CRNAs Value for Your Team and Bottom Line Sarah Chacko, JD Assistant Director of State Government Affairs and Legal Lynn Reede, CRNA, DNP, MBA Senior Director, Professional Practice Becker s 13th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference + The Business of Spine June 11, 2015
Value Based Care www.qualityforum.org
Trends Cost of care continues to be lower in ASC Complex cases and patients moving to ASC Enhanced recovery after surgery Increasing CRNA employment
ERAS Core Principles Sánchez-Jiménez, et al, ERAS (enhanced recovery after surgery) in colorectal surgery. 2014 http://www.intechopen.com/books/c olorectal-cancer-surgerydiagnostics-and-treatment/erasenhanced-recovery-after-surgeryin-colorectal-surgery
ERAS for elective colon resection surgery at Vancouver General Hospital Quality Forum 2014 http://www.slideshare.net/bcpsqc/reduce-overall-colorectal-morbidity-through-the-implementation-of-enhanced-recovery-aftersurgery-protocol
Meal containing fried, fatty foods or meat Light meal of toast and clear liquids NPO Guidelines Surgical Patients Adults NPO 8 or more hours before elective procedures NPO 6 hours prior to the procedure Pediatrics (>1 year of age) NPO for 6 hours Infants NPO for 6 hours Formula NPO for 6 hours NPO for 6 hours Breast Milk NPO for 4 hours NPO for 2 hours NPO for 2 hours Water & Clear Liquids Uncomplicated Pregnancy & Labor Pregnant women who have additional risk factors for aspiration Planned cesarean delivery or elective postpartum tubal ligation after vaginal birth NPO up to 2 hours prior to the procedure Obstetrics: Uncomplicated Pregnancy & Labor 12 ounces of Water/ Clear Liquids per hour of labor ONLY Ice Chips during labor Surgical NPO Guidelines Clear liquids such as water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, and sports drinks. morbid obesity diabetes those at high risk for operative delivery (ie, forceps, vacuum) ASA Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. 2011
Oral Fluid & Carbohydrate Fasting 2 hours for liquids and six hours for solids Carbohydrate beverage the evening before surgery and 2 hours before anesthetic induction Major surgery is associated with postoperative insulin-resistance Reduce thirst, hunger and postoperative insulin resistance Reduce protein catabolism, postoperative ileus and loss of lean muscle mass http://www.intechopen.com/books/colorectal-cancer-surgery-diagnostics-and-treatment/eras-enhanced-recovery-aftersurgery-in-colorectal-surgery
American Association of Nurse Anesthetists
Advanced Practice Registered Nurse (APRN) Certified Registered Nurse Anesthetist Anesthesia, anesthesia-related care and pain management services Certified Nurse Practitioner Health promotion, disease prevention, health education and counseling as well as the diagnosis and management of acute and chronic diseases Clinical Nurse Specialist Diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors Certified Nurse-Midwife Primary care for women (gynecologic care, family planning services, preconception care, prenatal /postpartum care, childbirth, care of the newborn)
CRNA Scope of Practice CRNA Education Certification, recertification State licensure State Statute Rule & regulation Practice Standards
Practice Model Team (multidisciplinary) Autonomous Collaborative Ferguson, T. How To Get What You Want From Health Care Workers (1980)
Value of CRNA Services
Salary http://drivinghp.com/consulting/its-all-in-the-mix-mdcrna-model-changes-can-reduce-your-anesthesia-subsidy/
Reimbursement Medical Direction Anesthesiologist meets 7 conditions for every case they are directing (RAC risk) Supervision Maximum reimbursement to anesthesiologist is 3 units (loss of revenue) CRNA QZ modifier, all available units paid (100%)
Practice Responsibility AANA / Resources / Professional Practice Blumenreich, G.A. Another article on the surgeon s liability for anesthesia negligence. Legal Briefs. AANA Journal 2007; April 2007, Vol 75, 89-93
Physician Supervision and CRNA Regulation Federal CMS conditions for Medicare Part A reimbursement include a physician supervision requirement for CRNAs in states that have not opted out. States can Opt Out of physician supervision requirement State scope of practice law, rule, regulation, opinion (e.g. Board of Nursing, Attorney General) Facility bylaws
State Supervision Opt Out The Nov. 13, 2001 final rule allows Governors in eligible states to request an opt-out (also known as an exemption ) from the federal Medicare Part A physician supervision of CRNA requirement. Federal Register / Vol. 66, No. 219 / Tuesday, November 13, 2001
Opt-Out Eligibility Criteria A Governor s opt-out letter must attest that: 1. The Governor has consulted with the state boards of medicine and nursing about issues related to access to and the quality of anesthesia services in the state; 2. The opt-out is consistent with state law (i.e., that supervision is not required); and 3. The Governor has concluded the opt-out is in the best interests of the state s citizens.
17 Opt Out States
Pain Management Pain is a universal experience. IOM 2011 100 million U.S. adults suffer from chronic pain Annual cost up to $635 billion Key recommendations Reduce barriers Increase pain management professionals Improving education programs for all advanced pain professionals
Pain Management Pain management is within CRNA professional scope of practice State law governs what CRNAs may do in particular state 2012 Medicare rule, confirms that the federal government recognizes CRNAs as qualified pain management providers
Value in a Nutshell Anesthesia professionals share one standard of care Low rate of direct anesthesia complications CRNAs are responsible for their practice CRNAs work with the healthcare team in every state, VA and military CRNAs can be reimbursed 100% of the case CRNAs offer more than anesthesia services
References No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians, Dulisse B. Cromwell J. (2010), Health Affairs, 29:1469-1475. Cost Effectiveness Analysis of Anesthesia Providers, Nursing Economic$, Hogan P, Seifert R, Moore C, Simonson B. (2010). 28, 3:159-169. Anesthesia Staffing and Anesthetic Complications During Cesarean Delivery, Simonson D, Ahern M, Hendry M. (2007), Nursing Research, 56, 9-17. Anesthesia Provider Model, Hospital Resources and Maternal Outcomes, Needleman J, Minnick AF (2009), Health Services Research, 44(Part I)464-82. Surgical Mortality and Type of Anesthesia Provider, Pine M, Holt KD, Lou YB, (2003), AANA Journal, 71:109-116.
References Studies Support Removing CRNA Supervision Rule to Maximize Anesthesia Workforce and Ensure Patient Access to Care, Jordan L. (2011). AANA Journal 79(2): 101-104. The Future of Nursing: Leading Change, Advancing Health, Institute of Medicine of the National Academies. (2010), Report Brief. Assessment of Recent Graduates Preparedness for Entry into Practice, Cook K, Marienau M, Wildgust B, Gerbasi F, Watkins J. (2013), AANA Journal, 81(5): 341-345. Physician Anaesthetists Versus Non-Physician Providers of Anesthesia for Surgical Patients, Lewis SR, Nicholson A, Smith AF, Alderson P. (2014). Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD010357. DOI: 10.1002/14651858.CD010357.pub2.
Discussion Sarah Chacko schacko@aana.com Lynn Reede lreede@aana.com info@aana.com Reference Documents Available at http://www.future-of-anesthesia-care-today.com/research.php