Anesthesia management Archives - Page 15 of 20 - Xenon Health

Nurses have been providing anesthesia care for patients in the United States for almost 150 years (1). Even before the credential of a Certified Registered Nurse Anesthetist (CRNA) was established in 1956, nurses had contributed greatly to the development of anesthesia for almost a century before (3). The first U.S. nurse to provide anesthesia worked during the Civil War in the 1860s. From then, nurse anesthesia has been developed as a specialty vital to surgery.

Nurses were the first professional group to specialize in anesthesia in the U.S. (2), starting with Sister Mary Bernard in 1877 (1). Surgeons sought to lower the mortality of using anesthesia during surgery and saw nurses as a solution (2). Before formal educational programs for anesthesia were established, surgeons trained nurses to provide anesthesia for their patients (1). Nurse anesthetists thus became pioneers in the field of anesthesiology and contributed to the development of many techniques and devices (2).

The standardization and growth of anesthesiology was aided by publications of techniques in anesthesiology and the establishment of an anesthetist program (1). Alice Magaw, a nurse anesthetist in the nineteenth century and “Mother of Anesthesia,” developed many successful techniques and published her findings between 1899 and 1906 (2). Nurses and physicians worked together to establish anesthesia care in surgery. Dr. Charles Mayo and Magaw helped establish a showcase of anesthesia techniques, which was attended by hundreds of physicians and nurses (2).

The first formal educational program for anesthesia was established at St. Vincent’s Hospital in 1909 (2). They offered a six-month program for a master’s level degree to physicians, dentists, and nurses (1). As the field of anesthesia developed, physician anesthetists started to advocate for anesthesia to be only practiced by physicians, alleging that there was risk in anesthesia care given by non-physician anesthetists. However, the verdicts of lawsuits filed against practicing nurse anesthetists were all in favor of nurses. In 1931, the National Association of Nurse Anesthetists, later named the American Association of Nurse Anesthetists (AANA), was established (1), and the title of a CRNA introduced in 1956.

Prior to 2001, there was a federal requirement that anesthesia administered by a CRNA must be supervised by a physician (1). In 2001, there were changes in Medicare rules that allowed each state to determine whether physician supervision was needed. Most states require physician supervision for practicing CRNAs. However, 17 states have opted out of this requirement as of 2012 (4).

Now, CRNAs practice in a wide range of settings such as delivery rooms, ambulatory centers, dentist offices, military bases (3). The AANA outlines “Standards for Nurse Anesthesia Practice,” as a general guideline for practicing CRNAs (5). In settings where physician supervision is required, CRNAs often work as care providers that constantly monitor patients under anesthesia while an anesthesiologist supervises two to four CRNAs (1). In settings where physician supervision is not required, CRNAs often are the main providers of anesthesia, especially in rural areas.

According to the AANA, CRNAs have contributed to the reduction of costs for anesthesia care and increased the availability of anesthesia (6). The American Society of Anesthesiologists (ASA), however, claims that a physician-directed anesthesia model is more cost effective (1). While there remains to be discussion on the best strategy for anesthesia care, the development of anesthesia has undoubtedly been aided by both CRNAs and physicians.

References:

1 http://europepmc.org/abstract/MED/21717163

2 https://www.aana.com/aboutus/Documents/historynap.pdf

3 http://pain.com/archives/2011/01/24-crna-brief-history/

4 http://www.aana.com/advocacy/stategovernmentaffairs/Pages/Fact-Sheet-Concerning-State-Opt-Outs.aspx

5 http://www.aana.com/resources2/professionalpractice/Documents/PPM%20Standards%20for%20Nurse%20Anesthesia%20Practice.pdf

The electronic health record (EHR) is a longitudinal electronic record of patient health information collected in multiple care delivery settings and includes patient demographics, progress notes, vital signs, problems, medications, past medical history, immunizations, laboratory data, and radiology reports.^[1] The widespread adoption of EHR promises to streamline clinician workflow, provide a more comprehensive, accurate, and convenient overview of a patient’s health history, and allow rapid sharing of records between healthcare providers.^[2] In the 2012 Physician Sentiment Index, 81 percent of physicians believed that EHRs can improve access to clinical data and over two-thirds believed that EHRs could improve patient care.^[3]

One major benefit of EHR usage is that all clinicians involved in a patient’s care can exchange information in a secure manner, improving clinical workflow, hospital interactions, and patient outcomes.^[4] Cues in the EHR software may ensure that essential information is recorded and fewer mistakes are made, provide insight into quality measures and productivity, and increase staff and provider efficiency.^[5] Additionally, patients are able to access their own medical records and view their history, lab results, and medications at any time.

The Meaningful Use program was created by the U.S. government in 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. It aims to promote nationwide adoption of EHR systems through a set of financial incentives and penalties. Healthcare providers that demonstrate meaningful use of EHRs, as defined by a set of criteria by the Centers of Medicare and Medicaid Services (CMS), are eligible to receive up to $44,000 through the Medicare Meaningful Use program or $63,750 through the respective Medicaid program. On the other hand, eligible providers who do not demonstrate meaningful use of EHR by 2015 will not receive 100 percent of their Medicare fee schedule.^[6]

There are three distinct stages to the Meaningful Use program which are designed to gradually increase EHR adoption over several years. Stage 1, Data Capture and Sharing, began in 2011 and required providers to establish proper standardized data capture, communicate information for care coordination, and engage patients and families using EHR. Providers were required to attest that they had met nine core objectives and one public health objective in order to receive their incentive payment. Stage 2, Advanced Clinical Processes, required providers to extend EHR to a larger segment of their patient population, increase the amount of patient-controlled data, and provide more rigorous health information exchange starting in 2014. The attestation requirements were the same in Stage Two as in Stage One. Stage Three, Improved Outcomes, intends to simplify the program, increase interoperability between EHRs, improve patient outcomes, and provide greater patient access to self-management tools. However, details of the objectives have not been finalized yet and providers are not required to begin Stage Three until 2018.^[7]

Providers must meet the standards issued by the Officer of the National Coordinator for Health Information Technology in order to receive Meaningful Use certification. They must demonstrate that their EHR system is secure, can maintain data privacy, and share information with other systems in order to qualify for a Medicare or Medicaid incentive payment.^[8]

According to CMS, only 422 anesthesiologists had received financial incentives as of June 19, 2012, less than 1 percent of physicians who identified their specialty as anesthesiology. Under CMS guidelines, anesthesiologists often fall under the category of “eligible professionals” rather than “hospital-based eligible professionals,” who are exempt from financial incentives and penalties. At least 90 percent of services must be performed within the inpatient setting for a physician to be deemed hospital-based, which excludes anesthesiology outpatient and office settings. Thus, many anesthesiologists faced pay reductions beginning in 2015.^[9]

Due to these concerns, CMS created a hardship exemption that would exempt anesthesiologists from payment penalties, recognizing the nature of the patient-anesthesiologist relationship, workflow challenges, and the state of current EHR technology for anesthesiologists. Anesthesiologists may still attempt to become meaningful users and receive incentives, as the hardship exemption only prevents them from being financially penalized.^[10]

The American Society of Anesthesiologists continues to advocate for additional flexibility for physicians who achieve a close percentage of all the Meaningful Use objectives and recommends excluding anesthesiologists from other requirements, including the clinical summary requirement, syndromic surveillance, e-communication with patients, and computerized order entry for transfers of care objectives.^[11]

^[1] http://www.himss.org/library/ehr/

^[2] http://www.athenahealth.com/knowledge-hub/ehr/emr-vs-ehr

^[3] http://www.athenahealth.com/knowledge-hub/ehr/advantages

^[4] http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/

^[5] http://www.athenahealth.com/knowledge-hub/ehr/benefits

^[6] http://www.athenahealth.com/knowledge-hub/meaningful-use/what-is-meaningful-use

^[7] http://www.athenahealth.com/knowledge-hub/meaningful-use/stages

^[8] http://www.athenahealth.com/knowledge-hub/meaningful-use/certification

^[9] http://monitor.pubs.asahq.org/article.aspx?articleid=2445240&resultclick=1

^[10] https://www.asahq.org/advocacy/federal-activities/regulatory-activity/electronic-health-record

^[11] https://www.asahq.org/advocacy/federal-activities/regulatory-activity/electronic-health-record

New research on the rare amino acid isovaline shows that it could act as an effective pain reliever with few side effects. Injecting mice with the amino acid inhibits the nervous system’s processing of pain, acting as both an ant nociceptive and an antiallodynic drug. In combination with propofol, isovaline could make procedural sedation significantly more effective and safe.

With potential applications such as these, one might wonder why isovaline’s properties have only recently been revealed. One reason is the amino acid’s unusual origin. Isovaline is extraterrestrial: it first appeared on Earth in 1969 when the Murchison meteorite crashed into Australia. The meteorite also contained common amino acids such as glycine and alanine.

Isovaline works as an analgesic because of its structural similarity to two neurotransmitters responsible for inhibiting pain in the central nervous system: glycine and GABA. These agonists reduce how much pain a person feels by fitting themselves into specially-shaped receptors. Chronic pain arises when there are not enough of these inhibitory agonists, and too many pain signals coming from free nerve endings or other sources. Isovaline can counteract this imbalance by acting as a substitute for glycine and GABA. By activating pain-inhibiting receptors, isovaline is an artificial substitute for the neurotransmitters.

In addition to its effectiveness as an analgesic, isovaline possesses the additional benefit of having no major side effects. Many drugs that relieve pain also cause confusion, sedation, respiratory depression, or addiction. Isovaline is a small molecule that does not cross the blood-brain barrier, and as such produces analgesia without a noticeable effect on the central nervous system. Mice injected with the amino acid both by IV and into the spinal theca experienced no alteration in their spontaneous activity, gait, posture, or respiratory rate.

A study just published in December of 2015 demonstrates isovaline’s potentially significant contribution to medicine as an adjuvant for propofol, the hypnotic agent that is increasingly used in procedural sedation. There is a pressing need to make propofol safer for patients. Sometimes the people who administer propofol are not trained in airway management. Lately the news has published stories about propofol-related respiratory complications, some of which have ended in death.

A mixture of propofol, which on its own causes hypnosis, and an analgesic like an opioid can result in general anesthesia. Under the power of these combined agents a patient both forgets what happened during the procedure and does not experience pain. The combination of opioid and propofol is effective but can lead to respiratory depression relatively easily.

This is where isovaline comes in. As a non-sedating analgesic, isovaline potentially provides the pain-relief of an opioid without the danger of respiratory complications. The recent study shows that isovaline combined with propofol can yield effective general anesthesia: hypnosis, analgesia, and conscious sedation.

If isovaline turned out to be a viable drug for human use, many patients may benefit. Patients would recover from general anesthesia more quickly and experience fewer adverse effects, reducing their health care costs. Medical centers would benefit from the increase in patient and staff satisfaction. And most importantly, the number of sedation-related deaths and complications could potentially be diminished.

References:
http://www.ncbi.nlm.nih.gov/pubmed/20357156

http://www.sciencedirect.com/science/article/pii/S030645221200382X

http://www.ncbi.nlm.nih.gov/pubmed/21906050

http://www.ncbi.nlm.nih.gov/pubmed/21906050

http://www.houstonpress.com/news/going-under-what-can-happen-if-your-anesthesiologist-leaves-the-room-during-an-operation-7842230

http://www.ncbi.nlm.nih.gov/pubmed/26579656

To meet the growing demands of anesthesia practices, there are currently four possible types of anesthesia administration teams, consisting of various arrangements of anesthesiologists, Certified Registered Nurse Anesthetists (CRNAs), and other anesthesia care practitioners. These are the all-physician model, the all-CRNA model, the physician/CRNA model, and the anesthesia care team model. The anesthesia care team model, made up of any combination of non-physician anesthesia providers performing under the guidance of a qualified anesthesiologist, creates a highly supervised and organized environment in a busy surgical facility.

Under the care team model, the anesthesiologist retains virtually all responsibility for a patient, but may delegate tasks to other providers to increase efficiency and improve care. These other team members may include CRNAs, anesthesiologist assistants (AAs), and CRNA or AA students. Anesthesiology fellows or residents may also be part of the care team, operating under the supervision of the lead anesthesiologist.

While the make-up of the team may resemble that of the physician/CRNA model, the responsibilities and specific roles of individuals differ significantly. Although CRNAs who are members of the care team may administer the anesthetic themselves, the anesthesiologist is responsible for prescribing a safe and high quality anesthetic plan and discussing it with the patient. Depending on the procedure and patient’s medical condition, the anesthesiologist may delegate certain anesthetic monitoring tasks to other members of the team, while remaining available for intervention in emergency situations. Non-physician personnel also contribute to collection and documentation of patient data in pre and post-operative evaluations, however the anesthesiologist makes the final decisions regarding the patient’s treatment plan or progress. Through this model, routine post-operative care is usually delegated to post-anesthesia nurses. More detailed information on the organization of the care team, as well as policies set forth by the American Society of Anesthesiologists (ASA) can be found on the ASA website.

The anesthesia care team model has been implemented by many hospitals to increase efficiency and cut down costs. It is less expensive than the all-physician approach and allows anesthesiologists to be available for patient evaluations, consultations, and other essential aspects of patient care. Of course, conflicts may sometimes arise, specifically in determining the roles and responsibilities of anesthesiologists and non-physician practitioners working in the same environment. A study conducted in 2009 by Terri S. Jones et al. found that the main causes of conflict between professionals operating under the care team model were a lack of clarity in role expectations as well as a narrow scope of practice for non-physician providers.

Nevertheless, the anesthesia care team model, with its many benefits, remains highly utilized among surgical centers in the U.S. As detailed in a statement from the American Academy of Anesthesiologist Assistants (AAAA), such a system allows all personnel to work together to focus on providing the highest quality of anesthesia care to patients and in ensuring their safety. Furthermore, as noted in the Jones et al. study, collaboration between anesthesiologists and other anesthesia care providers is maximized through this model, often leading to higher patient satisfaction and an increased number of positive surgical outcomes.

References:

“ASA Statement on the Anesthesia Care Team”: https://www.asahq.org/advocacy/state-activities/core-issues/anesthesiologist-assistants

http://www.beckersasc.com/anesthesia/ins-and-outs-of-4-asc-anesthesia-provider-models.html

https://www.asahq.org/lifeline/who%20is%20an%20anesthesiologist/anesthesia%20care%20team

https://www.aana.com/newsandjournal/Documents/crnacollaboration_1209_p431-436.pdf

https://aaaa.memberclicks.net/assets/docs/position%20statement%20-%20anesthesia%20care%20team.pdf

http://www.aana.com/advocacy/stategovernmentaffairs/Pages/Fact-Sheet-Concerning-State-Opt-Outs.aspx

http://crto.on.ca/pdf/Misc/Anesthesia_Care_Team_Ontario.pdf

With the role of anesthesia becoming ever more crucial to hospital treatments around the globe, ensuring the quality of the anesthetic treatment itself becomes an issue that all healthcare providers must consider in their practices. The Anesthesia Quality Institute (AQI) plays a large role in that capacity, as it manages the National Anesthesia Clinical Outcomes Registry (NACOR), which monitors anesthesia providers that have registered with the AQI, and provides feedback for improvement based on quality gaps that have been identified through performance results and other types of qualitative and quantitative data.

The NACOR is a registered Qualified Clinical Data Registry (QCDR), a designation given from the Centers for Medicaid and Medicare Services (CMS) that indicates that the database relies on a certain reporting mechanism to submit quality reports from qualified healthcare professionals. In 2008, the American Society of Anesthesiologists (ASA) funded the AQI to begin development of the NACOR, to address the lack of a national perspective and the lack of information on procedures that required anesthetics. The AQI began operations in 2009, and the NACOR was then approved and recognized as a QCDR database in 2014, where it was the first anesthesia registry to receive this recognition from CMS.

The NACOR presents a unique solution to the lack of comprehensive information on anesthesiology. The design of the registry itself was aimed to be adaptable for the evolution of healthcare with the development of technology. While most traditional registries for medical records rely on written reports from professionals in the field, NACOR solely collects data electronically, with information directly from anesthesia providers and other healthcare facilities to its database. This information requires a minimum of at least 20 fields of quality measurements, however, the most comprehensive files in NACOR include thousands of data points—including the patient’s vital signs, medication doses, and procedure notes.

The growth of the NACOR and its diversity in reporting anesthesia groups has been rapid. As of 2014, NACOR represented 2534 facilities, ranging from pain clinics to university hospitals and surgery centers. Approximately 317 different anesthesia groups managed these 2534 facilities, 268 of which provided descriptive information on their practices through the NACOR survey. The NACOR provides for a higher level of communication between the AQI, the individual practices, and those involved in the information technology of anesthesia. With the constant flow of information, the AQI can perform a number of tasks, including contracting “with individual practices and hospitals to exchange data” (1). Similarly, the individual practices can use this reported data to “meet various local, state, and federal regulatory requirements”, as well as increase the overall level of quality of their treatments based on the quality measures structured (1).

The NACOR now contains over 16 million records that provide critical information to healthcare providers all over the nation, including information on various types of procedures from different types of facilities. The AQI now hopes to develop a new model for the NACOR that provides a more universal reporting of data, with even more integration of electronic data and expert designed quality metrics. However, the data that is currently provided still serves as a way for anesthesia providers and facilities to identify and fill any quality gaps in their treatments, providing for a more streamlined and patient care oriented experience.

Sites Referenced:

1. https://www.aqihq.org

2. https://www.aqihq.org/introduction-to-nacor.aspx

3. https://www.aqihq.org/qcdr

4. http://repository.edm-forum.org/cgi/viewcontent.cgi?article=1070&context=egems