AANA Anesthesia E-ssential
AANA Anesthesia E-ssential
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Vital Signs

Stand Ready to Take Action for CRNA and APRN Full Practice Authority in the VHA and Fight Possible Anti-CRNA Amendments on Capitol Hill

Major developments are imminent on the issue of expanding Veterans access to care by supporting Full Practice Authority for CRNAs and other APRNs in the Veterans Health Administration (VHA). What’s the latest and how can AANA members help?
  • At press time, the AANA and its coalition partners were awaiting publication in the Federal Register of the proposed rule any day. The proposed rule triggers a 60-day public comment period, and AANA will be providing members convenient advocacy tools for making voices heard for our Veterans. AANA continues urging all members to use Veterans Access to Care 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.
  • On Capitol Hill, the Senate and House are beginning floor consideration of FY 2017 appropriations for the Veterans Administration. The AANA is at hard at work warding off the risk of possible anti-CRNA poison pill amendments – and your help may be needed on short notice. With the American Society of Anesthesiologists (ASA) holding its Washington advocacy day on May 18, AANA members are being asked to watch their email inboxes for CRNAdvocacy Alerts requiring immediate action if a legislator offers any controversial poison-pill amendment attacking CRNAs.
  • The AANA continues to encourage House members to cosponsor the “Improving Veterans Access to Quality Care Act” (H.R. 1247) and Senators to cosponsor the “Veterans Health Care Staffing Improvement Act” (S. 2279). The bills currently have 52 and 10 bipartisan cosponsors respectively. Be sure to thank your legislators who have supported expanding Veterans access to care through Full Practice Authority for CRNAs and other APRNs.
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CPC Facts

What Documentation will be Required to Prove Class B Credits, and in What Form/Format?

AANA members who have recertified and entered the CPC Program will be provided with access to an online portal (by the AANA, as a benefit of your membership) where you can record your Class B credit participation and deposit all of the supporting documentation to prove your involvement. AANA members who are in the current recertification program until 2017 will still see their traditional transcript. If you are not an AANA member, you will have to maintain your Class B credit records on your own and report them to the NBCRNA every four years much like you have managed your CE credits in the past. Regardless of your membership, the NBCRNA has developed a table of information that will detail what information needs to be collected and retained for Class B credits.

For more information about the NBCRNA's Continued Professional Certification (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

Register Now for the AANA Annual Congress!

Inspire, connect, and grow at the biggest CE event in nurse anesthesia—register by June 17 for the AANA Annual Congress and save $100! Travel and hotel discounts are also available. Join us September 9-13 at the Washington Marriott Wardman Park for nurse anesthesia's premier educational, professional, and social event. 


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Affecting Every CRNA Covered under Part B, Medicare Issues MACRA Proposed Rule; AANA Reviewing and Responding

On May 9, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA). Affecting Medicare payment for every CRNA and healthcare professional covered under Part B, the proposed rule is intended to transform the current Medicare fee-for-service payment system to one that rewards better healthcare quality and improved patient outcomes.

Under the proposed rule, CMS will pay clinicians participating in the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) beginning in 2019. According to Medicare, MIPS allows Medicare clinicians to be paid for providing high value care through success in four performance categories: Quality, Advancing Care Information (previously referred to as meaningful use), Clinical Practice Improvement Activities, and Cost (resource use). Medicare clinicians who participate to a sufficient extent in advanced APMs (comprehensive ESRD Care, Comprehensive Primary Care, Medicare Shared Savings Program Track 2 or Track 3, a next Generation ACO, or an Oncology Care Model with two-sided risk) would be exempt from MIPS and would qualify for financial bonuses. CMS states that most eligible clinicians would initially participate in the MIPS.

The AANA is analyzing the proposed rule and is preparing comments to CMS by the June 27 deadline. Of interest to CRNAs, initial review of the proposed rule shows:

  • According to Medicare, based on 2014 data, 31,737 CRNAs would be subject to MIPS while 23,547 CRNAs would be exempt due to being newly enrolled in Medicare in 2017, or due to falling under the low-volume threshold of less than $10,000 annually in Medicare billing charges and providing care for 100 or fewer Part B-enrolled Medicare beneficiaries, or being participants in an advanced APM (see pages 28369, 28373).
  • CMS estimates that 48.8 percent of its estimated 31,737 participating CRNAs would receive a positive MIPS adjustment based on 2014 data (p. 28373).
  • Under the MIPS program, CMS is proposing to provide special consideration for non-patient-facing MIPS eligible clinicians, defined as an individual MIPS eligible clinician or group that bills 25 or fewer patient-facing encounters during a performance period based on encounter codes that CMS proposes (p.28174). Under the proposal, CRNAs may be considered as a non-patient-facing MIPS eligible clinician, and would not have to submit cross-cutting measures for the quality performance category. CRNAs may have certain submission criteria exceptions with respect to the clinical practice improvement activity category (p.28210) and may also not be scored on the resource use performance category (p. 28208).
  • For the quality performance category, CRNAs would need to report at least six quality measures, one of which must be outcome measure, and a cross-cutting measure, if the CRNA is a patient-facing MIPS eligible clinician. CMS proposes to include several anesthesia-related measures for reporting for the quality performance category (see pages 28463-28464).
  • Taking previous AANA comments into consideration, CMS is proposing to not require CRNAs to participate in the advancing care information performance category for the first performance period (p. 28233) since CRNAs were not eligible to participate in the Medicare EHR (electronic health records) Incentive Program. CMS would assign a weight of zero for this category.

Read the proposed rule. and the press release.         

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International Nurse Anesthesia Advocate Passes Away

AANA Past President Ronald Caulk, CRNA, FAAN, passed away on April 29, 2016, surrounded by family. A “dynamic leader with strong convictions,” Caulk not only took a leadership role in the American Association of Nurse Anesthetists (AANA), serving as its president (1977-78), but also became intricately involved in the development and formation of the International Federation of Nurse Anesthetists (IFNA), serving as the AANA representative to the IFNA before serving as its first vice president, president, and ultimately as its first executive director from 1995 until he retired in 2004. Read more about Caulk's life and career in the obituary posted on the AANA website.
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CORRECTION: AANA NewsBulletin Story "AANA Launches CPC Modules"

In the cover story of the May 2016 AANA NewsBulletin, the launch date of the NBCRNA CPC Program was incorrectly stated as August 31, 2016. The program will begin August 1, 2016. For more information on all aspects of the CPC Program, visit cpc-facts.com.
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AANA 2016 Election Ends May 17 at noon CT

If you haven't already done so, be sure to vote in the AANA 2016 election, which started on April 19, and will continue until May 17, 12 noon CDT. By now, active AANA members should have received their ballot materials, including their election passcode and voting instructions, electronically or in the mail from Survey & Ballot Systems (SBS), the AANA's election coordinator. The email with the voting credentials originates from noreply@directvote.net. Please make sure this email did not end up in your spam or junk mail folder.

To vote online and view candidates’ biographical information and position statements visit the election site and enter your member number and the election passcode provided to you by SBS.

If you do not have your election login information, click on the “Email me my login information?” link on the login page and enter the email address on file with AANA, and your election login information will be emailed to you. SBS can be reached by phone at (952) 974-2339 (Monday through Friday, 8 a.m. to 5 p.m. CDT) or by email at support@directvote.net.

If it’s more convenient, please feel free to contact lrivera@aana.com or vgiannopoulos@aana.com, and they will ask SBS to re-send you your voting credentials.

To View Board Candidates' Video Speeches

Board candidates’ speeches presented at the April Mid-Year Assembly are available on the AANA website on the Video Speeches page.

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Will You Be Reporting With a Registry or QCDR for PQRS 2016?

A reminder: Claims-based reporting is no longer a viable reporting option for CRNAs in 2016. CMS has now posted both the 2016 PQRS Qualified Registries and the 2016 Qualified Clinical Data Registries (QCDR) List on their PQRS website. To assist CRNAs with their selections, the AANA Research and Quality Division has created Excel spreadsheets listing 62 Qualified Registries and 9 QCDRs that support anesthesia-specific PQRS and non-PQRS measures. These documents provide detailed information for each entity including the specific measures they support as well as their services and costs. Please see our PQRS Mechanism FAQ page to learn more about the different PQRS reporting options that are available
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2014 PQRS Experience and Trends Report

The Centers for Medicare & Medicaid Services (CMS) released their annual experience report on the Physician Quality Reporting System (PQRS) on April 15. This report summarizes the historical reporting experience of eligible professionals participating in PQRS through program year 2014. More than 40,000 nurse anesthetists reported to PQRS in 2014 and they were also ranked #1 for claims-based reporting among all specialties. To learn more, read our “Key Findings Summary for CRNAs” or download the zip file containing the full report and appendix tables from the CMS website.
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Big Changes for PQRS in 2016

The AANA Research and Quality Division's latest NewsBulletin article on the Physician Quality Reporting System (PQRS) outlines why, what, how, and when CRNAs should report for 2016. The article also includes a list of the 2016 anesthesia-specific PQRS measures, reporting requirements and deadlines, and a specific game plan designed for CRNAs. To access this and other viewpoint articles, please log in to Quality Resources.
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AANA Seeking Committee Members for Fiscal Year 2017

Positions are available on fiscal year 2017 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 FY16 committee, you must reapply for FY17.
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Student Excellence Award Deadline is May 15

The AANA Education Committee will present its Student Excellence Award at the 2016 AANA Nurse Anesthesia Annual Congress in Washington DC. The award will be presented to a student who demonstrates outstanding leadership and professionalism during his or her nurse anesthesia program, participates in activities that foster a positive public image of nursing, participates in activities that foster high-quality healthcare to consumers, or engages in volunteer activities of community service or support of healthcare.
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Students and CRNAs Needed for Anesthesia College Bowl

The annual Anesthesia College Bowl at the AANA Nurse Anesthesia Annual Congress will once again be a rousing battle of the brains. Contestants are being sought for student teams and a CRNA Challenge Team. Deadlines are: June 1 for students, July 1 for CRNAs.
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ASER Seeking Board of Directors Candidates

The American Society for Advanced Recovery (ASER) is seeking candidates for its Board of Directors: The deadline to apply is May 27. To best represent the multidisciplinary membership of ASER, the Board is very interested in applications from nurses, pharmacists, and other members who are in affiliated health disciplines. The deadline for candidates for the director positions on the ASER board has been extended 30 days to Friday, May 27, 2016.
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Professional Practice

CMS Approves Institute for Medical Quality’s Medicare ASC Accreditation Program

The Centers for Medicare & Medicaid Services (CMS) approved California-based Institute for Medical Quality (IMQ) as a national accrediting agency for ambulatory surgical centers seeking to participate in Medicare and Medicaid. While accreditation is voluntary and not required for Medicare participation, it is an alternative to initial and ongoing state survey review for Medicare certification. To receive CMS approval, IMQ had to demonstrate that its ASC accreditation program requirements were at least as stringent as the Medicare ASC Conditions for Coverage. IMQ’s approval is effective April 29, 2016, through April 29, 2020.
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Joint Commission Reverses Former Position and Allows Practitioners to Text Patient Care Orders

The Joint Commission’s recently revised rule allowing texting of practitioner orders through a secure messaging platform recognizes that technology has evolved to address concerns about verification and encryption. There are still restrictions on the type of texting program that can be used, including:
  • Secure sign-on process
  • Encrypted messaging
  • Delivery and read receipts
  • Date and time stamp
  • Customized message retention time frames
  • Specified contact list for individuals authorized to receive and record orders
Organizations should develop policies and procedures on how text orders will be dated, timed, confirmed, authenticated, and documented in the paper or electronic health record. For more information, read The Joint Commission’s update on texting orders.
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Meetings and Workshops

Fall Leadership Academy: Save the Date!

Learn to lead change and become an influencer at the Fall Leadership Academy, to be held November 11-13, 2016, in Rosemont, Ill. Watch the AANA website and future issues of the NewsBulletin and E-ssential for more information!
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Register Now for Business of Anesthesia Conference

Join the AANA on June 24-25 for a two-day conference 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. 
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Save the Dates for These Popular Hands-On Workshops

Visit Meetings for further information and to register!

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

AANA Foundation Friends for Life Deadline is June 15

Friends for Life help support the future of the nurse anesthesia profession through meaningful, lasting gifts. Contributions through Friends for Life help fund and sustain programs that further research and education in anesthesia. Friends for Life receive a medallion at the AANA Annual Congress Opening Ceremonies, an engraved plaque in the AANA Park Ridge office and an invitation to the Annual Awards and Recognition Event. The minimum gift commitment to join Friends for Life is $25,000. Members may fulfill this commitment through a cash gift, but there are many other ways to meet the commitment through planned gifts. Some of the most popular planned gift options for becoming a Friend for Life include:
  • A gift (bequest) in the will for a specific amount or a percentage of the total estate
  • Gift of personal property or real estate
  • Including the Foundation as a beneficiary on a retirement plan or a whole life insurance policy
For further information, please contact Nat Carmichael at (847) 655-1175 or ncarmichael@aana.com. The Friends for Life submission deadline for recognition at this year’s Annual Congress in Washington, DC, is June 15, 2016.
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Purchase Your Tickets Today for "Stepping Out in DC"

Planning to attend the AANA Annual Congress in Washington DC? Do you love to laugh? Dance? If so, you won’t want to miss a fabulous and fun event. Stepping Out in DC features live entertainment by the Capitol Steps followed by an awesome dance party.

Stepping Out in DC and Shake It for a Cause Dance Party: Sunday, September 11, 2016, 7:00 – 11:45 pm at Washington Marriott Wardman Park Registration fee is $250 and ticket includes dinner, drinks, entertainment featuring Capitol Steps, and the dance party.

Shake It for a Cause Dance Party: For those who don’t want dinner and a show, but want to support the Foundation and have some fun, plan to attend the dance party only from 9:30 – 11:45 pm. Tickets are $50 for CRNAs and $25 for SRNAs.

Capitol Steps: They put the MOCK in Democracy! The Capitol Steps began as a group of Senate staffers who set out to satirize the very people and places that employed them. They dig into the headlines of the day and create song parodies and skits that convey a special brand of satirical humor.

Shake It for a Cause Dance Party will feature a DJ playing all your favorite songs. Don’t miss the opportunity to have a little fun and dance up a storm with CRNAs and students from across the country.

You’re sure to have a fun time and a portion of your donation is tax deductible and supports nurse anesthesia education and research. See you in DC!
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Shop Amazon and Support the AANA Foundation: AmazonSmile Foundation to Donate 0.5% of Eligible Purchases

Amazon has it all, and AmazonSmile is a website operated by Amazon that offers the same wide selection of products and exact same low prices as Amazon.com. The difference is that the Amazon Smile Foundation will donate 0.5% of the price of eligible purchases to the AANA Foundation. To shop at AmazonSmile, go to smile.amazon.com from the web browser on your computer. You may want to add a bookmark to make it even easier to return and shop. To go directly to the AmazonSmile web page supporting the American Association of Nurse Anesthetists Foundation. Please log on and shop today! Select an item marked “Eligible for AmazonSmile donation” on their product detail pages. Thank you in advance for participating in this easy way to support the AANA Foundation!
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Federal Government Affairs

CMS Issues Medicaid Managed Care Rule Supporting AANA-backed Provider Nondiscrimination

On May 6, the Centers for Medicare & Medicaid Services (CMS) released its final Medicaid managed care rule, in which the agency finalized its recommendation for an AANA-backed policy of provider nondiscrimination. This is an important provision for protecting and advancing patient access to CRNA practice.

Last updated in 2002, CMS proposed a new Medicaid managed care rule in July 2015 to help modernize Medicaid managed care regulations and reflect changes in the use of managed care delivery systems. In comments last July, the AANA advised CMS that Medicaid plans in several states have policies that discriminate against care delivery by CRNAs and these discriminatory policies increase costs to the healthcare system, promote inefficient care delivery, impair access to quality care, and do not improve patient outcomes. The final rule reinforced that the agency supports applying the provider nondiscrimination law to Medicaid plans, stating that “a managed care plan may not discriminate against a provider solely for providing services within their scope of licensure.”

For further information, view the final rule, and the AANA's comment.

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Military CRNAs Incentive Special Pay (ISP) Extended by House Armed Services Committee

On April 27, the House Armed Services Committee passed the National Defense Authorization Act (NDAA) for Fiscal Year 2017 (HR 4909), that includes an AANA-backed provision extending Incentive Special Pay (ISP) for military CRNAs for one more year through December 31, 2017. Read the bill. Developed to help the U.S. Armed Forces recruit and retain CRNAs in support of its military mission, the ISP is a discretionary bonus available to qualified Nurse Corps officers who are CRNAs and who agree to remain on active duty for at least a year. The bill now heads to the House floor for legislative action later in May.
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Congress Takes Up Legislation Addressing Opioid Crisis

The House and Senate returned to Washington on May 10, and the House planned beginning May 11 to debate and vote on legislation intending to address the crisis in opioid abuse and diversion. With CRNAs involved in pain care, and in the use of regional anesthetic techniques intended to reduce the use of opiates intra- and postoperatively, some of the opioid-related bills coming before the U.S. House include:
  • “Jason Simcakoski PROMISE Act” (HR 4063), which directs the Department of Veterans Affairs (VA) and Department of Defense (DOD) to jointly update the VA/DOD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain.
  • “Improving Treatment for Pregnant and Postpartum Women Act of 2016” (HR 3691), which would reauthorize the residential treatment programs for pregnant and postpartum women and establish a pilot program to provide grants to State substance abuse agencies to promote innovative service delivery models for such women.
  • HR 4641, which would provide for the establishment of an inter-agency task force to review, modify, and update best practices for pain management and prescribing pain medication.
  • “Comprehensive Opioid Abuse Reduction Act of 2016” (HR 5046), which would authorize the Department of Justice to award grants to state, local, and tribal governments to provide opioid abuse services and to establish or expand programs for Veterans.
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At the White House, AANA Supports Opioid Prescription Education

On April 29, Paul Austin, PhD, CRNA, and AANA DC’s Frank Purcell attended a White House Champions of Change event honoring 10 leaders in combating prescription drug abuse. Linked to the event was the announcement that over 200 schools of nursing and several APRN groups, including AANA, have committed to enhance their education programs for APRN students using the new CDC Guidelines for Prescribing Opioids for Chronic Pain.

The AANA is pleased to partner with the American Association of Colleges of Nursing, American Association of Nurse Practitioners, American College of Nurse-Midwives, American Nurses Association, National Association of Clinical Nurse Specialists, and National Organization of Nurse Practitioner Faculties to develop and host an educational webinar series for nursing faculty, students, and clinicians.

For more information, read the White House Fact Sheet. See a recording of the event.

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Upcoming Presidential and Congressional Elections

The AANA encourages CRNAs to vote and be active in primary elections this spring in support of candidates of their choice. If you are involved in one of the following 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.
  • May 17, presidential and congressional primaries in Kentucky and Oregon; congressional primaries in Idaho
  • May 24, presidential primary in Washington; congressional primary in Georgia
  • May 28, Democratic presidential convention in Wyoming
  • June 4, Democratic presidential primary in Virgin Islands
  • June 5, presidential and congressional primary in Puerto Rico
  • June 7, presidential and congressional primaries in California, Montana, New Jersey, New Mexico, and South Dakota; Democratic presidential caucus in North Dakota; congressional primary in Iowa; U.S. House of Representatives primary in North Carolina

For an up-to-date list of 2016 election dates by state and by date.

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  • The number three cause of death in United States is healthcare, according to a major new study published in the journal BMJ. Read the article by Martin Makary MD, a past AANA meeting keynote speaker.
  • With UnitedHealthcare departing Affordable Care Act exchanges, other plans are moving in and raising premiums, reported the Wall Street Journal on May 5.
  • Engage with your profession’s social media feed on Facebook and Twitter.
  • Keep up with the AANA’s new efforts for educating hospital administrators, healthcare policymakers and other health industry leaders about the role and value of CRNA care at Future of Anesthesia-Care Today.
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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 US Citizen.
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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.

Shorter Hospital Stays and Reduced Costs Possible With IV Acetaminophen

A retrospective analysis indicates that stepping down opioid therapy and combining it with intravenous acetaminophen effectively manages acute postoperative pain while also cutting hospital stays and lowering costs. The study, from Mallinckrodt Pharmaceuticals, examined more than 2.2 million surgeries at nearly 300 U.S. hospitals over a two-year period. On average, the company found that hospital length of stay was shortened by 18 percent and opioid-related complications were cut by 28.5 percent, for collective annual cost savings of $4.7 million for a medium-sized facility. The data suggest that acetaminophen, along with a one-level reduction in opioid use [high to medium, medium to low, or low to none] "can be incorporated as part of a multimodal analgesia approach for acute pain management, which may contribute to reduced costs and improved outcomes for surgical patients," lead investigator George Wan, PhD, MPH, told the 41st Annual Regional Anesthesiology and Acute Pain Medicine Meeting in New Orleans in March.

From "Shorter Hospital Stays and Reduced Costs Possible With IV Acetaminophen"
Drug Topics (05/10/16) Blank, Christine

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Moderate Sedation Leads to Better Clinical Outcomes Than General Anesthesia for TAVR Patients

For patients undergoing transcatheter aortic valve replacement (TAVR), the use of moderate sedation leads to better clinical outcomes compared to general anesthesia, according to a study by researchers at the University of Pennsylvania. The researchers used the STS/ACC TVT Registry database to evaluate elective cases treated via a percutaneous transfemoral approach from April 2014 through June 2015 to compare the effectiveness of moderate sedation to general anesthesia. A total of 10,997 patients were assessed, with 1,737 (15.8 percent) receiving moderate sedation. The investigators concluded that while both patient groups had nearly equal rates of TAVR procedural success, the moderate sedation patients experienced lower rates of 30-day mortality, 30-day mortality or stroke, and shorter hospital stays. The researchers also conducted a propensity-matched analysis that accounted for 51 factors known to predict 30-day TAVR mortality, including age, gender, and heart failure status. The analysis further confirmed that moderate sedation was associated with lower 30-day mortality and 30-day mortality or stroke. TAVR has become the preferred therapy for severe aortic stenosis for patients who are at extreme- or high-risk for open heart surgery. Senior author Jay Giri notes, "Since there is no longer a definitive need for a surgical incision, we had to ask the question of whether there was a need for general anesthesia, the full sedation of a patient requiring breathing tube and nonresponsive unconsciousness." The findings were presented at the Society for Cardiovascular Angiography and Interventions 2016 Scientific Sessions in Orlando.

From "Moderate Sedation Leads to Better Clinical Outcomes Than General Anesthesia for TAVR Patients"
News-Medical.Net (05/09/16)

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Low-Dose Ketamine Infusion Appears Safe Even Without Continuous Hemodynamic Monitoring

A small, retrospective analysis suggests that low-dose ketamine infusions are safe for patients who are not in a setting with continuous monitoring. Jeffrey M. Carness and his colleagues at Naval Medical Center Portsmouth used a pharmacy database to identify patients receiving ketamine infusions with an average dose of 5 mcg/kg per minute. Electronic medical records in the institution were cross-referenced for cases in which patients treated with low-dose ketamine infusions experienced adverse effects (AEs). A total of 171 patients met the inclusion criteria. The records revealed AEs on 27 occasions, for an event rate of 15.8 percent. Twenty-five of the AEs were mild, and there were no major instances of morbidity, mortality, or hemodynamic instability. In future studies, the team plans to continue studying the rate and type of complications associated with low-dose ketamine infusion and create a new protocol to address the safety of ketamine with opioid combination versus opioids alone.

From "Low-Dose Ketamine Infusion Appears Safe Even Without Continuous Hemodynamic Monitoring"
Anesthesiology News (05/09/16) Duffy, Brigid

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How Do Anesthesiologists View Acupuncture and Acupressure?

U.S. anesthesia providers are generally receptive to the idea of using acupuncture and acupressure for pain relief but have not acted on this interest, a new study finds. Most say they have not received or used any education in acupressure, which may alleviate anxiety, or acupuncture—which, along with treating anxiety, could benefit patients with acute postoperative or chronic pain. Still, about 75 percent of anesthesia professionals participating in the research were interested in receiving instruction in the two disciplines, and more than 50 percent indicated that they would consider incorporating the alternative approaches into their practice. The study authors, out of Virginia Commonwealth University, believe their findings make a strong case for including some aspects of alternative medicine in the curriculum for anesthesia training. Their report, "Perceptions of Acupuncture and Acupressure by Anesthesia Providers," is published in the peer-reviewed journal Medical Acupuncture.

From "How Do Anesthesiologists View Acupuncture and Acupressure?"
HealthCanal.com (05/08/16)

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Blood Analyses May Predict Risk of Delirium in Older Surgical Patients

As many as 53 percent of older patients experience postoperative delirium—making them more vulnerable to complications, keeping them in the hospital longer, and increasing their odds of being released to a nursing home. Research spearheaded by Beth Israel Deaconess Medical Center, however, may help gauge delirium risk through blood-based markers. The investigators screened plasma from 566 adults aged 70 and older with no dementia who were having non-cardiac surgery. The blood analyses—collected preoperatively, in the postanesthesia care unit, on the first day after the operation, and one month later—revealed a correlation between delirium and high levels of C-reactive protein (CRP). That relationship was already known, but the Beth Israel study for the first time documented and analyzed CRP levels prior to the onset of symptoms. "From a clinical standpoint, our findings suggest that CRP could be used to risk stratify patients before surgery, enabling proactive interventions that target patients at risk for developing postoperative delirium," noted co-lead author Sarinnapha Vasunilashorn, PhD. The study is published online in Biological Psychiatry.

From "Blood Analyses May Predict Risk of Delirium in Older Surgical Patients"
Science Codex (05/06/16)

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New CDC Campaign Reminds Docs, Nurses That 'Clean Hands Count'

The Centers for Disease Control and Prevention (CDC) launched on May 5, World Hand Hygiene Day, its "Clean Hands Count" campaign to prevent healthcare-associated infections. Studies show that some healthcare professionals do not adhere to the CDC's hand hygiene recommendations. "Clean hands really do count and in some cases can be a matter of life and death," says CDC Director Tom Frieden, MD. The new campaign addresses some of the misconceptions about hand hygiene, including some about alcohol-based hand sanitizer. CDC noted, "Alcohol-based hand sanitizer kills germs quickly and in a different way than antibiotics, so it does not cause antibiotic resistance, and it causes less skin irritation than frequent use of soap and water." The CDC's initiative also encourages patients and families to ask their healthcare team to clean their hands if they do not see them do so prior to providing care. Statistics show that an estimated 722,000 healthcare-associated infections occur in U.S. hospitals each year, and about 75,000 patients with these infections die while in the hospital. http://www.cdc.gov/handhygiene/campaign/index.html

From "New CDC Campaign Reminds Docs, Nurses That 'Clean Hands Count'"
CDC News Release (05/05/16)

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Pre-op Exercise Programs Improve Post-op Outcomes

Interventions to improve fitness before an operation may curtail the likelihood of morbidity and mortality, investigators speculate. The retrospective analysis looked at more than 62,000 patients tested for exercise tolerance ahead of surgery between 1965 and 2015. Surgical patients aged 30 to 39 years who had an abnormal heart rate recovery (HRR)—or recovery under 42 beats per minute (bpm)—were significantly more likely to die. The mortality rate for those patients was 24.3 percent, much higher than the 1.2 percent of patients with HHR over 42 bpm who expired. Meanwhile, 52.2 percent of surgical patients older than 60 years subsequently died, compared with just 19 percent of older patients with normal HHR. "The relationship between abnormal heart rate and outcomes is something that can't be ignored," declared co-researcher Ruchir Gupta, MD, of New York's Stony Brook University. "Our next step is incorporating some of the newer studies in this review article and then implementing an exercise program on a small scale with controlled variables to assess for any benefit from the training program."

From "Pre-op Exercise Programs Improve Post-op Outcomes"
General Surgery News (05/04/16)

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Preoperative Opioid Use Linked With Lower Outcome Scores After TSA

Preoperative opioid use translated into poorer baseline evaluations before surgery and less-favorable outcomes afterwards, according to a retrospective study of patients undergoing total shoulder arthroplasty. Researchers compared results in 60 patients who took opioids for shoulder pain prior to replacement surgery against a control group of 164 patients with no history of opioid use. The data revealed lower preoperative and postoperative scores in the opioid cohort for pain, activity, mobility, and strength. While both sets of patients had improved greatly from baseline values at followup, outcomes for patient-reported measurements and range-of-motion measurements were markedly better in the non-opioid group. Additionally, patient satisfaction with the procedure was higher among patients who had not used opioids preoperatively—at 91 percent, compared to 80 percent among patients with a background of opioid consumption.

From "Preoperative Opioid Use Linked With Lower Outcome Scores After TSA"
Healio (05/02/2016) Tingle, Casey

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Severe Nausea and Vomiting in the Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia II Trial

Nitrous oxide has been shown to elevate the risk of postoperative nausea and vomiting (PONV), prompting researchers to question whether it is also a risk factor for severe PONV—which is persistent and/or recurring. The relationship between the two was explored as a secondary focus of the Evaluation of Nitrous oxide in the Gas Mixture for Anesthesia (ENIGMA) II trial. In that study, more than 7,000 non-cardiac surgical patients were randomly assigned to receive nitrous oxide or another anesthetic with no nitrous oxide. Researchers found that while nitrous oxide does indeed raise the risk for severe PONV, that risk can be avoided with antiemetic prophylaxis. The finding has clinical importance, considering that severe PONV can lead to postoperative fever, poor quality of recovery, and extended hospital stay.

From "Severe Nausea and Vomiting in the Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia II Trial"
Anesthesiology (05/16) Vol. 124, No. 5, P. 1032 Myles, Paul S.; Chan, Matthew T.V.; Kasza, Jessica; et al.

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Remimazolam Provides Adequate Sedation During Colonoscopy

Phase II testing has further demonstrated the efficacy and safety of remimazolam as a sedation agent for routine colonoscopy. The trial randomly assigned 162 adult patients to receive either midazolam or one of three different doses of remimazolam for induction of sedation. Procedural success rates were greater in each of the remimazolam groups compared with the midazolam cohort. Moreover, the success rate was highest with the lowest dose of remimazolam, whose short half-life allows for rapid onset and offset. "This study's success in documenting both efficacy as well as a good safety profile warrants further investigation through confirmatory phase III studies," the researchers concluded.

From "Remimazolam Provides Adequate Sedation During Colonoscopy"
Healio (04/29/2016) Leitenberger, Adam

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Endorphin Analogs May Offer Alternative to Opioids

As the quest continues for an analgesic that can temper pain without negative side effects, a team in Louisiana has produced promising results with analogs derived from endomorphins (EMs). Engineered variants of the neurochemical, which is naturally produced in the human body, delivered similar or better analgesia compared to morphine in studies on rats. Additionally, unlike analgesia triggered through interaction with the mu opioid receptor—which can cause respiratory depression, constipation, addiction, overdose, and even death—the new compound was associated with significantly fewer side effects. "The results indicated that EM analogs are clearly more effective and safer analgesics than morphine," the researchers write in Neuropharmacology.

From "Endorphin Analogs May Offer Alternative to Opioids"
Practical Pain Management (04/16) Ciccone, Thomas G.

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Doctors Recommend Prescribing Fewer Opioids After Surgery

Amid efforts to curb misuse of prescription pain medications, experts at the Washington University School of Medicine in St. Louis are asking surgeons to send patients home with fewer opioids. Writing in Anesthesiology, Evan D. Kharasch, MD, and L. Michael Brunt, MD, note that patients often do not use all of the pain medication prescribed following surgery. Once dispensed, however, the drugs are in the community and susceptible to misuse by others. Kharasch, an anesthesia provider, says doctors can simply reduce the number of opioids they prescribe, while pharmacies could get involved through programs encouraging patients to turn in unused opioids. Kharasch and Brunt, a surgeon, also hope to spark more discussion on how to better use pain medication during operations—perhaps by swapping short-acting drugs for longer-lasting ones that keep patients comfortable longer after surgery. "Would that mean they would need fewer pain pills when they go home?" Kharasch wonders. "That's something that needs to be studied." The doctors' recommendation follow on the heels of new Centers for Disease Control and Prevention guidelines that call for primary care physicians to consider their options before prescribing opioid analgesics.

From "Doctors Recommend Prescribing Fewer Opioids After Surgery"
Washington University in St. Louis (04/27/16) Dryden, Jim

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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.

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