mobile devices, keyboards, landlines, and the like in addition to high-touch surfaces such as light switches, elevator buttons, and doorknobs. They also must commit to self-monitoring and self-care, with those presenting respiratory symptoms abstaining from directly treating patients and those with their own comorbid health conditions possibly removing themselves from the risky environment. At the institution level, meanwhile, employers should ban cancel conferences and restrict work-related travel. HCPs will need to receive support not only as employees but also as individuals, write Adams and Walls, who suggest that institutions do all they can to help workers to create a protective environment at home.

From "Supporting the Health Care Workforce During the COVID-19 Global Epidemic"
Journal of the American Medical Association (03/12/20) Adams, James G.; Walls, Ron M.

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FDA: Surgical Mask and Gown Conservation Strategies

A letter from the Food and Drug Administration (FDA) advises health care workers on how to make personal protective equipment (PPE) last longer in the midst of the COVID-19 pandemic. The goal, according to the regulator, is to always to use FDA-approved PPE, avoiding imposter masks and gowns that often flood the market during a supply crunch. When access to these products is limited, staff should prioritize their use based on the type of interaction they will have with patients. Gowns would be reserved, for example, for aerosol-generating procedures, settings where splashes and sprays are likely, and any activity that could transfer pathogens to the provider's hands or apparel. When there is a dearth of masks and gowns to meet demand, more drastic measures are required. FDA in this case sanctions extended use of single-use gowns without changes between patients—unless the gown becomes contaminated—as long as the patients have the same diagnosis or exposure and are held in a confined area. Under this same scenario, staff could continue to wear the same surgical mask while removing used gloves and gowns and performing hand hygiene. Additional steps include using surgical masks that are beyond their shelf life—but still in good shape—for nonsurgical activities with less risk for transmission, while prioritizing unexpired masks for procedures where the wearer may be exposed to blood and/or bodily fluids. Gowns that are past their shelf life, meanwhile, could be used for training. Additionally, health care professionals could reuse surgical masks while tending to multiple patients in cases where the equipment is intended to protect them from a low-risk activity that presents a risk to neither provider nor patient.

From "FDA: Surgical Mask and Gown Conservation Strategies"
Anesthesiology News (03/16/20)

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The Incubation Period of COVID-19 From Publicly Reported Confirmed Cases: Estimation and Application

Government and private funding allowed researchers to measure the incubation period for COVID-19. With Johns Hopkins Bloomberg School of Public Health leading the way, the team analyzed demographic traits, dates and times of possible exposure, onset of fever and symptoms, and hospitalization in 181 confirmed cases. The study was limited to the first two months of the year and to COVID-19 patients outside Hubei province, China, where the virus originated. Based on the evidence, investigators narrowed the incubation period down to a median 5.1 days. They additionally determined that, for patients who develop symptoms, those markers will begin to appear within 11.5 days. The estimates suggest, on the conservative side, that 101 out of every 10,000 cases will be symptomatic after two weeks of active monitoring or isolation. That is in line with current guidelines for quarantine or monitoring of individuals who have potentially been exposed to COVID-19. Prolonged surveillance may be warranted, the authors add, in severe cases.

From "The Incubation Period of COVID-19 From Publicly Reported Confirmed Cases: Estimation and Application"
Annals of Internal Medicine (03/10/20) Lauer, Stephen A.; Grantz, Kyra H.; Bi, Qifang; et al.

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Outbreak of a New Coronavirus: What Anesthetists Should Know

Considering that roughly one-fifth of persons infected during the SARS outbreak in the early 2000s were health care professionals, researchers discuss how anesthesia providers should prepare for COVID-19. The authors, from Toronto University and Hong Kong University, note that today's clinicians are better positioned to protect themselves, based on lessons gleaned from the SARS experience. For example, they emphasize the importance of strict compliance personal protective equipment (PPE). Standard PPE, coupled with other precautions, is effective, they write, when practiced as prescribed. Therefore, that—not more stringent requirements—is the solution. In addition, the Centers for Disease Control and Prevention and the World Health Organization have offered recommendations for staying safe during aerosol-generating medical procedures in patients with confirmed or suspected COVID-19. Based on that guidance as well as input from anesthesia providers, respiratory specialists, emergency medicine physicians, and other experts, facilities should come up with their own plans for performing these procedures as safely as possible in infected patients. Meanwhile, mastery of infection prevention and control, vigilance in protective measures, strict compliance with donning and doffing of PPE, and preparedness for the care of infected patients are key.

From "Outbreak of a New Coronavirus: What Anesthetists Should Know"
British Journal of Anaesthesia (02/20) Peng, Philip W.H.; Ho, Pak-Leung; Hota, Susy S.

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Care for Critically Ill Patients with COVID-19

Based on preliminary evidence, intensive care will be necessary in an estimated 5 percent of COVID-19 cases. Most patients falling into this category are aged 60 years and older, and a good share of them have comorbidities such as diabetes or heart disease. The most common reason reported for a critical care designation is respiratory support, as two-thirds of patients with severe COVID-19 develop acute respiratory distress syndrome (ARDS). Existing critical care departments already have the skills to manage infections of the respiratory system, and their vast experience should be trusted to guide them in their treatment of severely ill patients with coronavirus. Staff will, for example, follow evidence-based guidance for ARDS as well as for septic shock and acute kidney injury, both of which are common—and, increasingly, deadly—complications in this setting. No specific treatment strategies have demonstrated efficacy so far. Most severely ill patients receive targeted therapy with neuraminidase inhibitors and corticosteroids, but the risk-benefit balance is uncertain at this point. While observational studies and clinical trials across a range of patient populations and care settings will help inform future treatment interventions, critical care staff in the meantime will need to take practical steps for their own safety—including keeping a minimum of two meters of space away for infected patients, using masks for those suspected of having COVID-19 and assigning them to private rooms, beefing up staff training on infection prevention, and using respirators, face masks, and goggles for airborne protection.

From "Care for Critically Ill Patients with COVID-19"
Journal of the American Medical Association (03/11/20) Murthy, Srinivas; Gomersall, Charles D.; Fowler, Robert A.

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Coronavirus-Infected Patients Needing Emergency Surgery: Anesthesia Standards

Writing from Guangdong Province, China, two physicians spell out precautions that must be taken in the event that a patient with COVID-19 requires emergency surgery. Anesthesia providers are responsible for administering anesthesia and performing intubation, they note in a letter to the editor, and therefore face a high risk of infection due to direct contact with the patient's airway. The authors recommend several steps to minimize cross infection—including the use of a negative-pressure operating room to carry out the procedure. Additionally, three-level protection requirements should be in place for the protection of the anesthesia providers, and all anesthetic equipment, appliances, and agents should be specially assigned. The doctors, Xianjie Wen and Yiqun Li, advise that fast induction of anesthesia with adequate muscle relaxation is preferred. This approach will suppress cough, which is important given that the primary mode of transmission for COVID-19 is through respiratory droplets. To avoid ventilator-related lung injury in the patient, Wen and Li direct clinicians to adopt a small tidal volume of lung protective ventilation strategy during the anesthesia maintenance period. They also stress that the operating theater must be thoroughly disinfected post-surgery, while the patient must be quarantined and observed for two weeks.

From "Coronavirus-Infected Patients Needing Emergency Surgery: Anesthesia Standards"
Surgical Infections (02/25/2020) Wen, Xianjie; Li, Yiqun

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Airway Management Guidance in COVID-19

Several U.K. medical societies, including the Association of Anaesthetists and Royal College of Anaesthetists, have released new recommendations for airway management of patients with COVID-19. Noting that tracheal intubation presents a high risk for anesthesia providers no matter the clinical severity of the disease, the organizations advise that staff should be limited during this procedure to a single intubator, one assistant, and another clinician to administer drugs and monitor the patient. The guidelines recommend preparing airway equipment and drugs, when possible, outside of the room, which should be a negative-pressure environment. Facilities should use their top airway specialist, with a goal of limiting the number intubation attempts required. Aerosol-generating procedures and face mask ventilation are to be avoided unless absolutely necessary. Other components of the guidance include wearing personal protective equipment at all times, using a checklist, keeping communication clear and simple, and fully monitoring the patient before and after intubation. After the procedure, all reusable equipment should be decontaminated.

From "Airway Management Guidance in COVID-19"
Medical Dialogues (03/17/20) Kohli, Kamal Kant

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News summaries © copyright 2020 SmithBucklin

 



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

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

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For more information on AANA and Anesthesia E-ssential, contact:

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Attn: Cathy Hodson
E–ssential Editor
chodson@aana.com

 

March 19, 2020