Anesthesia E-ssential

AANA Anesthesia E-ssential, September 13, 2018

Vital Signs

USDE Renews COA's Federal Recognition for Five Years

The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is pleased to announce that the U.S. Department of Education (USDE) has renewed the COA’s federal recognition for a period of five years, the maximum length for continued recognition. Following its May 2018 review by the National Advisory Committee on Institutional Quality and Integrity, the COA was notified on August 22, 2018, of the USDE’s renewal, which was granted with no compliance report. For additional details regarding the USDE decision, and more information on the COA’s scope of recognition, please visit the Council’s website.
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AANA 2017-2018 Annual Reports Available

The AANA Annual Reports for 2017-2018 are now available on the AANA website (member login required). Included are the reports of the standing committees, elected committees, other committees, the AANA Journal Editorial Committee, liaisons with other organizations, the AANA Foundation, councils, the International Federation of Nurse Anesthetists, and the report of the AANA Chief Executive Officer.
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ER SIG Highlights CRNA Contributions to ERAS Implementation

In the first story of the ER SIG series, Carol Schimdt, MS, CRNA, and Mary Beth Boeson, CRNA, detail the pathway implemented for vitrectomies at Beaumont Hospital. Learn more about how this pathway reduced the amount of total medications used (including a 53 percent reduction in versed) as well as a decreased average PACU stay by 27 minutes. Have questions or comments? Join the SIG discussion on AANA Connect.
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Hot Topics

CY2017 MIPS Feedback Reports Available for Review

Merit-Based Incentive Payment System (MIPS)-eligible CRNAs are subject to a 4 percent Medicare payment adjustment in 2019 based on their 2017 MIPS performance. The MIPS Feedback Report for Calendar Year (CY) 2017 data is now available through the QPP website. It includes performance category scores, weights and the final score from 2017, which were used to determine payment adjustments for 2019. If there is a question about the calculation of the final score and payment adjustment, providers can request a Targeted Review. The deadline to request a review is October 1, 2018. The AANA 2017 MIPS Reporting website has links to feedback fact sheets and the targeted review user guide.

To be granted a Targeted Review, eligible clinicians/groups must meet certain criteria which include but are not limited to:
  • Errors or data quality issues on measures and activities submitted;
  • Eligibility issues (e.g. you did not meet the low-volume threshold);
  • Being erroneously excluded from an alternative payment model (APM) participation list; and
  • Not being automatically reweighted even though you qualify for automatic performance category reweighting.
Clinicians/groups are urged to be prepared to provide additional supporting documentation if the Targeted Review is granted. CMS cautions clinicians that all decisions made during the Targeted Review will be considered final and not appealable.
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Intro QPP Alternative Payment Models Video Explains Key Participation Concepts

A brand-new introductory video on alternative payment models (APMS) in the Quality Payment Program (QPP) is available on the Research and Quality webpage. The video introduces CRNAs to the basic concepts they need to be familiar with when working with APMS in the QPP. The concepts include: What is an APM? The different APMs under the QPP. What is an Advanced APM versus a MIPS APM? What is a Qualified Participant (QP) status verses Partial QP status? What are the 2018 performance year payment and patient threshold requirements? The video complements the Advanced APM Fact Sheet and the MIPS APM Fact Sheet that also are available on the website.
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Business Meeting Materials Now Available on AANA Website

Important information for members attending the AANA Business Meeting on Saturday, September 22, at the AANA Annual Congress in Boston, is now available on the AANA website. Member login required.

The agenda for the meeting and the proposed resolution and bylaws amendments documents are available, along with other supporting documents. These documents will NOT be printed out or distributed at the Business Meeting, so if you are interested in having them to refer to in paper format, please print them from the website before you attend. These documents will be available in the AANA Meetings app before and during Annual Congress.
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Members, Here is the New Code to Use for Your Free Online CE Courses

Happy new (membership) year! With a new year comes a new promo code that you can use to get the AANA Learn courses offered in this year’s membership package. Choose from courses offering 1 Class A CE credit in topics such as pain management, anesthesia technology, AANA Journal courses, and more. Simply enter MEMBER19 during checkout. The code can be used up to six times through August 31, 2019. Get details
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Product Theater: Mock Malpractice Deposition Presented by AANA Insurance Services and MedPro

Most CRNAs have not witnessed or been involved in a deposition. Get a feel for the unpredictability, intensity, and stress associated with being deposed.

Angela L. Carr, JD, an experienced trial attorney and civil litigator, specializing in professional liability defense, general liability, and employment law, will depose a member of MedPro Groups’ CRNA Advisory Board. “The deposition is an integral part of any malpractice suit,” said Director of AANA Insurance Services, John Fetcho, CPCU, ARM. “We want attendees to recognize its importance and understand the benefit of having your own legal representation.”

This session will take place at the AANA Product Theater on Sunday, Sept. 23rd from 5-6 p.m., with a question and answer period to follow.
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Meetings and Workshops

Pre-Congress Workshops: Maximize Your CE Opportunities

The Pre-Congress Workshops take place on Friday, September 21, 2018 prior to the AANA 2018 Annual Congress. Topics include:
  • Advanced Physical Assessment for Pain Management Practice Workshop - The workshop will provide CRNA knowledge and hands-on practice for advanced physical assessment useful for differential diagnosis in pain management.
  • Writers Workshop: Writing for Professional/Scholarly Publication - The workshop will include presentations and a discussion regarding what constitutes a good idea, the process of marshaling that idea to a tangible product that merits consideration for publication, and anticipating what will occur during the peer review process. Exemplars will be used to explore optimizing the process and the workshop will be led by senior leaders of the AANA Journal Committee.
  • Fundamentals in Perioperative Transesophageal Echocardiogram Workshop - The workshop will provide didactic and hands-on learning opportunities featuring individualized and group instruction using cardiac and TEE simulation tools and intraoperative recordings to improve the understanding of real-time monitoring of cardiac function.
  • Airway on Demand Workshop - Attendees of this program will be exposed to both didactic and hands-on learning opportunities aimed at reinforcing learned knowledge and skills, as well as providing the opportunity for new learning, related to airway management under both normal and emergent conditions.
  • Crisis Resource Management Simulation Course - The Center for Medical Simulation's Crisis Resource Management Simulation Course will allow nurse anesthetists to improve their skills in managing and debriefing routine and critical clinical events, particularly in the realm of acutely deteriorating clinical situations, and managing difficult conversations with colleagues.
  • Neuraxial Regional Anesthesia-Epidural Workshop - The core faculty of the popular “AANA Regional Anesthesia Workshops” offers an opportunity to update current knowledge of epidural anesthesia techniques and clinical applications.
  • Gateway to Debriefing with Good Judgment Course - The Center for Medical Simulation’s Gateway Debriefing Skills Workshop introduces healthcare education faculty to the foundational practices of the Debriefing with Good Judgment© method of debriefing. This innovative workshop combines an immersive, day-long, in-person learning experience with supplemental online learning that includes customized peer-to-peer and mentor feedback. Participants will have the opportunity to learn how to efficiently improve future performance, set high standards while holding high regard for the learner, treat learners as thinkers and not just doers and practice various debriefing phases.
  • Neuromuscular Block Monitoring Workshop - Attendees of this didactic and hands-on instruction program will: 1) Review the incidence and outcomes of residual paralysis. 2) Explore techniques to improve the management and reversal of neuromuscular block. 3) Examine current and developing technologies available to assess neuromuscular block and reversal.
Please note: There is an additional registration fee for these workshops, they are not included in the Annual Congress registration fee. Learn more or register for the Pre-Congress Workshops.
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AANA Member Benefits

Nationwide: Celebrate National Hispanic Heritage Month

See how Nationwide, a longtime sponsor of Latina Style and NASCAR, brought together two great organizations for one tremendous outcome.

Nationwide Celebrates National Hispanic Heritage Month
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Associate Program Director of the Nurse Anesthesia Concentration

The University of Tennessee – College of Nursing is accepting applications for a Non-Tenure Track Clinical Assistant Professor position with administrative job duties as the Associate Program Director of the Nurse Anesthesia Concentration. 
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Check out the new AANA Career Center, CRNA Careers! Whether you’re a seasoned CRNA or just getting started, the new Career Center can connect you to the best opportunities.

Plus, there are robust search tools to help narrow your search, as well as tips for resume writing and salary negotiating. Add your resume and know that you can remain anonymous if you choose. Take advantage 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.

Preferring Oral and Subcutaneous Over IV Opioids May Reduce Overall Use

An experiment at Connecticut's Yale New Haven Hospital demonstrated that educational outreach on the advantages of oral and subcutaneous opioids can slash the amount of narcotic painkillers dispensed intravenously. There is solid evidence that subcutaneous opioid injections are effective and safer than IV pain medication, noted lead investigator Adam Ackerman, MD, but this knowledge is not well circulated. “We wanted to test whether increasing that awareness among prescribers and nurses could lead to decreased exposure to IV opioids,” he said. Ackerman and colleagues developed a prescribing protocol for the hospital that favored oral and subcutaneous opioids over IV delivery, and they educated internists and advanced practice providers on the new standard practice. To detect behavior changes, the researchers examined prescriptions for 127 inpatients treated during the three months following the rollout and education period and for 287 inpatients treated during a six-month control period. The educational initiative, they reported in JAMA Internal Medicine, was associated with an 84 percent decline in the use of IV opioid doses and a 55 percent reduction in the use of parenteral opioids. “This research adds to a growing body of literature demonstrating that routine administration of IV narcotics to hospitalized patients is both uncalled for and ineffective, as well as placing a significant percentage of patients at risk of addiction,” said anesthesiology professor Andrew Leibowitz, MD, of New York City's Icahn School of Medicine at Mount Sinai, who was not involved with the research.

From "Preferring Oral and Subcutaneous Over IV Opioids May Reduce Overall Use"
Anesthesiology News (09/10/18) Wild, David

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Benefits of NSAIDs as Part of Multimodal Analgesia Regimen in Children

Non-steroidal anti-inflammatory drugs (NSAIDs) have a role in curtailing pain and avoiding opioid-related complications in children, researchers have reported. They performed a review of 18 published studies that investigated NSAIDs as part of a multimodal analgesic protocol in the setting of pediatric surgery or emergency department visit. The studies targeted use of ibuprofen, ketoprofen, diclofenac, ketorolac, and lornoxicam—all of which were well tolerated by pediatric patients and lowered pain scores by some measure. Adverse events occurred at about the same rate with NSAIDs as with placebo, and both were less common with than with opioids. ”In pediatric studies where NSAIDs are evaluated as part of a multimodal regimen, pain relief is consistent with their use, often in an equivalent fashion to pain relief from opioid analgesics such as morphine or oxycodone," the investigators said at the recent 2018 PAINWeek conference in Las Vegas. "Additionally, NSAIDS are better tolerated than opioids and do not appear to be associated with increased operative blood loss over placebo, with the possible exception of ketoprofen."

From "Benefits of NSAIDs as Part of Multimodal Analgesia Regimen in Children"
Clinical Pain Advisor (09/08/18)

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Naldemedine Is Safe, Well Tolerated in Treatment of Opioid-Induced Constipation

Researchers presenting at the 2018 PAINWeek conference in Las Vegas said naldemedine (NAL) was well tolerated as an intervention for opioid-induced constipation in patients with non-cancer pain. The investigators analyzed three randomized controlled trials with more than 2,300 participants who fit the patient profile. All patients had taken opioids for a period of three months and then were treated for up to 12 weeks with either oral NAL or placebo. Just over 20 percent of patients in the NAL group reported treatment-emergent adverse events (TEAEs), versus 13.6 percent of the control group. However, overall incidence of TEAEs was comparable for both groups in all three of the Phase III trials. TEAEs—which included abdominal pain, diarrhea, and nausea—generally surfaced early in the treatment period, were mild to moderate in severity, and were short-lived. Opioid withdrawal also occurred at a relatively low rate of 1 percent of less in both treatment arms.

From "Naldemedine Is Safe, Well Tolerated in Treatment of Opioid-Induced Constipation"
Clinical Pain Advisor (09/07/18) May, Brandon

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Screening Tool Helps Find Pediatric Patients Who Can Undergo an MRI Without Anesthesia

Researchers have developed a screening tool, the modified Yale Preoperative Anxiety Scale (mYPAS), which they say can predict which children might be able to skip anesthesia for MRI procedures. The team from Nationwide Children's Hospital in Columbus, Ohio, used the screening test on a sample group of 80 patients older than five years who participated in simulation-based MRI preparation. Each child was assessed for mYPAS score both before and after practice sessions on a mock MRI scanner, with any score over 30 denoting anxiety. Average scores generally improved from 31 before simulation training to 27 afterwards. The investigators determined that just 14 percent of the patients required anesthesia to complete the MRI even after the pretend test run, and those children tended to have higher mYPAS scores both before and after simulation, suggesting little benefit from the intervention. In fact, the researchers concluded in the American College of Radiology, any child with a presimulation score above 33 would require anesthesia, regardless.

From "Screening Tool Helps Find Pediatric Patients Who Can Undergo an MRI Without Anesthesia"
Radiology Business (09/06/18) Walter, Michael

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Effect of PCEA vs. PCIA on Postoperative Pain Management and Short-Term Outcomes After Gastric Cancer Resection

Postoperative pain management following gastric cancer (GC) resection, which has not been widely studied, was the focus of new research out of China. The retrospective analysis compared short-term outcomes in a population of individuals who received either patient-controlled epidural analgesia (PCEA) or patient-controlled intravenous analgesia (PCIA) following their procedures. After propensity score matching based on preoperative variables, researchers formed two study groups with 917 participants each. There was no between-group difference in the length of hospital stay or the incidence of post-surgical complications. However, patients who received PCEA following GC resection exhibited lower pain scores in the recovery room as well as on postoperative days one and two, and they achieved first passage of flatus after surgery sooner than the PCIA patients. The researchers concluded that PCEA provided more effective postoperative pain control than PCIA following GC resection.

From "Effect of PCEA vs. PCIA on Postoperative Pain Management and Short-Term Outcomes After Gastric Cancer Resection"
Journal of Pain Research (09/18) Vol. 11, P. 1743 Wang, Liping; Li, Xuan; Chen, Hong; et al.

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First-Ever IV Ketamine Infusion Consensus Guidelines for Chronic Pain Released

The first consensus guidelines for using ketamine to treat acute pain are now on the books. The evidence-based recommendations were developed jointly by the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists; and they address dosing, treatment duration, management of adverse effects, monitoring, and requisite provider skills. “We hope these guidelines will help improve the safety and effectiveness of ketamine treatment,” said Eugene Viscusi, MD, of Philadelphia's Thomas Jefferson University, who notes that the anesthetic appears to alleviate chronic pain across a wide range of conditions—including depression, post-traumatic stress disorder, and complex regional pain syndrome—that have resisted other therapies. Although ketamine has associated side effects, Viscusi notes that it is supremely well tolerated when administered at subanesthetic doses by clinicians skilled in pain and anesthesia. Therefore, the new guidelines call for caregivers to be trained in moderate sedation. Based on its use as an anesthetic at high doses, ketamine treatment is generally not recommended for patients who have poorly controlled cardiovascular disease, who are pregnant, who have active psychosis, who suffer severe or moderate heptic disease, or who present elevated intracranial or intraocular pressure. There actually is not much evidence that ketamine is similarly problematic in these settings when used at subanesthetic doses, so Viscusi suggests there may be some wiggle room depending on a patient's individual risks and benefits from treatment.

From "First-Ever IV Ketamine Infusion Consensus Guidelines for Chronic Pain Released"
Pain Medicine News (09/04/18) Kronemyer, Bob

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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
September 13, 2018
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