A Ready Force: The U.S. Army Certified Registered Nurse Anesthetist Readiness Model.

The U.S. was at war for nearly two decades, supporting unprecedented survival on the battlefield. As the nation pivots to a relative peace, it is critical that U.S. Army certified registered nurse anesthetist (CRNA) leaders mitigate the loss of lessons learned and prepare future Army CRNAs for war. This article describes the U.S. Army CRNA Readiness Model that incorporates the knowledge, skills, and abilities required to sustain readiness. This model will provide U.S. Army nursing leaders with the framework to implement and evaluate solider readiness to provide anesthesia in operational environments.

Integrating the ASRA Pain Medicine Cannabis Consensus Guidelines into Certified Registered Nurse Anesthetist Clinical Practice.

The American Association of Nurse Anesthesiology Practice Committee and subject matter experts recently evaluated newly published cannabis guidelines titled "ASRA Pain Medicine Consensus Guidelines on the Management of the Perioperative Patient on Cannabis and Cannabinoids." A summative review of the evidence-based guidelines provides essential recommendations, which are directly applicable to certified registered nurse anesthetist clinical practice.

Entrustable Professional Activities: Can this Framework be Applied to Nurse Anesthesia Education to Assist in the Transition to Competency-Based Teaching?

Entrustable professional activities (EPAs) are the tasks or responsibilities which can be entrusted to a learner competent in that task to allow for unsupervised practice. The concept of EPAs is well documented in medical education literature, but only recently in nursing education. A paucity of literature exists on the application of an EPA framework specifically in nurse anesthesia. Based on the successful application of EPAs in competency-based medical and nursing education, we are of the opinion that this framework may also be utilized in the transition to competency-based education for nurse anesthesia learners. Many certified registered nurse anesthetists clinical preceptors lack training in competency-based education and teaching. The concept of EPAs may assist clinical preceptors in the translation of competencies and performance evaluation of learners. EPAs are defined for the nurse anesthesia clinical education setting. Examples of EPAs specific to nurse anesthesia include anesthesia machine checks, intubation, invasive line placement, regional anesthesia blocks, and preoperative assessment. Criteria of EPAs, barriers to use, and concrete examples are provided. Deliberate use of the EPA framework by clinical preceptors may lead to a more effective evaluation of the learner, thus resulting in purposeful progression to competence.

A Commitment to Quality: The History of Nurse Anesthesia Accreditation Part Two: 1983-2019.

In 1934, Gertrude Fife, President of the National Association of Nurse Anesthetists (NANA) sought to elevate the standards of anesthesia practice and standardize the education of nurse anesthetists. NANA members located schools, developed education standards and a school approval process, that eventually led to creation of the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) in 1975. Examination of historical documents demonstrated that COA developed into a well-known accreditation agency recognized by both governmental and non-governmental organizations, enhancing the standards of anesthesia education and promoting high-quality educational programs. Note: See the April 2020 issue of AANA Journal for Part One of this article.

Psychometric Testing of a Structured Assessment Instrument for Non-technical Skills (NANTS-no) for Use in Clinical Supervision of Student Nurse Anesthetists.

BACKGROUND: This study evaluated psychometric properties of a structured behavioral assessment instrument, Nurse Anaesthetists' Non-Technical Skills-Norway (NANTS-no). It estimated whether reliable assessments of nontechnical skills (NTS) could be made after taking part in a workshop. An additional objective was to evaluate the instrument's acceptability and usability. METHODS: An explorative design was used. Nurse anesthetists (n = 46) involved in clinical supervision attended a 6-hour workshop on NTS, then rated NTS in video-recorded simulated scenarios and completed a questionnaire. RESULTS: High reliability and dependability were estimated in this setting. Participants regarded the instrument as useful for clinical supervision of student nurse anesthetists (SNAs). CONCLUSIONS: Findings suggest that NANTS-no may be reliable for performing clinical assessments of SNAs and encouraging critical reflection. However, further research is needed to explore its use in clinical settings.

The Psychometric Analysis of an Instrument to Measure the Perceived Workload for Certified Registered Nurse Anesthetists.

BACKGROUND AND PURPOSE: In a previous study, the CRNA Workload Perception Scale (CWPS) was developed. The purpose of this study was to investigate the psychometrics of the CWPS. METHODS: The CWPS was tested in a population of CRNAs. This study was conducted in two phases. Phase I consisted of classical psychometrics; the 12-item instrument was piloted in a sample of 265 CRNAs. Phase II consisted of qualitative analysis to provide feedback on items that did not perform well. RESULTS: Phase I: Instrument demonstrated good reliability (r = .77). Parametric and nonparametric analysis indicated 6 of 12 items were good fit to measure perception of workload. PHASE II: Qualitative analysis resulted in refinement of four items, addition of one item, and elimination of two items. CONCLUSIONS: A revised 11-item CWPS was developed.

Association between leniency of anesthesiologists when evaluating certified registered nurse anesthetists and when evaluating didactic lectures.

Daily evaluations of certified registered nurse anesthetists' (CRNAs') work habits by anesthesiologists should be adjusted for rater leniency. The current study tested the hypothesis that there is a pairwise association by rater between leniencies of evaluations of CRNAs' daily work habits and of didactic lectures. The historical cohorts were anesthesiologists' evaluations over 53 months of CRNAs' daily work habits and 65 months of didactic lectures by visiting professors and faculty. The binary endpoints were the Likert scale scores for all 6 and 10 items, respectively, equaling the maximums of 5 for all items, or not. Mixed effects logistic regression estimated the odds of each ratee performing above or below average adjusted for rater leniency. Bivariate errors in variables least squares linear regression estimated the association between the leniency of the anesthesiologists' evaluations of work habits and didactic lectures. There were 29/107 (27%) raters who were more severe in their evaluations of CRNAs' work habits than other anesthesiologists (two-sided P < 0.01); 34/107 (32%) raters were more lenient. When evaluating lectures, 3/81 (4%) raters were more severe and 8/81 (10%) more lenient. Among the 67 anesthesiologists rating both, leniency (or severity) for work habits was not associated with that for lectures (P = 0.90, unitless slope between logits 0.02, 95% confidence interval -0.34 to 0.30). Rater leniency is of large magnitude when making daily clinical evaluations, even when using a valid and psychometrically reliable instrument. Rater leniency was context dependent, not solely a reflection of raters' personality or rating style.

The Role of a Certified Registered Nurse Anesthetist Led Acute Pain Service in Preventing Persistent Postoperative Opioid Use.

Given the present opioid crisis, the use of opioids in the hospital setting is an increasing concern among hospital administrators and healthcare professionals. A serious problem related to surgical care is persistent postoperative opioid use among previously opioid-naïve patients. Certified registered nurse anesthetists (CRNAs) are strategically positioned within the hospital setting to address these concerns. These individuals are actively involved in managing the pain of their patients and can therefore lead change in relation to the opioid crisis. This article profiles a multidisciplinary acute pain service developed in a Magnet redesignated hospital led by CRNAs that has demonstrated positive outcomes in decreasing the use of opioids postprocedure and postdischarge, education for healthcare providers, information for community members related to opioid abuse, and support of new protocols, including Enhanced Recovery After Surgery.

Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma "Go-Team".

OBJECTIVE: The R Adams Cowley Shock Trauma Center (STC) is Maryland's primary adult resource center for trauma care. The Shock Trauma "Go-Team" is a specialized component of Maryland's emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team. METHODS: A retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018. Go-Team call logs/records were identified from multiple sources. Medical records were reviewed for patient demographics, mechanisms of injury, and treatments in the field. There was a total of 61 activations, with 22 deployments to the scene of injury. RESULTS: The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required. CONCLUSION: The STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system.

Effects of opting-out from federal nurse anesthetists' supervision requirements on anesthesiologist work patterns.

OBJECTIVE: To estimate the impact of opting-out from Medicare supervision requirements for certified registered nurse anesthetists (CRNAs) on anesthesiologists' work patterns. DATA SOURCES/STUDY SETTING: Secondary data from two national surveys of anesthesiologists and the Area Health Resource File. STUDY DESIGN: We use a matching difference-in-difference regression which contrasts the change in work patterns for anesthesiologists in California, which dropped supervision requirements, to the change for similar anesthesiologists. Key outcome variables include the number of weekly hours worked, the type of work done, and type of care delivery teams. DATA COLLECTION/EXTRACTION METHODS: Self-reported national survey data drawn from members of the American Society of Anesthesiologists. PRINCIPAL FINDINGS: Anesthesiologists in California saw no change in time spent working or time spent supervising CRNAs. There was a decrease in direct care clinical work hours along with a shift in working more in intraoperative care, a decrease in postoperative care, and an increase in the percentage of cases supervising residents. CONCLUSIONS: Anesthesiologists had small but real responses to California's decisions to opt-out of the physician supervision requirement for CRNAs, doing more work in intraoperative care and less outside of the operating room. Total hours worked saw no change.

Accuracy of Visually Estimated Blood Loss in Surgical Sponges by Members of the Surgical Team.

It is important that operating room personnel monitor the correct amount of blood loss during surgery in order to properly replace lost volume. The aim of this study was to investigate the accuracy of operating room personnel in visually estimating blood loss in surgical sponges. We performed an observational study with comparative descriptive design at a university hospital including all members of the surgical team. In total, 163 observations were completed. The participants estimated the amount of blood in surgical sponges in 4 stations with varying amounts of blood and/or numbers of sponges. Data were analyzed using the Wilcoxon signed rank, Kruskal-Wallis, and Mann-Whit-ney tests. Both overestimations and underestimations occurred. Underestimations dominated and tended to increase with major amounts of blood. Operating room personnel miscalculated the amount of blood by a median value of 30% regardless of profession, years of experience, and self-assessed ability about visual estimation. This study highlights that assessments of patients' conditions can be partially based on methods often demonstrated to be inaccurate. Inaccurate visual estimation of blood loss might endanger patient safety.

Ultrasound-guided Intravenous Line Placement Course for Certified Registered Nurse Anesthetists: A Necessary Next Step.

Ultrasonography (US) proficiency has become a desirable skill for anesthesia providers. It is commonly used in the perioperative arena for establishing peripheral and central vascular access. Establishing intravenous access is one of the most common procedures performed by Certified Registered Nurse Anesthetists (CRNAs) as frontline anesthesia providers. However, there is no structured US training program for CRNAs for vascular access at our institution. We designed and implemented a multimodality US training program specifically for the use of surface US for central and peripheral vascular access for CRNAs. The course was conducted over 2 days and consisted of an online self-paced didactic component, integrated proctored hands-on workshops, and a posttraining examina-tion to quantify knowledge gain. Twenty-five CRNAs attended the course, with significant improvement in knowledge (pretest mean (SD) score = 59.13% (15.74%) vs posttest mean score = 70.0% (9.43%), P = .03). Two weeks after the course, each participant reported that they attempted 1.46 (1.56) ultrasound-guided vascular access procedures on average. Therefore, it is feasible to design short, focused, multimodality training programs for proficiency in the use of surface US for obtaining venous access. The CRNA's proficiency in US is likely to improve efficiency, patient experience, and safety.

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.

It's not you, it's the design - common problems with patient monitoring reported by anesthesiologists: a mixed qualitative and quantitative study.

BACKGROUND: Patient monitoring is critical for perioperative patient safety as anesthesiologists routinely make crucial therapeutic decisions from the information displayed on patient monitors. Previous research has shown that today's patient monitoring has room for improvement in areas such as information overload and alarm fatigue. The rationale of this study was to learn more about the problems anesthesiologists face in patient monitoring and to derive improvement suggestions for next-generation patient monitors. METHODS: We conducted a two-center qualitative/quantitative study. Initially, we interviewed 120 anesthesiologists (physicians and nurses) about the topic: common problems with patient monitoring in your daily work. Through deductive and inductive coding, we identified major topics and sub themes from the interviews. In a second step, a field survey, a separate group of 25 anesthesiologists rated their agree- or disagreement with central statements created for all identified major topics. RESULTS: We identified the following six main topics: 1. "Alarms," 2. "Artifacts," 3. "Software," 4. "Hardware," 5. "Human Factors," 6. "System Factors," and 17 sub themes. The central statements rated for the major topics were: 1. "problems with alarm settings complicate patient monitoring." (56% agreed) 2. "artifacts complicate the assessment of the situation." (64% agreed) 3. "information overload makes it difficult to get an overview quickly." (56% agreed) 4. "problems with cables complicate working with patient monitors." (92% agreed) 5. "factors related to human performance lead to critical information not being perceived." (88% agreed) 6. "Switching between monitors from different manufacturers is difficult." (88% agreed). The ratings of all statements differed significantly from neutral (all p < 0.03). CONCLUSION: This study provides an overview of the problems anesthesiologists face in patient monitoring. Some of the issues, to our knowledge, were not previously identified as common problems in patient monitoring, e.g., hardware problems (e.g., cable entanglement and worn connectors), human factor aspects (e.g., fatigue and distractions), and systemic factor aspects (e.g., insufficient standardization between manufacturers). An ideal monitor should transfer the relevant patient monitoring information as efficiently as possible, prevent false positive alarms, and use technologies designed to improve the problems in patient monitoring.

Nurse Anesthetists' Communication in Brief Preoperative Meeting With Orthopaedic Patients-An Interview Study.

PURPOSE: To explore the experience of preoperative communication of nurse anesthetists (NAs) in brief meetings with patients in an orthopaedic setting. DESIGN: Qualitative research. METHODS: Three group interviews based on experiences of 18 NAs were conducted. Content data analysis was used. FINDINGS: The brief communication was characterized by both difficulties and opportunities. Protecting the patient's integrity, informing worried patients, lack of routines, language difficulties, being present at the meeting, protecting the patient from disturbance, and encouraging the patient to participate were stated as the main challenges in the brief meeting with patients. The NAs also gave some suggestions for improvement. CONCLUSIONS: The Preoperative meetings need to be developed and structured to improve communication. A way to assess the results of this conversation should be developed. Other recommendations include finding a way to improve patient involvement in this dialogue and development of skills of NAs to enhance the meeting for patients.

Validating international CanMEDS-based standards defining education and safe practice of nurse anesthetists.

AIM: To investigate whether the CanMEDS-based International Federation of Nurse Anesthetists' Standards could adequately define the scope of practice and reliably be used to train and evaluate Swiss nurse anesthetists (NAs). BACKGROUND: Although nurse anesthetists represent a majority of the global workforce in anesthesia, policies that define the scope of practice are frequently non-existent. In low- and middle-income countries, the lack of anesthesia providers with adequate training is a major challenge. INTRODUCTION: Despite stringent training requirements, the scope of practice of Swiss nurse anesthetists is actually not defined. Therefore, we surveyed and assessed whether nurse anesthetists felt that the professional competencies outlined in this framework were aligned with their clinical practice. METHODS: A cross-sectional survey investigated Swiss nurse anesthetists' relevance ratings of 76 competencies of the International Federation of Nurse Anesthetists according to their professional practice. Cronbach's alpha coefficients were used to determine the internal consistency of the competencies, as well as factor analyses to assess construct validity of these competencies integrated into the CanMEDS roles model. RESULTS: Participants rated the Standards overall as very relevant with high reliability. Factor analyses provided evidence of construct validity of these. DISCUSSION: The International Federation of Nurse Anesthetists' Standards of Practice provide a highly relevant framework and a valuable set of competencies for the scope of practice of Swiss nurse anesthetists, which enabled translation from global guides to local national standards. CONCLUSION AND IMPLICATION FOR NURSING AND HEALTH POLICY: Adopted by low- and middle-income countries or countries where national standards are non-existent, this survey could introduce national and local policies at minimally acceptable standards of care for nurse anesthetists worldwide. The above standards have the potential to align education, outcomes and assessment of nurse anesthetists with the needs of national healthcare systems.

Swedish Operating Room Nurses and Nurse Anesthetists' Perceptions of Competence and Self-Efficacy.

PURPOSE: To compare perceived competence and self-efficacy (SE) among Swedish operating room (OR) nurses and registered nurse anesthetists (RNAs), and to evaluate the relationship between SE and competence, gender, age, and years of experience. DESIGN: Comparative cross-sectional survey. METHODS: Two validated questionnaires, Perceived Perioperative Competence Scale-Revised and General Self-Efficacy Scale, were sent to members of the Swedish Association of Health Professionals (n = 2,902). FINDINGS: The response rate was 39% (n = 1,033). OR nurses showed significantly higher scores on Perceived Perioperative Competence Scale-Revised subscale foundational knowledge and leadership as well as General Self-Efficacy Scale scores compared with RNAs. The RNA group showed significantly higher empathy scores compared with OR nurses. Among the OR nurses professional development made the strongest contribution to SE and proficiency among the RNAs. CONCLUSIONS: These results suggest that there are differences in perceived competence and SE between OR nurses and RNAs. Gender may be an independent factor affecting SE.

Improving infection control practices of nurse anesthetists in the anesthesia workspace.

BACKGROUND: Anesthesia providers commonly cross-contaminate their workspace and subsequently put patients at risk for a health care-acquired infection. The primary objective of this project was to determine if education and implementation of standardized infection control guidelines that address evidence-based best practices would improve compliance with infection control procedures in the anesthesia workspace. METHODS: Patient care-related hand hygiene of nurse anesthetists was observed in 3 areas of anesthesia practice before and 3 weeks and 3 months after staff education, placement of visual reminders, and the implementation of infection control guidelines. After the observation periods, the percent compliance on the part of the providers was calculated for each of the 3 areas of anesthesia practice, and the results were compared using the Fisher exact test. RESULTS: There were a total of 95 observations performed during the 3 observation periods. When compared with preimplementation baseline data, there was a 26.2% increase in the number of providers compliant with hand hygiene practices after airway instrumentation (P = .029) and a 71.9% increase in the number of providers who separated clean from contaminated items in the workspace (P = .0001). CONCLUSIONS: Education, visual reminders, and standardized infection control guidelines were shown to improve compliance with infection control best practices in a group of nurse anesthetists.

Electronic Audit and Feedback With Positive Rewards Improve Anesthesia Provider Compliance With a Barcode-Based Drug Safety System.

BACKGROUND: We implemented a previously described barcode-based drug safety system in all of our anesthetizing locations. Providers were instructed to scan the barcode on syringes using our Anesthesia Information Management System before drug administration, but the rate of provider adherence was low. We studied an implementation intervention intended to increase the rate of scanning. METHODS: Using our Anesthesia Information Management System and Smart Anesthesia Manager software, we quantified syringe drug administrations by anesthesia providers with and without barcode scanning. We use an anesthesia team model in which an attending anesthesiologist is paired with a certified registered nurse anesthetist (CRNA) or a resident. Our system identified the pair of providers associated with a particular drug administration, but did not distinguish which providers actually administered the drug. Therefore, the rate of barcode scanning for a particular case was assigned to both providers equally. A baseline rate of scanning was established over a period of 17 months. An audit and feedback intervention was then performed that consisted of monthly performance reports sent by email to individual providers along with coffee gift card awards for top performers. The coffee gift cards were awarded in only the first 2 months of the intervention, while the email performance reports continued on a monthly basis. The coffee card awards were made public. The monthly emails reported the individual provider's rank order of performance relative to other providers, but was otherwise anonymous. The baseline rate of scanning was compared to the rate of scanning after the intervention for a period of 7 months. RESULTS: From November 2014 to March 2017, we accumulated 60,197 cases performed by 88 attending anesthesiologists, 65 CRNAs, and 148 residents. The total number of syringe drug administrations was 653,355. Average scanning performance improved from 8.7% of syringe barcodes scanned during the baseline period from November 2014 to February 2016 to 64.4% scanned during the period September 2016 to March 2017 (P < .001). Variation in performance among individuals was marked, ranging from 0% to 100% of syringes scanned. The performance of some individuals showed marked oscillation over time. There was greater variation in performance attributable to residents than in performance attributable to CRNAs. CONCLUSIONS: Feedback of individual provider performance data from the anesthesia information system to providers can be used in conjunction with other measures to improve performance. Despite improved average performance, there was marked variation in performance between individuals, and some individuals had marked oscillation of their performance over time.