Vital Signs

At their recent Board of Directors meeting at the Assembly of Didactic and Clinical Educators (ADCE) and subsequent Board call, the Board approved several practice documents.

The new documents are:

• Analgesia and Anesthesia for the Patient with Substance Use Disorder, Practice Considerations - This document offers practice considerations for anesthesia professionals to provide safe care to the patient with substance use disorder, whether alcohol or drugs, and both active and remission states. To supplement this document, the 2017 Jan Stewart Memorial Lecture titled, Non-Opioid Anesthesia Considerations for Patients with Substance Use Disorder, is available on AANA Learn. The course will enhance understanding of the acute and recovery phases of substance use disorder with knowledge of how to create an anesthesia care plan that supports the patient's recovery efforts.
• Clinical Privileges and Other Responsibilities of Certified Registered Nurse Anesthetists, Policy Considerations - This policy considerations resource provides information about credentialing, privileging, and recommended clinical and non-clinical responsibilities of CRNAs.
• Office-Based Anesthesia Practice, Position Statement - This position statement affirms that CRNAs have long been the predominant anesthesia professional and leader in providing anesthesia services in physicians’ offices.
• Standards for Nurse Anesthesia Practice - These updated Standards are intended to support the delivery of patient-centered, consistent, high-quality, and safe anesthesia care and assist the public in understanding the CRNA’s role in anesthesia care. The revision includes the addition of new standards on wellness and the culture of safety.

These documents are incorporated in the Professional Practice Manual for the CRNA and can be accessed at www.aana.com/PracticeManual.

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Less than two years after Oceanus Insurance Company was declared insolvent, another malpractice insurance company insuring CRNAs has run into financial difficulties. Texas-based Capson Physicians Insurance Company (Capson) has been put under state control after the Texas Department of Insurance determined that Capson’s surplus and capital had fallen below minimum required levels.

If you currently have a policy with Capson or a Granite State Insurance Company policy through Capson and are seeking alternative coverage, AANA Insurance Services can help. Contact us to learn about prior acts coverage, alleviating the need to purchase a “tail” from Capson and convertible claims-made coverage that enables you to easily convert from claims-made to occurrence coverage.

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The next step in the CPC Program is just around the corner, as the two-year check-in window opens April 2, 2019 for most CRNAs who recertified or originally certified in 2017. The two-year check-in is the mid-point requirement in the four-year CPC Program cycle, where CRNAs will confirm current licensure and practice, update their contact information, pay the CPC fee for the upcoming two years, and check CPC Program compliance progress. Class A and B credits and Core Modules are not required at the check-in.

For those due to complete their two-year check-in, watch for the opening email announcement on April 2 with a link to the NBCRNA portal. Find a two-year check-in deadline chart, FAQs, videos, and more at www.nbcrna.com/2YCI.

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In honor of National Vietnam War Veterans Day, Friday, March 29, 2019, AANA honors its members who served during the Vietnam War. Thank you for your service. Today we spotlight 1LT Robert Springer, CRNA, APN, who served at the 24th Evac Hospital in Long Binh.

AANA continues to record the history of our nurse anesthetists who served during the Vietnam War and other wars. If you would like to submit your experiences, see the submission guidelines.

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Hot Topics

• APSF - Our Position
• AANA Name Change - For or Against?
• Congratulations to Joseph Rodriguez, voted AZANA CRNA of the Year at March 2019 AZANA State Meeting

Stay tuned for the latest Building Brydges blog post, coming your way this Friday, March 29.

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April is Celebrate Diversity Month, and the American Association of Nurse Anesthetists (AANA) is observing it with our second annual “I AM ME” campaign.

AANA's Diversity and Inclusion Committee is asking that Certified Registered Nurse Anesthetists (CRNAs) and Student Registered Nurse Anesthetists (SRNAs) send a photo and one to three sentences about what makes you, you! The statements will be posted in English primarily; however, if you speak more than one language, please send it to us in that language as well.

Our goal is to post your personalized “I AM ME” statement on the AANA’s Twitter, Instagram, and Facebook channels the entire month of April. Please share widely with fellow CRNAs and SRNAs! #IAmMe 

The deadline for submissions is Sunday, March 31st, 2019.

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The AANA Connect 2019 Board Candidate Forum will be available beginning April 8, 2019, for members to interact with candidates for the AANA Board of Directors. View the 2019 Election Slate and find information about voting in the Election Center on AANA.com.

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On Tuesday, Jan. 14, AANA President Garry Brydges, DNP, MBA, CRNA, ACNP-BC, FAAN, sent an email to members asking for your help with our grassroots efforts.

The Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force recently released a draft version of its report "Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations.”

The AANA supports the draft report’s recommendation to expand the availability of non-physician pain specialists. However, we are gravely concerned that another recommendation in the report for credentialing and training requirements limits the pathways available for non-physician practitioners, such as CRNAs, to provide interventional pain procedures.

The draft report, which is available online, is available for open comment until April 1, 2019. We urge you, your friends, and even patients to submit a comment asking HHS not to adopt these recommendations as drafted and request that the credentialing and training requirements be amended to be inclusive of all types of practitioners and their educational pathways.

Please follow these instructions to contact HHS today:

1. Login to https://crna-pac.com/composeletters/2883 with your AANA username and password.
2. You will be directed to a sample letter that you can personalize and send.
3. Click “send letter” to have your letter posted to the comment site. Please note that all comments are public.

Non-AANA members can submit comments through the regulations.gov website. If you have any questions, please don’t hesitate to contact AANA Federal Government Affairs at info@aanadc.com or 202-484-8400.

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Preliminary data from PRODIGY, a global study to identify people at high risk for opioid-induced respiratory depression (OIRD), was presented at the Society of Critical Care Medicine’s 48th Critical Care Congress, February 17-20, 2019, in San Diego. PRODIGY stands for PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY.

The study met its primary objective to create and validate a risk prediction scoring tool to identify adult patients receiving opioid medication on hospital general care floors at increased risk for OIRD. Respiratory compromise, a potentially life-threatening condition, causes a progressive decrease in drive to breathe adequately. Despite known risk factors, prediction of postoperative respiratory compromise remains a challenge. The risk scoring tool can serve as a guide to determine which patients would benefit most from monitoring, potentially preventing respiratory compromise, improving patient safety on the general care floor and decreasing the risk of unplanned ICU admissions. The PRODIGY score performed well, identifying 76 percent of patients with respiratory depression (AUC=0.7620).

“Prior studies have not been successful in predicting the patients at highest risk of respiratory compromise when recovering on the general care floor,” said Dave Giarracco, vice president, global marketing. “The PRODIGY study reflects our commitment to do just that and improve solutions for respiratory compromise – a common, costly, and deadly but preventable condition. We look forward to working with our customers when the final results are available and helping monitor those patients who would most benefit from continuous capnography and pulse oximetry monitoring.”

The Medtronic-sponsored study was conducted in nearly 1,500 patients at 16 hospitals worldwide, including in the United States, Europe, and Asia. This is the largest known study using continuous capnography and oximetry. It evaluated surgical and medical general care floor patients receiving opioids and found respiratory depression events (RDE) occurred in 46 percent of patients. RDE was defined by one or more of the following: etCO₂ ≤ 15 or ≥ 60 mmHg for ≥ 3 minutes, RR ≤ 5 breaths for ≥ 3 minutes, SpO₂ ≤ 85 percent for ≥ 3 minutes, apnea episode lasting > 30 seconds, or any respiratory opioid-related adverse event. To avoid including potential artifact, monitoring data from each patient having an RDE was reviewed by a four-physician expert panel.

The primary and secondary publications of the PRODIGY study (expected later in 2019) will:

1. Characterize the predictive values of individual monitoring parameters (etCO₂, SpO₂, and RR) and the Integrated Pulmonary Index™ algorithm in predicting RD episodes, and
2. Compare RD risk subjects versus no-risk subjects in terms of incidence of adverse events and healthcare resource use.

For more information:

• Visit PRODIGY study microsite
• Visit AANA’s Monitoring Resources

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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 committee request submissions has been extended to April 15, 2019. Please note: If you currently serve on a fiscal year 2019 committee, you must reapply for fiscal year 2020.

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The AANA Education Committee members include a student representative. The student representative facilitates the AANA Connect SRNA Community, contributes content to the AANA for SRNAs Facebook page, and writes the Student News column for the AANA NewsBulletin.

In addition, the student representative will participate in the efforts and mission of the Education Committee. The committee supports the professional development of nurse anesthesia didactic and clinical educators. Primary activities of the committee include planning the Assembly of Didactic and Clinical Educators (ADCE) meetings and the Student Session at Annual Congress. The committee also hosts the Student Luncheon and Anesthesia College Bowl at Annual Congress.

Students interested in education who wish to run for the position of Student Representative to the Education Committee can obtain an application from the AANA website under CE & Education > Education> Opportunities for Students. The application must be submitted by May 6, 2019 to education@aana.com. The election will be held at Annual Congress.

Questions? Contact the Education department by e-mail or at 847-655-1161.

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Congratulations to former AANA President Tom McKibban (2003-04), MS, CRNA, who is retiring after 42 years at Susan B. Allen Memorial Hospital in El Dorado, Kans. McKibban began his healthcare career on March 3, 1977, and for the first 26 years, two anesthetists covered the hospital around the clock. In 2003, a third anesthetist was added so McKibban could fulfill his new responsibilities as AANA president.

McKibban strongly believes in the importance of rural community hospitals and how vital it is for community members to support them when possible. "El Dorado is fortunate to have good healthcare facilities and talented, dedicated local people to provide care in them," he said. Learn more.

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Congratulations to John Preston, DNSc, CRNA, FNAP, APN, who has been elected vice president of the Accreditation Board for Specialty Nursing Certification (ABSNC) for the 2019-2021 term of office.

Preston will assume his new role in July 2019. ABSNC is the only accrediting body specifically dedicated to nursing certification. Currently ABSNC accredits more than 60 certification programs from 20 specialty nursing certification organizations. Learn more. 

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On paper, Major Jennifer Hall, MS, CRNA, might have been the ideal candidate to be a part of Medical Readiness Exercise 19-1 at the Military Teaching Hospital in the African country of Chad. To complement her civilian experience, her 12 years in the military between the National Guard and Reserves as a nurse has taught her to adapt and overcome things as they come her way.

Yet Major Hall was surprised at the lack of equipment and medications available, or that there was only one set of vital emergency airway equipment to cover multiple surgical operating rooms. Her stress hit a peak early in the mission as she was called into an ongoing surgical case in another room to assist with an anesthesia emergency. Learn more.

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Meetings and Workshops

You are invited to submit an abstract for consideration to present at the 2020 Assembly of Didactic and Clinical Educators (ADCE) on February 19-22, 2020, at the Chateau Elan Winery & Resort, Atlanta, Ga. The ADCE is the only forum that brings together all nurse anesthesia programs nationwide. Please visit the Call for Abstracts page on the AANA website for the Submission Guidelines and Content Questions.

The ADCE provides a variety of educational topics that will develop the maximum effectiveness of CRNAs in their roles as program administrators, didactic and clinical educators in diverse settings across the nation. Attended by hundreds of CRNAs, it is an excellent opportunity to present your best practices and research pertinent to education to your peers and nurse anesthesia students interested in becoming educators.

Build your reputation as an expert speaker while elevating your thought leadership. Get exposure to hundreds of top nurse anesthesia program decision-makers. All speakers are promoted in marketing materials that reach thousands of CRNAs and SRNAs leading up to the conference, and on the AANA website and AANA Meetings mobile app.

The ADCE goals are as follows:

1. Provide an organized learning experience that augments the knowledge and skills of the CRNA in all educational settings.
2. Serve as a forum to present best practices and research pertinent to nurse anesthesia didactic and clinical education.
3. Facilitate interaction and networking between participants on a professional and social level.

Submission Deadlines and Notifications

• Submission Deadline: April 16, 2019, at 11:59 p.m. CST.
• Grading Deadline: May 20, 2019.
• Notification Deadline: All presenters will be notified of their acceptance status no later than July 8, 2019.

Still have questions about the submission process after reviewing the website? Contact ADCEabstracts@aana.com.

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Jobs

Anesthesia Associates of York, a PhyMed Company, is a rapidly growing, clinician-managed and led healthcare group located in York, Pennsylvania. Ask about the $25,000 sign on bonus! Learn more.

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Certified Registered Nurse Anesthesiologist have the primary responsibility for monitoring the patient's vital signs during surgery. In addition to basic measurements, such as pulse, blood pressure and temperature, anesthesiologists also measure the patient's respiration. The Certified Registered Nurse Anesthesiologist will be in charge of administering either a general or local anesthetic to the patient. During the surgery, the anesthesiologist will monitor the patient's blood pressure, heart rhythm, temperature, level of consciousness, and amount of oxygen in the blood. Learn more.

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This is full-time faculty/administrative position with the School of Nurse Anesthesia. Under the general supervision of the Director of the School of Nurse Anesthesia, the Assistant Director provides assistance to the Director in all phases of the administration of the School. In the absence of the Director, this individual will perform the Director’s duties. The incumbent also performs duties and tasks in accordance with the performance standards established for the position, while adhering to financial targets for revenue and expense. Learn more.

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Busy outpatient surgery center in South Carolina near coast looking for a full time CRNA. Case mix includes all ambulatory procedures to include Endoscopy, General Surgical, Orthopedics, Plastics, Hand, Eye, Podiatry, Pediatric Dental and ENT, Pain management. Work 5 days per week, no weekends, no call duties. Cases go from 7-7:30 a.m. until 3 p.m. on average. Job is W2, includes insurance benefits, retirement, and vacation. Team anesthesia practice: anesthesiologist supervision for every case. All subspecialties with established surgeons and surgery center is majority-owned by physicians. Learn more.

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We have full-time, part-time and PRN openings available! Team of 70 Full Time CRNAs work in a collaborative practice with Anesthesiologists. Learn more.

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Johns Hopkins All Children’s Hospital, a 259-bed teaching hospital in St. Petersburg, Florida, is recruiting 3 additional full-time CRNAs for our growing program. Our Department of Anesthesia is nationally recognized for its quality outcomes and consistent clinical practices. Our team of pediatric CRNAs and pediatric anesthesiologists are experts in treating infants and children of all ages. Our diverse group of anesthesia providers trained at esteemed institutions around the country and have brought their pediatric anesthesia expertise to Johns Hopkins All Children’s Hospital. Many of our anesthesia colleagues have advanced training and specialize in the areas of pain management and congenital heart disease. Learn more.

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Healthcare Headlines

Ultrasound-Guided Nerve Blocks as Analgesia for Nonoperative Management of Distal Radius Fractures

Dutch researchers explored the efficacy of conventional fracture hematoma block (FHB) for nonoperative management of distal radius fractures treated in the emergency department. They performed two prospective studies at a single trauma center with 50 and 60 patients, respectively. For the first, participants were randomly assigned to FHB or to cubital nerve block (CNB), a type of ultrasound-guided peripheral block. The CNB group experienced less pain during the block, finger trap traction, fracture reduction, and after both plaster cast application and control radiography. For the second study, patients were randomized to either CNB or another peripheral technique known as axillary nerve block (ANB). This time, it was the ANB patients who reported less pain during these stages of treatment. The findings suggest that peripheral nerve blocks, ANB especially, provide superior analgesia during closed reduction of distal radius fracture. Going forward, the investigators conclude, research should address technical factors—including adequate placement and time to let the block set up as well as issues such as resource utilization—to better determine the pros and cons of other analgesia techniques, such as FHB.

From "Ultrasound-Guided Nerve Blocks as Analgesia for Nonoperative Management of Distal Radius Fractures"
Journal of Orthopaedic Trauma (04/19) Vol. 33, No. 4, P. 124 Siebelt, Michiel; Hartholt, Klaas A.; van Winden, Daniëlle F. M.; et al.

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Second Complete Response Letter Issued for IV Meloxicam

Efforts to introduce an intravenous formulation of meloxicam, a long-acting nonsteroidal anti-inflammatory drug with preferential COX-2 inhibition, have taken another step backward. The Food and Drug Administration (FDA) has issued the manufacturer a second Complete Response Letter (CRL). Recro Pharma received the first CRL in May of last year, when the regulator said the drug's analgesic effects—demonstrated in ad hoc analyses—and selective secondary outcomes fell short of its expectations. This time, FDA cited concerns with delayed onset as well as regulatory questions over the role of I.V. meloxicam as a monotherapy for acute pain. Recro expressed disappointment and disagreement with the new FDA rejection but said it will continue to work with the agency to resolve the issues keeping it from market.

From "Second Complete Response Letter Issued for IV Meloxicam"
Clinical Pain Advisor (03/26/19) Duffy, Steve

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Incidence of Post-Discharge Nausea and Vomiting Higher Than Expected

A Mayo Clinic survey suggests that post-discharge nausea and vomiting (PDNV)—which can trigger infections, trips to the emergency department, and unplanned readmissions—affects more people than initially suspected. Researchers analyzed responses from about 350 individuals who completed an online questionnaire 72 hours after being released from the clinic's outpatient surgery center. The results indicated that 34.7 percent of poll-takers suffered nausea within three days of discharge, while 8.3 percent and 7.2 percent experienced vomiting and retching, respectively. Nearly 30 percent of those who had nausea, meanwhile, rated it as 5 or higher on a scale of 0-10. Even so, the researchers calculated that only a fraction of affected patients took medications to alleviate their symptoms. Adam Jacob, MD, an associate anesthesiology professor at Mayo Clinic, said the findings underscore the need for multimodal strategies that depend less on opioids in the post-anesthesia care unit and that curb PDNV. He also pointed out the need for better patient follow-up, possibly via web-based interfaces. The survey results were presented at the American Association of Nurse Anesthetists 2018 Annual Congress.

From "Incidence of Post-Discharge Nausea and Vomiting Higher Than Expected"
Anesthesiology News (03/25/19) Doyle, Chase

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Anesthesia May Help Take Away Painful Memories of PTSD Patients

Researchers in Spain believe that propofol, a general anesthetic, can blunt the pain of traumatic memories. The team recruited 50 volunteers who were already scheduled to undergo sedation for a gastroscopy or colonoscopy. One week ahead of their procedures, each participant viewed two slide show stories with neutral beginnings and endings but disturbing scenarios in the middle. They were asked to recollect one of the stories just before propofol induction and then again afterwards. Half of the group had their memory tested immediately after their procedure, and they recalled the stories in detail. The other half, who were questioned after 24 hours had passed, had a more difficult time remembering the emotional details of the scenario. Both groups had equal recollection of the less-distressing aspects of the stories, meanwhile. "The [brain] circuitry involved in emotional memory is probably quite sensitive to anesthetics," study author Bryan Strange, a neuroscientist at the Technical University of Madrid, told New Scientist. "This is good for a potential treatment because you don't want to remove information that isn't dramatic or unwanted." He and his colleagues hope that a general anesthetic can eventually be used to help people suffering from post-traumatic stress disorder. Their findings are published in Science Advances.

From "Anesthesia May Help Take Away Painful Memories of PTSD Patients"
Tech Times (03/22/19) Carlos, Naia

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Novel Approach 'Drastically' Cuts Opioid Use After Joint Replacement Surgery

New evidence supports a multimodal anesthetic technique, with continuous peripheral nerve block at the core, that can "drastically" curb opioid prescribing to patients after knee or hip replacement. The key, according to lead study author André P. Boezaart, MD, PhD, is to place the catheter in a deep enough space to the membrane around the nerve—which then avoids the common issue of secondary block failure. Boezaart and collaborators tested the approach by analyzing prescribing behaviors and outcomes after installing a quality improvement initiative to minimize postoperative opioid use at their center. "The extent of the opioid crisis is well-known, and orthopedic surgeons are the third highest opioid prescribers," the University of Florida professor of anesthesiology and orthopedic surgery noted. "Also, 15 percent of opioid-naïve patients undergoing TJA [total joint arthroplasty] will become chronic opioid users postoperatively." The review included nearly 2,800 patients undergoing TJA between January 2014 and 2018. The number of opioids prescribed per surgeon plummeted 45.8 percent for inpatients and 53.2 percent for outpatients; and hospital length of stay was cut more than in half, to 1.5 days from 3.2 days. There were no readmissions for pain; and rehospitalization for chest pain, pneumonia, and other postoperative diagnoses fell to 5.6 percent from 7.9 percent. Lastly, discharges to a skilled nursing facility instead of home dropped from 40 percent to 10 percent, generating significant healthcare savings.



From "Novel Approach 'Drastically' Cuts Opioid Use After Joint Replacement Surgery"
Medscape (03/12/19) Lowry, Fran

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Are Surgical Caps on the Verge of a Comeback?

The medical community is finally coming to terms on what constitutes appropriate headwear in the operating room, after years of squabbling over whether surgical caps or bouffants provide the most infection control. Guidelines released by the Association of periOperative Registered Nurses (AORN) in 2015 and picked up by the Centers for Medicare & Medicaid and the Joint Commission stipulated complete coverage of the hair—including sideburns—and skin, such as the ears and nape of the neck. The result was an unofficial but widespread ban by health systems on surgical skull caps. Mounting evidence since then, however, suggests that neither caps nor bouffants reduce the rate of patient surgical site infections compared to the other. Given the findings, experts are starting to rethink policies governing OR attire; and some institutions, like the Cleveland Clinic, have reversed their surgical cap bans. Earlier this year, AORN drafted revisions to its recommendations based on input from a task force that reviewed the research. The new version advises that OR personnel "cover scalp, hair, and beards when entering the semi-restricted and restricted areas," but does not dictate what type of head or beard covers should be worn or whether ears should be covered in that setting. AORN said the update will be published online in June.

From "Are Surgical Caps on the Verge of a Comeback?"
General Surgery News (03/07/19) Stern, Victoria

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