American Association Of Nurse Anesthetists Research Articles

Onward and Upward: Introducing the Healthcare Simulation Standards of Best PracticeTM

The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards Committee and the INACSL Board of Directors (BOD) introduce the fourth edition of the Standards of Best Practice. Since originally announced in 2011, the INACSL Standards of Best Practice have guided the integration, use, and advancement of simulation-based experiences within academia, clinical practice, and research. Healthcare professionals around the globe have and continue to champion simulation; thus, allowing the Standards to flourish. Before reflecting on the revision process, it is necessary to acknowledge how this past year has been a challenge for simulationists around the world. Although the COVID-19 pandemic disrupted healthcare practice and academia, the simulation community stepped up to the challenge with a rapid pivot to an unprecedented collaboration of resources. Through this camaraderie, we supported each other, our patients, our teams, our learners, and our frontline workers. Through a massive virtual response and a careful consideration of how to bring learners back to face-to-face simulation learning environments, we facilitated patient safety, supported frontline healthcare workers, and continued to educate our healthcare students while showcasing teamwork for healthcare professionals around the world. As we look to the future, we are excited to announce the INACSL Standards' re-envisioning and re-branding to the Healthcare Simulation Standards of Best Practice as we continue to engage the global and interprofessional community herein referred to as the Healthcare Simulation SOBP (HSSOBPTM). For the 2021 revision, the Standards Committee gathered to commence work in the later part of 2018 with focus placed on historical and foundational elements of the Standards of Best Practice, survey data from both INACSL membership and the simulation community, current directions within practice and research, and future recommendations noted within the 2016 Standards. In January of 2019, the INACSL Standards Committee welcomed a medical librarian and a diverse team of interprofessional healthcare professionals to serve as sub-committee members. Once the team was in place, work began by conducting an extensive literature review supported by our Medical Librarian, Jean Hillyer. Clearly emerging from both the literature and the membership survey was the need to develop two new Standards: "Professional Development" and "Prebriefing: Preparation and briefing." It is important to note that a rigorous discussion occurred regarding the creation of another new Standard about virtual simulation. After reviewing the literature and discussing with multiple stakeholders including the BOD, a decision was made that “virtual” learning was a method of simulation and the Standards would apply just as it would to the other areas of simulation methodology: manikin-based, standardized patient, skill performance, online, etc. We recognize that the pandemic and rapidly advancing technology may have a profound effect and change this decision for future iterations of the Standards. The process for Standards revision was not always easy, requiring constant and thoughtful debate and discussion. As an ever-evolving science, there continues to be a growth in new and different modalities, applications, changes in terminology, as well as unpredictable life changes such as a global pandemic. At some point, we had to impose a stopping point or the Standards would never be published. The end date for literature became December 2020. We had to work through the pandemic and recognize that some of the profound impacts of it will not be present in this version. At some point, we had to recognize that the committee members were also affected by the pandemic and needed to focus on their other obligations. We became a support system, a welcome touch point for each other, and an acknowledgement that simulationists continue to lead and innovate even when it's difficult. You will see that a few Standards had minimal revisions, while others underwent significant changes. As a committee, we have spent hundreds of hours searching and reviewing the literature then debating and discussing all things related to the Standards. When we had questions or a new comment or area of feedback was provided, we returned to the literature. These Standards are based on and reflect the evidence in the literature. These documents represent the passion, blood, sweat, and tears of a dedicated team who were committed to producing their best work to benefit the simulation community. In this iteration of the Standards, we have integrated the SSH Healthcare Simulationists Code of Ethics and have used the SSH Healthcare Simulation Dictionary as the basis for terminology. The Glossary will continue to support the HSSOBPTM and clarify terms but was significantly reduced in support of the SSH dictionary. These Standards follow standard terminology and definitions from the simulation community. Recognizing that there is some variability in terminology from center to center, profession to profession, and around the world, we have included the glossary to make these standards more accessible to individuals regardless of background, profession, language, or geographical area. The glossary helps define and demonstrate how we are using these words in the context of these Standards. Our goal is to provide this as a keystone for translation for anyone implementing these Standards. The 2021 edition of the Standards is the collective effort of the Standards Committee and subcommittee members that represented multiple professions and international input as well as, advisory panel professional organizations, expert reviewers, INACSL Board of Directors, and a medical librarian. We want to thank them for their contributions. All participants aimed to ensure the Healthcare Simulation Standards of Best Practice were a platform for all simulationists and represented the best practices to design, conduct, and evaluate simulation-based experiences. While the pandemic delayed our initial release date of 2020, we are excited and know that the time is right for publication of these new healthcare focused Standards. These new Standards were a collaborative effort, and every person participating made a valuable contribution to the final product. The HSSOBPTM consist of the following individual Standards:Professional Development (NEW)Prebriefing: Preparation and Briefing (NEW)Simulation DesignFacilitationThe Debriefing ProcessOperationsOutcomes and ObjectivesProfessional IntegritySim-Enhanced IPEEvaluation of Learning and PerformanceSimulation Glossary It is important to note that these Standards are aspirational and serve as a guide. We recognize and understand that context, resources, accreditation needs, etc., may affect the implementation and attainment of the Standards, however, we hope that they provide talking points of discussion with stakeholders in your own institutions and areas of practice. As our work continues in the simulation community, we challenge simulationists around the world to:•Continue simulation research, ingenuity, and creativity.•Keep publishing, presenting, and disseminating work.•Seek best practice and excellence in simulation experiences.•Apply the Standards and seek to integrate them into all simulation programs. As the Standards are living documents, there will ALWAYS be ongoing opportunities for change and growth within them and in our community of practice. We, as a simulation community, must continue to seek excellence and quality in simulation education and practice. We look forward to the future of healthcare simulation and the journey for excellence in best practice. INACSL Board of Directors 2021 Standards Committee: Chair, Penni I. Watts, PhD, RN, CHSE-A Lead Professional Development Standard: Beth Hallmark, PhD, RN, CHSE-A, ANEFSubcommittee Members:Michelle Brown, PhD, MS, MLS(ASCP)CM, SBBCM, CHSEDawn Taylor Peterson, PhDMary Fey, PhD, RN, CHSE-A, ANEF, FAANSharon Decker, PhD, RN, FSSH, ANEF, FAANElizabeth Wells-Beede, PhD, RN, C-EFM, CHSETeresa Britt, MSN, RN, CHSE-ALori Hardie, MSN, RNC, NPD-BC, CHSECynthia Shum, DNP, MEd, RN, CHSE-AHenrique Pierotti Arantes, MD, PhDMatthew Charnetski, MS, NRP, CHSOS, CHSECatherine Morse, PhD, MSN, RN, ACNP-Ret Lead Prebriefing: Preparation and Briefing Standard: Donna McDermott, PhD, RN, CHSESubcommittee Members:Jocelyn Ludlow, PhD, RN, CHSE, CNE, CMSRNElizabeth Horsley, RN, MSMS, CHSEColleen Meakim, MSN, RN, CHSE-A, ANEF Lead Operations Standard: Matthew Charnetski, MS, NRP, CHSOS, CHSESubcommittee Members:Melissa Jarvill, PhD, RNC-NIC, CHSE, CNE Lead Professional Integrity Standard: Fara Bowler, DNP, ANP-C, CHSESubcommittee Members:Mary Klein, PharmD, BCACP, CHSEAmanda Wilford, MA, DipANC, RGN (Hons) Lead Evaluation of Learning and Performance Standard: Erin McMahon, CNM, EdD, FACNMSubcommittee Members:Francisco A. Jimenez, PhD, CHSEKay Lawrence, PhD, RN, CHSEJoyce Victor, PhD, RN, NPD-BC, CHSE-A Lead Debriefing Process Standard: Sharon Decker, PhD, RN, FSSH, ANEF, FAANSubcommittee Members:Scott B. Crawford, MD, FACEP, FSSH, CHSOSRandy M. Gordon, DNP, FNP-BC, CNEGuillaume Alinier, PhD, PgCert, MPhys, SFHEA, NTFDeborah Jenkins, MSN, RN, NPD-BC, CCRN-KCheryl Wilson, DNP, APRN, ANP-BC, FNP-BC, CNE, CHSE Lead Outcomes and Objectives Standard: Carrie Miller, PhD, RN, CHSE, CNE, IBCLCSubcommittee Members:Cathy Deckers, EdD, RN, CNE, CHSEMeghan Jones, MSN, RN, CHSEElizabeth Wells-Beede, PhD, RN, C-EFM, CHSEElisabeth McGee, PhD, DPT, MOT, PT, OTR/L, MTC, CHT, CHSE Lead Facilitation Standard: Lori Persico, PhD, RN, CHSESubcommittee Members:April Belle, DNP, RN, CCNSHeiddy DiGregorio, PhD, APRN, PCNS-BC, CHSE, CNEBarbara Wilson-Keates, PhD, RN, CHSEChasity M. Shelton, BS, PharmD, FCCP, BPCS, BCPPS Lead Simulation Design Standard: Penni I. Watts, PhD, RN, CHSE-ASubcommittee Members:Donna McDermott, PhD, RN, CHSEPooja A. Nawathe, MD, FAAP, FCCM, CHSE-A, CHSOSGuillaume Alinier, PhD, MPhys, PgCert, SFHEA, NTFMatthew Charnetski, MS, NRP, CHSOS, CHSEJocelyn Ludlow, PhD, RN, CHSE, CNE, CMSRNColleen Meakim, MSN, RN, CHSE-A, ANEFElizabeth Horsley, RN, MSMS, CHSE Lead Simulation-Enhanced Interprofessional Education Standard: Kelly Rossler, PhD, RN, CHSESubcommittee Members:Neena Xavier, MD, FACEMargory A. Molloy, DNP, RN, CNE, CHSEAmy M. Pastva, PT, MA, PhD, CHSEMichelle Brown, PhD, MS, MLS(ASCP)CM, SBBCM, CHSE Lead Glossary: Margory A. Molloy, DNP, RN, CNE, CHSESubcommittee Members:Jo Holt, DNP, APRN, CCNS, CEN, CHSE, CSSBBMatthew Charnetski, MS, NRP, CHSOS, CHSEKelly Rossler, PhD, RN, CHSE Medical Librarian Jean Hillyer, MAE, MLS, AHIP-S Expert Reviewers Jeff Camack, DNP, RN, CHSE Suzanne Campbell, PhD, RN, IBCLC Kristina Thomas Dreifuerst, PhD, RN, CNE, ANEF, FAAN Carol Fowler Durham, EdD, RN, ANEF, FSSH, FAAN Laura Gonzalez, PhD, APRN, CNE, CHSE-A, ANEF, FAAN Teresa Gore, PhD, DNP, APRN, FNP-BC, CHSE-A, FSSH, FAAN Leslie Graham, RN, MN, CNCC, CHSE Nicole Harder, PhD, RN, CHSE, CCSNE Val Howard, EdD, MSN, RN Kim Leighton, PhD, RN, CHSOS, CHSE, ANEF, FSSH, FAAN Advisory Council American Association of Colleges of Nursing American Association of Colleges of Pharmacy (AACP) American Association of Nurse Anesthetists (AANA) American Society for Clinical Pathology American Council of Academic Physical Therapy (ACAPT) Association of Standardized Patient Educators (ASPE) Australian College of Nursing Australian Society for Simulation in Healthcare Canadian Alliance of Nurse Educators Using Simulation (CAN-Sim) Emergency Nurses Association Global Network for Simulation in Healthcare (GNSH) Hong Kong Society for Simulation in Healthcare International Pediatric Simulation Society (IPSS) National Association of EMS Educators (NAEMSE) National Association of Emergency Medical Technicians (NAEMT) NLN Commission for Nursing Education Accreditation (CNEA) National Association of Pediatric Nurse Practitioners (NAPNAP) Pediatric Simulation Training and Research Society of India (PediSTARS India) Physician Assistant Education Association (PAEA) SimGHOSTS Simulation Canada Society for Simulation in Healthcare Spanish Society for Clinical Simulation and Patient Safety The INACSL Standards Committee gratefully acknowledges the previous contributions from former INACSL Board of Directors and former Standards Committee Members. The current Standards would not be possible without their foundational work.

Putting the Physician Back Into Anesthesiologist on the Front Lines of Advocacy

Features| August 2021 Putting the Physician Back Into Anesthesiologist on the Front Lines of Advocacy Jay Epstein, MD, FASA Jay Epstein, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor August 2021, Vol. 85, 24. https://doi.org/10.1097/01.ASM.0000768796.84283.8a Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Jay Epstein; Putting the Physician Back Into Anesthesiologist on the Front Lines of Advocacy. ASA Monitor 2021; 85:24 doi: https://doi.org/10.1097/01.ASM.0000768796.84283.8a Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: advocacy Anesthesiologists are physicians first and specialists in anesthesia second. This important distinction is often lost on policymakers and has been well documented in public surveys conducted by ASA in which many of our neighbors and friends apparently fail to realize we are doctors. The latest “blur-the-lines” tactic developed by the American Association of Nurse Anesthetists is the nonsensical and self-appointed “nurse anesthesiologists” moniker, which the ASA and multiple state component societies are aggressively pushing back against. This misrepresentation and lack of transparency confuses patients, lawmakers, the media, and health care executives into thinking that anesthesiologists are interchangeable with non-physicians, who despite possessing less education and training, are attempting to take advantage of these ambiguities. Within this challenging health care nomenclature landscape, anesthesiologists should continue to distinguish themselves from those who are not doctors but who nonetheless claim to be able to do what we do as well as we do... You do not currently have access to this content.

Ketamine: Safe and Effective Treatment for Severe Depression.

Depression resistant to standard treatment is devastating to an individual's quality of life. Ketamine offers a safe and effective alternative to standard depression treatment, but many patients and providers are often unaware of this option. The American Association of Nurse Anesthetists and the American Psychiatric Nurses Association partnered in developing a collaborative approach to providing ketamine infusion therapy for psychiatric disorders. The purpose of this project was to disseminate information through an educational video about the safety and efficacy of outpatient low-dose ketamine infusions as an alternative therapy for treatment-resistant depression. A thorough literature review was conducted in PubMed, PsychINFO, CINAHL, and Google Scholar for articles describing the safety and efficacy of ketamine use in treatment-resistant depression. Based on the current research, an educational video reporting the benefits and safety of ketamine was developed and launched on two social media platforms-YouTube and Facebook-for individuals to view. The effectiveness of the video was evaluated through the number of views, likes, shares, and comments recorded. At 9 months, 156 views, 60 likes, 8 shares, and 4 comments were recorded in both platforms. Comments indicated that viewers found the video informative and encouraging. A short evidence-based educational video provides individuals with information regarding the safety and efficacy of low-dose ketamine infusions as an option for depression treatment. Ketamine outpatient clinics support and treat depressed patients who do not benefit from conventional pharmacologic medications.

Assessment of Staffing and Service Provision in the Post-Anesthesia Care Unit of Hospitals Found in Amhara Regional State, 2020.

BackgroundPost-anesthesia recovery is a continuous process which is considered to be complete after the patient returns to their preoperative physiological state. Although all patients who have had an operation under anesthesia are in a potentially unstable physiological state, most patients recover safely without significant problems due to better and immediate post-anesthesia care. Therefore, this study aimed to assess the staffing and service provision in the post-anesthesia care unit.MethodsA multicenter, institution-based cross-sectional study was conducted in post-anesthesia care units from November 28 to December 31, 2020. The data were collected using a questionnaire prepared from standards and guidelines of the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, and the Royal College of Anesthetists by direct observation.ResultsTen hospitals found in Amhara regional state were examined for their staffing of and service provision in their post-anesthesia care units. The total ratio of nurses assigned in post-anesthesia care units to post-anesthesia care unit beds was around 1:3, with a minimum and a maximum ratio of 1:8 and 1:2, respectively. The average number of patients admitted in post-anesthesia care units per week was 98. Eighty percent of the hospitals' post-anesthesia care units had no policy or caregivers for cardiac arrest management.Conclusions and RecommendationsStandards, policies, and guidelines are not well prepared and posted so as to be visible to every caregiver. The majority of the hospitals have staff without special training for the management of possible complications in the post-anesthesia care unit. Generally, hospitals need to ensure standardized patient care in the post-anesthesia care unit for better and safer patient outcomes.

AORN Position Statement on Managing Distractions and Noise During Perioperative Patient Care

AORN JournalVolume 111, Issue 6 p. 675-680 From AORNFree Access AORN Position Statement on Managing Distractions and Noise During Perioperative Patient Care First published: 28 May 2020 https://doi.org/10.1002/aorn.13064Citations: 2AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat POSITION STATEMENT AORN believes: A multidisciplinary team approach is required to reduce distractions and noise in perioperative settings and create a safer environment for patients and perioperative team members. Distractions and noise that do not serve a clinical function should be minimized. During critical phases of the surgical procedure, surgical team members should create a no-interruption zone in which nonessential conversation and activities are prohibited. Interventions to reduce distractions and noise should be adaptable to all areas where invasive procedures are performed (eg, traditional ORs, ambulatory surgery centers), and the actions included should be applicable to the specific practice and team members. RATIONALE The perioperative setting is one of the most complex work environments in health care and is an information-intensive environment in which performance and safety are heavily reliant on the smooth flow of information.1, 2 Distractions and noise contribute to the complexity of the care environment.3 Distractions occur frequently in the perioperative setting. Intrinsic sources of distraction include noise and alarms from monitors; equipment; and communication relevant to the patient, procedure, and environment. Extrinsic distraction sources include personal electronic devices, pagers, phone calls, computers, traffic, visitors, and communication from personnel outside the OR.4, 5 The use of personal electronic devices (eg, mobile phones, tablets, laptop computers) has greatly increased and may distract caregivers from focusing on the patient.6-8 Ring tones and alarms from personal electronic devices contribute to distraction.6 Undisciplined use of cellular devices in the OR by any member of the perioperative team may be distracting and may affect patient care.4, 9 In a survey of perfusionists, 55.6% reported they had used a cell phone while performing cardiopulmonary bypass, and 49.2% reported sending text messages during procedures.10 Distractions increase the possibility of adverse patient outcomes (eg, incorrect counts11; wrong procedure, side, or site)12 by diverting a team member's attention from the current task, which could lead to omissions, prolonged procedure duration,13, 14 and mental lapses.3, 15-20 Excessive noise in the health care environment may minimize the ability to communicate effectively, make it difficult to understand content, and contribute to miscommunication15, 21 that could potentially lead to an error.22-24 The Environmental Protection Agency (EPA) recommends that the level of continuous background noise in hospitals not exceed 45 decibels (dB) during the day. The World Health Organization recommends that environmental noise levels not exceed 30 dB.25 The Occupational Safety and Health Administration permissible exposure limit (PEL) for noise is 90 dBA for all workers for an 8-hour day.26 Studies measuring noise levels during surgery demonstrate high noise levels, with many exceeding the EPA recommendation.27-34 Specialties in which powered surgical tools and impact-producing equipment are used (eg, orthopedics31, otolaryngology33) demonstrated higher noise levels than other specialties.30-33 Noise has been linked to poor task performance35-37; poor concentration38, 39; and the inability to perform complex, problem-solving tasks. Working in a noisy environment has been associated with physical and psychological symptoms, including tachycardia40, fatigue, illness and injury, irritability, anxiety, emotional exhaustion, job dissatisfaction, stress,22, 23, 41 emotional exhaustion,22 and burnout.22 Noise is also a distraction that interrupts patient care and potentially increases the risk for error.42 In a prospective study that measured noise and distraction in the OR during 50 trauma procedures, the average noise level was 85 dB, with a range of 40 to 130 dB.43 The average number of interruptions and distractions was 60.8 for each surgery, with a range of five to 192. The main causes of distractions and interruptions were team members entering and leaving the room, equipment alarms, parallel conversations, and telephones or pagers.43 Studies by Kurmann et al,44 Dholakia et al,45 and Tschan et al46 found that increases in noise (eg, talking during the closing phase of a surgical procedure45) may be associated with increases in surgical site infection. Factors that contribute to distractions and noise levels in the perioperative practice setting may include patient care activities: ○ medical records (eg, charting, viewing test results) ○ clinical alarms40, 43, 47 ○ monitors23, 40 ○ medical equipment and devices (eg, lasers, radiology equipment, waste management, smoke evacuators, forced-air warming units)40 behavioral activities: ○ conversations (essential and nonessential) ○ personnel moving in and out of the room43, 48-50 mechanical (physical) environment: ○ heating, ventilation, and air conditioning systems ○ metal equipment (eg, instruments, basins, rigid containers)23, 40 ○ powered surgical instruments40, 51, 52 ○ moveable equipment ○ equipment operations and troubleshooting14, 19 ○ acoustic surfaces on floors, walls, and ceilings41, 53 ○ pneumatic tube systems22, 47 technology: ○ telephones (eg, smart phones, cell phones,54, 55 land lines)43, 48, 56 ○ wireless devices (eg, tablet computers, personal digital assistants, personal gaming devices)20 ○ wireless communication systems20, 57 ○ paging systems (eg, personal pagers,48, 56 intercoms, overhead paging systems)20, 43 ○ computers ○ music devices (eg, radios, subscription music services)48, 51, 52 electronic activities: ○ email ○ texting ○ use of applications and social media ○ Internet searches ○ games Identifying critical phases of a surgical procedure may assist surgical team members in ensuring nonessential conversation and activities do not occur.20, 58, 59 Critical phases are times during the patient's surgical experience when any activity could distract surgical team members or interfere with the safe conduct of their duties. Critical phases may include time-out periods, critical dissections, surgical counts, medication preparation and administration,60 confirming and opening of implants, induction61 and emergence from anesthesia, and care and handling of specimens.59 The reduction in activity and noise during the critical phases has been referred to as a no-interruption zone,62 sterile cockpit,43, 58 zone of silence,47 and red zone.20 Surgical team members should give their full attention to performing their responsibilities during critical phases. Critical phases may occur at different times for different team members. Operative and invasive procedures are high-risk activities that require vigilance, concentration, and situational awareness.15 Distractions and noise can cause disruptions in communication and teamwork, which may contribute to errors that can compromise patient safety.2, 63 Distractions and noise cannot be eliminated completely from the perioperative environment; therefore, AORN is committed to advocating for a controlled environment in which distractions and noise are minimized to the greatest extent possible.5, 43 Glossary Decibel (dB): A logarithmic unit that measures the intensity of sound. Distraction: That which diverts attention from or prevents concentration on a task. Interruption: An unplanned or unexpected event that causes a discontinuation of a task or performance. Noise: Any sound that is undesired or interferes with the ability to hear. REFERENCES 1Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. 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The association of noise and surgical-site infection in day-case hernia repairs. Surgery. 2015; 157(6): 1153- 1156. CrossrefPubMedWeb of Science®Google Scholar 46Tschan F, Seelandt JC, Keller S, et al. Impact of case-relevant and case-irrelevant communication within the surgical team on surgical-site infection. Br J Surg. 2015; 102(13): 1718- 1725. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 47 Minimizing noise and distractions in the OR and procedural units. Joint Commission Quick Safety. 2017; 35 (August). https://www.joint​commi​ssion.org/asset​s/1/23/Quick_Safety_Issue_35_2017_Noise_in_OR_FINAL.pdf. Accessed January 22, 2020. Google Scholar 48Antoniadis S, Passauer-Baierl S, Baschnegger H, Weigl M. Identification and interference of intraoperative distractions and interruptions in operating rooms. J Surg Res. 2014; 188(1): 21- 29. CrossrefPubMedWeb of Science®Google Scholar 49Reznick D, Mino J, Monteiro R, Siperstein A. Perioperative inefficiencies and distractions in an endocrine surgical service. Perioper Care Oper Room Manag. 2016; 4: 7- 11. CrossrefGoogle Scholar 50Sevdalis N, Undre S, McDermott J, Giddie J, Diner L, Smith G. Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments. World J Surg. 2014; 38(4): 751- 758. CrossrefPubMedWeb of Science®Google Scholar 51Chen L, Brueck SE, Niemeier MT. Evaluation of potential noise exposures in hospital operating rooms. AORN J. 2012; 96(4): 412- 418. Wiley Online LibraryPubMedGoogle Scholar 52Chen L, Brueck Seds. Health Hazard Evaluation Report: Evaluation of Potential Noise Exposures in Hospital Operating Rooms, Morgantown, WV. [NIOSH HETA no. 2008-0231-3105]. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; 2010. Google Scholar 53 A1.2-6.1.4.1 Room noise levels in operating rooms. In: Facilities Guidelines Institute, ed. Guidelines for Design and Construction of Hospitals. Chicago, IL: American Society for Healthcare Engineering; 2018. Google Scholar 54Avidan A, Yacobi G, Weissman C, Levin PD. Cell phone calls in the operating theater and staff distractions: an observational study. J Patient Saf. 2017;. https://doi.org/10.1097/PTS.00000​00000​000351. Google Scholar 55Cohen TN, Shappell SA, Reeves ST, Boquet AJ. Distracted doctoring: the role of personal electronic devices in the operating room. Perioper Care Oper Room Manag. 2018; 10: 10- 13. CrossrefGoogle Scholar 56Anderson CE, Nicksa GA, Stewart L. Distractions during resident handoffs: incidence, sources, and influence on handoff quality and effectiveness. JAMA Surg. 2015; 150(5): 396- 401. CrossrefPubMedWeb of Science®Google Scholar 57Friend TH, Jennings SJ, Copenhaver MS, Levine WC. Implementation of the Vocera Communication System in a quaternary perioperative environment. J Med Syst. 2017; 41(1): 6. 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CrossrefPubMedWeb of Science®Google Scholar 63 Guideline for team communication. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2020: 1039- 1070. Google Scholar ORGANIZATIONAL RESOURCES American Association of Nurse Anesthetists Mobile information technology position statement. https://www.aana.com/docs/defau​lt-sourc​e/pract​ice-aana-com-web-docum​ents-(all)/mobile-infor​mation-techn​ology.pdf?sfvrs​n=61004​9b1_26. Revised February 2015. Accessed January 22, 2020. American College of Physicians Farnan JM, Sulmasey LS, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-627. http://annals.org/artic​le.aspx?artic​leid=16759​27&cm_mid=24314​09&cm_crmid​=%7b388​a30e3-915e-de11-91d2-00156​00f60​10%7d&cm_mediu​m=email​#r35-2111. Accessed October 2, 2019. American College of Surgeons American College of Surgeons Committee on Perioperative Care. Statement on distractions in the operating room. https://www.facs.org/about-acs/state​ments/​89-distr​actions. Published October 1, 2016. Accessed October 2, 2019. American Nurses Association Principles for Social Networking and the Nurse. American Nurses Association. https://www.nursi​ngwor​ld.org/nurses-books/​ebook​—anas-princ​iples-for-social-netwo​rking-and-the-nurse/. Accessed January 27, 2020. American Society of PeriAnesthesia Nurses A position statement on workflow interruptions, technology, social media and perianesthesia practice. https://www.aspan.org/Porta​ls/6/docs/Clini​calPr​actic​e/Posit​ionSt​ateme​nt/Curre​nt/PS9.pdf. Accessed January 25, 2020. Council on Surgical and Perioperative Safety Safe surgery resources #21. Noise and distraction. http://www.cspst​eam.org/21-noise-and-distr​action. Accessed January 25, 2020. Federation of State Medical Boards of the United States Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice. Euless, TX: Federation of State Medical Boards of the United States, Inc; 2018. https://www.polic​ymed.com/2012/06/feder​ation-of-state-medic​al-boards-model-policy-guide​lines-for-social-media.html. Accessed January 27, 2020. National Council of State Boards of Nursing White paper: a nurse's guide to the use of social media. https://www.ncsbn.org/Social_Media.pdf. Published August 2011. Accessed October 2, 2019. Publication History Original approved by the House of Delegates, March 2009 Revision approved by the House of Delegates, April 2014 Revision approved by the membership March 2020 Citing Literature Volume111, Issue6June 2020Pages 675-680 ReferencesRelatedInformation

AORN Position Statement on Environmental Responsibility

AORN JournalVolume 111, Issue 6 p. 667-674 From AORNFree Access AORN Position Statement on Environmental Responsibility First published: 28 May 2020 https://doi.org/10.1002/aorn.13063Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat POSITION STATEMENT AORN believes: All health care professionals have an ethical and professional responsibility to protect patients’ health through advocacy.1-3 Because human health is affected by and is dependent on the surrounding environment, health care professionals must actively work to incorporate best practices that mitigate negative environmental impact.4-6 The interdisciplinary health care community serves as a steward of the environment by seeking knowledge about climate and health effects and assessing health care work environments for opportunities to reduce waste, conserve natural resources, and prevent exposure to hazardous materials. Environmentally responsible practices in perioperative services should align with the framework of the United Nations Sustainable Development Goals (SDGs) #3 Good Health and Well-Being; #6 Clean Water and Sanitation; #7 Affordable and Clean Energy; #9 Industry, Innovation and Infrastructure; #11 Sustainable Cities and Communities; #12 Responsible Consumption and Production; and #13 Climate Action7-9 and be consistent with action to combat climate change and its effects. Education for health care professionals on environmental sustainability should include ○ general knowledge about the climate crisis effects on population health, including10, 11 ▪ air pollution, ▪ exposure to toxins, ▪ heat-related illnesses,10, 11 ▪ extreme weather events,10, 11 ▪ physical and mental health effects of natural disasters,12 ▪ need for reliable access to clean food and water, and ▪ modification of vector-borne, zoonotic, and waterborne diseases13; disaster preparedness10; health system infrastructure resilience14-17; supply chain engagement18; financial, social, and environmental benefits of environmental best practices19; and real-world examples of environmental best practices in health care services. Environmentally responsible decision-making in health care delivery should align with local, state and federal regulations and support patient safety and optimal clinical outcomes. AORN endorses the ANA's Principles of Environmental Health for Nursing Practice with Implementation Strategies4 and the International Council of Nurses Code of Ethics for Nurses,6 which states, “The nurse practices to sustain and protect the natural environment and is aware of its consequences on health.”6(p4) AORN supports environmental responsibility in the perioperative setting and provides guidance for incorporation of environmentally responsible practices, where applicable, in the AORN Guidelines for Perioperative Practice.20-22 ENVIRONMENTALLY RESPONSIBLE PRACTICES Environmentally responsible practices must adhere to local, state, and federal regulations and should align with guidelines and priorities from professional organizations. Environmental best practices can be implemented in perioperative settings through perioperative team education, interdisciplinary collaboration, and advocacy. Conserve natural resources by using life-cycle assessment (LCA) data when evaluating products for purchase and use13, 23, 24; selecting reusable equipment, supplies, and materials when they are equivalent in performance and safety; reprocessing equipment, supplies, and materials; advocating for Leadership in Energy and Environmental Design (LEED) certification,25 Green Globes certification, WELL building certification, or other green building codes during facility construction and renovation; considering telehealth/telemedicine23 for preoperative and preanesthesia visits when no other testing is needed, to reduce unnecessary patient travel; establishing diversified facility energy portfolios that prioritize renewable energy sources23; installing motion-activated fixtures on lighting systems; replacing incandescent light fixtures with energy-efficient light bulbs and lamps; implementing procedures to power down lights, equipment including sterilizers,21 and computers when they are not in use; programming heating, ventilation, and air conditioning systems and evacuation systems to save energy when ORs are unoccupied; and acquiring and retrofitting energy and water-efficient durable medical equipment and supplies (eg, washers, sterilizers, LED light sources). Reduce waste by adopting environmentally preferable purchasing policies and practices; using LCA data when evaluating products for purchase and use13, 23, 24; opening only necessary sterile supplies, medical devices, medications, and implants upon surgeon confirmation; regularly reviewing procedural packs, instrument sets, and preference cards to remove unused items that result in waste26; avoiding supply overages by reducing supply purchases and maintaining an accurate inventory to reduce the number of expired supplies; avoiding supply shortages that require extra or expedited supply shipments; installing closed fluid management systems with reusable canisters that eliminate unnecessary exposure to bloodborne pathogens and chemical solidifiers and reduce regulated medical waste; selecting environmentally preferable reusable products, supplies, instrumentation, materials and equipment that meet environmental criteria over other options when they are equivalent in performance27, 28; reprocessing single-use devices29, 30 according to US Food and Drug Administration (FDA) guidelines31; refurbishing instruments and equipment with proactive maintenance and repairs; donating expired or obsolete, clean, unused materials and equipment to those in need; standardizing appropriate waste receptacle placement and sizing; recycling and exploring revenue potential32 for clean, noninfectious quality material (eg, medical plastics, packaging material, paper); and educating personnel about properly segregating waste (ie, landfill waste, recycling, regulated medical waste). Reduce hazardous material exposure by participating in procurement of supplies, furnishings, and equipment that do not contain ○ mercury, lead, cadmium or heavy metal toxicants; and ○ chemicals of concern,28, 33 such as ▪ di[2-ethylhexyl]phthalate [DEHP] and polyvinylchloride [PVC]), which may be found in some enteral nutrition products and tubes, general urological supplies, gloves, parenteral infusion devices and sets, respiratory therapy products, and vascular catheters; ▪ triclosan/triclocarban, which may be found in some hand soaps and sanitizers; and ▪ flame retardants, per- and poly-fluorinated alkyl substances,34 and volatile organic compounds, which may be found in furnishings and building interiors; selecting surgical instruments and other medical devices that can be sterilized using the least-toxic methods; purchasing and using the least-toxic cleaning agents, sterilization and disinfection processes, and equipment21, 35; implementing surgical smoke evacuation (ie, plume from electrosurgical units, lasers, and powered equipment)36; providing education on the global warming potential (GWP) of anesthetic gases and referring anesthesia professionals to the American Society of Anesthesiologists37, 38 and American Association of Nurse Anesthetists39 recommendations for environmental practices in the perioperative environment; evaluating anesthesia equipment for energy efficiency, fresh gas flow alerts, and sequestration of waste anesthesia gases to prevent their release to outside air; complying with local, state, and federal regulations; manufacturers’ instructions; and health care organization policy when disposing of pharmaceuticals20; using reusable batteries where approved by biomedical engineering personnel and complying with safe disposal or recycling practices for batteries; and ensuring electronic equipment (eg, monitors) and related supplies (eg, printer ink and cartridges) are energy-efficient and managed in an environmentally responsible and regulatory-compliant manner or are recycled at end-of-life. RATIONALE Climate change has been called the “greatest global health threat”40 and addressing climate change the “greatest global health opportunity of the 21st century.”41 The health care sector plays a significant role in the global climate crisis in the following ways: The health care industry's climate footprint represents 4.4% of global net emissions.42 Of health care's global climate footprint, supply chain comprises 71%.42 The US health care sector's climate footprint is equivalent to 9.8% of US net emissions and contributes to ○ acid rain (12%), ○ smog (10%), ○ air pollutants (9%), ○ stratospheric ozone depletion (1%), and ○ carcinogenic and non-carcinogenic air toxins (1%-2%).43 Perioperative practice settings ○ generate up to 70% of a facility's total waste44-46 and ○ consume three to six times more energy per square foot than the rest of the hospital.29 Supply costs can comprise up to 56% of the total OR budget.47 Anesthesia gases comprise more than 51% of the surgical procedure footprint29 and represent 5% of a facility's greenhouse gas emissions.48 The health effects of the US health care industry's greenhouse gas emissions are estimated to be equivalent to 470,000 years of healthy life lost (disability-adjusted life years [DALYs]) from pollution-related disease and malnutrition.43, 49 Many multidisciplinary studies exist regarding the health effects of climate change,17, 29, 49-56 as well as the economic and health co-benefits of mitigation, adaptation, and resilience.32, 54, 57 A survey of physicians in obstetrics and gynecology found that physicians were more likely than the general public (84% versus 54%) to believe that global warming is real, that portrayal in the media of its seriousness is accurate, and that it is generated by human activities.58 Two-thirds of the surveyed physicians believe the amount of surgical waste generated in the operating room is excessive and increasing,58 and the majority (95%) of the physicians supported efforts to reduce waste by opting for the use of reusable surgical tools, instruments, and equipment over disposable items where clinically equivalent.58 However, barriers to environmentally responsible practices exist and include a lack of knowledge of appropriate waste segregation practices,57 lack of leadership buy-in,59 and overall resistance to change.60 It is important, however, to balance environmental impact with patient safety concerns. For example, the FDA recommends that health care organizations use duodenoscopes with disposable components or those that are fully disposable because of documented cleaning and disinfection failures that have resulted in patient harm.61 Research on LCA of materials used in the OR demonstrates that single-use devices; anesthesia gas; and heating, ventilation, and air conditioning24 are the top emission sources in the OR. To reduce the environmental emissions of surgeries, health care providers can adopt a combination of collaborative approaches, including minimizing materials, moving away from anesthetic gases with high GWP, maximizing instrument and equipment reuse, and reducing energy use when operating rooms are unoccupied.30 One study found cost feedback to physicians, combined with a small departmental financial incentive, was associated with significantly reduced surgical supply costs without negatively affecting patient outcomes.19 In addition to supporting public health and well-being, adopting best environmental practices also can deliver triple bottom line returns,62 which reduce costs,18 optimize operational efficiency, and enhance patient and worker safety.35 The health care industry, whose mission is to protect and promote health, contributes to the climate crisis—the greatest health threat of the 21st century.41 Perioperative services contribute significantly to the health care climate footprint. Nurses, the largest group of health care professionals63 and the most trusted of health care professionals,64 have an opportunity to fulfill their ethical responsibility and help lead the way toward a healthier future for all. Glossary Chemicals of concern: Chemicals that are designated by the US Environmental Protection Agency (EPA) as persistent, bioaccumulative, toxic, and that are known or suspected human carcinogens. These are listed in the US EPA Toxics Release Inventory. Environmental criteria: A set of preferred attributes, characteristics, credentials, and certifications used during the procurement process to evaluate environmental and health effects and benefits of purchased goods and services. Environmentally preferable purchasing: Buying products or services that have a reduced negative effect on human health and the environment when compared to competing products or services that serve the same purpose. Global warming potential (GWP): A measure of heat-trapping gases in the atmosphere up to a specific time horizon (typically 20, 100, or 500 years) relative to carbon dioxide. Green building codes: Codes used to design buildings to be energy efficient and water conserving, have low environmental impact, and have high indoor air quality, among other requirements. Infectious waste: Broadly defined, this is waste that is capable of spreading infectious disease (eg, blood, body fluids, sharps and other potentially infectious materials). The definition may vary by state. LEED: An acronym for Leadership in Energy and Environmental Design, which was established in 1998 by the US Green Building Council. LEED status: A standardized rating system through which organizations can earn LEED credits and certifications to validate the design, construction, and operation of green buildings. Sustainability: Business operations that meet the needs of the present without compromising the ability of future generations to meet their own needs. Sustainable procurement: Supply management practices that include purchase and selection of environmentally friendly products, equipment, and devices. Terminology may vary by region. Synonyms: preferable purchasing, environmentally preferable purchasing. Triple bottom line: An accounting framework whereby companies commit to focus on social and environmental measures in addition to financial measures. The conceptual framework is comprised of three bottom lines: people, planet, profit. Waste stream: The flow of discarded materials and fluids that eventually return to the land, water system, or air through sewer, landfill, or incineration. Zoonotic: Infectious diseases that are spread between animals and people. REFERENCES 1 Nursing: Scope and Standards of Practice. 3rd ed. Silver Spring, MD: American Nurses Association; 2015. 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Operating room greening initiatives—the old, the new, and the way forward: a narrative review. Waste Manag Res. 2019; 37(1): 3- 19. CrossrefPubMedWeb of Science®Google Scholar 60Chiarini A, Vagnoni E. Environmental sustainability in European public healthcare. Leadersh Health Serv (Bradf Engl). 2016; 29(1): 2- 8. CrossrefPubMedGoogle Scholar 61 The FDA is recommending transition to duodenoscopes with innovative designs to enhance safety: FDA Safety Communication. US Food and Drug Administration. https://www.fda.gov/medic​al-devic​es/safety-commu​nicat​ions/fda-recom​mendi​ng-trans​ition-duode​nosco​pes-innov​ative-desig​ns-enhan​ce-safety-fda-safety-commu​nication. Current as of January 17, 2020. Accessed February 13, 2020. Google Scholar 62Turkay M, Saracoglu O, Arslan MC. Sustainability in supply chain management: aggregate planning from sustainability perspective. Plos One. 2016; 11(1):e0147502. https://doi.org/10.1371/journ​al.pone.0147502. CrossrefPubMedWeb of Science®Google Scholar 63 Occupational employment and wages [news release]. Bureau of Labor Statistics. https://www.bls.gov/news.relea​se/ocwage.htm. Published March 29, 2019. Updated 2019. Accessed October 8, 2019. Google Scholar 64 Honesty/ethics in professions. Gallup News. https://news.gallup.com/poll/1654/Hones​ty-Ethics-Profe​ssions.aspx. Published December 2018. Accessed October 8, 2019. Google Scholar RESOURCES Axelrod D, Bell C, Feldman J, et al; Task Force on Environmental Sustainability Committee on Equipment and Facilities. Greening the Operating Room and Perioperative Arena: Environmental Sustainability for Anesthesia Practice. American Society of Anesthesiologists. https://www.asahq.org/about-asa/gover​nance-and-commi​ttees/​asa-commi​ttees/​commi​ttee-on-equip​ment-and-facil​ities/​envir​onmen​tal-susta​inabi​lity/green​ing-the-opera​ting-room. Accessed February 13, 2020. The Business Case for Greening the OR: Why Focus on the Operating Room? Reston, VA: Practice Greenhealth; 2011. https://pract​icegr​eenhe​alth.org/sites/​defau​lt/files/​upload-files/​casef​orgor_r5_web_0.pdf. Accessed February 13, 2020. CHANT: Climate Health and Nursing Tool. Alliance of Nurses for Healthy Environments. https://envirn.org/nurses-clima​te-surve​y/. Accessed February 13, 2020. Environmentally preferable products. US General Services Administration. https://www.gsa.gov/gov​er​nment​wide-initi​ative​s/susta​inabi​lity/buy-green-produ​cts-servi​ces-and-vehic​les/buy-green-produ​cts/envir​onmen​tally-prefe​rred-products. Accessed February 13, 2020. First Do No Harm: Assessing & Selecting High-Quality Medical Surplus Recovery Organizations. Washington DC: Catholic Health Association of the United States; 2012. Fox M. Climate change: what does it mean for the future of surgery? American College of Surgeons. https://bulle​tin.facs.org/2019/09/clima​te-change-what-does-it-mean-for-the-future-of-surge​ry/#print​preview. Published September 2019. Accessed February 13, 2020. Green certifications and label claims. Practice Greenhealth. https://pract​icegr​eenhe​alth.org/tools-and-resou​rces/green-certi​ficat​ions-and-label-claims. Accessed February 13, 2020. Health Care Plastics Recycling Council. https://www.hprc.org/. Accessed February 13, 2020. Healthcare Environmental Resource Center: http://www.herce​nter.org. Accessed February 13, 2020. Join our Physician Network. Health Care Without Harm. https://noharm-uscan​ada.org/conte​nt/us-canad​a/join-our-physi​cian-network. Accessed February 13, 2020. The Medical Society Consortium on Climate & Health. https://medso​cieti​esfor​clima​tehea​lth.org/. Accessed February 13, 2020. Mercury in medical equipment. Local Hazardous Waste Management Program in King County, Washington. https://www.hazwa​stehe​lp.org/mer​cu​ry/mercu​ry-medic​al.aspx. Accessed February 13, 2020. Nurses Climate Challenge. https://nurse​sclim​atech​allen​ge.org/. Accessed February 13, 2020. Safer chemicals. Health Care Without Harm. https://noharm-uscan​ada.org/safer​chemi​cals. Accessed February 13, 2020. Sustainability solutions for health care. Practice Greenhealth. https://pract​icegr​eenhe​alth.org/. Accessed February 13, 2020. Sustainable marketplace: greener products and services. Environmental Protection Agency. https://www.epa.gov/green​erpro​ducts/​ident​ify-green​er-produ​cts-and-services. Accessed February 13, 2020. Toxics Release Inventory (TRI) Program: persistent bioaccumulative toxic (PBT) chemicals covered by the TRI Program. Environmental Protection Agency. https://www.epa.gov/toxics-relea​se-inven​tory-tri-progr​am/persi​stent-bioac​cumul​ative-toxic-pbt-chemi​cals-cover​ed-tri. Accessed February 13, 2020. U.S. call to action on climate, health, and equity: a policy action agenda. https://clima​tehea​lthac​tion.org/media/​cta_docs/US_Call_to_Action.pdf. Accessed February 13, 2020. U.S. Climate Resilience Toolkit. https://toolk​it.clima​te.gov/#steps. Accessed February 13, 2020. Water-efficient technology opportunity: steam sterilizer condensate retrofit kit. Office of Energy Efficiency and Renewable Energy. https://www.energy.gov/eere/femp/water-effic​ient-techn​ology-​oppor​tunity-steam-steri​lizer-conde​nsate-retro​fit-kit-retro​fit-kit. Accessed February 13, 2020. Editor's note: AORN has taken a stance on environmental issues for more than 20 years. The format of the documents has changed since the original position statement was approved by the Board of Directors in September 1990. In October of 1993, the position statement was revised into a recommended practices document. In March of 2006, the content from the recommended practices document was revised into a guidance statement as well as a position statement. In 2012, the content from the guidance statement was revised and consolidated into the position statement and added to online content at http://www.aorn.org. PUBLICATION HISTORY Original approved by the House of Delegates, March 2006 Reaffirmed by the Board of Directors, December 2009 Revision approved by the House of Delegates, April 2014 Revision approved by the membership March 2020 Citing Literature Volume111, Issue6June 2020Pages 667-674 ReferencesRelatedInformation

Perioperative Pain Management Strategies in the Age of an Opioid Epidemic

According to the US Department of Health and Human Services 2016 and 2017 data, an estimated 130 people per day died from opioid-related drug overdoses; 42,249 people died from overdosing on opioids; and 2.1 million people had opioid-use disorder. Health care organizations such as the American Association of Nurse Anesthetists, the Association of periOperative Registered Nurses, the American Society of PeriAnesthesia Nurses, the American Society of Anesthesiologists, the American College of Surgeons, and the American Medical Association have information related to pain management and/or the opioid epidemic on their Web sites. It is imperative for health care providers to be cognizant of, and use low-dose opioid/opioid-free pain management therapies. This article reviews the pain process and outlines low-dose opioid/opioid-free pain management modalities.

PROLONGED LYSERGIC ACID DIETHYLMIDE INDUCED SEROTONIN SYNDROME

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Serotonin syndrome (SS) is a life threatening condition which may often be difficult to diagnose. The increasing incidence of SS is attributable to the wide use of selective serotonin reuptake inhibitors, opioids, and recreational drugs like Lysergic Acid Diethlymide (LSD) which act primarily through 5-HT2 serotonin receptors1. Severe cases often require aggressive intervention in the Intensive Care Unit (ICU) to manage hyperthermia, ventilation, seizures, delirium, rhabdomyolysis, and autonomic instability; however, frequently used analgesics in the ICU such as Fentanyl also contribute to increasing serotonergic levels, thereby, prolonging SS2. CASE PRESENTATION: A 28 year old male visiting from Europe with an unknown medical history was brought in to the hospital after sudden onset of diaphoresis, agitation, and confusion at a restaurant. He presented in status epilepticus with combative behavior leading to intubation, sedation, and paralysis. Seizure control required multiple agents. Initial objective data revealed no electrolyte or metabolic abnormalities, and negative toxicology. Imaging of the brain and infectious workup was unremarkable. Within hours, the patient became hyperthermic and hypertensive; pertinent exam findings included clonus and hyperreflexia. Based on these findings, SS versus sympathomimetic toxicity were the highest on our differential diagnosis. Treatment with cyproheptadine was initiated. The hospital course was prolonged and complicated by aspiration pneumonia, multiple deep vein thrombosis, and prolonged delirium. Higher amounts of Fentanyl and Propofol were required to maintain adequate sedation. The patient remained hypertensive, febrile, with signs of hyperreflexia, and clonus for seven days. Fentanyl was discontinued due to potential serotonergic additive effects. Rapid clinical signs of improvement were observed. It was ultimately discovered that the patient was using lysergic acid diethylamide (LSD). DISCUSSION: LSD is a widely used hallucinogen and a recognized cause of SS³. In the ICU, patients can be exposed to multiple serotonergic agents including opiates and antiemetics, thus, it is imperative clinicians are aware of which agents precipitate and prolong the course of SS. Moreover, each individual’s risk for developing and recovering from SS is dependent on several factors including age, liver, renal function, and genetic polymorphisms in the cytochrome P450 pathway. A thorough review of medications in the ICU may prevent further complications and result in a faster and favorable prognosis. CONCLUSIONS: Our case demonstrates a unique presentation of SS with a favorable outcome due to early suspicion of the diagnosis, recognition of serotonergic agents, and aggressive intervention. Reference #1: Wacker, D. (2017). Crystal Structure of an LSD-Bound Human Serotonin Receptor. Cell, 168(3), pp.377-389.e12. Reference #2: Greenier, E. (2014). Serotonin syndrome: fentanyl and selective serotonin reuptake inhibitor interactions. American Association of Nurse Anesthetists, 82(5), pp.340-5. Reference #3: Halberstadt, A. (2017). Hallucinogenic Drugs: A New Study Answers Old Questions about LSD. Current Biology, 27(4), pp.R156-R158. DISCLOSURES: No relevant relationships by Sujith Puskoor, source=Web Response No relevant relationships by Rebecca Saunders, source=Web Response No relevant relationships by Anita Singh, source=Web Response

Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness.

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

ANESTEZIOLOGINĖ DARBO ZONA OPERACINĖJE – INFEKCIJŲ PREVENCIJOS REKOMENDACIJOS

2019 m. Amerikos sveikatos priežiūros epidemiologijos draugija (SHEA) kartu su Amerikos anesteziologų draugija (ASA), Anestezijos ligonių saugos fondu (APSF) ir Amerikos slaugytojų anesteziologų asociacija (AANA) publikavo infekcijų prevencijos operacinėje rekomendacijas anesteziologinėje darbo zonoje. Siekiant palaikyti optimalią infekcijų kontrolę svarbu gerinti rankų higieną: rekomenduoti minimalūs rankų higienos reikalavimai, antiseptiko dozatorių lokalizacijos, pirštinių mūvėjimas intubacijos metu. Taip pat išskirti pagrindiniai aplinkos dezinfekcijos reikalavimai, tokie kaip laringoskopų, anestezijos aparatų, vežimėlio priežiūra tarp operacijų, sterilumo priemonių laikymasis centrinės venos kateterizacijos metu ir kiti. Infekcijų prevencijos gerinimui rekomenduojama nuolat tobulinti higienos planus bei suteikti galimybę praktikams naudotis standartais.

Developing the Continued Professional Certification Program for Nurse Anesthetists

Recertification assures the public that a certificant remains competent throughout his or her career and has knowledge and skills beyond those needed at entry into the profession. Health professions address the concept of recertification using many different approaches. In 2008, the National Board of Certification and Recertification for Nurse Anesthetists, or NBCRNA, initiated a recertification redesign, and, in 2016, it launched the continued professional certification program. The initiative included a benchmarking study of the recertification programs of other health and medical professionals and an analysis of the literature to identify credentialing best practices and trends. Surveys and other communications in coordination with the American Association of Nurse Anesthetists solicited input of nurse anesthetists. This article reviews the key findings, trends, and influences for the continued professional certification program and the process the NBCRNA used to create and implement a recertification redesign to support lifelong learning and the expanding role of nurse anesthetists.

The Evolution of a Peer Assistance Network for Nurse Anesthetists' Substance Use Disorder.

The American Association of Nurse Anesthetists has a long history of providing peer support for its members with substance use disorder (SUD). The American Association of Nurse Anesthetists' Peer Assistance Advisors Committee (PAAC) is a group of certified registered nurse anesthetist volunteers who strive to promote the awareness of SUD through education and research and provide support to certified registered nurse anesthetists and students with this disease. During the committee's 33-year history, educational outreach to nurse anesthesia educational programs and anesthesia workplaces has expanded, the peer support network has been strengthened, resources and guidelines have been developed, and research related to SUD has been conducted in an effort to accomplish these goals. Although faced with challenges along the way, the PAAC's dedication and commitment to the association and members have helped overcome these challenges as well as strengthen the program. Through its generous catalog of online resources, peer support network, and helpline, the PAAC continues to provide help to those in need.

The First Men in Leadership Positions in the American Association of Nurse Anesthetists

This exploratory study focuses on the American Association of Nurse Anesthetists. It sheds light on the process by which men gain access to leadership positions in a female-dominated setting. It also expands the narrative of the professional association's history. As soon as men became eligible for membership in 1947, they gained access to leadership positions in disproportionate numbers and at a faster pace than women at the national level and in a number of states. The specific pattern of findings is consistent with volitional relational practices, suggesting that women facilitated the integration and empowerment of male colleagues who constituted a small minority in the association. The paper discusses the need to understand and manage the interactions between relational practices that are gendered female and views of leadership as male-gendered.

A New Day Dawns For Workforce Redesign

From the Editor-In-Chief Health AffairsVol. 32, No. 11: Redesigning The Health Care Workforce A New Day Dawns For Workforce RedesignJohn K. IglehartPUBLISHED:November 2013Free Accesshttps://doi.org/10.1377/hlthaff.2013.1211AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSNursesPhysician shortagesMedical educationNurse shortagesGraduate medical education paymentPrimary carePhysiciansHealth professionalsAffordable Care ActHealth professions educationThe composition of America’s health care workforce is formed by an array of players who negotiate their interests through a mix of training, government actions, and market forces. Although many countries use workforce planning models sanctioned by their governments to estimate demand and supply, US exceptionalism considers such centralization as anathema. This uncoordinated American approach has been challenged by a handful of academics and an occasional policy maker, but it has never been seriously threatened with major change.With the enactment of the Affordable Care Act (ACA), which extends coverage to millions of uninsured people, and growing demands for closer linkages between health professions education and the delivery of care, a new day has arrived on the workforce landscape, and it spells health care teams. Among the subjects featured in this thematic issue are proposed solutions that focus on strengthening the primary care workforce; reforming medical education; expanding the scopes of practice of nurses with advanced training; bolstering the capacity of mental health caregivers; and devoting more resources to research that tracks future patient care needs, thus influencing the composition of the workforce. Calls for change emanate not only from government, policy analysts, and researchers but also from provider interests, which typically favor the status quo.The overview by Thomas Ricketts and Erin Fraher is a tour de force focused on contemporary health workforce issues. The authors assert that the rapid diffusion of accountable care organizations and patient-centered medical homes will greatly alter the current mix of providers as these entities assume greater financial risk for their performance and respond to new payment incentives. They write that these “revolutionary changes” are reverberating backward into medical and allied health education programs as health professions education becomes more closely linked to real-time care delivery.Primary Care ShortageWithin the workforce dialogue, no subject attracts greater attention than the shortage of primary care providers. Many authors favor solutions other than expanding the number of physicians, although Atul Grover and Lidia Niecko-Najjum assert that even if more advanced-practice nurses and physician assistants are trained, the United States needs to add 4,000 more physicians a year to expand capacity. But Thomas Bodenheimer and Mark Smith write that the “crisis” is a demand-capacity mismatch, not a physician shortage. They and others call for other professionals to fill the gap.In their simulation, David Auerbach and coauthors conclude that broader adoption of patient-centered medical homes and nurse-managed health centers could relieve the shortage of primary care physicians. Scott Shipman and Christine Sinsky write that the shortage could be alleviated by reducing wasted motion in a physician’s day and delegating nonclinical tasks to others, such as medical assistants.Medicare’s RoleFor decades the federal government has been the major supporter of graduate medical education (GME) through Medicare, funneling $10.1 billion in 2010 to teaching hospitals where some 89,000 residents are in training. Academic medicine has fought off repeated attempts to cut this support, but ongoing efforts to reduce the government’s budget deficit could threaten GME funding anew and also call for better measures designed to determine how these programs are investing public funds to serve societal needs.Stephen Shannon and coauthors summarize major changes called for by the Blue Ribbon Commission for the Advancement of Osteopathic Medical Education. Also, in a development not reported in this issue, the American Medical Association has called for the “transformation of [undergraduate] medical education.” A broad examination of GME financing and governance is moving toward completion by an Institute of Medicine committee.Authors David Goodman and Russell Robertson (a medical school dean) propose a new system of distribution of federal GME based on “a system of public guidance and competitive funding that shares some similarities with…the process used by the National Institutes of Health for peer-reviewed research awards.” The approach bears some similarity to a recommendation put forward in 2010 by the Medicare Payment Advisory Commission.Acknowledgment Of Support Publication of this issue of Health Affairs derived support from a dozen private organizations with strong interests in the health care workforce, and we are indebted to all of them. They are the Robert Wood Johnson Foundation, Josiah Macy Jr. Foundation, Association of American Medical Colleges, American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Nurse Anesthetists, American Nurses Association, American Nurse Credentialing Center, American Organization of Nurse Executives, American Osteopathic Association, and American Association of Colleges of Pharmacy. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 7 History Published online 1 November 2013 Information Project HOPE—The People-to-People Health Foundation, Inc. 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Multisociety sedation curriculum for gastrointestinal endoscopy

Introduction—VargoSedation Pharmacology—DeLeggeInformed Consent for Endoscopic Sedation—FeldPeriprocedure Assessment for Endoscopic Procedures—KwoLevels of Sedation—LightdaleTraining in the Administration of Specific Agents for Moderate Sedation—GerstenbergerTraining in Airway/Rescue Techniques and Management of Complications—RexAnesthesiologist Assistance for Endoscopic Procedures—VargoIntraprocedure Monitoring—NuccioPostprocedure Assessment Training—VargoEndoscopy in Pregnant and Lactating Women—VargoAssessment of Competency in Endoscopic Sedation—SchillerBibliographyAppendix: Primer in Sedation Pharmacology—DeLegge The Multisociety Sedation Curriculum for Gastrointestinal Endoscopy (MSCGE) grew out of the need for a complete and programmatic approach to the training of procedure sedation. As a natural outgrowth of the Gastroenterology Core Curriculum, the sponsoring societies thought that a comprehensive document covering the aspects of procedure sedation from pharmacology, periprocedure assessment, airway management, and the use of anesthesia services was necessary for a variety of reasons. Chief among these was to ensure a standardized basis for instruction through the use of competency-based training. This constitutes a living document that represents the sponsoring societies' vision of best practices in procedure sedation training based on published data and expert consensus. It provides a framework for developing an individual plan of study and growth that should be tailored to meet the needs of each individual trainee based on the strengths and special qualities of each individual training program. Additionally, the curriculum can serve the practicing gastroenterologist in the updating of both knowledge and skills. The curriculum will continue to evolve with time as new knowledge, methods of learning, novel techniques and technologies, and challenges arise. This edition has been divided into an overview of training and 11 sections encompassing the breadth of knowledge and skills required for the practice of procedural sedation for GI endoscopy. This MSCGE represents a joint collaborative effort among the national gastroenterology societies—the American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association Institute, and the American Society for Gastrointestinal Endoscopy. In addition, the Society for Gastroenterology Nurses and Associates played a crucial role in the development of the MSCGE. Other professional non-GI societies and regulatory organizations were invited to take part in the development of the MSCGE. This included the American Association of Nurse Anesthetists, the American Society of Anesthesiologists (ASA), and the Centers for Medicare and Medicaid Services (CMS). The American Association of Nurse Anesthetists did not respond to inquiries, CMS decided not to participate, and the ASA appointed a nonvoting observer who participated in the developmental process. The executive committees of each of the sponsoring societies, as well as several subject matter experts, made specific recommendations for revising the core curriculum. Each society then named representatives who were charged with overall responsibility for developing, communicating, and distributing the curriculum. Throughout this document, the paramount importance of practice and research based on the highest principles of ethics, humanism, and professionalism is reinforced. Endoscopic sedation strives to seek a balance between patient comfort and drug-related side effects. Optimal sedation allows the patient the greatest degree of comfort while preserving the greatest degree of safety. To achieve this, the endoscopist must fully understand the sedation that he or she is are using. This also requires careful consideration of the patient, the endoscopy facility, and the variables of the procedure itself. Patient factors include age, weight, medical history, concurrent medications, intubation assessment, preprocedure anxiety, and pain tolerance. Procedure variables include the amount of anticipated discomfort, the duration of examination, and how invasive the procedure will be. The drugs most widely used for endoscopic sedation were the benzodiazepines and opioids. Recently, there has been growing interest in the use of other agents with unique pharmacologic properties designed to enhance sedation and analgesia. The endoscopist should be familiar with the sedation agents used including the drug's pharmacokinetic parameters (time of onset, peak response, and duration of effect), pharmacodynamic profile (individual variations in clinical response to a drug), elimination profile, potential adverse effects, and drug-drug interactions. Trainees should gain an understanding of the following: 1The pharmacokinetics and pharmacodynamics of different sedation agents, their synergy and potential interactions with other medications and potential adverse reactions.2Mastery of the titration of these agents for the desired level of sedation. For the vast majority of endoscopic cases, this should be moderate sedation. 1Trainees should develop a thorough knowledge of the pharmacokinetics and pharmacodynamics of sedation agents before embarking on endoscopic training.2Trainees should develop expertise in the administration of sedation medications under direct supervision in the endoscopy suite. If a high-fidelity sedation simulator is available, this should be used before training in the endoscopy suite. A brief primer in sedation pharmacology is provided in Appendix A. Knowledge of sedation pharmacology should be assessed as part of the overall evaluation of trainees in gastroenterology during the fellowship. Questions relating to sedation pharmacology should be included on the board examination and should reflect a general knowledge of this content. The ethical and legal requirement to obtain informed consent before performing endoscopy derives from the concept of personal (patient) autonomy. The competent patient, after receiving appropriate disclosure of the material risks of the procedure and understanding those risks and the benefits and alternative approaches, makes a voluntary and uncoerced informed decision to proceed. The process of obtaining informed consent is both a basic ethical obligation and also a legal requirement for physicians. It allows the patient to gain an understanding of the proposed treatment and the risks involved, as well as learn about alternatives or voice any concerns or questions. The physician has the opportunity to ask about the patient's treatment goals and discover any patient-specific information that will enable the most optimal choice of treatment. When an informed patient agrees to proceed with a course of treatment, this allows substantial transfer of the risk of adverse outcome to the patient who understands and accepts the imperfect nature of the procedure and therapy. Most state laws specify that obtaining informed consent is a nondelegatable duty, ie, it must be performed by the physician and cannot be relegated to one's staff or endoscopy nurse. However, consent is a process, and if sufficient and thorough information is provided, the final portion, in which the physician finalizes consent before the procedure and asks the patient whether there are any other questions remaining, may be very brief. This is most important for the success of an open-access process, so that open-access patients have already received information and have been given the opportunity to ask questions to satisfaction before preparation for the procedure. Language issues need to be addressed by using an interpreter. If the patient is unable to give consent, an appropriate legal representative should be sought. A risk management recommendation particularly relevant for informed consent for open access is to have an intake/preparation process for open access in which the patient is sent or verbally given information about the procedure, including the purpose, description of the procedure, and risks, benefits, and alternatives. It would be useful to instruct the patient to call in if any concerns or questions occur after having read the information and document this instruction. Further, one could instruct the office staff to be alert to patients who appear uncertain, seem to have many questions, or very worried about proceeding; these patients may be best served with a preprocedure consultation. At the time of the open access, the physician can meet state law obligation by briefly summarizing the information. The nature of moderate sedation is such that a patient may perceive, but may not be aware of the context and surroundings to sufficiently understand the implications of a demand to stop the procedure. The discomfort is likely to be short-lived and the procedure safe and successful, and often the patient has no recall of difficulty or any request to stop the procedure. Additional medication or additional techniques may allow more comfortable completion of the procedure. Indeed, the patient may wish the discomfort to stop, not the procedure! However, the endoscopist and staff must be aware that consent can be withdrawn. The author surmises, based on conversations with experienced endoscopists, that most requests to stop are not truly withdrawal of consent, but an artifact of sedation causing misperception of the context of procedure activity. However, the prudent endoscopist will carefully evaluate a request to stop, assessing, for example, whether the patient is speaking in full coherent sentences or mumbling incomprehensibly, to be as certain as possible that it is not a true withdrawal of consent. During training, the trainee should gain an understanding of the following: IThe principles of informed consent ACapacity to give consentBMaterial risks of endoscopic sedationCShared decision making 1Discussion of sedation alternatives, from no sedation to anesthesiologist-provided general deep sedation.DExemptions for the consent requirement 1Emergency exception/waiverEWithdrawal of consentFRegulatory and institutional requirements to obtain and document consentIIUnderstand that informed consent includes endoscopic sedation as well as endoscopic procedures, ie, it applies to the sedation portion of the global procedure experienceIIIUnderstand the special situations and considerations, such as the applications of informed consent in an open-access settingIVUnderstand shared decision-making conceptsVUnderstand the concept of withdrawal of consent AAn ineffectively sedated patient has the right to demand that the procedure be stopped, even though partially sedated.BBe aware of risk factors for ineffective sedation, which may prompt withdrawal of consent in a patient expecting significant sedation. These include chronic narcotic and/or anxiolytic use with patients in whom anxiolytic/narcotic sedation is planned and medical conditions that may preclude effective sedation, such as chronic obstructive pulmonary disease, cor pulmonale, advanced cardiomyopathy, and severe obstructive sleep apnea.VIGive the patient the opportunity to ask questions. A short training process will likely be sufficient because most trainees will already have a basic understanding of informed consent. Targeted review and training for endoscopic sedation may include reading materials and/or lecture(s) and/or direct observation of faculty with discussion by faculty. Adequacy of learning may be assessed by written examination and/or oral discussion with faculty and/or observation by faculty. Periprocedure assessment is a crucial component of the practice of endoscopic sedation. Preprocedure assessment should encompass a thorough review of the patient's sedation history, the identification of medical conditions that may increase the risk of procedure sedation, and balance these findings with the type of procedure scheduled and the targeted level of sedation. Intraprocedure assessment encompasses the maintenance of stable and safe cardiovascular parameters and level of sedation. The postprocedure assessment focuses on ensuring the recovery of baseline physiologic parameters and the identification of any complications. The trainees should be competent in the periprocedure assessment of the patients undergoing sedation for all GI endoscopic procedures. During fellowship, trainees should obtain a comprehensive understanding of the following during the preprocedure evaluation of patients undergoing endoscopic procedures with sedation: 1Confirm the patient's suitability to undergo the planned procedure at the targeted sedation level (Table 1).TABLE 1ASA physical status classificationPS 1Normal healthy patientNo organic, physiologic, or psychiatric disturbance; excludes the very young and very old; healthy with good exercise tolerancePS 2Patients with mild systemic diseaseNo functional limitations; has a well-controlled disease of 1 body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without COPD; mild obesity, pregnancyPS 3Patients with severe systemic diseaseSome functional limitation; has a controlled disease of >1 body system or 1 major system; no immediate danger of death; controlled CHF, stable angina, previous heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent symptomsPS 4Patients with severe systemic disease that is a constant threat to lifeHas at least 1 severe disease that is poorly controlled or at end stage; possible risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failurePS 5Moribund patients who are not expected to survive without the operationNot expected to survive >24 h without surgery; imminent risk of death; multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathyPS 6A declared brain-dead patient who organs are being removed for donor purposesASA, American Society of Anesthesiologists; PS, physical status; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure. Open table in a new tab 2The trainee will obtain a directed history that addresses the potential influence on the procedure and the anticipated level of sedation with particular attention to the following: aCardiopulmonary disease (ischemic heart disease, congestive heart failure, asthma, chronic obstructive pulmonary disease). Assessment for obstructive sleep apnea, stridor, neurologic, or seizure disorders. Previous experience with procedural sedation should also be queried.bA complete list of medications, including over-the-counter agents, and allergies should be recorded.cThe patient should be assessed according to the ASA physical status classification scale (Table 1).3Trainees will gain knowledge about the role of moderate sedation in ASA classes 1 through 3.4Trainees must ascertain the duration of fasting before a procedure, ie, 2 hours after clear liquid intake and 6 hours after a light meal before sedation to allow administration of moderate sedation or anesthesiologist-directed sedation. These intervals should be lengthened in the setting of gastric-emptying abnormalities.5The trainee will perform a targeted physical examination, including vital signs with heart rate, blood pressure, and baseline oxygen saturation. The patient should have a cardiopulmonary assessment to screen for stridor, wheezing, heart murmurs or arrhythmias, as well as an abdominal examination for surgical scars and masses. A limited neurologic examination should assess presedation mental status orientation to assess for obvious focal deficits. Finally, a detailed evaluation of the airway, including body habitus, neck structure, cervical spine, hyoid mental distance, and oropharynx, should be performed.6Trainees should gain knowledge about periprocedure endoscopic sedation in special circumstances, such as pregnancy. Trainees should clearly document the patient's preanesthesia assessment history, physical examination, and informed consent. Before administration of anesthesia, a time out should be performed according to the Joint Commission's Universal Protocol and should include, at a minimum, the procedure team's agreement as to the patient's identity and the type of procedure to be performed. ASA, American Society of Anesthesiologists; PS, physical status; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure. Procedure assessment for endoscopic procedures should be assessed as part of the overall evaluation of trainees in gastroenterology during fellowship. Questions relating to procedure assessment should be included on the board examination and should reflect a general knowledge of this content. In recent years, the Joint Commission has identified the following 4 levels of sedation, which stretch along a continuum without clear boundaries: minimal sedation or anxiolysis, moderate sedation, deep sedation, and general anesthesia. To date, these levels of sedation have been defined by a patient's response to verbal, light tactile, or painful stimuli, although they are generally also associated with physiologic changes in patient vital signs. Viewed from the perspective of a continuum of sedation, targeting minimal levels of sedation by definition creates the potential for patients to become deeply sedated. Accordingly, it has been recommended that all providers be prepared to rescue patients from deeper levels of sedation than targeted. It should be noted that there are no physiologic data to support these definitions. Most cardiopulmonary events during GI endoscopy stem from hypoventilation cascading into hypoxia and cardiac decompensation. As a basic component of monitoring, pulse oximetry has become a standard of care in endoscopy units around the world. Yet, pulse oximetry may not adequately reflect hypoventilation, apnea, impending hemodynamic instability, or vasoconstrictive shock. In particular, patients may be well saturated with oxygen and still experience significant carbon dioxide retention. Technological advances in the past decade have enabled the practical measurement of real-time end-tidal carbon dioxide and ventilatory waveforms in nonintubated patients. In this way, capnography has emerged as a noninvasive way of measuring patient ventilation that may be especially useful in patients undergoing deeper levels of sedation. Consensus also dictates that levels of sedation are directly related to patient risks. Minimal sedation implies the retention of a patient's ability to respond voluntarily to vocal commands (eg, “take a deep breath” or “turn on your back”) and to maintain a patent airway with protective reflexes. Moderate sedation describes a depth of sedation at which patients are able to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function, protective airway reflexes, and the ability to react to verbal or tactile stimulation. Deep sedation implies a medically controlled state of depressed consciousness from which the patient is not easily aroused, but can respond purposefully to painful stimulation. General anesthesia describes the deepest level of sedation wherein the patient is unarousable with painful stimuli. Generally speaking, depth of sedation is directly related to cardiovascular and airway instability; the deeper the level of sedation, the more a patient is considered to be at risk of cardiopulmonary events (Table 2). Monitored anesthesia care may include varying levels of sedation, analgesia, and anxiolysis as necessary.TABLE 2Ramsay sedation scaleResponse to verbal stimulationNumerical scoreAgitated6Responds readily to name spoken in normal tone5Lethargic response to name spoken in normal tone4Responds only after name called loudly and/or repeatedly3Responds only after mild prodding or shaking2Does not respond after mild prodding or shaking1Does not respond to test stimulus0 Open table in a new tab Trainees in endoscopic sedation should gain an understanding of the following: 1The concept of sedation depth as a continuum2Definitions (stimulus and effect) of the 4 codified levels of sedation and expected physiologic changes in vital signs for each3Clinical training in targeting appropriate levels of sedation for patients and/or procedures4Patient and/or procedure factors that may affect the depth of sedation targeted and/or achieved5Clinical training in assessing levels of sedation continuously throughout a procedure6The difference between oxygenation and ventilation, as well how these physiologic processes are reflected by various patient monitors7Indications for advanced clinical monitoring during endoscopic procedures, including capnography Training should take place within the framework of clinical care and problem solving. Successful programs require skilled and experienced endoscopic instructors who continually maintain and improve the instructional talents required to teach endoscopy and the periprocedure assessment that is crucial to the performance of such procedures. A structured training experience coupled with ongoing evaluation of trainees' progress should be used. Knowledge of periprocedure assessment should be assessed as part of the overall evaluation of trainees in gastroenterology during the Fellowship program. Questions relating to periprocedure assessment should be included in the board examination and should reflect a general knowledge of this content. The safe and effective administration of pharmacologic agents to induce and maintain a state of moderate sedation is a core skill essential to the performance of GI endoscopic procedures. All trainees should receive comprehensive instruction in the selection and administration of agents used for moderate sedation. Although moderate sedation for endoscopic procedures is most often achieved through the intravenous bolus delivery of opioids and benzodiazepines, trainees should understand that moderate sedation may also be induced and maintained with combination regimens using propofol. Although propofol used in combination with other agents is a valuable option for moderate sedation, deep sedation generally results when it is administered as a single agent for endoscopic sedation. Trainees should recognize that deep sedation may also result from conventional sedation techniques using only opioids and benzodiazepines even when moderate sedation is targeted. As the use of propofol has rapidly expanded across the spectrum of endoscopic sedation and anesthesia, the specific manner in which it is used, including bolus or continuous-infusion dosing schemes, whether it is used in combination with adjunctive sedating and analgesic agents, and the type of health care provider (registered nurse, nurse anesthetist, physician endoscopist, anesthesiologist, nonanesthesiologist physician) who administers or supervises its use has varied widely in the United States and around the world. This variation is attributable to differing institutional history and professional culture, legal and regulatory requirements, issues of training and credentialing, and economic factors. Endoscopists who do not personally administer propofol or direct its use must still be prepared to make decisions when propofol-mediated sedation by an anesthesia provider is appropriate. They must be skilled in the recognition of delayed propofol-related adverse events that may arise after recovery from sedation, such as fever, chills, or myalgia that may arise within 48 hours of administration. In many states, a certified registered nurse anesthetist must be supervised by the physician endoscopist if the certified registered nurse anesthetist is not otherwise supervised by an anesthesiologist. Endoscopists may also assume responsibility at a managerial or ownership level for the development, approval, and monitoring of policies and procedures defining how propofol is procured, stored, administered, and accounted for in their units. The technique of titrating propofol to a level of moderate sedation after low presedation doses of an opioid, benzodiazepine, or both is known as balanced propofol sedation, which is a form of nonanesthesiologist-administered propofol sedation. Moderate sedation using propofol may also be achieved using a computer-assisted personalized sedation system known as SEDASYS, which at this time is experimental though has been granted “approvable” status by the U.S. Food and Drug Administration. Although moderate sedation, during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation, is an appropriate target level of sedation for most endoscopic procedures, deep sedation, during which the patient is not easily arousable but is purposely responsive after repeated or painful stimulation, should be anticipated when patient-related or procedure-related factors suggest that moderate sedation may be inadequate. The trainee must be familiar with these factors and must recognize that transient deep sedation at some time during endoscopic procedures is a frequent outcome of conventional sedation using benzodiazepines and opioids, even when these agents are specifically titrated with the intent of maintaining moderate sedation. Although unintended periods of deep sedation may occur when moderate sedation is targeted, the planned targeting of deep sedation raises specific regulatory concerns in addition to requiring a higher level of competency in rescue techniques. The CMS has defined moderate sedation, as described previously, to be outside the scope of anesthesia services and thus exempt from the facility requirements to which hospitals are subject when anesthesia is provided. In contrast, targeted deep sedation or general anesthesia requires elements of the preanesthesia and postanesthesia evaluations that must be documented in the medical record and require that these evaluations and the anesthesia care itself be provided only by individuals who are qualified under statute §482.52(a) to administer anesthesia. Deep sedation, in contrast to moderate sedation, is currently viewed by the CMS to be a form of anesthesia (monitored anesthesia care), and thus deep sedation is subject to the statutory requirements that are applicable to anesthesia services in general. The selection and dosing of sedation agents must reflect an understanding of key principles of endoscopic sedation. 1An individual patient's response to each sedation agent is unique. Response may be related to age, weight, and pharmacologic profile as well as unpredictable and unidentified factors. This patient-specific unique response necessitates careful titration to effect and to the procedure needs rather than strict adherence to standard dosing regimens.2Accumulation of drug effect occurs with repeated dosing, necessitating an understanding and consideration of time to onset of action, time to peak action, and the half-life of action for each agent used.3Synergism of drug effect occurs among sedating agents, necessitating appropriate dose reductions.4Levels of stimulation during the course of endoscopic procedures may vary markedly, potentially necessitating related adjustments to the depth of sedation during the procedure. Anticipation of periods of increased noxious stimulation allows anticipatory strategic dosing schemes, particularly if propofol is used in the balanced moderate sedation model. During a fellowship, trainees should gain an understanding of the following: 1Appropriate selection of patients for moderate sedation based on findings from personal consultation and consideration of aThe nature of the intended procedurebComorbiditiescAirway factors and other physical factors potentially affecting the sedation processdPharmacologic profileeHistory of illicit drug or alcohol usefPsychiatric profilegSedation/anesthesia history (including intolerance or potential allergy to any of the planned drugs)hPatient expectations and consent issues relating specifically to the sedation process2Pharmacologic profiles of drugs used for endoscopic sedation (see Sedation pharmacology section and Table 3)TABLE 3Pharmacologic profile of drugs used for endoscopic sedation⁎For healthy individual <60 years of age.DrugOnset of action, minPeak effect, minDuration of effect, minInitial dosePharmacologic antagonistSide effectsDexemedetomidine, μg<515Unknown1/kgNoneHypotension, bradycardiaDiazepam, mg2-33-53605-10FlumazenilRespiratory depression, chemical phlebitisDiphenhydramine, mg2-360-90>24025-50NoneDizziness, prolonged sedationDroperidol, mg3-1030120-2401.25-2.5NoneQT interval prolongation, ventricular arrhythmia, extrapyramidal effectsFentanyl, μg1-23-530-6050-100NaloxoneRespiratory depression, vomitingFlumazenil, mg1-23600.1-0.3Agitation, withdrawal symptomsKetamine, mg<1110-150.5/kgNoneEmergence reaction, apnea, laryngospasmMeperidine, mg3-65-760-18025-50NaloxoneRespiratory depression, pruritus, vomiting, interaction with MAOIMidazolam, mg1-23-315-801-2FlumazenilRespiratory depression, disinhibitionNaloxone, mg1-2530-450.2-0.4Narcotic withdrawalNitrous oxide2-3Dose dependent15-30Titrate to effectNoneRespiratory depression, headachePromethazine, mg2-5Unknown>12012.5-25NoneRespiratory depression, hypotension, extrapyramidal effectsPropofol, mg<11-24-810-40NoneRespiratory depression, cardiovascular instabilityMAOI, Monoamine oxidase inhibitor. For healthy individual <60 years of age. Open table in a new tab 3Dosing regimens for induction and maintenance of moderate sedation that reflect consideration of age, weight, and pharmacologic synergy that include appropriate time intervals between doses and maximum recommended doses for commonly used moderate

Anesthesia Patient Safety Foundation Consensus Conference Report

In October 2006, an Anesthesia Patient Safety Foundation (APSF) workshop with more than 100 clinicians, researchers, and industry representatives considered the dangers of patient-controlled analgesia (PCA) pumps and postoperative respiratory depression.1 Consensus recommendations called for increased electronic monitoring of postoperative patients receiving opioids, increased education of patients and providers on postoperative opioid risks, increased use of multimodal analgesia to reduce postoperative opioid use, and more research to identify higher risk populations and to develop better technologies to detect and alert providers of impending respiratory depression. The APSF espoused the vision that “no patient shall be harmed by opioid-induced respiratory depression in the postoperative period.” However, in the ensuing 5 years, these recommendations have only been implemented sparingly, perhaps because of an underappreciation of the severity of the problem and limited implementation of existing monitoring technology. Consequently, postoperative patients continued to experience opioid-induced respiratory depression leading to preventable brain damage and death. Because of this lack of progress, on June 8, 2011, the APSF convened a second consensus conference in Phoenix, Arizona on “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period.” Approximately 134 participants represented clinicians and researchers from nursing, anesthesia, and surgery as well as the Veterans Health Administration, American Society of Anesthesiologists, American Association of Nurse Anesthetists, American Hospital Association, American College of Surgeons, American Society of Peri-Anesthesia Nurses, the Joint Commission, other societies and nonprofit agencies (Association for the Advancement of Medical Instrumentation, American Society of Healthcare Risk Management, Institute for Safe Medication Practices), malpractice insurers, family members of patients who have died from this complication, and representatives from the monitoring technology industry. Robert K. Stoelting, APSF President, and Frank J. Overdyk, from the Medical University of South Carolina, comoderated the 24 brief presentations and 6 small breakout groups. The conference focused exclusively on the following 2 questions: (1) Should electronic monitoring be utilized to facilitate detection of drug-induced postoperative respiratory depression? and (2) Who should be monitored and what monitors/technology should be utilized? Dr. Stoelting began the conference by asserting that significant opioid-induced respiratory depression in the postoperative period is a serious patient safety risk and that continuous electronic monitoring of oxygenation and/or ventilation could facilitate more rapid diagnosis and prevention. Dr. Stoelting commented that, “waiting for the perfect randomized controlled study on the perfect monitor does not justify the current inaction. Maintaining the status quo in hopes that a different result will occur is unrealistic.” He stated that the conference's goal was to determine which strategies would provide effective early warning of clinically significant postoperative ventilatory depression. Dr. Overdyk asserted that these high-severity adverse events occur more frequently and are much easier to recognize than awareness under anesthesia, for which there has been considerable investment in research and technology. He recommended that this initiative become a “national patient safety priority.” His research has shown that up to 29% of patients may develop severe drug-induced respiratory depression postoperatively, with naloxone administration occurring in 0.2% to 0.7% of patients receiving postoperative opioid analgesics. Determining which patients should be electronically monitored postoperatively for drug-induced respiratory depression proved problematic. Several speakers described risk factors associated with postoperative opioid-induced respiratory depression including obesity, sleep apnea syndromes, advanced age, and preoperative chronic opioid tolerance. However, many patients who develop opioid-induced respiratory depression do not have any obvious predisposing conditions (and, as suggested below, may be due to the inappropriate use of basal infusions). Frances Chung from the University of Toronto presented data showing that up to 82% of men and 93% of women with moderate to severe sleep apnea are undiagnosed, with a prevalence ranging from 7% to 22%. Consequently, targeting a “high-risk” population for increased postoperative electronic monitoring would potentially miss a large number of patients who are at higher risk. Dr. Chung demonstrated that the apnea-hypopnea index in patients with sleep apnea peaks on the third postoperative night after surgery and does not return to baseline until the seventh postoperative night. Matthew B. Weinger from Vanderbilt University reiterated the evidence for an incidence of severe postoperative opioid-induced respiratory depression of approximately 0.3% with up to 20,000 United States patients requiring naloxone rescue annually (and perhaps one-tenth of these patients being harmed). He also showed data that all parenteral opioids are possible culprits. Dr. Weinger then presented a synopsis of the reliability, sensitivity, specificity, and response time for currently available monitoring modalities to detect respiratory depression. For nonintubated patients, pulse oximetry without supplemental oxygen and capnography fared best. J. Paul Curry from the University of California, Los Angeles and Larry A. Lynn, the Executive Director of the Sleep and Breathing Research Institute in Columbus, Ohio, presented literature evidence for 3 different patterns of unexpected hospital death: progressive metabolic acidosis (e.g., sepsis), opioid-induced carbon dioxide narcosis, and drug-induced arousal failure with sleep apnea.1 Pulse oximetry values, minute ventilation, respiratory rate, and arterial carbon dioxide levels seem to follow specific and distinguishable patterns preceding each of the 3 types of death. Lynn and Curry argued that the use of threshold alarms (i.e., alarming upon reaching a specific value) do not distinguish meaningful from nuisance alarms. Setting alarm thresholds to lower values will reduce “false” alarms, but also delay response times to real conditions. They advocated for the development of smarter technologies to detect and alert to these specific patterns and increased clinician education. David Scott from St. Vincent's Hospital, Melbourne, Australia, and Chris Pasero, a pain specialist from El Dorado Hills, California, both emphasized the critical role of nursing in assessing sedation levels to detect opioid-induced respiratory depression. Some participants recommended advocating sedation as the sixth vital sign. Other experts described the potential safety and other benefits of continuously monitoring patients including improved survival after in-hospital arrests and decreased intensive care unit transfers. Rapid response team studies demonstrated that using associated medical conditions as predictors of arrest or near-arrest situations only captured approximately 50% of events. Similar to opioid-induced respiratory depression, the multifactorial etiology of these events precludes reliable prediction. George Blike from Dartmouth University noted that the key difference between the best and worst quality hospitals was not their incidence of complications, but their ability to recover from adverse events. His work has shown that routine pulse oximetry surveillance with direct nurse alerts significantly decreased the incidence of rescues and intensive care unit transfers. Other speakers expressed concern about “alarm fatigue” in nurses, and thus failure to respond to real events because of the high number of false-positive alarms from motion artifact, dislodgement of monitoring probes, or patient noncompliance. Several speakers expressed concern over the cost of continual electronic monitoring of all postoperative patients receiving opioids, whereas others asserted that the cost of not monitoring may prove to be higher. After the formal presentations, all participants were assigned to 1 of 6 different breakout groups to reach consensus on the questions proposed at the beginning. There was nearly universal agreement across all groups that electronic monitoring should be utilized to facilitate detection of opioid-induced postoperative respiratory depression. However, the nature and duration of this monitoring and how it should be tapered before patient discharge were not agreed upon. It was generally acknowledged that implementation would be incremental and initially aimed at higher risk patient groups because of limited resources. All groups agreed that pulse oximetry should be utilized for monitoring as many patients as possible. Most groups advocated the inclusion of a continual monitor of ventilation such as capnography, if supplemental oxygen was provided. Most groups recommended that monitors should be interfaced with a central station with a dedicated trained observer. Improved monitoring of sedation and increased training of postoperative nurses were also thought to provide significant benefits. A few individuals were concerned that investing vast sums of money nationwide for electronic monitoring was premature and that resources would be better invested in research for more effective prevention and monitoring strategies. Although a legitimate concern, the immediate application of imperfect but still useful technology, specifically pulse oximetry, was considered appropriate by most conference attendees given the continued loss of lives from this preventable complication. Additional comments were provided from the groups and during the question and answer session. Steve Shafer, Editor-in-Chief of Anesthesia & Analgesia, urged everyone to examine the outcomes of any new monitoring initiatives. Mark Warner, American Society of Anesthesiologists (ASA) President, noted that the ASA would work with key nursing and surgical groups to carry forth conference recommendations. In summary, the majority of conference attendees believed that continual electronic monitoring should be utilized for inpatients receiving postoperative opioids. Pulse oximetry in patients not receiving supplemental oxygen was believed to be the most practical monitor. Patients receiving supplemental oxygen should also have their ventilation monitored (e.g., with capnography). More reliable and timely detection of sedation was considered important, as were more intensive training of nurses and other clinicians in the recognition and treatment of opioid-induced respiratory depression. Limited resources may necessitate staged implementation of continual monitoring strategies starting with higher risk groups. Finally, appropriate use of PCA and multimodal analgesic therapies in the postoperative period will reduce the risk of opioid-induced ventilatory depression for all postsurgical patients. ADDENDUM The Section Editor would note that another more important factor that was not discussed at this consensus conference was the continued inappropriate use of continuous (basal) infusions of potent opioids with both IV2,3 and epidural PCA.4 The addition of a continuous opioid infusion negates the inherent safety in the concept of PCA and contributes to both serious morbidity and mortalities in the postoperative period. Lorri Lee, MD Department of Anesthesiology and Pain Medicine University of Washington School of Medicine Seattle, Washington [email protected] Matthew B. Weinger, MD Department of Anesthesiology Vanderbilt University School of Medicine VA Tennessee Valley Healthcare System Nashville, Tennessee [email protected]

Research News: Nurse Anesthesia

IS THE PRACTICE of nurse anesthetists nursing? The American Association of Nurse Anesthetists (AANA), representing more than 42,000 Certified Registered Nurse Anesthetists (CRNAs), clearly defines the role as advanced practice nursing. Thehistory of nurse anesthetists is long and impressive. As early as theCivilWar (1861-1865), nurseswereproviding anesthesia care. In 1877, SisterMaryBernard of Pennsylvaniawas recognized as the first nurse to specialize in anesthesia. Today, few in the United States would argue against their legitimacy. ‘‘CRNAs practice in every setting where anesthesia is available and in some states are the sole anesthesia professionals in nearly 100% of rural hospitals.’’

Saint René Goupil, Surgeon: Witness to the Sanctity of Life in Seventeenth-Century North America.

Saint René Goupil is the patron of the American Association of Nurse Anesthetists. Given his training as a surgeon and his efforts to relieve the suffering of others, he makes an excellent patron for physicians also. Goupil worked at the Hôtel Dieu Hospital in Sillery, near Quebec City, which combated the Indians' practice of euthanasia by providing palliative care. There, as well as in his captivity, he epitomized a Catholic medical practice which shows concern for the soul as well as the body. Finally, Goupil bore heroic witness to the dignity of all human persons when he offered medical treatment even to one of his Mohawk torturers.

Growing leaders in a professional membership organization

This study describes the background, development and delivery of an innovative approach to prepare elected state association leaders for their new leadership roles in their respective state organizations. State-based professional associations face unprecedented threats to scope of practice in the current volatile healthcare environment. In 2009 the American Association of Nurse Anesthetists (AANA) began offering a Leadership Development 'Boot Camp' for all nurse anesthetist state association presidents-elect designed with the intent of providing the participants with information, resources and tools they need in their new role. An organizational assessment examined the philosophy of and need for leadership development across the entire organizational structure. Recommendations from the assessment included the need for intensive leadership development at the state level. A 3-day intensive workshop was designed and implemented. Adult learning theory was used for its development. The success of this programme has lead to its implementation as part of leadership development of the AANA. Nurse managers and elected volunteer leaders in state-based professional associations face similar challenges requiring sound leadership ability. Principles applied to the development of the AANA programme can be applied to leadership development for new nurse managers.

Groundbreaking Summit

The American Association of Nurse Anesthetists (American Association of Nurse Anesthetists (AANA), 2003American Association of Nurse Anesthetists (AANA) (2003). Provisions of pain relief by medication administered via continuous epidural, intrathecal, intrapleural, peripheral nerve catheters, or other pain relief devices. Position statement no. 2.8. Retrieved September 24, 2009, from AANA Web site: http://www.aana.com/resources.aspx?id=778Google Scholar) developed a position statement titled “Provisions of Pain Relief by Medication Administered via Continuous Epidural, Intrathecal, Intrapleural, Peripheral Nerve Catheters, or Other Pain Relief Devices” (1988, reaffirmed 2003). Likewise the “Association of Women's Health, Obstetric and Neonatal Nurses” (Association of Women's Health, Obstetric and, 2007Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) (2007). Role of the registered nurse (RN) in the care of the pregnant woman receiving analgesia/anesthesia by catheter techniques (epidural, intrathecal, spinal, PCEA catheters). AWHONN epidural statement. Retrieved September 24, 2009, from AWHONN Web site: http://www.awhonn.org/awhonn/binary.content.do?name=Resources/Documents/pdf/5H2a_PS_Epidural.pdfGoogle Scholar) developed an epidural statement titled “Role of the Registered Nurse (RN) in the Care of the Pregnant Woman Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEA Catheters)” (2001, reapproved 2007). In June 2007, an article was published in Pain Management Nursing titled “Registered Nurse Management and Monitoring of Analgesia by Catheter Techniques: Position Statement” (Pasero et al., 2007Pasero C. Eksterowicz N. Primeau M. Cowley C. Registered nurse management and monitoring of analgesia by catheter techniques: Position statement.Pain Management Nursing. 2007; 8: 48-54Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar).The difference between the American Society for Pain Management Nursing (ASPMN) position statement and the two others mentioned is that if a registered nurse (RN) is educated and supported by an institution, ASPMN's position is that the RN may manage analgesia by catheter. Management includes “reinjection of medication (bolus dose) after establishment of an appropriate therapeutic range and adjustment of drug infusion rate in compliance with a licensed independent practitioner order.”The AWHONN position statement does not permit for RNs rebolus injection, initiation of a continuous infusion, or increasing or decreasing the rate of the continuous infusion. As president of ASPMN, Nancy Eksterowicz was receiving calls asking why there were differences in the statements and if there were differences between states. This led to a summit conducted during ASPMN's annual convention. There were representatives from AWHONN, Oncology Nursing Society, Academy of Medical Surgical Nurses, ASPMN, and AANA. The goal of the summit was to have consistency in position statements between the organizations.A great deal of discussion, led by nurse anesthetists centered on the difficulties in establishing a patent airway in the pregnant and laboring mother. This was the rationale for not permitting RNs to change the dose rates, reinject the catheter, or resume an infusion after it has been stopped. Comments by ASPMN members centered around a lack of information about the differences between pregnant and nonpregnant women's airway management.All present at the summit agreed to integrate these special considerations in position statements. More collaboration was agreed upon. Nancy Eksterowicz agreed to send a summary statement to all parties involved.Overall, the meeting was very enlightening, respectful, and collaborative and focused on patient safety. Everyone considered this summit for consensus on nursing practice guidelines for patients receiving epidural analgesia via catheter infusion to have been a great success. The American Association of Nurse Anesthetists (American Association of Nurse Anesthetists (AANA), 2003American Association of Nurse Anesthetists (AANA) (2003). Provisions of pain relief by medication administered via continuous epidural, intrathecal, intrapleural, peripheral nerve catheters, or other pain relief devices. Position statement no. 2.8. Retrieved September 24, 2009, from AANA Web site: http://www.aana.com/resources.aspx?id=778Google Scholar) developed a position statement titled “Provisions of Pain Relief by Medication Administered via Continuous Epidural, Intrathecal, Intrapleural, Peripheral Nerve Catheters, or Other Pain Relief Devices” (1988, reaffirmed 2003). Likewise the “Association of Women's Health, Obstetric and Neonatal Nurses” (Association of Women's Health, Obstetric and, 2007Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) (2007). Role of the registered nurse (RN) in the care of the pregnant woman receiving analgesia/anesthesia by catheter techniques (epidural, intrathecal, spinal, PCEA catheters). AWHONN epidural statement. Retrieved September 24, 2009, from AWHONN Web site: http://www.awhonn.org/awhonn/binary.content.do?name=Resources/Documents/pdf/5H2a_PS_Epidural.pdfGoogle Scholar) developed an epidural statement titled “Role of the Registered Nurse (RN) in the Care of the Pregnant Woman Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEA Catheters)” (2001, reapproved 2007). In June 2007, an article was published in Pain Management Nursing titled “Registered Nurse Management and Monitoring of Analgesia by Catheter Techniques: Position Statement” (Pasero et al., 2007Pasero C. Eksterowicz N. Primeau M. Cowley C. Registered nurse management and monitoring of analgesia by catheter techniques: Position statement.Pain Management Nursing. 2007; 8: 48-54Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar). The difference between the American Society for Pain Management Nursing (ASPMN) position statement and the two others mentioned is that if a registered nurse (RN) is educated and supported by an institution, ASPMN's position is that the RN may manage analgesia by catheter. Management includes “reinjection of medication (bolus dose) after establishment of an appropriate therapeutic range and adjustment of drug infusion rate in compliance with a licensed independent practitioner order.” The AWHONN position statement does not permit for RNs rebolus injection, initiation of a continuous infusion, or increasing or decreasing the rate of the continuous infusion. As president of ASPMN, Nancy Eksterowicz was receiving calls asking why there were differences in the statements and if there were differences between states. This led to a summit conducted during ASPMN's annual convention. There were representatives from AWHONN, Oncology Nursing Society, Academy of Medical Surgical Nurses, ASPMN, and AANA. The goal of the summit was to have consistency in position statements between the organizations. A great deal of discussion, led by nurse anesthetists centered on the difficulties in establishing a patent airway in the pregnant and laboring mother. This was the rationale for not permitting RNs to change the dose rates, reinject the catheter, or resume an infusion after it has been stopped. Comments by ASPMN members centered around a lack of information about the differences between pregnant and nonpregnant women's airway management. All present at the summit agreed to integrate these special considerations in position statements. More collaboration was agreed upon. Nancy Eksterowicz agreed to send a summary statement to all parties involved. Overall, the meeting was very enlightening, respectful, and collaborative and focused on patient safety. Everyone considered this summit for consensus on nursing practice guidelines for patients receiving epidural analgesia via catheter infusion to have been a great success.