Anesthesia E-ssential

AANA Anesthesia E-ssential
CRNA Week 2018

Vital Signs

AANA Tells AMA: Promote Patient Care, Don’t Prevent It

In response to the American Medical Association’s (AMA) latest attack on non-physician healthcare professionals who ensure millions of Americans access to safe, cost-effective healthcare each year, the AANA has demanded that the AMA focus its time and energy on promoting patient care rather than preventing it. 
AMA Resolution 214, (see page 14) which was initiated by the American Society of Anesthesiologists (ASA) and recently approved by the AMA House of Delegates, proposes the creation of a national legislative, regulatory and public relations campaign to empower “physician stakeholders” to oppose independent practice for healthcare professionals who are not medical doctors (MDs) or doctors of osteopathy (DOs). 
In a statement released on Nov. 20, AANA President Bruce Weiner, DNP, MSNA, CRNA, said: “Patients across the United States, especially those in medically underserved areas of the country and the military, rely on non-physician providers such as Certified Registered Nurse Anesthetists (CRNAs) for excellent, timely healthcare. Yet once again, here comes the AMA with its latest resolution seeking to prevent CRNAs and other highly qualified healthcare experts who are MDs or DOs from caring for patients to the full scope of their education, training and licensure.”
Weiner went on to point that in the specialty of anesthesiology the ASA is well known for its efforts to marginalize the scope of practice of nurse anesthetists. Yet every research study since 2000 has confirmed that CRNAs are as safe as and more cost-effective than their physician counterparts. He said the AANA urges the AMA to reconsider Resolution 214 and instead work with, not against, their non-MD/DO colleagues to ensure patients across the United States receive the best, most timely, most cost-effective care possible.
For further information, read the Nov. 20 AANA Statement and AMA Resolution 214.
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Hot Topics

AANA Releases Two Positions on AAs

At its November meeting, the AANA Board of Directors approved two positions on anesthesiologist assistants (AAs) developed by a task force of AANA Board members, CRNAs at large, and AANA professional staff: AANA Position on AAs and AANA Position on CRNAs Teaching AA Students. 
The positions and corresponding Frequently Asked Questions (FAQ) are posted in the AA area on the member side of the AANA website. Member login is required. 
The AANA, state associations of nurse anesthetists, and CRNAs may use the AA positions to inform their arguments or as leave-behinds to help educate hospital administrators, healthcare professionals, policymakers, health media, and other stakeholders when addressing legislative, regulatory, and other efforts to expand AA practice.
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2016 PQRS Feedback Reports and Annual QRURs:
Informal Review Period Ends Dec. 1, 2017 at 8 p.m. ET

The 2016 Physician Quality Reporting System (PQRS) Feedback Reports and 2016 Annual Quality and Resource Use Reports (QRURs) are available. If you believe that your payment adjustment status was made in error, you may request an informal review by Dec. 1 at 8 p.m. ET.
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New Medical Staff Bylaws Resources Available for Members

Medical staff bylaws serve as the roadmap for the governance structure of the organization’s clinical practice. Medical staff classification may impact CRNA rights, responsibilities and prerogatives, including important issues such as criteria for clinical privileges, whether CRNAs have voting rights and are eligible to serve as officers or on committees, and what type of disciplinary and fair hearing procedures apply to CRNAs. To learn more, review AANA’s new medical staff bylaw resources:
  • CRNA Employment/Practice Setting Considerations, Medical Staff Bylaws Checklist
  • Introduction to Medical/Professional Staff Bylaws
  • Medical/Professional Staff Bylaw Framework
These can be accessed at AANA Member Business Resources (login required), under the Bylaws, Rules and Regulations section.
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Be Safe and Well this Holiday Season!

The AANA wishes you and your family all the best this holiday season! Take this time to catch up on sleep, be physically active, avoid germs, help those in need, and celebrate in moderation. More information can be found in AANA Wellness Milestones on Seasons and Holidays.  
This time of the year can be stressful and may not be a joyous time for everyone. Maintaining wellness and proper self-care is vital. The holiday season and winter are especially difficult for anyone facing seasonal depression, emotional crisis, or recent loss; challenging to those in recovery to maintain sobriety; and perilous for those contemplating suicide and battling active addictions. Remember, there is always help available — reach out to a loved one and your doctor, or your workplace might have an employee assistance program with available resources. If you need help overcoming drugs or alcohol, contact AANA Peer Assistance (see Getting Help for additional information). 
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COA Seeks Reviewers

The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is seeking practitioner onsite reviewers, defined as individuals spending 40 percent or more of their time in the practice of anesthesia (actual administration of anesthesia, clinical supervision/instruction of students, related clinical activities).  Applications are due Dec. 11, 2017.  For criteria and details on how to apply, please visit the COA website.
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Healthcare Careers Presentation Available on AANA Website

The Careers in Healthcare: Nursing and Nurse Anesthesia Profession 
is a PowerPoint presentation designed to assist CRNAs and other individuals presenting to high school, college, community groups, or any civic organization about nurse anesthesia and other healthcare careers in general. Careers in Nursing and Nurse Anesthesia High School and College Preparation will provide high school and nursing students with an understanding of the preparation, requirements, and descriptions of the endless opportunities available to them in the healthcare field.   
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Professional Practice

Enter the National Improvement Video Challenge

The Council on Patient Safety in Women’s Health Care has announced the second cycle of the National Improvement Video Challenge. The Challenge is designed to provide an opportunity for institutions to share how they have utilized the Council’s Patient Safety Bundles in an innovative and interactive way.  View last year’s winners and learn more about the application process and awards.
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Open Comments: Management of Waste Gases, Policy Considerations

The draft practice document titled, Management of Waste Gases, Policy Considerations, is available for open comment through Dec. 15, 2017.

Please review and provide feedback to  Download the draft document at Open Comment.
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Visit to view or place job postings

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Featured Career Opportunity

Nurse Anesthesia Program Director - The University of Tulsa

The University of Tulsa seeks applications for a Program Director to launch a Nurse Anesthesia program leading to a DNP. Pending initial accreditation, the program will launch in Fall 2018.
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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.

Ring Block Improves Analgesia for Newborn Circumcision

Clinicians can make neonatal circumcision less painful by supplementing topical anesthesia and sucrose with ring block, researchers contend. Their prospective study randomized 70 newborns to one of four analgesic interventions: EMLA cream, which includes lidocaine and prilocaine; EMLA plus sucrose; EMLA plus sucrose and dorsal penile nerve block (DPNB); or EMLA plus sucrose and ring block. Nurses blinded to treatment group rated the boys on the Neonatal Infant Pain Scale (NIPS)— which takes facial expression, duration and intensity of crying, breathing patterns, arm movements, and state of arousal into consideration. Based on their observations in the first four hours after the surgery, babies who received ring block experienced the least amount of pain; while the 10 infants treated with EMLA cream alone suffered the most. In fact, the team from American University of Beirut Medical Center in Lebanon reported in Pediatrics, all of the analgesic combinations offered greater pain relief than EMLA only. However, they concluded, "the most effective analgesia is RB combined with oral sucrose and EMLA cream."

From "Ring Block Improves Analgesia for Newborn Circumcision"
Medscape (11/17/17) Lewis, Ricki

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Evaluation of Postoperative Recovery in Day Surgery Patients Using a Mobile Phone Application

Postoperative complications often occur following anesthesia and surgery, potentially affecting the patient's level of satisfaction, but researchers wondered if checking up on them using a mobile phone application might improve the recovery process. The colleagues, hailing from Sweden's Örebro University, equally randomized a total of about 1,000 outpatients at multiple locations to undergo two-week recovery assessment using phone points (RAPP) or paper-based questionnaires (standard care). The app reminded users daily to answer the 24-item quality-of-recovery (QoR) questions, while a single reminder was issued to controls on postoperative day 14. At postoperative day seven, the RAPP patients reported markedly better values compared with standard care on eight of the 24 metrics, including pain/swelling of the surgical wound and trouble sleeping. Overall, 69 percent of these participants reported good postoperative recovery after one week, versus 57 percent in the control group. At two weeks, RAPP users still outperformed controls on four of the QoR values and achieved good postoperative recovery at a rate of 70 percent compared with 64 percent among recipients of standard followup. The findings indicate that systematic evaluation of patient-reported outcomes using a smartphone-based app resulted in less discomfort from a number of postoperative symptoms and, subsequently, good postoperative recovery.

From "Evaluation of Postoperative Recovery in Day Surgery Patients Using a Mobile Phone Application"
British Journal of Anaesthesia (11/01/2017) Vol. 119, No. 5, P. 1030 Jaensson, Maria; Dahlberg, Karuna; Eriksson, Monica; et al.

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'Checking a Box' Is Not Enough to Prevent Surgical Site Infections

Antimicrobial prophylaxis is proven to lower the rate of surgical site infections (SSIs), yet new research indicates that many clinicians are not following through on standards put in place for this purpose. A retrospective analysis done at Penn State Health Milton S. Hershey Medical Center considered 283 SSIs that occurred there over a two-year period. Of 228 patients who had undergone antibiotic prophylaxis in the operating room, Centers for Medicare & Medicaid standards were followed in only 54—or 20 percent—of the cases. The appropriate type of antibiotic agent was used 80 percent of the time, but an appropriate dose was administered less than half of the time. Moreover, of 76 patients who required redosing of antibiotics, only 9 percent were appropriately redosed. "Based on our findings, it appears that merely 'checking a box' for antibiotic administration during surgery is not enough. A multidisciplinary approach should be followed to ensure the appropriateness of antibiotics administration," Kunal Karamchandani, MD, an anesthesia provider at Milton Hershey, said during a presentation at the Anesthesia Research Society 2017 annual meeting. "Multiple reviews and articles have discussed how [anesthesia providers] can contribute to preventing SSIs. If we do our jobs properly, this is one way we can."

From "'Checking a Box' Is Not Enough to Prevent Surgical Site Infections"
General Surgery News (11/15/17) Doyle, Chase

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Evidence-Based Approach to Treating Post-Delivery Pain in New Moms During Opioid Crisis

Stanford University researchers say their study results show that opioid-based pain management often is unnecessary after childbirth, depending on how the baby is delivered. The investigation tracked pain, opioid use, and pace of recovery for six weeks post-partum in 213 healthy first-time mothers. Nearly a third of those who delivered vaginally required opioids for a brief time while hospitalized; however, most discontinued use after just one day and fewer than 10 percent still needed them after being discharged. Their pain was resolved in a median 14 days. About 90 percent of women who underwent cesarean section, by comparison, required opioids. It took nine days for them to stop taking the drugs, and a median 21 days for the pain to resolve. Patients who had a vaginal delivery needed 47 days to resume their normal level of daily functioning, versus 95 days for those who had surgical deliveries. "Based on our observations, routine opioid prescription for new moms after vaginal delivery is not recommended, and prescription of opioids at discharge from the hospital for women undergoing cesarean delivery should be limited," according to the investigators, who report in Anesthesiology.

From "Evidence-Based Approach to Treating Post-Delivery Pain in New Moms During Opioid Crisis"
Medical Xpress (11/14/17)

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Studies Look to Hone Remifentanil Dosing for Special Populations

Recent research has focused on fine-tuning remifentanil dosing and administration in three specific populations: the very young, the elderly, and the overly heavy. One study out of the Netherlands developed a predictive performance model for children, especially those younger than age three years. The single mathematical model, which identifies clinically acceptable performance for all subgroups, has proven superior to the standard Minto model. "Imagine trying to predict remifentanil concentrations in an 18-year-old," remarked primary investigator Douglas Eleveld, PhD. "Should the child or adult model be used? Our model makes this choice unnecessary." Meanwhile, researchers at the University of Utah came up with a general pharmacokinetic model for obese and geriatric patients. "Big people need more drugs, but not nearly as much suggested by their body weight," explained Talmage Egan, MD, who chairs the university's anesthesiology department. The data indicated that the cumulative dose requirement for a heavier 25-year-old is about 125 percent of that of a younger, thinner individual. At the same time, the colleagues reported, the cumulative dose for a 75-year-old is considerably lower than that of a younger, leaner person. "Older folks—65-plus and, especially, as you get older—need at least 50 percent dosage reduction," according to Egan.

From "Studies Look to Hone Remifentanil Dosing for Special Populations"
Pain Medicine News (11/14/2017) Geyer, Sherree

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Ultrasound-Guided Rectus Sheath Block, Caudal Analgesia, or Surgical Site Infiltration for Pediatric Umbilical Herniorrhaphy

Colleagues at Nationwide Children's Hospital and Ohio State University teamed up to evaluate the analgesic efficacy of three alternative approaches to opioids following umbilical hernia repair. The prospective study included 39 patients with similar demographic and surgical characteristics—all of whom were undergoing the surgery, which is common in the pediatric population. Participants were randomly and evenly assigned to one of three pain-management techniques: caudal epidural block, ultrasound-guided bilateral rectus sheath blocks, or surgical site infiltration with local anesthetic. Following the procedure, patients were transferred to the post-anesthesia care unit where a blinded observer monitored their progress. Based on a comparison of outcomes, the investigators found equivalent opioid requirements and no between-group differences in pain scores or time to recovery. Subsequently, they conclude that all three strategies offer effective analgesia after umbilical hernia surgery.

From "Ultrasound-Guided Rectus Sheath Block, Caudal Analgesia, or Surgical Site Infiltration for Pediatric Umbilical Herniorrhaphy"
Journal of Pain Research (11/17) Vol. 2017, No. 10, P. 2629 Relland, Lance M.; Tobias, Joseph D.; Martin, David; et al.

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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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November 30, 2017
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