Anesthesia E-ssential

AANA Anesthesia E-ssential, November 29, 2018

Vital Signs

Breaking Advocacy News: AANA to Fight Novitas on Restrictive LCD

Dear Colleagues,

It is with serious disappointment that I must update you on the latest activities of Medicare Administrative Contractor (MAC) Novitas Solutions. As you may recall, on Aug. 16, 2018, we received the good news that Novitas had decided not to implement a final draft local coverage determination (LCD) which would have made it policy to not recognize nurse anesthesia education and preparation, resulting in denials for CRNA reimbursement for facet joint injections in 11 states, the District of Columbia, the Indian Health Service, and the Department of Veterans Affairs. The LCD would have had a terrible impact on chronic pain patients, especially those in medically underserved areas, who rely on CRNAs to manage their pain and provide quality of life. The Novitas decision to not implement the LCD was the result of an aggressive, coordinated advocacy effort by the AANA. The AANA also reached an agreement with the MAC to work for up to one calendar year to reach an amicable, long-term solution regarding CRNA qualifications that would enable CRNAs to be reimbursed for interventional pain management procedures.

In late August, AANA and Novitas leadership met in Dallas to begin negotiating a definitive resolution on CRNA reimbursement for pain-management services. During these negotiations, the AANA and NBCRNA sought provider neutrality for CRNAs and recognition by Novitas of the nonsurgical pain management subspecialty certification (NSPM-C) as sufficient training for CRNAs to qualify for reimbursement for providing facet-joint injections and other forms of pain management. In September, at the request of Novitas, the AANA submitted extensive comments to the MAC regarding the CRNA pain management qualifications and certification.

On Nov. 27, Novitas pulled a fast one.

Despite assurances of open negotiation, Novitas has announced that it is lifting the hold on the LCD for facet joint injections and that the LCD will become effective on January 3, 2019. The LCD will be posted on the Novitas website on December 6. According to an email from Novitas, the language in the LCD has not been changed. Given that, we strongly suspect that Novitas also has not changed its thinking regarding CRNA education and preparation after receiving our response letter in September. Therefore, we believe at this time that Novitas intends to deny payment for facet joint injections for CRNAs who have the NSPM-C, are fellowship trained, or who have any other advanced training in interventional pain management.

While we are deeply disappointed by this turn of events, we remain determined to fight this LCD and change Novitas’s mindset on CRNA pain management qualifications. As in our previous dealings with Novitas, the AANA is exploring all avenues to address this injustice—and I mean all.

I will keep you informed of further developments regarding Novitas as they occur.


Garry Brydges, DNP, MBA, ACNP-BC, CRNA , FAAN
AANA President

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CRNAs to be Recognized as “Covered Recipients” under the Sunshine Act Starting Jan. 1, 2022

Hidden deep within H.R. 6, The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which was signed into law by President Trump in October 2018, is another change that may affect many CRNAs starting Jan. 1, 2022.

As reported numerous times by the AANA, the big news for nurse anesthetists regarding the SUPPORT Act was that CRNAs, along with clinical nurse specialists and certified nurse midwives, were granted authority to prescribe buprenorphine through medication-assistant treatment (MAT) for a period of five years. AANA leadership, staff, and countless members lobbied aggressively and successfully for CRNAs to be recognized in H.R. 6, which built upon the Comprehensive Addiction and Recovery Act of 2016.

In addition to prescriptive authority related to buprenorphine, another change introduced by the SUPPORT Act is the expanded definition of “covered recipients” in the Physician Payments Sunshine Act/Open Payments. The Sunshine Act was part of the 2010 Affordable Care Act and requires some drug and device manufacturers to report annually to the Centers for Medicare & Medicaid Services (CMS) on certain payments or transfers of value made to covered recipients. For the first time, CRNAs will be identified as covered recipients starting Jan. 1, 2022, just as physicians currently are.

The Sunshine Act requires applicable manufacturers of certain drugs, medical devices, and biologics that are paid for by Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) to report transactions of value involving covered recipients. Until the passage of the SUPPORT Act in October, the definition of a covered recipient was limited to physicians and teaching hospitals. The SUPPORT Act expands the definition of covered recipient to include:
  • A physician assistant, nurse practitioner, or clinical nurse specialist
  • A certified registered nurse anesthetist
  • A certified nurse-midwife
The Sunshine Act is primarily a reporting requirement that manufacturers must pay close attention to, but because of transparency requirements their reports of payments are available on the CMS website and can be searched under the recipient’s name. Therefore, there could be some implications for CRNAs who receive Medicare, Medicaid or CHIP payments. CRNAs can check out the website.

While 2022 seems a long way off, CRNAs who qualify as or may become covered recipients thanks to the SUPPORT Act should mark their calendars for Jan. 1 of that year, and in the meantime endeavor to learn all there is to know about being a covered recipient under the Sunshine Act.

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Medication-Assisted Treatment (MAT) Resources Available

New online resources ( have been posted about CRNAs and Medication-Assisted Treatment (MAT), which includes the AANA Position Statement Certified Registered Nurse Anesthetists Medication-Assisted Treatment with information on the use of MAT to treat opioid abuse within a comprehensive treatment plan. This also includes counseling and behavioral therapies, prescriptive authority limitations, and information on how to apply for a waiver.

This resource follows the recent October legislation within Section 3201 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which expands availability to MAT by adding Certified Registered Nurse Anesthetists (CRNAs), as well as clinical nurse specialists and Certified Nurse Midwives, to the healthcare professionals who can prescribe buprenorphine for MAT. Although the waiver application is not open to CRNAs yet, the resources include educational requirements prior to waiver application.
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Hot Topics

Reminder: Nominations for the 2019 AANA Election Are Due Dec. 1

We are seeking nominations for the following AANA elected offices by December 1, 2018:
  • President-elect
  • Vice President
  • Treasurer
  • Directors from Regions 1, 4 and 5
  • Nominating Committee Regions 1, 4, and 5, and
  • Resolutions Committee

Please note that nominations can be submitted by state associations, members, and we also accept self-nominations. If your state association has already nominated members for these positions you can disregard this message.

The Official State Nomination Form can be found online here
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Register Now for the Following State Government Affairs Division Webinars

CRNA Dental Practice: December 6, 2018, 7-8 p.m. CST 
Register/More Information 
This webinar will provide an update on the latest dental resources for state associations and CRNAs who provide anesthesia in dental offices, including the opportunity for members to ask questions and share information with their colleagues.

Legislative Update for Attorneys and Lobbyists: December 18, 2-3 p.m. CST
Register/More Information   
Members also are welcome to attend this update for state association attorneys and lobbyists.

Anesthesiologist Assistants Update: December 19, 2018, 7-8 p.m. CST
Register/More Information 
This webinar is designed to help CRNA state leaders develop a stronger understanding about legislative and regulatory issues relating to anesthesiologist assistants (AAs) and provide an update on the latest resources available from the AANA.

GRC Chat – Testifying Effectively
This webinar will be done live on two separate occasions to accommodate CRNAs in different time zones. Members of the AANA Government Relations Committee will provide practical advice on testifying effectively, including the opportunity for members to participate and ask questions.
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Will Your Assets Be Protected?

There are significant differences between admitted and non-admitted malpractice insurance companies – and choosing the wrong company can put you, your reputation, and your personal assets at risk. Learn which questions to ask your insurance agent to ensure you have protection when you need it most. Learn more.
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Seeking Candidates for Delegate to the Education Committee

The AANA Education Committee is seeking candidates who are interested in serving on the committee as a Delegate. The deadline for receiving completed candidate packets is January 7, 2019. The election will be held and the winner announced at the Assembly of Didactic and Clinical Educators (formerly called the Assembly of School Faculty) meeting in February 2019.

Delegates must be CRNAs who spend at least 50 percent of their time in the didactic and/or clinical instruction of nurse anesthesia students at the time of application. During their tenure on the committee, they must:
  • Be continuously involved in the didactic and/or clinical instruction of nurse anesthesia students.
  • Attend the February Assembly of Didactic and Clinical Educators and Nurse Anesthesia Annual Congress during both years of their term.
  • Attend Education Committee meetings and conference calls for the two-year term which begins immediately following the AANA Annual Congress in the year elected.
The candidate information packet is available on the AANA website under CE & Education, Opportunities for Educators. Questions? Contact the Education department at 847-655-1161 or
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NewsMaker: CRNA Barbara Barnhill Saves Husband's Life With CPR

Barbara Barnhill, CRNA, was beginning to videotape her husband Tom "preparing to fire up his replica front-engine dragster," according to the Observer-Reporter of Washington, Pa. Tom collapsed, she rushed to his side and, after having someone call 911, began administering CPR with the help of a neighbor. Read more.
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NewsMaker: CRNA Mary Hobson Combines Love of Travel With Volunteerism

Most days, Mary Elizabeth Hobson, CRNA, works in Nashville, Tenn., administering anesthesia for cardiothoracic surgeries or outpatient orthopedic procedures. But since 2009, she has spent her vacations on medical missions, primarily in African countries such as Nigeria, Kenya, and now Togo, a West African nation on the Gulf of Guinea, according to the Andalusia Star News. Read more.
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NewsMaker: Retired CRNA Honored with Lifetime Achievement Award

Retired CRNA Jeannette Emily Barnes has been presented with the Albert Nelson Marquis Lifetime Achievement Award by Marquis Who's Who. "Ms. Barnes celebrates many years' experience in her professional network, and has been noted for achievements, leadership qualities and the credentials and successes she has accrued in her field," stated the press release that announced her award. Read more.
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Meetings and Workshops

Save the Date – AANA Annual Leadership Conference for ALL Nurse Anesthetists

Disappointed to see that the Practice Leadership Assembly didn’t include tracks for state leaders or federal and state government? We have good news! The 2019 Annual Leadership Conference will meet the needs of ALL CRNAs—from Chief CRNAs and administrators, to Federal Political Directors, state association leaders, practice owners and managers, and those aspiring to future leadership.

Mark your calendar to join us next November for unparalleled networking and leadership sessions for CRNAs by CRNAs. Registration opens July 2019. Watch your inbox for details.
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CRNA: St. Vincent Anderson Regional Hospital, Anderson, Indiana

St. Vincent has an opportunity for a full-time Certified Registered Nurse Anesthetist at St. Vincent Anderson Regional Hospital! Five-day work week, no weekends, holidays, Average 8-hour work day, bread and butter cases (no cardiac, no neonatal, includes OB, includes Ortho). Learn more.
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CRNA: WellSpan Health, Ephrata, Pennsylvania

WellSpan Ephrata Community Hospital is seeking a full-time Certified Registered Nurse Anesthetist. WellSpan Ephrata Community Hospital has been serving the community for over 65 years and is noted for its distinct ability to combine medical technology with the friendly, personalized care the community has come to expect. Learn more.
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Looking to Grow Your Career?

Visit CRNA Careers today, the official career center of the AANA. Job searching that is catered to meet your needs. Here's what we offer:

  • The Best CRNA Jobs: Connecting you to top employers in anesthesia.
  • Targeted Email Alerts: You can automate your search by setting up email alerts that match your criteria. Plus, search through CRNA positions that fit your needs.
  • Post Your Resume Anonymously: You're in control. Make your profile confidential and respond to employers with the best opportunities.

Start Your Search Today!


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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.

Reconsider Interscalene Nerve Block for Shoulder Surgery in Obese Patients

Interscalene nerve blocks are the standard of care for pain control during shoulder surgery—except, say Canadian researchers, in the case of obese patients. Individuals with a higher body mass index (BMI) are more vulnerable overall to postoperative complications, according to Carla Henderson, MD, who led the study out of the University of Ottawa. Diaphragmatic dysfunction, which can occur when deposition of local anesthetic during the block freezes the phrenic nerve, is especially worrisome. To validate these concerns, Henderson and colleagues examined the charts of patients who underwent shoulder surgery during 2007-2016 at three teaching hospitals in Toronto. In all, 996 patients—182 with BMI scores over 30 and 814 with scores below—were propensity matched to allow for comparison of outcomes. Analysis showed that obese patients who received interscalene block remained in the post-anesthesia care unit (PACU) about 50 percent longer and were more likely to develop hypoxemia and require more oxygen supplementation during their PACU stay. Additionally, Henderson said, "Unplanned hospital admission from compromised respiratory status—which some people define as a failure of ambulatory surgery because they require an inpatient admission—was also higher in obese patients, both to the hospital and to the intensive care unit." Based on the findings, Henderson believes "we should consider moving to other blocks in these patients, and considering whether everybody needs to have different blocks based on their own specific comorbidities." She presented the results at the 2018 Joint World Congress on Regional Anesthesia and Pain Medicine and annual meeting of the American Society of Regional Anesthesia and Pain Medicine.

From "Reconsider Interscalene Nerve Block for Shoulder Surgery in Obese Patients"
Anesthesiology News (11/21/18) Vlessides, Michael

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Addition of Dexmedetomidine or Fentanyl to Ropivacaine for Transversus Abdominis Plane Block

Researchers assessed the impact of adding dexmedetomidine or fentanyl to ultrasound-guided transversus abdominis plane (TAP) block, a leading pain control technique following abdominal surgery. The team from China's Chongqing University Cancer Hospital/Chongqing Cancer Institute assembled a sample of 100 patients undergoing elective gynecological surgery and randomized them to one of four treatment arms. A quarter of the participants received TAP block with ropivacaine, a quarter received TAP block with ropivacaine plus dexmedetomidine, a quarter received TAP block with ropivacaine plus fentanyl, and the remaining quarter received patient-controlled intravenous analgesia (PCIA) and served as the control group. All of the blocks were administered postoperatively. The investigators discovered that TAP block plus dexmedetomidine generated the highest postoperative recovery scores. In addition, patients in this group lasted longest before requesting PCIA and had the lowest mean PCIA bolus consumption in the first 24-48 hours after surgery. The findings suggest that dexmedetomidine as an adjuvant to TAP block could facilitate postoperative analgesia and improve quality of recovery without increasing harms.

From "Addition of Dexmedetomidine or Fentanyl to Ropivacaine for Transversus Abdominis Plane Block"
Journal of Pain Research (11/18) Vol. 2018, No. 11, P. 2897 Chen, Qi; Liu, Xing; Yang, Bin

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Dexmedetomidine Good for Conscious Sedation During Colorectal ESD

Evidence indicates that dexmedetomidine is a viable alternative to propofol for conscious sedation during endoscopic submucosal dissection (ESD) of colorectal lesions. Not only does the technique reduce the risk for respiratory depression that propofol presents, it appears to garner greater patient satisfaction with the procedure. The finding comes from a prospective, randomized trial in Japan that enrolled 80 participants. Each participant received the analgesic pethidine along with either dexmedetomidine or placebo. Outcomes—including patient satisfaction, pain level, and adverse effects—were more favorable with the dexmedetomidine group. Additionally, about a third of those patients slept through the procedure, compared with only 6 percent of controls. The research was presented at the 2018 Digestive Disease Week.

From "Dexmedetomidine Good for Conscious Sedation During Colorectal ESD"
Gastroenterology & Endoscopy News (11/18) Helwick, Caroline

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Designing a Safer OR

Adverse events arise in roughly one in 10 surgeries, in part due to fatigue on the part of anesthesia providers and poor workflow in the operating room (OR). A four-year learning lab at Clemson University and the Medical University of South Carolina (MUSC) is tackling these, and other problems, in an effort to design a safer, more ergonomic OR for ambulatory surgery. Participants came up with a final 579-square-foot prototype at the beginning of this year. One key element is optimization of physical movement and flow. The design aims to achieve this by dividing the room into four quadrants, including an anesthesia zone at the head of surgical table. The setup, which includes sterile zones on both sides of the bed as well as a circulation zone, improves access to the anesthesia zone for anesthesia providers and allows circulating nurses to navigate more effectively. Additionally, recessed supply storage areas in the anesthesia and circulation zones minimize travel for team members when surgery is in progress. In addition to making it harder for OR staff to trip over cords or collide with one another or equipment, the concept aims to improve flexibility and adaptability, minimize industrial clutter, curtail surface contamination and microbial load, support visual awareness and communication, and reduce stress via daylighting and artificial lighting. Students have erected a mock-up of the design and will continue to refine it in 2019. Post-occupancy assessment of the ORs, meanwhile, will offer insight on satisfaction and flow disruptions. The findings will also inform a web-based OR design tool to help educate healthcare design teams and clinical users about safety-related issues in the built environment that should be taken into consideration.

From "Designing a Safer OR"
Healthcare Design (11/16/18) Joseph, Anjali; Allison, David

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A High Risk of Sleep Apnea Is Associated With Less Postoperative Cognitive Dysfunction After Intravenous Anesthesia

A prospective pilot study explored the relationship between high risk of obstructive sleep apnea syndrome (OSAS) and postoperative cognitive dysfunction after anesthesia. With OSAS, patients experience repetitive episodes of temporary cerebral hypoxia—which can impair cognitive function but which can also boost ischemia resistance and preserve cardiovascular and brain function. German researchers wondered if this intermittent hypoxia exposure—known as ischemic conditioning—might actually have a protective effect in the setting of general anesthesia, where hypoxia-induced neurocognitive deficits also have been observed. To investigate, the team compared 22 patients with a high risk of OSAS and 21 control patients aged 55-80 years who were scheduled for non-cardiac surgery with total intravenous anesthesia. In line with the study hypothesis, the OSAS group presented less impairment of memory function and work memory performance after I.V. anesthesia—possibly due to the beneficial effect of intrinsic hypoxic preconditioning in these patients. The findings are reported in BMC Anesthesiology.

From "A High Risk of Sleep Apnea Is Associated With Less Postoperative Cognitive Dysfunction After Intravenous Anesthesia"
Medscape (11/15/18)

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Treating Anemia in the Pre-anesthesia Assessment Clinic

A German study looked at how treating preoperative anemic patients with intravenous iron (IVI) affects their hemoglobin levels ahead of surgery. As a secondary outcome, the research also assessed the relationship between IVI and use of red blood cell (RBC) transfusions and death. The retrospective investigation was conducted at Muenster University Hospital, which implemented a patient blood management (PBM) program along with a pre-anesthesia assessment clinic to screen and treat anemia prior to elective surgery. Patients at risk for RBC transfusion for procedures performed in 2013 were checked for preoperative anemia and treated with IVI when needed. Of about 1,100 patients who visited the anesthesia/PBM clinic ahead of their procedures, nearly 30 percent presented with anemia—about 47 percent of whom were treated with ferric carboxymaltose. Drawing from electronic health records and patient telephone interviews, the investigators determined that IVI supplementation was safe and effective. However, it decreased RBC transfusions only in the subset of patients undergoing gynecology/obstetric procedures. Cox regression analysis, meanwhile, linked anemia to reduced survival, with or without IVI.

From "Treating Anemia in the Pre-anesthesia Assessment Clinic"
Anesthesia & Analgesia (11/18) Vol. 127, No. 5, P. 1202 Ellermann, Ines; Bueckmann, Andreas; Eveslage, Maria; et al.

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News summaries © copyright 2018 SmithBucklin

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

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

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Attn: Cathy Hodson
E–ssential Editor
November 29, 2018
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