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Novitas Agrees to Change LCD on Epidural Injections

In response to the AANA’s June letter to Novitas Solutions requesting that the Medicare Administrative Contractor (MAC) reconsider its local coverage determination (LCD) restricting CRNAs’ ability to provide epidural injections, the AANA received a positive response indicating that Novitas will further modify the language of the LCD. In a letter from Novitas to the AANA, the MAC indicated that it will make the following changes to the LCD:
  • Replace the word “medical” with “professional” to read “all aspects of care must be within the provider’s professional licensure” under the Provider Qualifications section.
  • While Novitas will not remove its training and competency requirements, it has indicated that it will modify the section on training and competency to clarify that it is provider neutral and is not confined to selected physician specialties. Furthermore, Novitas states that “Nothing in this policy seeks to or has the authority to abridge practice scope as provided by states.”
  • While Novitas will not remove the requirement regarding radiologic imaging, it will modify the language for clarity.  
These changes indicate that Novitas has reconsidered its position since first issuing the LCD, when it stated that it was “not aware of any available training/certification programs for non-physician practitioners that would enable them to meet the stated requirements.”
 
The AANA is grateful for the leadership of U.S. senators and members of Congress who called the Centers for Medicare & Medicaid Services (CMS) to express concern with Novitas’s LCD and especially the seven members of Congress who sent a formal letter to the agency back in June, including Representatives Gregg Harper (R-MS), Jared Polis (D-CO), Tom Cole (R-OK), Michelle Lujan Grisham (D-NM), Ben Ray Lujan (D-NM), Lloyd Doggett (D-TX) and Eddie Bernice Johnson (D-TX). 
 
The AANA will continue to keep membership posted on developments concerning the Novitas LCD.
 
 
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Hot Topics


AANA Board Announces New Vice President

The AANA Board of Directors has appointed Mark Haffey, MSN, CRNA, APN, of Sioux Falls, SD, as AANA vice president. He fills the vacancy left by the selection of Randall D. Moore II, DNP, MBA, CRNA as AANA’s chief executive officer.  Moore had been elected to serve as vice president for fiscal year 2018.
 
As a former AANA Board director, Haffey was one of several candidates eligible and considered by the FY2018 Board of Directors to fill the vacancy.  The Board approved his appointment on Sept. 12, 2017. Read the rest of the announcement. Member login and password required.
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A Video Message from AANA President Bruce Weiner: “We Are All in this Together!”

In this motivational video message to the AANA membership, fiscal year 2018 President Bruce Weiner, DNP, MSNA, CRNA, shares his views on the AANA’s ongoing efforts to protect and advance the practice of nurse anesthesia. View the video.
 
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CRNAs Featured in USA Today Insert on Future of Anesthesiology

A special insert on the "Future of Anesthesiology" that appeared in the September 15 weekend edition of USA Today includes a two-page spread featuring an interview article with CRNAs discussing Enhanced Recovery after Surgery (ERAS) and a full-page ad promoting the role and value of CRNAs in today's healthcare system.
 
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OB Guidelines Comment Period Open

Review and submit comments on the draft practice guidelines, Analgesia and Anesthesia for the Obstetric Patient. Deadline to comment is Friday, October 13, 8 am CT. Visit Open Comments for more information. 
 
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Diversity and Inclusion Task Force Posts Recruitment Video
Be a Nurse. Be a Nurse Anesthetist

The AANA Diversity and Inclusion Task Force has posted a new recruitment video that speaks to the diversity within nurse anesthesia and the opportunity for nurses from all backgrounds to become CRNAs. View the video titled Be a Nurse. Be a Nurse Anesthetist
 
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Remembering World War I Hero Nurse Anesthetist Anne Penland

Anne Penland, a nurse anesthetist whose service in World War I influenced the British Royal Army Service to train female nurses as anesthetists, was honored at a service at the Pack Memorial Library in Asheville, NC, September 16, 2017. A historical marker honoring this hero was unveiled outside the library following the ceremony.

The program included a letter from the British Royal Army Medical Service published in the American Journal of Nursing in 1918: “A number of nurses shall be trained in the administration of anesthetics for service in base hospitals. The departure will liberate medical men for other duties, and in this way will be of great assistance in relieving the strain upon the medical service due to shortage of medical men. The suitability of nurses for this important work was made evident to the authorities by the practical demonstration of efficiency in the administration of anesthetics shown by you and some other American nurses  in the C.C.S.’s and base hospitals in France.  I think it right that I should inform you of the high appreciation which we have of the splendid services in taking the place of medical officers, whose services are urgently needed for the other work.” 

 Angela Mund, DNP, CRNA, director, Region 2, and AANA Former Presidents Sandy Ouellette, MEd, CRNA, FAAN; Dick Ouellette, ME, CRNA; and Nancy Bruton Maree, MS, CRNA; represented AANA at the ceremony. Sandy Ouellette gave the keynote address. A number of CRNAs and students from the Asheville area attended the service as well as one CRNA from Pennsylvania. Appreciation is extended to Luanne Nelson, member of the Buncombe Chapter of  Daughters of the American Revolution (of which Penland was a member), for a program highlighting Penland's life and legacy.
 
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Professional Practice


FDA Issues Reminder About Forced Air Thermal Regulating Systems

The Food and Drug Administration (FDA) is reminding healthcare providers that using thermoregulation devices during surgery, including forced air thermoregulating systems, has been demonstrated to result in less bleeding, faster recovery times, and decreased risk of infection for patients. The FDA recently became aware that some healthcare providers and patients may be avoiding the use of forced air thermal regulating systems during surgical procedures due to concerns of a potential increased risk of surgical site infection (e.g., following joint replacement surgery). After a thorough review of available data, the FDA has been unable to identify a consistently reported association between the use of forced air thermal regulating systems and surgical site infection.  View the letter to healthcare providers
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The Joint Commission’s New Sentinel Event Alert, Issue 58: Inadequate Hand-off Communication

Addressing a longstanding issue with hand-off communication between healthcare providers, The Joint Commission has posted a new Sentinel Event Alert intended to help providers communicate more effectively between patient transitions. The alert includes an infographic of “8 Tips for High-Quality Hand-Offs.”
 
These recommendations apply to both the sender and receiver of the communication and include:
  • Caregivers within hospitals and other healthcare settings
  • Hospital caregivers and those not located in a hospital
Hand-off communication failures may lead to medication errors, medical complications, readmissions and death.  The new Sentinel Event Alert helps healthcare organizations and providers improve the hand-off process.
 
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Federal Government Affairs


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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.

Delaying Minor Surgery for Pediatric Patients May Not Offer Any Neurodevelopmental Benefit

The impact of anesthesia on young children remains a hotly debated topic, with researchers at Columbia University among the latest to weigh in. Their study, an analysis of a decade's worth of claims data from two states, investigated whether exposure to anesthesia before age five was tied to elevated risk for mental disorder. The sample population included nearly 38,500 kids who had undergone any of four common childhood operations, along with almost 192,500 controls who had not been subjected to general anesthesia early in life. Exposed children were 26 percent more likely to be diagnosed later with a mental disorder—especially ADHD and developmental delay—but the timing of the surgery did not appear to be a factor in that risk. "While children exposed to anesthesia appear to be at a slightly increased risk for neurodevelopmental disorder, whether this excess risk can be attributed directly to the neurotoxic effects of anesthetic agents remains unclear," notes first author Caleb Ing, MD. "Our results, however, suggest that delaying commonly performed surgical procedures for pediatric patients may not offer any neurodevelopmental benefit." He and his colleagues report their findings online in Anesthesia & Analgesia.

From "Delaying Minor Surgery for Pediatric Patients May Not Offer Any Neurodevelopmental Benefit"
News-Medical (09/14/17)

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Differences in Blood Pressure in Infants After General Anesthesia Compared to Awake Regional Anesthesia

A multinational team of researchers collaborated to investigate the impact of general anesthesia (GA) on neurodevelopment at age five. In addition, their trial—General Anesthesia Compared to Awake Regional Anesthesia (GAS)—aimed to compare rates of intraoperative hypotension following anesthesia as well as identify risk factors for the complication. The sample population was made up of 722 infants at multiple sites who underwent inguinal herniorrhaphy with either sevoflurane GA or bupivacaine regional anesthesia (RA), as dictated by randomization. Analysis revealed that RA curtailed the incidence of hypotension compared with GA; however, interventions to correct low blood pressure were more likely in the GA group. Besides randomization group, the GAS team also discovered that infant weight at time of surgery and minimal intraoperative temperature were risk factors for hypotension in this population.

From "Differences in Blood Pressure in Infants After General Anesthesia Compared to Awake Regional Anesthesia"
Anesthesia & Analgesia (09/17) Vol. 125, No. 3, P. 837 McCann, M.E.; Withington, D.E.; Arnup, S.J.; et al.

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Local Anesthetic Injection Through Catheter Improves Block Outcomes

Researchers investigated a hunch that secondary block failure—or inadequate postoperative analgesia—with interscalene continuous peripheral nerve block might be the result of delivering local anesthetic via needle prior to catheter insertion. The team from Stanford University suspected that the approach prevents surgical staff from detecting improper catheter placement, which subsequently deteriorates the quality of postoperative analgesia. A retrospective chart review, led by Daniel Moy, MD, from the department of anesthesiology and perioperative and pain medicine, helped to support that theory. The single-site, retrospective study captured all patients undergoing interscalene catheter for postoperative analgesia over a one-year period. A total of 205 of those patients—181 of whom received injections of local anesthetic directly through the catheter and 24 of whom received them by needle—met inclusion criteria and were included in the final analysis. The results indicated that local anesthetic delivery via catheter only as opposed to needle delivery was associated with improved pain scores at 24 hours as well as lower opioid demand in the post-anesthesia care unit at 24 hours. Moy presented the findings at the 2017 annual meeting of the American Society of Regional Anesthesia and Pain Medicine.

From "Local Anesthetic Injection Through Catheter Improves Block Outcomes"
Anesthesiology News (09/12/17) Doyle, Chase

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Intravenous Lidocaine Safe, Effective for Chronic Pain

The results of a retrospective chart review indicate that intravenous lidocaine may deliver sufficient and long-lasting analgesia for neuropathic pain, posttraumatic or postsurgical pain, trigeminal neuralgia, and headache or migraine. The study covered 233 chronic pain sufferers who were given an initial lidocaine infusion of 1,000 mg/h for up to one half-hour. The treatment was halted after 30 minutes, at the point when patients achieved complete pain relief or experienced intolerable adverse effects, or if and when patients requested discontinuation. Pain was alleviated in more than 40 percent of the study population after the initial infusion, and the effect lasted one to two weeks on average. Patients responding to initial treatment received a second infusion, and 60 percent of them continued to benefit. I.V. lidocaine was, however, associated with mild adverse effects like perioral tingling, dizziness, and tinnitus. Affected patients—accounting for nearly half of the sample—were less likely to benefit. Side effects subsided, however, with the second and third lidocaine infusions. "Lidocaine may be beneficial for a range of chronic pain diagnoses," according to study authors. "Future studies are necessary to explore the relationships between lidocaine infusion dosage, treatment frequency, benefit duration, and treatment cost-effectiveness."

From "Intravenous Lidocaine Safe, Effective for Chronic Pain"
Clinical Pain Advisor (08/30/17) Martin, Jessica

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Are Anesthesia and Surgery During Infancy Associated With Decreased White Matter Integrity and Volume During Childhood?

Researchers at the University of Iowa questioned whether the neurotoxic effects of anesthesia observed in newborn animals also applied to young humans. To investigate, they designed a structural neuroimaging study, with a sample population of 34 pediatric patients. All of the participants underwent structural magnetic resonance imaging; but half had, as infants, been exposed to general anesthesia for one of four operations that are common among otherwise healthy children. Investigators discovered that whole brain white matter volume, as a share of total intracranial volume, was higher among control patients than among the children with a history of surgery and anesthesia. Similar patterns were separately documented in the parietal and occipital lobes, infratentorium, and brainstem. White matter integrity, meanwhile, was lower in anesthesia-exposed patients than in nonexposed patients in superior cerebellar peduncle, cerebral peduncle, external capsule, cingulum, and fornix, and/or stria terminals. Although exposure to surgery and anesthesia early in life may account for the disparities, the study authors concede there also may be other explanations.

From "Are Anesthesia and Surgery During Infancy Associated With Decreased White Matter Integrity and Volume During Childhood?"
Anesthesiology (08/17) Block, Robert I.; Magnotta, Vincent A.; Bayman, Emine O.; et al.

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Uniport vs Multiport Catheters for Labor Epidural Analgesia

Researchers in Texas compared pain scores in women about to give birth, stratified according to whether labor epidural analgesia (LEA) was delivered via open-tip uniport catheter or closed-tip multiport catheter. The team from Baylor All Saints Medical Center in Fort Worth worked with a sample population of about 600 expecting mothers, who were randomized to one LEA approach or the other. Although the design of multiport catheters facilitates multidirectional flow of epidural solution, analgesic adequacy—as gauged by visual analog scores—was similar between uniport and multiport users 30 minutes after LEA. The two treatment arms also registered comparable rates of anesthetic success and maternal satisfaction with the quality of LEA. "Our findings demonstrate the presence of multiports in flexible catheters may not provide additional analgesic benefit," reported lead investigator John Philip, MD, of Baylor's department of anesthesia. The study findings appear in Anesthesia & Analgesia.

From "Uniport vs Multiport Catheters for Labor Epidural Analgesia"
Clinical Pain Advisor (08/22/17) Olechowska, Anna

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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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September 21, 2017
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