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VHA Publishes Proposed Rule that Extends Full Practice Authority to CRNAs and other APRNs


In an effort to ensure access to timely, quality healthcare for America’s veterans, the Veterans Health Administration (VHA) has published a proposed rule in the May 25 Federal Register that allows CRNAs and other advanced practice registered nurses (APRNs) to provide patient care to the full extent of their education and abilities.

The policy change, which is consistent with recommendations from the National Academies of Medicine (formerly the Institute of Medicine), would define Full Practice Authority in VHA facilities for CRNAs, Nurse Practitioners, Clinical Nurse Specialists and Certified Nurse Midwives. Its definition of Full Practice Authority means that APRNs working within the scope of VA employment would be authorized to practice as described in the law in section 17.415(b) “without the clinical oversight of a physician, regardless of state or local law restrictions on that authority.”

The policy of allowing CRNAs and other APRNs to practice in the VHA to the full extent of their education and skill is supported by more than 60 organizations, including veterans’ groups such as the Military Officers Association of America and the Air Force Sergeants Association. The policy is also supported by AARP (whose membership includes 3.7 million veteran households), numerous healthcare professional organizations including the American Association of Nurse Anesthetists (AANA) and other APRN associations, and 80 Democratic and Republican members of Congress. Read more in the AANA Press Release and take action at www.veteransaccesstocare.com.

 

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CPC Facts


CPC Program Costs: Similar to Today’s

When considering all expenses, the NBCRNA anticipates that the cost of the CPC Program will be similar to what the total cost of recertification is today. Let's start with CEs. Just as CRNAs do now, they will primarily obtain their continuing education from facility-based inservice programs and CE vendors who will be offering various programs at various price levels as they do today. No change here. Additionally, Core Modules (voluntary the first four years) will count toward Class A CE requirements, so CRNAs can "double-dip" by taking Core Modules and applying them to both the Class A requirement and the Core Module requirement, when needed. As for the exam, the CPC Exam will take place every eight years and is estimated to cost what would be $300 today, so an average of about $37.50 per year. That is roughly the cost of one CE.

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


AANA Election Results Announced

The AANA is pleased to announce the results of the election for the FY2017 Board of Directors, Nominating Committee, and Resolutions Committee. New Members Elected for the FY 2017 Board of Directors
  • Bruce Weiner, MS, CRNA, President-elect
  • Kathryn Jansky, MHS, CRNA, APRN, USA, LTC(ret), Vice President
  • Randall Moore II, DNP, CRNA, USAR, MAJ(ret), Treasurer
  • Dina Velocci, DNP, CRNA, APN, Director – Region 2
  • Christine Salvator, MSN, CRNA, APN, Director – Region 3
  • John Bing, BSN, CRNA , Director – Region 6
  • Heather Rankin, DNP, CRNA , Director – Region 7
AANA Board of Directors FY 2017
  • Cheryl Nimmo, DNP, MSHSA, CRNA, President
  • Bruce Weiner, MS, CRNA, President-elect
  • Kathryn Jansky, MHS, CRNA, APRN, USA, LTC(ret), Vice President
  • Randall Moore II, DNP, CRNA, USAR, MAJ(ret), Treasurer
  • Robert Gauvin, MS, CRNA, Director – Region 1
  • Dina Velocci, DNP, CRNA, APN, Director – Region 2
  • Christine Salvator, MSN, CRNA, APN, Director – Region 3
  • Mark Haffey, MSN, CRNA, APN, Director – Region 4
  • Alison Carter, MS, CRNA, Director – Region 5
  • John Bing, BSN, CRNA , Director – Region 6
  • Heather Rankin, DNP, CRNA , Director – Region 7
FY 2017 Nominating Committee
  • Susan DeCarlo-Piccirillo, DNP, CRNA, Region 1
  • Cheryl Schosky, MSN, CRNA, Region 2
  • Phillip Robles, MS, CRNA, Region 3
  • Julie Zerwas, MS, CRNA, Region 4
  • Sherry Swearngin, MHS, CRNA, Region 5
  • Jay Thomas, MS, MPA, CRNA, Region 6
  • Rosann Spiegel, DNAP, JD, CRNA, ARNP, Region 7
FY 2017 Resolutions Committee
  • Katherine Jacobsen, MSN, CRNA, APRN – Minnesota
  • Ann Culp, DNP, CRNA – Pennsylvania
  • Donna Fiaschetti, DNAP, MS, CRNA – Kentucky
  • Chris Muckler, DNP, CRNA, CHSE – North Carolina
  • Mark Talon, DNP, MSNA, CRNA – Texas
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June 30 Deadline for GPRO Registration Quickly Approaching

Will you be reporting to Physician Quality Reporting System (PQRS) as part of a group practice for the 2016 performance period? Is so, your group needs to register your Group Practice Reporting Option (GPRO) with Centers for Medicare & Medicaid Services (CMS)—whether be it qualified registry, Qualified Clinical Data Registry (QCDR), Electronic Health Record (EHR), or Web Interface—by June 30, 2016, via, their Physician Value-PQRS Registration System. As a reminder a group practice is defined as two or more eligible professionals (EPs) who have reassigned their billing rights to a single Taxpayer Identification Number (TIN). CRNAs belonging to one or more group practices also have the option of reporting as individual EPs. For more information on GPROs, please visit our 2016 PQRS Reporting Mechanisms FAQ page on the AANA Quality-Reimbursement website.
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Professional Practice


AANA Supports FDA’s Ban on Powdered Gloves

The AANA has issued a letter to the US Food and Drug Administration (FDA) supporting the proposal to ban powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s glove to mitigate the adverse events related with these devices, thus promoting patient and healthcare worker safety. Read the letter here.
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Joint Commission Launches New Scoring Methodology to Help Organizations Prioritize Corrective Actions

The new SAFERTM (Survey Analysis for Evaluating Risk) approach gives organizations additional information related to deficiency risks. Organizations will be able to view noncompliance areas on a macro level, reflecting risk analysis, including likelihood of harming a patient, staff or visitor and the scope/frequency of a cited deficiency. All accredited organizations (except psychiatric hospitals, which will receive the information sooner) will receive the SAFER matrix in their reports after January 1, 2017. Important revisions to the accreditation process include requiring 60 days for corrective action to all cited deficiencies. Read more here.
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With Summer Just a Few Short Weeks Away, Are You Prepared for Zika?

Warmer weather means increased mosquito activity, heightening the risk of possible transmission of the Zika virus. This means that CRNAs could see patients presenting with Zika and need to be prepared. Visit the AANA Zika Resources page to learn more about Zika and precautions that you can take in practice.
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Meetings and Workshops


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. Just take a look at the lineup of top notch sessions and unparalleled networking events on the schedule at a glance.
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Save the Dates for These Popular Hands-On Workshops

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

Jack Neary Pain Management Workshop 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 fund and sustain programs that further research and education in anesthesia and support the future of nurse anesthesia through meaningful, lasting gifts. The Friends for Life submission deadline for recognition at this year’s Annual Congress in Washington, DC is June 15, 2016. For further information, please contact Nat Carmichael at (847) 655-1175 or ncarmichael@aana.com.
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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.

Annual Congress Registration is now open: Click here to register and purchase your tickets today. 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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Support Important Research: Donate to the AANA Foundation Annual Campaign Today!

The AANA Foundation supports important research with the help of individuals, state associations, and corporations. Evidence provides proof, and proof is power!

Take a moment today to make your tax-deductible gift to AANA Foundation’s Proof is Power campaign – click here to access the Foundation’s secure donation page.

Donations of $100 or more made by July 1, 2016, will be included in the AANA Foundation Fiscal Year 2016 Annual Report and Recognition booklet.

Thank you in advance for your contribution and support of nurse anesthesia through the AANA Foundation!
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Federal Government Affairs


Do’s and Don’ts for CRNAs Supporting Expanded Access to Care for our Veterans and CRNA Full Practice Authority in the VHA

What can CRNAs do to advance veterans' access to quality care and support CRNA and APRN practice?
  • Do use www.VeteransAccessToCare.com to submit a comment and make your voice heard!
  • Do share www.VeteransAccessToCare.com with your friends, colleagues and family – especially those who are Veterans – and ask them to submit comments and make their voices heard, too.
  • Do keep all of your comments and social media postings factual and professional.
  • Don’t submit a comment if you feel it would put your job at risk. VA employees in general should not submit comments on this VA policy; AANA is advised that the agency will match employee names against commenters’ names and discard comments from employees. If you are a VA employee, or are uncomfortable submitting a comment, share www.VeteransAccessToCare.com with your colleagues, friends and family and multiply your voice effectively.
  • Don’t use the ASA-backed site to submit comments, even if you rewrite comments to favor the AANA’s point of view. There is no reason to trust the ASA site to faithfully submit CRNA-friendly comments to the Veterans Administration.
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Congress Passes FY 17 Appropriations Legislation to Fund the Veterans Administration with No Anti-CRNA Amendments

On May 19, the US House and Senate voted to pass their respective appropriations bills funding the Department of Veterans Affairs for Fiscal Year 2017. With the American Society of Anesthesiologists on Capitol Hill May 18 for their annual fly-in, there was concern that amendments could be offered in opposition to CRNA and APRN Full Practice Authority in the Veterans Health Administration. Thanks to AANA efforts including nearly three thousand CRNA contacts with Congress, the bills passed without any anti-CRNA amendments offered or voted on.

The measures now go to a House and Senate Conference Committee, which will resolve the differences between the House and Senate bills, including advisory report language regarding Full Practice Authority. The compromise language will be finalized in September or, more likely, during the post-election “lame duck” session omnibus appropriations package.
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US House Extends Incentive Special Pay for CRNAs Serving in the US Armed Forces

The US House of Representatives on May 18 passed the National Defense Authorization Act (NDAA), HR 4909, for Fiscal Year 2017, which included an AANA-backed provision extending Incentive Special Pay (ISP) for military CRNAs for one year through December 31, 2017. Read the bill here. Developed to help the US 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.

Similar legislation, S. 2943, was introduced in the Senate on May 18. The bill awaits consideration by the Senate Armed Services Committee.
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Honoring LTC Ira Gunn, MLN, CRNA, FAAN, on Memorial Day


Memorial Day takes place Monday, May 30, and AANA expresses thanks for those men and women who served in uniform and, as President Lincoln said, “gave their last full measure of devotion” to their country. If you are in the National Capital Area, you can mark Memorial Day by paying a visit to the final resting place of one of the titans of the nurse anesthesia profession. LTC Ira P. Gunn, MLN, CRNA, FAAN, served 21 years in the Army Nurse Corps and the profession's highest advocacy honor is named for her. She rests in honor at Arlington National Cemetery, Sec. 21, Site 385, about 30 yards east of the Nurses' Memorial. Learn more about LTC Gunn here, and about the AANA’s Ira P. Gunn Award for Outstanding Professional Advocacy here.



 

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US House Passes Opioid Abuse and Diversion Legislation

To address the public crisis in opioid abuse and diversion, the US House of Representatives passed 18 bills related to the issue May 11-13, then combined them and adopted them as a package (S 524) on a vote of 240-165. Read the bill here and the vote here. The next step for the bill is a House-Senate Conference Committee to resolve the differences in the two bills and develop compromise language to be considered by both chambers of Congress. Bills that passed the House of interest to CRNAs include:
  • “Jason Simcakoski PROMISE Act” (H.R. 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. Passed by voice vote.
  • “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. Passed by voice vote.
  • 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. Passed 412-4.
  • “Comprehensive Opioid Abuse Reduction Act of 2016” (H.R. 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. Passed 413-5.
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AANA Requests Clarification from Health Care Payment Learning and Action Network on the Role of CRNAs and Anesthesia in Maternity Care Bundles

The AANA requested that the Health Care Payment Learning and Action Network (LAN) fully recognize the role of CRNAs and of anesthesia in maternity care bundled payments in a comment letter submitted to the LAN on May 20 in response to its white paper, “Accelerating and Aligning Clinical Episode Payment Models: Maternity Care.” The LAN is intended to examine issues and challenges associated with the development and deployment of alternative payment models across the public and private sectors.

The letter, signed by AANA President Juan Quintana, DNP, MHS, CRNA, stated, “As CRNAs personally administer more than 40 million anesthetics to patients each year in the United States, including for labor and delivery, CRNA services contribute extensively to the successful development and implementation of the maternity payment episode of care. Anesthesia contributes to a maternity episode through multimodal pain management that allows the parturient to be comfortable, yet able to engage in activities related to labor, delivery, neonate bonding and personal recovery… We request clarification on how anesthesia fits into the model as it is not apparent in this white paper. More to the point, the healthcare professionals who contribute to the success of an episode of care should be included not only in reimbursement discussions, but more importantly in the design of care and outcome measures to identify successes and opportunity to improve across transitions of care.”

For further information, read the AANA comment on the draft white paper and view the draft white paper at http://hcp-lan.org/workproducts/maternity-whitepaper-draft.pdf.     
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CMS Identifies “Anesthesiology” as a Provider Specialty that has Inequities in Quality Reporting Measures
 
The Centers for Medicare & Medicaid Services (CMS) identified “anesthesiology” as a specialty that has a quality measure gap, with fewer than 10 Physician Quality Reporting System preferred measures in its final Quality Measure Development Plan for the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The agency identified this as a priority and said that it plans to collaborate with specialty groups and associations, such as the AANA, on topics that are important to both patients and clinicians and to develop measures to close important performance gaps. The CMS Quality Measure Development Plan outlines how existing measurement strategies, policies, and principles will guide the agency’s efforts in building measure portfolios for MIPS and APMs. According to CMS, future measure development will prioritize person- and caregiver-centered experience of care, patient-reported outcomes and patient health outcomes, communication and care coordination, and appropriate use of resources across six quality domains. Those six domains are clinical care, safety, care coordination, patient and caregiver experience, population health and prevention, and efficiency and cost reduction.

For further information, see AANA’s comments and the final plan.
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Medicare Issues Finalized Fire Safety Requirements for Healthcare Facilities

In a May 4 final rule CMS removed its fire safety requirement for installation of smoke control for anesthetizing locations in hospitals, critical access hospitals, and ambulatory surgical centers. In comments to the agency’s original 2014 proposal, the AANA advocated that CMS retain these requirements.

Other commenters to CMS suggested that requiring installation of smoke controls would have been too expensive relative to their benefit. In the preamble to the final rule, the Medicare agency states, “[i]n light of the concerns raised by commenters, we agree that requiring the installation of smoke ventilation systems would not be an effective use of hospital and ASC resources. We agree that a focus on preventing and quickly extinguishing surgical fires will likely have a more significant positive impact on patient safety, and encourage hospitals, CAHs, and ASCs to continue this important work. We also agree that the presence of quick response sprinkler heads, alternative smoke purge systems, which can continue to be used, and the use of non-flammable anesthetics all contribute to a very minimal risk of smoke requiring ventilation in the first place. Therefore, we have removed this requirement from the regulations text for hospitals, CAHs, and ASCs.” The final rule becomes effective July 5.

For further information, read the final rule and the AANA comment letter.
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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, 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.
  • 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
  • June 14, Democratic presidential and congressional primary in Washington, DC; Congressional primaries in Maine, Nevada, North Dakota, South Carolina, and Virginia
For an up-to-date list of 2016 election dates by state and by date, go to http://www.fec.gov/pubrec/fe2016/2016pdates.pdf.
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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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Jobs


Visit www.crnacareers.com to view or place job postings
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Featured Career Opportunity

Certified Registered Nurse Anesthetists - Dartmouth-Hitchcock
Lebanon, NH

D-H is seeking CRNAs whom are interested in the practice of Anesthesiology. Positions are full-time with highly competitive salary and benefits, a student loan forgiveness program, and a desirable schedule.

Read more about this position
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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.

Naldemedine Improves Opioid-Induced Constipation in Patients With Chronic Noncancer Pain

The COMPOSE I and II studies have found naldemedine to be a safe and effective treatment for opioid-induced constipation in people with chronic noncancer pain. The twin, phase 3 trials randomly assigned hundreds of participants to receive either naldemedine or placebo every day for 12 weeks. Compared to individuals in the placebo cohort, patients taking naldemedine experienced significantly more spontaneous bowel movements. Although abdominal pain and diarrhea were common side effects, the drug did not trigger any signs or symptoms of opioid withdrawal, nor did it dilute the analgesic effect of the opioids. "Overall the consistent results of these two studies demonstrate that once daily naldemedine 0.2 mg was effective in treating [opioid-induced constipation] sufferers with chronic noncancer pain and was generally well-tolerated," summed up Martin E. Hale, MD, of Gold Coast Research.

From "Naldemedine Improves Opioid-Induced Constipation in Patients With Chronic Noncancer Pain"
Healio (05/24/2016) Leitenberger, Adam

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Shoulder Surgery Is the New Testing Ground for Painkiller Alternatives

As medical professionals aim to curtail the use of opioids, new approaches to pain control increasingly are being tried out first on people with injured rotator cuffs. The hope is that if a non-opioid technique works well with this shoulder surgery, which has a particularly painful recovery process, it will gain widespread adoption by orthopedic surgeons—who are leading prescribers of narcotic painkillers. Strategies such as single-dose regional nerve block, prolonged continuous nerve block, short-course narcotic therapy, cryotherapy, and rehabilitation are not new in and of themselves but are innovative in their combined use. This process, known as multimodal management, is attracting a following as more people fall victim to opioid addiction. Not only does it spare patients the risk of forming a habit or other dangerous side effects, it also promises to lower surgery costs over the long term by saving on the high costs associated with narcotic overuse.

From "Shoulder Surgery Is the New Testing Ground for Painkiller Alternatives"
Wall Street Journal (05/23/16) Landro, Laura

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Opioids Provide Only 'Modest' Relief for Low Back Pain

While nearly one-fourth of all opioid prescriptions written in the United States are to treat low back pain, research does not support this practice. According to a systematic review of 20 clinical studies involving several thousand participants suffering from the condition, narcotic painkillers offer "modest" short-term relief, at best. In fact, the Australian researchers report, roughly half of the 7,300 or so patients enrolled in the trials withdrew after experiencing negative side effects or receiving no relief from the drugs. "Our review challenges the prevailing view that opioid medicines are powerful analgesics for low back pain," concluded lead study author Andrew McLachlan, PhD, a professor of pharmacy at the University of Sydney. "Opioid analgesics had minimal effects on pain, and even at high doses the magnitude of the effect is less than the accepted thresholds for a clinically important treatment effect on pain." The findings are published in JAMA Internal Medicine.

From "Opioids Provide Only 'Modest' Relief for Low Back Pain"
Pain News Network (05/23/16) Anson, Pat

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Buprenorphine 'Underused' in Primary Care as Opioid Abuse Soars

Despite the mushrooming need for it, not many primary-care physicians (PCPs) in the United States are prescribing the lone drug available to them to treat opioid addiction. According to research presented at the American Pain Society's 35th Annual Scientific Meeting, 88 percent of PCPs surveyed cited inadequately trained staff for the low rate of buprenorphine use the primary-care setting. In turn, 80 percent blamed insufficient time and 37 percent pointed to the regulatory burden. Doctors must secure waivers from the Drug Enforcement Administration in order to prescribe buprenorphine for addiction—but not for pain—and the share that have done so is low, according to research. "Primary care is an ideal place for this drug to be used, with PCPs being the ones treating most of the chronic pain out there," says Lucinda Grande, MD, of the University of Washington's family medicine department, adding that patient access would be widened if nurse practitioners and physician assistants were authorized to prescribe buprenorphine. "Many of our patients are not thriving on opioids, and PCPs have been struggling to find a better option for them."

From "Buprenorphine 'Underused' in Primary Care as Opioid Abuse Soars"
Medscape (05/20/16) Melville, Nancy A.

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Conscious Sedation Same as Anesthetic for Stroke Thrombectomy

Findings from the SIESTA clinical trial refute earlier evidence linking general anesthesia to poorer outcomes, compared with conscious sedation, in patients with acute ischemic stroke undergoing thrombectomy. Unlike SIESTA, the previous investigations were not randomized to compare one approach against the other. Results from the newer study, however, found no difference in primary outcome—change in National Institutes of Health Stroke Severity score from baseline to 24 hours postoperatively—between patients randomly assigned to have the procedure under conscious sedation and patients randomly assigned to undergo general anesthesia. "We were surprised by the results as we expected conscious sedation to be superior, as this is what has been suggested by retrospective studies," admitted researcher Julian Bosel, MD, of Germany's University Hospital Heidelberg. He presented the data recently at the European Stroke Organisation Conference 2016. The medical community is eagerly awaiting results from the second part of the trial, which will measure differences between the two sets of patients at three-month followup. That data is expected to be unveiled at the World Stroke Congress in October.

From "Conscious Sedation Same as Anesthetic for Stroke Thrombectomy"
Medscape (05/19/16) Hughes, Sue

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Reportedly 90 Percent of Infusion Pump 'Events' Have Common Cause

Analyzing data from more than 20,000 infusion pumps, researchers discovered that 90 percent of programming "events" involved titration—changes in the amount of medication administered once infusion has begun. The study information, collected from 45 U.S. hospitals over a six-month period, specifically targeted "high alert" drugs delivered for anesthesia, surgery, or critical care. Propofol, for example, was titrated nine times per infusion, creating nine openings where programming errors could occur. Despite the high rate of medication errors tied to dose changes and infusion pumps, there remains a lack of protocol to monitor titrations. The researchers hope their results will enhance patient safety by helping the industry develop more effective infusion practices.

From "Reportedly 90 Percent of Infusion Pump 'Events' Have Common Cause"
Dotmed (05/19/16) Dubinsky, Lauren

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Ketamine Infusion May Be Safe and Effective Adjunct to Sedation in the Critically Ill

In critically patients who are mechanically ventilated, preliminary evidence suggests that continuous ketamine infusion may be an option when both sedation and analgesia are needed. Not only is ketamine a potent analgesic, according to Lara Groetzinger, PharmD, of the University of Pittsburgh Medical Center, but it offers protective hemodynamic and respiratory properties. Her team hypothesizes that continuous ketamine infusion could be a viable alternative to continuous benzodiazepine infusion—which has been linked to prolonged ICU stay and other poor outcomes—although they stress that much more study is required. "While the risks associated with benzodiazepine use are reasonably well described, there is not enough evidence currently to definitely say that ketamine is more or less harmful, or that ketamine provides better outcomes than other sedatives," Groetzinger notes. "We did not evaluate any patient outcomes associated with the use of ketamine in these patients. The bottom line is more information is needed."

From "Ketamine Infusion May Be Safe and Effective Adjunct to Sedation in the Critically Ill"
Pharmacy Practice News (05/17/16) Rosenthal, Thomas

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Opioids Pose Infection Risk to Patients With RA Pain

People suffering from rheumatoid arthritis (RA) are vulnerable to serious infection, the risk of which is compounded by opioid analgesics. Looking at data from nearly 14,000 Tennessee Medicaid enrollees with the condition, researchers from Vanderbilt University found risk of infection to be almost 40 percent greater during periods of opioid use compared with periods of nonopioid use. "The highest rates of infections were associated with the current use of long-acting opioids, high doses of opioids and opioids with potentially immunosuppressive properties," according to first author Andrew Wiese, MPH. Although opioids typically are not the first line of defense against RA, Petros Efthimiou, MD, of Weill Cornell Medical College, said it will be important to explain this risk to patients in cases when doctors do prescribe narcotic painkillers. While he was not involved in the Vanderbilt study, Efthimiou said the findings add credibility to a suspected correlation between opioids and immunodepression. Wiese noted that further investigation must focus on specific opioids and formulations. "That additional information could then inform the selection of appropriate pain control medications in susceptible populations," he concluded. The research is reported in Arthritis & Rheumatology.

From "Opioids Pose Infection Risk to Patients With RA Pain"
Pain Medicine News (05/16/2016) Holzman, David C.

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Catheters With Non-Narcotic Nerve Block May Better Control Children's Pain After Chest Surgery

Mayo Clinic researchers have found that paravertebral blockade after chest surgery can get pediatric patients released from the hospital sooner and get their pain under control with fewer opioids. The study involved 132 children undergoing surgery to correct a sunken sternum, 114 of whom went home with catheters in place to deliver the paravertebral blockade. Not only did they require fewer narcotic painkillers than the 18 patients who were administered an anesthetic epidural, their median hospital stay lasted only 80 hours—significantly less than the normal 120 hours. "Pain was an issue for our patients, but this new technique has solved the problem," according to Mayo pediatric and thoracic surgeon Christopher Moir, MD. "It's better than an epidural, because it's reliable, and kids can go home with it. For the first time, we consistently deliver on our promise to minimize pain."

From "Catheters With Non-Narcotic Nerve Block May Better Control Children's Pain After Chest Surgery"
Medical Daily (05/15/16) Venosa, Ali

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Noninvasive Monitor Assesses Patients' Response to Painful Stimulation During Surgery

Research results support use of the nociception (pain) level index, a new, noninvasive way to gauge the body's response during an operation. Patients under general anesthesia are not conscious but still react reflexively to pain in ways that can be dangerous and warrant adjustments to anesthetic and analgesic levels. Inadequate medication risks leaving patients with intense pain upon emergence from anesthesia, notes lead study author Ruth Edry, MD, of Israel's Rambam Medical Center, while over-medicating can trigger nausea and vomiting or other adverse effects. Her team tracked pain in 58 surgical patients through routine anesthesia monitoring along with a pain monitoring device that generated the nociception (pain) index. Compared to traditional monitoring of individual responses like fluctuating heart rate and blood pressure, the new measure more effectively distinguished between pain-causing stimuli and non-pain-causing stimuli. It additionally quantified the body's response to increasingly more painful stimulation, while signaling a decline with analgesia administration. "Our results demonstrate the superiority of combining multiple physiologic measures over any individual parameter in the evaluation of the body's response to pain during surgery," Edry concluded. The findings were reported online, ahead of print in Anesthesiology.

From "Noninvasive Monitor Assesses Patients' Response to Painful Stimulation During Surgery"
Science Codex (05/15/16)

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University of Minnesota Goes Off-Label to Treat Post-op Pain Without Opioids

Controversy has flared up over the off-label use of Exparel, a long-acting form of bupivacaine that is injected into wounds during surgery to control pain. Although the FDA specifically rejected its use as a peripheral nerve block when it approved the drug in 2011, anesthesia providers at the University of Minnesota Medical Center have been giving patients Exparel preoperatively in order to curb pain during the recovery process. Advocates say the strategy more effectively reduces pain with less need for opioid medications; other advantages, they cite, include less nausea and shorter length of stay in the hospital. But critics say there is little evidence that Exparel is safer or more effective than other drugs; and they also question the close ties between the drug's manufacturer, Pacira, and the school's Jacob Hutchins, MD, a paid adviser to the drugmaker. Most off-label investigation of the drug has come with industry strings attached; but of 48 current trials, only five are industry-sponsored.

From "University of Minnesota Goes Off-Label to Treat Post-op Pain Without Opioids"
Minneapolis Star Tribune (05/15/16) Olson, Jeremy

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General Anesthesia Affects Heart Muscle Proteins and Causes Depressed Heart Function, Study Shows

Laboratory investigations have shed new light on the role anesthetics play in depressed heart function. An article published by Johns Hopkins researchers in the FASEB Journal identifies the particular regions in heart muscle proteins that are most affected by anesthesia. The team studied the binding patterns of anesthetics to protein extracts of heart muscle. The most extensive bindings of anesthetics to the proteins were found in the regions producing muscle force and contractile function. The results underscore the importance of understanding the effect of general anesthesia on heart performance in order to predict and counteract harm, especially in patients with a known risk for heart failure. In addition, the findings lay the groundwork for future anesthetic agents that would not trigger depressed heart function.

From "General Anesthesia Affects Heart Muscle Proteins and Causes Depressed Heart Function, Study Shows"
News-Medical (05/13/16)

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

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

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May 27, 2016
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