A Review of New and Updated Professional Practice Documents
The American Association of Nurse Anesthetists (AANA) Practice Committee, in collaboration withAANA Professional Practice staff, annually applies a standardized evidence-based process to review, evaluate, and revise clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist). This article highlights several revised and newly developed documents, which include topics such as the standards for nurse anesthesia practice, office-based anesthesia practice, anesthesia for patients with substance use disorder, clinical privileges for CRNAs, ketamine infusion therapy, postanesthesia care, and medicationassisted therapy.
Keywords: Code of ethics, ketamine infusion therapy, medication-assisted therapy, postanesthesia care, standards of nurse anesthesia practice.
Each year, the American Association of Nurse Anesthetists (AANA) Practice Committee, in collaboration with AANA Professional Practice staff, reviews, evaluates, and revises clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist). The Practice Committee applies a standardized evidence-based process in the revision or development of new practice resources. The process entails a detailed literature review, assessment, evaluation, and synthesis to develop documents that have a sound evidentiary basis as well as reflect current and emerging nurse anesthesia clinical practice. Several types of documents are produced and housed in the Professional Practice Manual, including standards, guidelines, position statements, practice considerations, and policy considerations. All documents in the Professional Practice Manual undergo AANA Board of Directors’ approval. This article highlights several revised and newly developeddocuments, which can be accessedat www.aana.com/PracticeManual.
Standards for Nurse Anesthesia Practice
Revised in February 2019, the Standards for Nurse Anesthesia Practice provide a foundation for practice across all practice settings. These standards are intended to support the delivery of patient-centered, consistent, high-quality, and safe anesthesia care and to assist the public in understanding the CRNA’s role in anesthesia care. The revision of this document was a multiyear project for the Practice Committee and staff, which included an extensive literature search and review, benchmarking, analysis, drafting, and input from various stakeholders, including subject matter experts, legal counsel, and AANA members through an open comment period and multiple focus sessions. The essential elements of the standards include patients’ rights, which are prioritized as Standard 1 in the revised document; preanesthesia patient assessment and evaluation; the anesthesia care plan; informed consent; documentation; equipment; anesthesia plan implementation and management; monitoring and alarms; infection control and prevention; and transfer of care. The revision also includes the addition of new standards on wellness and the culture of safety. Office-Based Anesthesia Practice, Position Statement Revised in March 2019, this position statement affirms that CRNAs have long been the predominant anesthesia professional and leader in providing anesthesia services in physicians’ offices. Highlighted in this document are the unique and specific responsibilities to consider before administration of anesthesia in the office setting. In addition to the Standards for Nurse Anesthesia Practice, which apply to office-based practice, this position statement revised in March 2019, this position statement affirms that CRNAs have long been the predominant anesthesia professional and leader in providing anesthesia services in physicians’ offices. Highlighted in this document are the unique and specific responsibilities to consider before administration of anesthesia in the office setting. In addition to the Standards for Nurse Anesthesia Practice, which apply to office-based practice, this position statement contains 2 resource appendixes:
• Minimum Elements for Providing Anesthesia Services in the Office Based Practice Setting
• Anesthesia Equipment and Supplies Checklist
Analgesia and Anesthesia for the Patient With Substance Use Disorder, Practice Considerations
Revised in February 2019, this document, written jointly by the Practice and Peer Assistance Advisors committees, offers practice considerations for anesthesia professionals to provide safe care to patients with substance use disorder, whether alcohol or drugs and both active and remission states. Considerations include understanding of the disease of addiction in the patient-centered approach to care throughout the preanesthesia assessment and evaluation, development of a plan of care in collaboration with the patient and the interdisciplinary healthcare team, deployment of an opioid-sparing multimodal approach to managing pain, and responsible oversight that includes safe prescribing practices and discharge planning. To supplement this document, the 2017 Jan Stewart Memorial Wellness Lecture, titled “NonOpioid Anesthesia Considerations for Patients with Substance Use Disorder,” is available on AANALearn at https://shop.aana.com/. The course will enhance understanding of the acute and recovery phases of substance use disorder with knowledge of how to create an anesthesia care plan that supports the patient’s recovery efforts.
Clinical Privileges and Other Responsibilities of Certified Registered Nurse Anesthetists, Policy Considerations
Revised in February 2019, this policy considerations resource provides information about credentialing, privileging, and recommended clinical and nonclinical responsibilities of CRNAs. The current revision modernizes and aligns the content with the Scope of Nurse Anesthesia Practice and includes updated core and special privileges, such as inserting nasopharyngeal, nasogastric, or bougie tubes; performing a diagnostic lumbar puncture; performing a history and physical examination; inserting, monitoring, and interpreting a transesophageal echocardiogram; and performing, reading, and interpreting advanced diagnostic tests. Nonclinical responsibilities were also expanded to reflect the breadth of CRNA roles in facilities, including leadership and management, clinical and administrative oversight, quality assessment and improvement, and education, research, and interdepartmental liaison roles.
Postanesthesia Care, Practice Considerations
Revised in August 2019, this document highlights how CRNAs contribute to the postanesthesia care of the patient during handoff of care, postanesthesia care that may include analgesia, management of postoperative nausea and vomiting (PONV), airway management and resuscitation, discharge from the postanesthesia care unit (PACU), development of policies, and continuous quality improvement for staff education and improved processes. The CRNA role varies across practice settings and facilities in accordance with facility bylaws and policy as well as individual competencies. The AANA has developed these practice considerations to support the delivery of safe, consistent care of the patient in the postanesthesia period. These practice considerations address topics including the phases of postanesthesia care; transport and handoff to the PACU; multiple patient safety considerations (eg, multimodal pain management, PONV, obstructive sleep apnea, patients receiving opioids in the PACU, end-tidal carbon dioxide monitoring, postoperative delirium, residual neuromuscular blockade, malignant hyperthermia, infection control, and family/caregiver involvement); determining readiness for PACU discharge; and PACU staffing.
AANA and APNA Joint Position Statement on Ketamine Infusion Therapy for Psychiatric Disorders
Ketamine infusion therapy is increasingly being used to treat illnesses such as major depressive disorder, bipolar disorder, treatment-resistant depression, and posttraumatic stress disorder. In August 2019, the AANA and the American Psychiatric Nurses Association (APNA) released a joint position statement regarding ketamine infusion therapy with a focus on patient safety, positive outcomes, and general well-being. This statement outlines the important roles of psychiatric-mental health (PMH) nurses and CRNAs in providing ketamine infusion therapy for psychiatric disorders and provides crucial resources to support each provider. CRNAs are educated and trained to provide ketamine infusion therapy services to individuals with chronic and medication-resistant mental health disorders, collaborating with professionals such as PMH nurses, who specialize in the assessment, diagnosis, and treatment of PMH disorders. By leveraging the scope and standards of practice of both PMH nurses and CRNAs, these professionals collaborate to provide ketamine infusion therapy in a manner that promotes safe and effective treatment for patients. Two supplemental ketamine resources were also updated to support CRNAs and other clinicians who are interested in integrating ketamine infusion therapy into their practice.
• Ketamine Infusion Therapy for Psychiatric Disorders and Chronic Pain Management, Practice Considerationsa
• Ketamine Infusion Therapy Considerations Checklist
Additionally, visit AANA’s ketamine infusion resources page at www.aana.com/KetamineInfusion.
Code of Ethics for the Certified Registered Nurse Anesthetist
Revised in July 2018, the modernized Code of Ethics for the Certified Registered Nurse Anesthetist establishes the ethical standards for the nurse anesthesia profession and guides the CRNA in ethical analysis and decision making in daily nurse anesthesia practice. The substantial revisions and updates bring this document into the millennium by adding standards that address contemporary anesthesia care and addressing important areas of nurse anesthesia practice, such as leadership, research, and business. The Code of Ethics sets forth the ethical values and responsibilities of the individual CRNA and the profession of nurse anesthesia as expressed in broad principles of conduct and professional integrity; expresses the nurse anesthesia profession’s understanding of its commitment to society; applies to CRNAs in all practice roles (eg, clinical practice, nurse anesthesiarelated leadership, educational and research activities); and serves as a resource to the AANA Board of Directors in reviewing and acting on complaints of professional misconduct against members of the AANA.
Discharge After Sedation or Anesthesia on the Day of the Procedure: Patient Transportation With or Without a Responsible Adult, Position Statement and Policy Considerations
Adopted in July 2018, this document summarizes the AANA’s position and presents policy considerations for outpatient or same-day surgical settings regarding discharge planning specific to patient transportation. Noted as an increasing trend, patients are arriving for ambulatory surgical procedures with the intent to leave the facility unaccompanied after surgery. Many patients are turning to ride-share or taxi services to transport them to and from their healthcare visits. The AANA believes that patient safety is critical during any same-day procedure, particularly one requiring sedation or anesthesia. Patients should have a responsible adult who is able to safely transport the patient home, or a facility needs to establish policies and procedures if an exception is made. Patients should not be permitted to drive themselves home after the procedure or surgery, particularly if they received sedation or anesthesia. This resource details considerations for policy development to optimize postprocedure patient safety. Alternative policy considerations for various situations are presented, as each facility will establish policies that best serve its patients.
Certified Registered Nurse Anesthetists MedicationAssisted Treatment, Position Statement and Practice Considerations
Adopted in October 2018, this resource summarizes the requirements for the provision of medication-assisted treatment (MAT) services by CRNAs. The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was enacted on October 24, 2018. This act expanded earlier legislation in the 2016 Comprehensive Addiction and Recovery Act (CARA) to include CRNAs among providers able to prescribe MAT to individuals with opioid addiction. CRNAs may prescribe MAT in states where they have prescriptive authority, consistent with state law. CRNAs must provide MAT in accordance with their professional state-specific scope of practice, state and federal laws and regulations, and their respective facility’s institutional policies. Additionally, information on obtaining the MAT waiver and the application process can be found at www.aana.com/MAT.
This article highlights several recently updated AANA professional practice documents. All CRNAs, student registered nurse anesthetists, researchers, facility administrators, and other stakeholders are encouraged to review these and all other resources found at www.aana.com/PracticeManual. These resources should be used in conjunction with a CRNA’s clinical expertise and judgment in providing high-quality anesthesia services to patients. For questions or comments, please contact the AANA Professional Practice Division at firstname.lastname@example.org.
Jessica Poole, DNAP, CRNA, is a chief CRNA who focuses on outpatient anesthesia services. Dr Poole is chair of the fiscal year (FY) 2019 and FY 2020 Practice Committee. Ewa Greenier, MPH, MBA, CAE, is the AANA director of professional practice, providing staff support for Practice Committee activities. DISCLOSURES The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request.
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