Anesthesia E-ssential

AANA Anesthesia E-ssential
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AANA Pushes for CRNA Full Practice Authority in the VA Following Reports of Postponed Surgeries

Last Wednesday, television station KDVR Denver reported that VA surgeries were postponed because there aren't enough anesthesiologists. The Oct. 11 report indicated that, since August, 65 to 90 surgeries have been cancelled or postponed at the Denver Veterans Affairs Medical Center due to a lack of anesthesia providers. The Denver Post released a similar story on Oct. 12. These reports come in the wake of the 2016 Veterans Affairs final rule that stated:
"VA's position to not include the CRNAs in this final rule does not stem from the CRNAs' inability to practice to the full extent of their professional competence, but rather from the VA's lack of access problems in the area of anesthesiology."

In an AANA Connect post informing members about the situation, AANA CEO Randall Moore, DNP, MBA, CRNA, said, "This situation illustrates that advocating for our members and their patients is the most important work we do as an association. As a veteran myself, it infuriates me that veterans are being harmed by red-tape and politics."

In response, the AANA is asking members to contact their legislators and is working with the Colorado Association of Nurse Anesthetists and the Association of Veterans Affairs Nurse Anesthetists.

On Oct. 12, AANA President Bruce Weiner, DNP, MSNA, CRNA, sent a letter to David Shulkin, MD, secretary of Veterans Affairs outlining the case for full practice authority for CRNAs within the VA. "We believe that our veterans deserve better, and that it is well past time to follow the litany of recommendations to grant CRNAs full practice authority in the VHA," Weiner said. "This incident is simply the latest fallout from an unwarranted decision that needs to be revisited with all due speed."

The AANA will keep the membership informed of developments to this important story through AANA Connect, this website and future issues of AANA publications.
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Field Testing of MACRA Episode-Based Cost Measures Begins Oct. 16

The Centers for Medicare & Medicaid Services (CMS) and its contractor, Acumen, LLC, will be conducting field testing for eight episode-based cost measures before consideration of their potential use in the cost performance category of the Merit-based Incentive Payment System (MIPS) of the Quality Payment Program. Field testing will take place from Oct. 16 to Nov. 15, 2017. During this time, CRNAs and clinician groups (TINs) who are attributed episodes for performing or managing certain procedures/medical conditions will have the opportunity to view a confidential report with information about their performance. All stakeholders will be able to view a mock report and supplemental documentation on the measures that will be publicly posted. CRNAs may provide feedback on the measures, confidential or mock report, and supplemental documentation through an online survey.
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Physician Compare 30-day Preview Period Begins Oct. 18

Beginning this week, CRNAs have the opportunity to preview their 2016 performance information before it is publicly reported on Physician Compare later this year. As of Oct. 18, 2017, CRNAs may access their secured preview through the Provider Quality Information Portal (PQIP). An active EIDM system account is required.  Data available for preview includes 2016 Physician Quality Reporting System (PQRS) measures; 2016 Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS measures; 2016 non-PQRS Qualified Clinical Data Registries (QCDR) measures; and 2015 clinician utilization data. The preview period ends on Nov. 17, 2017, at 8 pm ET. For additional assistance with accessing PQIP, or obtaining your EIDM user role, contact the QualityNet Help Desk at (866) 288-8912. If you have any questions about public reporting or preview period, please contact
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AANA Members Invited to Submit Abstracts to Present at the 2018 Annual Congress

Attended by more than 2,500 CRNAs, the AANA Annual Congress is an excellent opportunity to present your research to peers and nurse anesthesia students. The 2018 Congress will be held Sept. 21-25 in Boston. The deadline to submit abstracts is Nov. 17, 2017. 
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Upcoming Webinar: Examining the Role of the Environment in Infections Across the Continuum of Care

Join the American Nurses Association and the Centers for Disease Control and Prevention for a complimentary webinar on Wednesday, Oct. 25, at 11 am ET, discussing empowering nurses to protect themselves and their patients by providing real-time infection prevention and control training to U.S. nurses.
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Upcoming Webinar: Patient, Family, and Staff Support After Obstetric Hemorrhage

Join the Council on Patient Safety in Women’s Health Care for a complimentary webinar on Tuesday, Oct. 31, at 1:30 pm ET, to learn about the role of providers and staff related to a patient's mental health and stress status during and after an obstetric hemorrhage. The presentation will also provide a framework for communication and actionable steps for support that staff may adapt for use when women in their institutions have an obstetric hemorrhage.
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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 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 our 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. All contributors must be US citizens. 
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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.

PACU Respiratory Status Predicts Risk for Opioid-Induced Respiratory Depression on General Hospital Floor

Research suggests that respiratory volume monitoring in the post-anesthesia care unit (PACU) may help flag patients who are still at risk for opioid-induced respiratory depression after being discharged to a general hospital ward. Many of those floors lack monitors, allowing severe hypoxemia to be missed. An observational investigation led by Wael Saasouh, MD, of the Cleveland Clinic Anesthesiology Institute found that low minute ventilation in the first two hours after an operation successfully predicted risk for respiratory issues up to 48 hours later. Most of the 167 colorectal surgery patients who participated maintained adequate minute ventilation, but those initially identified as at-risk remained so for the entire study. "One might suspect that postoperative hypoventilation is limited to the PACU stay as a consequence of anesthesia and opioid administration, and would resolve by the time a patient is deemed fit to be transferred to the general hospital floor," Saasouh noted. "Based on these results, however, that turns out to not be entirely true." While it may not be necessary to monitor every patient postoperatively, he suggested that providers at the very least keep higher-risk patients on a respiratory volume monitor until they are "out of the danger zone."

From "PACU Respiratory Status Predicts Risk for Opioid-Induced Respiratory Depression on General Hospital Floor"
Anesthesiology News (10/14/17) Doyle, Chase

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Oral Morphine Plus Ibuprofen Inadequate for Pain in Kids in ED

New evidence shows that oral morphine and oral ibuprofen—whether taken alone or in tandem—do not deliver sufficient pain relief to children who present in the emergency department (ED) with musculoskeletal injuries. Canada's OUCH trial involved more than 450 kids seeking care for acute sprains or fractures at three hospital EDs. They were randomly allocated to treatment with 0.2 mg/kg of oral morphine plus placebo, 10 mg/kg of oral ibuprofen plus placebo, or a combination of oral morphine and oral ibuprofen at those same dosages. The primary endpoint was a reduction in pain score to less than 30 mm—indicating mild pain—from a mean baseline level of 60.9—indicating moderate pain—within an hour of medication administration. This outcome was achieved in 29.3 percent of the morphine-only cases, in 33 percent of the ibuprofen-only cases, and in 29.9 percent of cases where both drugs were administered. The between-group differences were not statistically significant, and none of the three treatments achieved an adequate level of pain control. Rather than addressing severe acute pain with oral medication only, first author Sylvie Le May, RN, PhD, said pairing a fast-acting opioid with another medication might be a better approach—as long as the opioids are carefully and properly administered.

From "Oral Morphine Plus Ibuprofen Inadequate for Pain in Kids in ED"
Medscape (10/12/17) Hackethal, Veronica

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Ibuprofen Better Than Morphine for Kids After Minor Surgery

The Canadian Medical Association Journal has reported new study results indicating that children should be given ibuprofen—not oral morphine—after minor orthopedic surgery. The clinical trial, performed in Ontario, included 154 patients between the ages of five and 17 years. While both approaches worked equally well to relieve pain—although neither completed negated it—adverse effects like drowsiness, dizziness, nausea, vomiting, and constipation occurred more frequently with morphine. "This result suggests that adequate pain management should be an important goal of care, even after minor outpatient surgery, and that more effective pharmacologic and nonpharmacologic strategies should be explored," concluded lead investigator Naveen Poonai, MD, of Western University and Lawson Health Research Institute.

From "Ibuprofen Better Than Morphine for Kids After Minor Surgery"
United Press International (10/10/17) Wallace, Amy

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Epidurals Do Not Prolong Labor

Contrary to widely held belief, researchers have demonstrated that epidural anesthesia administered in the final stage of delivery does not prolong the duration of labor. The evidence comes from a double-blinded trial of 400 laboring patients, each randomly assigned to receive epidural anesthesia or a saline solution. Average time from full cervical dilation to delivery was comparable between the two groups of women, as were the number of forceps deliveries, cesarean sections, and episiotomies. The only outcome that differed was satisfaction with pain management, which was higher among the epidural recipients. "If you decide you want an epidural for pain relief, you should not be concerned that it's going to prevent a vaginal delivery or cause any negative effect on labor," assured Philip Hess, MD, an associate professor of anesthesia at Harvard and the study's senior author. The findings appear in Obstetrics & Gynecology.

From "Epidurals Do Not Prolong Labor"
New York Times (10/10/17) Bakalar, Nicholas

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Prolonged Anesthesia Duration Linked to Surgical Complications

Based on new findings, prolonged exposure to anesthesia translates to more complications following head and neck microvascular reconstruction. Researchers divided 630 patients into five subsets based on mean anesthesia duration, ranging from 1,358.1 minutes (group 1) to 5,922.1 minutes (group 5). Bivariate analysis revealed an overall 30-day complication rate of 43.7 percent in group 1 versus 63.5 percent in group 5. Similarly, postoperative surgical complications were 35.7 percent compared with 61.9 percent. In addition, investigators documented a greater likelihood of postoperative transfusion and/or wound disruption with longer anesthesia exposure. At 0.8 percent, meanwhile, mortality rates were comparable in the groups with the least and most exposure. Multivariable analysis also indicated a strong correlation between longer anesthesia duration and overall complications, surgical complications, and postoperative transfusion; however, the association between longer time under anesthesia and wound disruption was considered insignificant. The study results appear in JAMA Facial Plastic Surgery.

From "Prolonged Anesthesia Duration Linked to Surgical Complications"
Healio (10/09/2017) Volansky, Rob

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How One Hospital Reduced Alarms Without Undermining Patient Safety

An experiment at one New Jersey hospital suggests that smart alarms can reduce the "noise" of constant device notifications—which staff tend to tune out, at the risk of missing clinically important alerts. In order to maintain patient safety, Virtua Memorial Hospital installed smart alarms in the post-anesthesia care unit, where patients need to be monitored for respiratory depression and other complications. The technology turns off unnecessary notifications from various pieces of machinery, making nurses and other caregivers more responsive when their attention is actually needed. During the study, 25 sleep apnea patients were being cared for in the post-anesthesia care unit. Use of the smart filter lowered the overall number of alarms by 98 percent, without compromising patient safety. "We learned a lot from this study," according to Leah Baron, MD, who chairs Virtua's anesthesiology department. "A lot still needs to be done in this field. With this exciting technology, we are a step closer to being able to bring safer care to our patients and a better work environment to nurses and physicians caring for these complex patients." She and her co-authors published the study in Biomedical Instrumentation & Technology.

From "How One Hospital Reduced Alarms Without Undermining Patient Safety"
MedCity News (10/05/17) Dietsche, Erin

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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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