Anesthesia E-ssential

AANA Anesthesia E-ssential
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Vital Signs

Brace for MIPS Program Changes in CY 2019

Some highly influential organizations are making proposals that could significantly alter the Merit-Based Incentive Payment Systems (MIPS) Program as it is currently defined.  Recently, the Medicare Payment Advisory Commission (MedPAC) recommended that the MIPS Program be repealed because its reporting requirements are too burdensome. Similarly, the White House’s Proposed Budget for 2019 put forward that MIPS eliminate the Advancing Care Information and Improvement Activities performance categories, leaving only the Quality and Cost performance categories. Adding more fuel to this fire to change MIPS, the Bipartisan Budget Act of 2018, Section 53106, recommends changing the Physician Fee Schedule update drop from 0.50 percent to 0.25 percent for CY 2019 only. What will happen to MIPS in the future is up in the air, but the AANA Research and Quality Division as well as Federal Government Affairs is actively monitoring all proposals that would affect the program. As of now eligible MIPS CRNAs should stay the course and continue to participate according to the 2018 MIPS performance period requirements. Please visit Quality and Reimbursement for more information on MIPS and the Quality Payment Program.
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Hot Topics

The Joint Commission Updates Hospital Life Safety Standard Affecting Anesthesia

Effective March 11, 2018, Joint Commission-accredited hospitals, critical access hospitals, ambulatory surgery centers, and office-based surgery settings must comply with the following standard.
EC 02.05.01 EP 27:
Areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum are as follows: – Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturers’ instructions are considered before reducing humidity levels to those allowed by ASHRAE. – Existing smoke control systems automatically vent smoke, prevent the recirculation of smoke originating within the surgical suite, and prevent the circulation of smoke entering the system intake, without interfering with exhaust function. New occupancies have no smoke control requirement. – For hospitals that use Joint Commission accreditation for deemed status purposes: Existing smoke control systems are maintained according to the edition of NFPA 101 adopted by The Centers for Medicare & Medicaid Services at the time of installation. (For full text, refer to NFPA 101-2012: 20/; NFPA 99-2012: 9.3.1)
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Earn MIPS Points: Participate in CMS MIPS Reporting Burden Study

The Centers for Medicare & Medicaid Services (CMS) is inviting eligible clinicians to participate in a study that will examine the burden clinicians face when reporting MIPS quality measures. In the study, CMS is specifically targeting the following areas: (1) clinical workflows and data collection methods using different submission systems; (2) challenges clinicians have when they collect and report quality data; and (3) changes to try to lower clinician burden, improve quality data collection and reporting, and enhance clinical care. Successful participation in this study will result in full credit for the 2018 MIPS Improvement Activities performance category. CMS anticipates that the study will run from April 2018 to March 2019. Applications are due March 23, 2018.
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FDA Alerts Clinicians Not to Use Compounded Drugs from Cantrell Drug Company

The US Food and Drug Administration (FDA) is alerting healthcare professionals and patients not to use drug products produced by Cantrell Drug Company of Little Rock, Arkansas, including opioid products and other drugs intended for sterile injection, that were produced by the company and distributed nationwide. The agency is concerned about serious deficiencies in Cantrell’s compounding operations, including its processes to ensure quality and sterility assurance that put patient safety at risk. Read more in the FDA press release.
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CRNAs Can Be Part of the Solution to the Opioid Crisis

A new online course is now available on AANA Learn featuring three virtual simulations of opioid prescribing scenarios. Based on Centers for Disease Control (CDC) Guidelines for safe opioid prescribing, the content in this new course is immediately applicable to the work CRNAs do every day. Register for the course today or watch the video tutorial to learn more.

Learning Objectives:
  1. Understand and calculate morphine equivalent.
  2. Use CDC Opioid Guidelines for safe prescribing strategies of opioids in the acute and chronic pain setting.
  3. Use CDC Opioid Guidelines to offer alternative and complementary non-opioid pain control measures.
Educational benefits of virtual simulation:
  • Gain experience in three realistic scenarios in a no-risk patient interaction.
  • Unlimited attempts to practice the clinical scenario until you succeed. 
  • No test at the end. Assessment is built into the serious gaming experience.
  • Multi-sensory, interactive learning increases retention.
  • Accessible from your own computer, 24x7. 
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AANA Learn Member Exclusive: Take Advantage of Free Sponsored Course

The online course – Danger in the Operating Room: Concentrated Drugs –  is now live on AANA Learn.

You can find this course in the New! and Member Exclusives categories. This course is worth 1 Class A credit, and as a Member Exclusive course, it is free to all members. Visit AANA Learn Member Exclusives and be sure to log in before taking the course.


Danger in the Operating Room: Concentrated Drugs

  • Member Price: $0.00
  • 1.0 Class A Credit
  • 1.0 Pharm Credit
  • Course Expiration Date: 2/27/2019
Supported by an educational grant from Fresenius Kabi.
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Learn More about FDA’s MedWatch Program

Join the US Food and Drug Administration (FDA) for a complimentary webinar on March 13 at 1 pm ET to learn more about FDA’s MedWatch Adverse Reporting Program, how to report adverse events to MedWatch, and how to obtain safety information. Register here.
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AAAHC Releases 2017 Quality Roadmap

AAAHC Quality Roadmap 2017 is the Accreditation Association for Ambulatory Health Care’s annual review and analysis of standards compliance. The 2017 report reflects data from 1,385 surveys on 2016 standards, including data from Ambulatory Surgery Centers (ASCs), Medicare Deemed Status ASCs (MDS ASCs), and office-based surgery facilities (OBSs). For ASCs, overall results of highest deficiency rates are consistent with past years’ findings, including: credentialing and privileging, documentation, quality improvement, and patient safety/safe injection practices. For OBSs, the findings were similar, but also included high deficiency rates for benchmarking a formal, documented infection prevention and control program; cleaning, disinfection, and sterilization of medical equipment per manufacturers’ instructions; monitoring/disposal of expired products (medications, reagents, solutions, and supplies) that have a manufacturer’s printed expiration date in compliance with facility policy and manufacturers’ guidelines; and completing a written evaluation of emergency drills. 
AAAHC notes that safe injection practices is a high-deficiency theme, which is borne out by the AAAHC Institute for Quality Improvement’s Safe Injection Practices Benchmarking Study begun in 2017. Initial study findings indicate that AAAHC-accredited organizations need to assess compliance with national guidelines on safe injection practices and develop quality improvement interventions to improve compliance. AAAHC has many resources to help organizations comply with safe injection practices, as well as other high-deficiency areas. 
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ANA Position Statement Available for Public Comment

The American Nurses Association (ANA) is seeking public comment on the proposed position statement, The Nurse's Role in Addressing Discrimination: Protecting and Promoting Inclusive Strategies in Practice Settings, Policy, and Advocacy. The deadline for comments is March 13, 2018.
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Professional Practice

The Joint Commission’s Waste Anesthesia Gas Accreditation Standard

Did you know that The Joint Commission has an environment of care standard relevant to waste anesthesia gas?  The Joint Commission requires that waste anesthesia gas, along with other hazardous medical gases and vapors such as nitrous oxide, be managed under a facility management plan. See Environment of Care Standard 02.02.01, Elements of Performance 9 and 10. This standard requires that the hospital manage risks related to hazardous materials and waste. The specific elements of performance, or requirements, state that the hospital must minimize the risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors, including nitrous oxide gases and waste anesthetic gases.  The hospital must also monitor levels of hazardous gases and vapors to determine that they are in a safe range.
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Meetings and Workshops

New Location for Spring Spinal Epidural with Obstetric Essentials Workshop
May 3-5, 2018, Cincinnati, OH

This comprehensive workshop combines enrollment for two of our most popular live CE activities: the Essentials of Obstetric Analgesia/Anesthesia Workshop and the Spinal and Epidural Workshop. Earn valuable Class A CE credits and stay current with expert lectures and hands-on instruction. Time will be allotted for group discussions of representative clinical cases.
Bonus: Included with registration, all attendees will receive Clinical Techniques of Regional Anesthesia: Spinal and Epidural Anesthesia Techniques, edited by the workshop's senior faculty member Charles A. Reese, PhD, CRNA.
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Visit to view or place job postings

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Featured Career Opportunity

Chief Anesthetist – Grady Health System

Grady Health System is a Level 1 Trauma Center in the heart of Atlanta seeking an experienced Chief Anesthetist to provide leadership to 50+ FTE’s.  All specialties included except for Transplant.  Please contact William Kelly at wekelly@GMH.EDU 
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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.

Opioid Prescriptions Are Twice as Likely to Be Refilled by Patients Who Underwent TKA vs THA

Based on an analysis of online prescription data, researchers say opioids are used more heavily after knee replacement than after hip replacement. Within a population of 197 total knee arthroplasty (TKA) patients and 186 total hip arthroplasty (THA) patients, the former filled a greater number of prescriptions, were prescribed a higher total quantity of pills and total morphine equivalent doses, spent more days taking opioids, and required twice as many refills as the latter. Moreover, with the TKA patients, there was a significant association between the need for refills and the presence of comorbidity or depression/anxiety. "Orthopedic surgeons can provide leadership in addressing the opiate crisis in our country by establishing valid data regarding opiate utilization following orthopedic operations and by developing improved, postoperative pain treatment protocols," primary investigator William Healy, MD, said. "Opiate prescribing patterns should be based on science and evidence-based research." He and his research partners reported the study results in the Journal of Arthroplasty.

From "Opioid Prescriptions Are Twice as Likely to Be Refilled by Patients Who Underwent TKA vs THA"
Healio (03/05/2018) Tingle, Casey

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Opioids Linked to Complications in OSA Patients Undergoing Arthroplasties

Patients with obstructive sleep apnea (OSA) who receive higher levels of opioids for joint replacement surgery are more prone to perioperative complications, evidence shows. Led by Eva E. Mörwald, MD, an anesthesiology research fellow at New York's Hospital for Special Surgery, investigators performed a retrospective analysis of the Premier Perspective Database. They identified 107,610 OSA patients nationwide who underwent total hip or knee arthroplasty between 2006 and 2013, separating them into quartiles based on the amount of opioids prescribed. The data revealed a greater risk of gastrointestinal complications in OSA patients with the highest opioid utilization, as well as prolonged length of hospital stay and higher cost of care. Interestingly, the likelihood of pulmonary complications was reduced, even though OSA patients generally tend to experience these problems more often and opioids are respiratory depressants. "It's possible that practitioners increased their efforts to prevent those complications or that interventions were started earlier to avoid those complications," Mörwald suggested. "Nevertheless, this finding should not encourage the administration of high doses of opioids in an unmonitored setting, and attempts to further reduce opioid prescription in patients with OSA should be continued."

From "Opioids Linked to Complications in OSA Patients Undergoing Arthroplasties"
Anesthesiology News (03/05/18) Doyle, Chase

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An Effective Drug for Preventing ICU Delirium?

A Phase II Canadian study has found that low-dose dexmedetomidine appears to prevent sedated ICU patients from developing delirium. The multi-site trial included 100 critically ill adults with comparable levels of sleep quality, none of whom showed signs of delirium at enrollment. Participants were randomly assigned to nocturnal administration of dexmedetomidine or placebo. All patients had similar durations of mechanical ventilation, ICU stay, and hospital stay as well as similar mortality rates; but only 76 percent of those in the intervention group required a fentanyl infusion, compared with 94 percent of those in the placebo group. Based on 12-hour assessments following the Intensive Care Delirium Screening Checklist, delirium was avoided in 80 percent of the dexmedetomidine patients versus 20 percent of the placebo patients. "The lower proportion of patients requiring a fentanyl infusion during the ICU stay in the intervention group may be related to a dexmedetomidine-associated analgesic effect, particularly since fentanyl infusions at the time of randomization were frequent and similar between the two groups," the team from McGill University Health Centre speculated. "While patient-reported sleep quality appears unchanged, future investigations incorporating polysomnography may better characterize the relationship between ICU delirium and sleep quality." The findings were published online in the American Journal of Respiratory and Critical Care Medicine.

From "An Effective Drug for Preventing ICU Delirium?"
MedPage Today (03/02/18) Lou, Nicole

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Study: Multiple Pain Relievers After Joint, Knee Replacements Ease Opioid Use

New research indicates that a multimodal strategy for pain relief, rather than an opioid-only approach, benefits patients after total joint arthroplasty. Tapping into 10 years' worth of information from a nationwide database, investigators studied the types of pain relievers used in more than a million knee replacements and more than half a million hip replacements. Multimodal plans—including opioids plus one or more other methods such as peripheral nerve block, acetaminophen, or gabapentin/pregabalin—were employed more than 85 percent of the time. Patients who received more than two additional types of pain relief besides narcotic analgesics not only used significantly fewer opioids, they also experienced fewer respiratory and gastrointestinal complications and were discharged from the hospital sooner. "This study does not answer the question of what combinations of analgesic approaches are best—we would need to conduct a much more complicated analysis, because there are so many potential combinations of drugs to consider," said Stavros Memtsoudis, MD, director of critical care services in the anesthesiology department at New York's Hospital for Special Surgery. "Future studies are needed to identify optimal multimodal regimens and patient subgroups most likely to benefit from each combination." The study appears in Anesthesiology.

From "Study: Multiple Pain Relievers After Joint, Knee Replacements Ease Opioid Use"
United Press International (03/02/18) Cone, Allen

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Association of Hospital-Level Neuraxial Anesthesia Use for Hip Fracture Surgery With Outcomes

The utilization rate for neuraxial anesthesia across hospitals in Ontario, Canada, ranges from 0 percent to 100 percent for hip fracture surgery, prompting researchers to look at survival outcomes relative to hospital-level use. The team consulted administrative data for the population-based cohort study, identifying about 107,300 patients older than age 65 years who underwent total hip arthroplasty between 2002 and 2014. Of that number, about 57,000 received neuraxial anesthesia; and 8.5 percent of the patients died within 30 days of their procedure. Taking into account the share of patients who received neuraxial anesthesia at the same facility in the year before each hip fracture surgery—and taking patient-level anesthesia type and confounders into account—investigators determined that survival rates improved with higher hospital-level neuraxial use. The benefit was observed primarily with an increase in hospital-level neuraxial use above 20 percent to 25 percent, however, with little impact on survival beyond that point. No significant associations between hospital neuraxial anesthesia-use and other outcomes were found.

From "Association of Hospital-Level Neuraxial Anesthesia Use for Hip Fracture Surgery With Outcomes"
Anesthesiology (03/18) Vol. 128, No. 3, P. 480 McIsaac, Daniel I.; Wijeysundera, Duminda N.; Huang, Allen; et al.

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Study Uncovers Changes to the Brain During Unconsciousness

Researchers at the Center for Consciousness Science have been busy trying to understand what happens in the human brain in an unconscious state. In a study published in the Journal of Neuroscience, a team led by Anthony Hudetz, MD, examined different parts of the brain during sedation, surgical anesthesia, and a vegetative state. Hudetz speculated that loss of consciousness knocks different areas of the brain out of normal communication with one another. In Frontiers in Human Neuroscience, meanwhile, researchers reported on the brain's ability to integrate information. "Essentially, we looked at how the brain network fragmentation was taking place and how to measure that fragmentation, which gives us the sense of why we lose consciousness," said senior author UnCheol Lee, MD. Finally, center investigators published a third study in Trends in Neurosciences. That work analyzed unconsciousness across physiological, pharmacological, and pathological settings. The results revealed disrupted connectivity in the brain during unconscious state, which prevented the efficient transfer of information needed while awake. The next steps for the Center for Consciousness Science are to pursue strategies for quantifying the intensity of anesthesia in the operating room and to evaluate consciousness in stroke victims or people with brain damage.

From "Study Uncovers Changes to the Brain During Unconsciousness" (03/01/2018)

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

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

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