Certified Registered Nurse Anesthetists Research Articles

Perceptions of Nurse Practitioners and Physician Assistants/Associates Toward the Concept of Developing an Advanced Practice Postgraduate Residency/Fellowship Program at a Large Academic Medical Center.

Introduction There have been exponential growth and increased interest in postgraduate residency/fellowship formalized training among nurse practitioners (NPs) and physician assistants/associates (PAs). Although not a requirement for state licensure and entry-level practice, postgraduate NP and PA residency/fellowship programs offer a structured pathway for new graduates and experienced PAs and NPs looking to transition into a new medical or surgical specialty/subspecialty. In this article, we examine the perceptions of employed NPs and PAs toward postgraduate training including the concept of developing a program at our institution. Methodology This was a cross-sectional single-large academic medical center (AMC) study, where an anonymous electronic survey was initially developed by the director of advanced practice providers (APPs). The survey was piloted by members of the Advanced Practice Council (APC) comprising NPs, PAs, and certified registered nurse anesthetists (CRNAs), and their collective feedback was used to finalize the survey prior to distribution. Descriptive statistics were used to describe and summarize the data. In addition, we assessed the association between respondents' characteristics and perceptions regarding NP and PA residency/fellowship programs using chi-squared tests of independence. Results The majority of the respondents (69.1%; 65/94) believed that starting an advanced practice residency/fellowship program at our AMC has many benefits such as increasing specialty-specific knowledge and training (79.8%; 75/94), improving medical decision-making (73.4%; 69/94), promoting professional development and clinical education (73.4%; 69/94), and improving procedural competency (60.6%; 57/94). Moreover, over half of the respondents (53.2%; 50/94) indicated that there is value in an APP residency/fellowship program obtaining optional accreditation. Additionally, over half of the respondents (56.4%; 53/94)indicated that they would be interested in participating as a clinical preceptor if an APP residency/fellowship program was developed at our AMC. Lastly, about one-third of the respondents felt strongly that APP residency/fellowship training programs should offer post-professional doctoral degree options such as Doctor of Nursing Practice (DNP), Doctor of Medical Science (DMSc), and Doctor of Health Science (DHSc). Conclusion Although most respondents have never completed a formalized postgraduate training program and were less familiar with the published literature regarding these programs, our findings suggest that the attitudes ofemployed NPs and PAs aregenerally positivetoward the concept of postgraduate specialty-specific training.

Bridging an Education Gap: Ultrasound-guided Peripheral IVs

PurposeTo provide ultrasound (US) education to anesthesia providers to increase usage for peripheral intravascular (IV) cannulation on difficult IV access patients. DesignThis project reflects a qualitative descriptive quality improvement project with outcomes measured. Data in this project include the overall knowledge and competency scores from the provider’s US survey before and after education and training were provided. MethodsA presentation was developed and provided to 38 certified registered nurse anesthetists (CRNA) via the hospital’s online platform. Next, in-person simulations were conducted to facilitate the skills of US utilization. Each CRNA participating in simulations successfully performed the skill. The impact and success of the education bundle were collected via the disbursement of a Likert-scale survey via an automated data collection software. FindingsSeventeen of the 38 (45%) participants responded to the survey. Of these respondents, 88% of providers indicated that their US skills and confidence had increased following the intervention, and 100% of participants stated that the intervention was helpful in learning US-guided peripheral IV insertion. ConclusionsEducation and hands-on skills sessions increased provider confidence in US use. While this project focused on educational training of CRNAs, this is applicable to all health care providers who are responsible for IV cannulation. The project team members will disseminate these findings and plan to improve perioperative nurses’ confidence in US-guided peripheral IV insertions; thus, improving efficiency in the operative setting.

Barriers to effective clinical preceptorship in nurse anesthesiology

BackgroundClinical preceptorship is an effective teaching tool for Certified Registered Nurse Anesthetists (CRNAs) and Student Registered Nurse Anesthetists (SRNAs). Strategies for success and barriers to effective clinical preceptorship have been explored across the literature to improve learning experiences for SRNAs. PurposeThe purpose of this literature review was to identify barriers to effective clinical preceptorship in the field of nurse anesthesiology. MethodA rapid review of the literature utilizing PubMed, Embase, CINAHL, Scopus, and Cochrane Library ultimately yielded 14 relevant articles. ResultsClinical preceptorship in the discipline of nurse anesthesiology has a significant impact on both student experiences and preceptor satisfaction. Barriers within the clinical preceptorship model have been identified across the literature from both the preceptor and student perspectives. ConclusionsThe overarching theme is that development of clinical preceptor workshops and specific guidelines would enhance the experiences of both clinical preceptors and students and allow goals and objectives to be more easily met.

The impact of an anesthesia residency teaching service on anesthesia-controlled time and postsurgical patient outcomes: a retrospective observational study on 15,084 surgical cases

BackgroundLimited data exists regarding the impact of anesthesia residents on operating room efficiency and patient safety outcomes. This investigation hypothesized that supervised anesthesiology residents do not increase anesthesia-controlled or prolonged extubation times compared to supervised certified registered nurse anesthetists (CRNA)/certified anesthesiologist assistants (CAA) or anesthesiologists working independently. Secondary objectives included differences in critical outcomes such as intraoperative hypotension, cardiac and pulmonary complications, acute kidney injury, and mortality.MethodsThis retrospective single-center 24-month (January 1, 2020- December 31, 2021) cohort focused on primary outcomes of anesthesia-controlled times and prolonged extubation (>15 min) with additional assessment of secondary patient outcomes in adult patients having general anesthesia with an endotracheal tube or laryngeal mask airway for elective non-cardiac surgery. The study excluded sedation, obstetric, endoscopic, ophthalmology, and non-operating room procedures. Procedures were divided into three groups: anesthesiologists working solo, anesthesiologists supervising residents, or anesthesiologists supervising CRNA/CAAs. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes.ResultsA total of 15,084 surgical cases met the inclusion criteria for this study for the three different care models: solo anesthesiologists (1,204 cases), anesthesiologist/resident pairing (3,146 cases), and anesthesiologist/CRNA/CAA (14,040 cases). Before multivariate analysis, the resident group exhibited longer anesthesia-controlled times (median, [interquartile range], 26.1 [21.7–32.0], p < 0.001), compared to CRNA/CAA (23.9 [19.7–29.5]), and attending-only surgical cases (21.0 [17.9–25.4]). After adjusting for covariates in a general linear regression model (age, BMI, ASA classification, comorbidities, arterial line insertion, surgical service, and surgical location), there were no significant differences in the anesthesia-controlled times between the provider groups. Prolonged extubation times (>15 min) were significantly less common in the anesthesiologist-only group compared to the other groups (p < 0.001). Despite these time differences, there were no clinically significant differences among the groups in postoperative pulmonary or cardiac complications, renal impairment, or the 30-day mortality rate of patients.ConclusionAnesthesia residents do not increase anesthesia-controlled operating room times or adversely affect clinically relevant patient outcomes compared to anesthesiologists working independently or supervising certified registered nurse anesthetists or certified anesthesiologist assistants.

Turnover Factors for Certified Registered Nurse Anesthetists

Objective: The objective of this scoping review is to understand the extent and type of evidence related to occupational turnover factors for certified registered nurse anesthetists (CRNA) in the United States. Introduction: Demand for anesthesia services is increasing dramatically. CRNAs provide a significant number of anesthetics each year and are crucial to accessible anesthesia in the U.S. Understanding occupational turnover factors for CRNAs is vital to providing cost effective, reliable anesthesia services for Americans. Inclusion criteria: Studies relevant to CRNA turnover in the U.S. were included for this review. Due to differences in education, scope of practice, and practice environment, studies involving nurse anesthetists outside the U.S. were excluded. Studies with mixed provider populations including physicians, registered nurses, other advanced practice providers, and students were also excluded. Methods: MEDLINE Complete, Embase, and Google Scholar were sources searched for relevant literature. Studies were only limited to those published in English. No publication date limitations were used. Titles and abstracts were reviewed, with potential papers retrieved for independent review by the authors. Data extraction was conducted independently by the authors using the Joanna Briggs Institute (JBI) data extraction instrument template. Themes identified after data extraction are described in narrative format. Results: After review of the literature, five studies were included for data extraction. All the studies employed electronic or mailed questionnaires. Common factors associated with occupational turnover were compensation, retirement, job satisfaction, and burnout. Conclusions: Findings suggest that occupational turnover factors are multifactorial and include broad concepts such as job satisfaction, burnout, and organizational climate.

Predictors of Substance Use Risk in Nurse Anesthetists.

Certified registered nurse anesthetists (CRNAs) are exposed daily to highly addictive substances and stressful work environments, placing them at risk for substance use disorders (SUDs). Previous research, which is scarce, indicated that drugs of choice were opioids and propofol. Therefore, the purpose of this study was to investigate predictors of SUD risk using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test. From June to July 2020, an online survey was sent via the American Association of Nurse Anesthesiology Research Survey Service to 3,000 CRNAs with a response of approximately 225 members. CRNAs were found to be at a moderate risk for SUDs in the following categories: 10.27% for tobacco, 23.56% for alcohol, and 6.28% for cannabis. Regression analysis by substance category includes robust, differing models in this homogeneous sample. Predictors for all three models include a collection of demographic variables, religiosity, anxiety, difficulties due to anxiety, depression, substance use history, contact with the American Association of Nurse Anesthesiology Peer Assistance Program, and organizational support. Over 10% of CRNAs are at risk for developing tobacco use disorder, and almost one quarter of those surveyed are at a moderate risk for developing alcohol use disorder. These data are of concern and may indicate a shift of preferred substances used by CRNAs from controlled substances to alcohol.

Design of a Workshop for Focused Transesophageal Echocardiography During Noncardiac Surgery in Nurse Anesthesia Education.

The use of transesophageal echocardiography (TEE) by certified registered nurse anesthetists (CRNAs) during noncardiac surgery is relatively uncommon despite its unique potential to diagnose causes of hemodynamic instability. To address this problem, educational endeavors designed to provide practical TEE skills to CRNAs are needed. The aim of the current study was to evaluate the feasibility, acceptability, efficacy, and utility of a 2-day focused TEE workshop in nurse anesthesia education that employed a protocol involving a limited number of views and used goal-directed, qualitative assessments of critical physiologic parameters. This was a prospective, observational study involving 14 second-year nurse anesthesia students. The cohort was evaluated following completion of this workshop by simulator-based testing involving hypothetical clinical scenarios, and this test data was analyzed according to the percent successful acquisition and interpretation of TEE views to determine immediate objective teaching efficacy. The acceptability, perceived efficacy, and perceived utility of the workshop were assessed by online survey, and survey responses were qualitative and quantitative in nature. Participants acquired appropriate TEE views associated with clinical scenarios 99% of the time and correctly interpreted the pathology in those views 93% of the time. Participants uniformly perceived significant educational value in this workshop and intend to incorporate TEE in their future clinical practice. A 2-day workshop to teach focused TEE to nurse anesthesia trainees directed by a streamlined protocol is feasible, acceptable, and perceived as useful by participants, and provides practical experience and entry-level competency in this point-of-care ultrasound modality.

Analysis of a Needs Assessment Survey to Develop an Online Resource Repository Supporting Nurse Anesthesia Educators.

Without highly qualified nurse anesthesia educators and administrators, the health care system will be threatened by the inadequate supply of certified registered nurse anesthetists (CRNAs). American Association of Nurse Anesthesiologists' Faculty Stabilization Task Force (FSTF) analyzed reasons for high faculty turnover and developed recommendations to support nurse anesthesia faculty and administrators. A survey evaluated participants' current role, leadership development opportunities, mentorship experiences, and resource needs. Of 109 respondents, 87 (80%) were program administrators or assistant administrators with less than 5 years of experience in their role. Despite academic experience, 51% felt adequately prepared for their role. The FSTF provided 2 recommendations: to create a robust faculty development program for all faculty at all levels of CRNA education and a repository of information needed for program administrators and faculty to oversee and educate students in a high-quality CRNA program.

Using Simulation Training to Reduce Skill Decay Among Certified Registered Nurse Anesthetists.

Skill decay refers to the loss of skills and knowledge resulting from lack of consistent use. Among certified registered nurse anesthetists (CRNAs), skill decay can lead to negative results. One method that has been shown to mitigate skill decay is low-dose, high-frequency (LDHF) simulation. There is a gap in the LDHF simulation literature regarding CRNAs to determine its effectiveness in reducing skill decay or increasing confidence levels. This study used a quasi-experimental pretest-posttest follow-up design. The pretests and posttests were evaluated using a Wilcoxon signed rank test to determine CRNAs' proficiency and confidence in central venous catheter (CVC) insertion before and after a simulated refresher training course. The CRNAs showed a significant improvement in CVC insertion proficiency, from a 50% pretest average to a 94% posttest average (p < .0001), and they retained proficiency 6 months later (91%, p = .0109). There was no significant change in CRNAs' confidence level following the training (p = .4486). A program of LDHF simulation training is an important activity in meeting the continuing education/training needs of CRNAs in improving and retaining CVC insertion proficiency. This study demonstrates the efficacy of a LDHF simulation program for CRNAs and helps to bridge the gap in the literature on the use of LDHF simulation among CRNAs. [J Contin Educ Nurs. 2024;55(4):187-194.].

The influence of body painting on L4 spinous process palpation accuracy in novice palpators

ABSTRACT Objectives Current literature remains inconclusive regarding the best methodology to accurately palpate lumbar spinous processes (SP). Body painting (BP) uses markers to draw anatomical structures on the skin’s surface. While BP can be a useful tool for engaging learners, it is unknown whether it improves palpation accuracy. The purpose of this study was to investigate whether the addition of body painting to palpation education improves lumbar spinous process palpation accuracy in first-year Doctor of Physical Therapy (DPT) students. Methods Thirty-eight DPT students were randomized into a traditional palpation group and a body painting (BP) group. Each group received identical instruction on palpating the lumbar spine, with the BP group additionally drawing lumbar SPs on their laboratory partner with a marker. Students were then assessed on their ability to accurately palpate the L4 SP on randomly assigned subjects. Two Certified Registered Nurse Anesthetists (CRNAs) used ultrasound imaging to confirm the location of each student’s palpation. Palpation time was also recorded. The BP group also completed a survey on the learning experience. Results Forty-five percent of students were able to accurately palpate the L4 SP. There was no significant difference (p = 0.78) in palpation accuracy between the traditional and BP group, although students in the BP group were randomly assigned subjects with a significantly (p = 0.005) higher BMI. Ninety-five percent of students were able to palpate within one spinal level of the L4 SP. Students in the BP group reported that the BP activity facilitated learning and active participation. There was no significant difference in palpation time (p = 0.98) between groups. There was a fair correlation (r=-0.41) between palpation accuracy and subject BMI. Discussion/Conclusion While body painting was an enjoyable activity to incorporate into palpation laboratory, it is unclear whether it enhanced lumbar SP palpation accuracy in first-year DPT students.

California Certified Registered Nurse Anesthetist Workforce Study

BackgroundNurse anesthesia in California has been instrumental in shaping Certified Registered Nurse Anesthetist (CRNA) practice nationally, but to date, no workforce data has been published on this group of Advanced Practice Registered Nurses. PurposeThe purpose of this workforce study was to explore the demographic information, education, and practice patterns of CRNAs working in California. MethodsSurvey methodology was conducted to gather workforce data from a sample of licensed CRNAs working in California. DiscussionCalifornia CRNAs provide anesthesia services in very diverse settings among different anesthesia delivery models, including independent practice. CRNAs practice in a majority of California counties and are the sole anesthesia providers for four underserved counties. ConclusionThe CRNA workforce in California is comparatively young, highly educated, and desires more education. CRNAs improve access to care for California patients; however, more ethnically diverse CRNAs and CRNAs with Non-Surgical Pain Management Certification are needed.

Flow Disruptions as A Result of Personal Electronic Devices in Orthopedic Surgery

The operating room (OR) is a complex environment in which highly trained individuals perform cognitively demanding tasks. Distractions in this environment may lead to deleterious effects, as a loss of situational awareness can interfere with surgical procedures. The present study aims to quantify the frequency and nature of distracting events associated with personal electronic devices (PEDs) during twenty elective orthopedic surgery cases. PED use was coded using a real-time, custom data collection tool beginning in the pre-operative area and terminating at the time of handoff with the post-anesthesia care team. PED use accounted for 242 flow disruptions in the OR. The vendor showed the highest frequency of flow disruptions (73), followed by the circulating nurse (52) and the certified registered nurse anesthetist (CRNA) (52). Thus, taking a proactive safety approach to account for intraoperative distractions associated with PEDs among OR team members will be critical to ensure high-quality patient care.

Improving Certified Registered Nurse Anesthetists’ Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol

The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. This quality improvement project was conducted using a pre- and postimplementation design. Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P=.588), confidence (P=.031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.

Implementation of a Time-out Structured PreSurgical Hand-off Between PreAnesthesia Nurses and Certified Registered Nurse Anesthetists

Implementation of a Time-out Structured PreSurgical Hand-off Between PreAnesthesia Nurses and Certified Registered Nurse Anesthetists

Operationalizing risk-appropriate perinatal care in a rural US State: directions for policy and practice

BackgroundRisk-appropriate care improves outcomes by ensuring birthing people and infants receive care at a facility prepared to meet their needs. Perinatal regionalization has particular importance in rural areas where pregnant people might not live in a community with a birthing facility or specialty care. Limited research focuses on operationalizing risk-appropriate care in rural and remote settings. Through the implementation of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe), this study assessed the system of risk-appropriate perinatal care in Montana.MethodsPrimary data was collected from Montana birthing facilities that participated in the CDC LOCATe version 9.2 (collected July 2021 – October 2021). Secondary data included 2021 Montana birth records. All birthing facilities in Montana received an invitation to complete LOCATe. LOCATe collects information on facility staffing, service delivery, drills, and facility-level statistics. We added additional questions on transport.ResultsNearly all (96%) birthing facilities in Montana completed LOCATe (N = 25). The CDC applied its LOCATe algorithm to assign each facility with a level of care that aligns directly with guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM). LOCATe-assessed levels for neonatal care ranged from Level I to Level III. Most (68%) facilities LOCATe-assessed at Level I or lower for maternal care. Close to half (40%) self-reported a higher-level of maternal care than their LOCATe-assessed level, indicating that many facilities believe they have greater capacity than outlined in their LOCATe-assessed level. The most common ACOG/SMFM requirements contributing to the maternal care discrepancies were the lack of obstetric ultrasound services and a physician anesthesiologist.ConclusionsThe Montana LOCATe results can drive broader conversations on the staffing and service requirements necessary to provide high-quality obstetric care in low-volume rural hospitals. Montana hospitals often rely on Certified Registered Nurse Anesthetists (CRNA) for anesthesia services and telemedicine to access specialty providers. Integrating a rural health perspective into the national guidelines could enhance the utility of LOCATe to support state strategies to improve the provision of risk-appropriate care.

Improving Waste Segregation in the Operating Room to Decrease Overhead Cost.

Operating rooms (ORs) disproportionally contribute 20% to 33% of hospital waste nationwide and therefore have a major impact on hospital waste management. Seventy percent of general OR waste is incorrectly eliminated as clinical waste, which compounds unnecessary financial burden and produces negative environmental impact. The primary purpose of this quality improvement (QI) project was to evaluate the effectiveness of waste segregation education for OR anesthesia staff on improving waste segregation compliance in the OR. A waste segregation QI project was implemented at a 19-OR hospital. Sharps bins in each OR were monitored for weight in pounds and 6 ORs were monitored for percent compliance both pre- and post-institution of a waste segregation education. In addition, a waste segregation knowledge assessment, waste segregation barriers assessment, and a demographic survey were administered to anesthesia staff. Twenty-two certified registered nurse anesthetists (CRNAs), 13 anesthesiologists, and 4 anesthesia technicians responded to the initial surveys and assessments while 30 of these original 39 participants (77%) responded following the educational intervention. A cost analysis was calculated pre- and post-implementation by multiplying total weight of the sharps bins by the price per pound of sharps. Twenty-three percent of participants reported having formal waste segregation training. Survey responses revealed that the greatest barrier to waste segregation involved bin location (56.4%), followed by lack of time to segregate (25.6%), lack of knowledge of what content goes in the bin (25.6%), and lack of incentive (25.6%). A waste segregation knowledge assessment showed improvement from pre- ( M = 9.18, SD = 1.66) to post-implementation ( M = 9.90, SD = 1.64). Pre-implementation sharps bin compliance was 50.70% while post-implementation bin compliance improved to 58.44%. A 27.64% decrease in sharps disposal cost occurred following implementation, which is estimated to produce a $2964 cost savings per year. Waste segregation education for anesthesia staff increased their waste management knowledge, improved sharps waste bin compliance, and produced an overall cost savings.

Plastic Surgery Roles in Wound Centers in the Northeastern United States.

Wound care is a substantial industry costing nearly $19 billion USD, and dedicated wound care centers play a critical role via a multidisciplinary team-based approach. At the same time, plastic surgeons are often considered experts in evaluation and management of wounds, particularly chronic and complex wounds. However, the extent of direct involvement of plastic surgeons in wound care centers is unclear. In this study, we sought to evaluate the presence of plastic surgeons and other specialties in wound care centers across all Northeastern states Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Jersey, New York, New Hampshire, Pennsylvania, Rhode Island, Virginia, West Virginia, and Vermont. A comprehensive list of wound care clinics in northeastern United States was obtained from the Healogics website. For each site, information was gathered via website listings, including number of providers and the professional certification/specialization for each provider. Providers were those with qualifications including Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Doctor of Physical Therapy (DPT), Doctor of Podiatric Medicine (DPM), Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner (CRNP), Physician Associate (PA), and Physical Therapist (PT). A total of 118 Healogics wound care clinics and 492 providers were located across 14 northeastern states including District of Columbia. After researching each location, updated in November 2022, plastic surgeons were only 3.7% (18 of 492) providers employed. Specialties such as internal medicine (90 of 492 [18%]), general surgery (76 of 492 [15%]), podiatry (68 of 292 [13.8% ]), and other midlevel providers such as nurse practitioners (35 of 492 [7.1%]) were more frequently employed over plastic surgery. All plastic surgeons were board certified the American Board of Plastic Surgery. Wound care requires collaboration between specialties, with significant repercussions on health care costs and patient outcomes. Plastic surgery provides unique surgical services for the healing of wounds, and the natural expectation would be that plastic surgery should be heavily involved at wound care centers. However, the data do not reflect significant involvement at an official level. Further studies will investigate causes and the societal, financial, and patient impacts of this lack of direct engagement. Although many plastic surgeons may not desire the majority of their practice to be wound care management, it stands to reason that some affiliation, at least for patient awareness and referral, may be warranted.

Optimal Use of Advanced Practice Providers at an Academic Medical Center: A First-Year Retrospective Review.

Background Physician assistants/associates (PAs) and nurse practitioners (NPs), together known as advanced practice providers (APPs), practice with a high degree of clinical autonomy and professional respect, and play a critical role in team-based care. Aligning APPcaredeliverymodels to promote top-of-license practice is essential to improving ambulatory capacity and bottom-line expectations at academic medical centers (AMCs) in the 21stcentury and beyond. This administrativequality improvementstudy assesses the downstream impact of restructuring our APP care models to promote independent practice sessions. Methods Our AMC formed an APP oversight committee in April 2021 to optimize the ambulatory care model, realign APP funds flow, and set performance standardsto whichPAs and NPsare being held accountable. We conducted a one-year retrospective review of internal data from July 2021 to June 30, 2022. Certified registered nurse anesthetists (CRNAs) were excluded from this analysis. Results APP productivity year-over-year (YOY) aggregate data across all School of Medicine (SOM) departments, demonstrated a 53% increase inwork relativevalueunits (wRVUs), 84% increase in payments, and 79% increase in charges from the prior fiscal year (July to June). Regarding APP ambulatory clinical effort (YOY), there was a 45% increase in the number of APP completed visits (92% return patient visits, 8% new visits). An increase in APP productivitydid not adversely impact patient satisfaction, physician-generated wRVUs, or delay programmatic expansion efforts. Lastly, in a recent engagement survey, the majority of PA and NP respondents (78%) reported working either "most of the time" or "always" at the top-of-license. Conclusion This quality improvement study demonstrates that enhancement of PA and NP utilization through top-of-license initiatives can be achieved without jeopardizing physician wRVUs or performance. While we acknowledge, there are differencesbetween healthcare institutions in terms of care delivery and compensation models, organizational culture, and distribution of clinical resources, there remains an opportunity among hospitals and health systems to optimize this critical and essential APP workforce.

Incorporating Evidence-Based Ultrasound-Guided Vascular Access (USGVA) Standards Into the Nurse Anesthetist Armamentarium: A Quality Improvement Project

PurposeThis quality improvement (QI) project developed and implemented a hybrid training program, that included online modules and hands-on training for experienced certified registered nurse anesthetists (CRNAs) to increase confidence, knowledge, and competency with ultrasound-guided vascular access (USGVA). DesignThis QI project used a pre-post design. Seventeen volunteer CRNAs participated in USGVA training and education, and a 90-day follow-up assessment was performed. MethodsThe Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines were used as a framework to assess confidence, knowledge, and hands-on competency of 17 CRNAs who regularly place vascular access devices using USGVA in patients with difficult vascular access at a single facility. These assessments were measured at: (1) baseline, (2) immediately after attending a hybrid training educational program, and (3) 90 days after implementation into clinical practice. Additionally, the number of vascular access attempts required for successful placement of peripheral intravenous (PIV) catheters, arterial catheters, and central venous catheters (CVC) with ultrasound assistance over a 90-day period was reviewed. FindingsCertified registered nurse anesthetists’ median confidence score increased significantly from pre- to posteducation (P = .009). The confidence reported from post- to 90 days posteducation improved, however it did not reach statistical significance (P = .812). The knowledge scores from pre- to posteducation indicated significant improvement (P <. 001), as well as from pre- to 90 days posteducation (P = .03). However, knowledge scores from post- to 90 days posteducation revealed a statistically significant decline (P = .004). The overall median score for hands-on USGVA competency declined from post- to 90 days posteducation (P = .109). The number of successful USGVA placements increased from 50% to 80% within a 90-day period. ConclusionsThe implementation of a USGVA hybrid training and education program improved overall provider confidence, knowledge, and competency. While confidence remained high in the 90-day follow-up, knowledge retention declined. Despite a decline in knowledge retention over time, results showed a significant improvement when compared to baseline scores. Although a decline in hands-on USGVA competency was seen at 90 days posteducation, it was not statistically significant. The percentage of overall successful USGVA placements in clinical practice increased following implementation.

Provider turf wars and Medicare payment rules

Barriers to entry and scope of work restrictions are common features of US labor markets, especially within healthcare industries. However, concerns over access and costs of care have encouraged some deregulation. We empirically explore relaxed occupational rules of anesthesia care whereby physician-trained anesthesiologists and certified registered nurse anesthetists (CRNAs) perform overlapping services but often engage in joint production. After CRNAs were granted practice independence, we find only modest (3%) reductions in anesthesiologist billing for CRNA supervision and no evidence of greater use of CRNAs. Our results caution policymakers against overestimating the downstream impact resulting from removing these provider regulations.