EXAM 1 - Lec 1 - Scope of Practice & Standards of Care

Anesthesiology is both ___ and ___

An art and a science

How do we render patients insensitive to pain?

-Anesthetic agents and related drugs
-Procedures e.g. GETA, RA, local MAC

What types of services are included in anesthesia and anesthesia related care? Example.

Services upon request or referral by physician/healthcare professional
-Epidural blood patch for spinal headache after a myelogram

T/F CRNAs are certified to diagnose.

False

T/F When a CRNA performs an anesthetic, it is the practice of medicine.

False... the practice of nursing :)

What was the purpose of the AMA Committee on Nursing developed in 1970? (3)

1. To define nursing
2. Gain control of the healthcare system
3. Define anesthesiology as a practice of nursing vs. medicine depending on who performs the anesthetic (ASA did not like this)

The unique role of anesthesia is physiologic ____, ____, and _____

1. Support
2. Monitoring
3. Intervention

T/F The surgeon is responsible for the patient's anatomy , and the anesthetist is responsible for the patient's physiology.

True

What is the definition of the medicine?

The practice of DIAGNOSING, PREVENTING, and TREATING illness and disease

Does the role of anesthesia involve a Diagnostic or Cure paradigm?

No...the role of anesthesia is not a diagnostic or cure paradigm

What is the essence of anesthesia?

-SUPPORT the physiologic functions of the patient
-MONITORING
-INTERVENTION

T/F Support provided by anesthesia is the epitome of intensive care and CRNAs excel as critical care nurses.

Hell yes!!!

What do we primarily monitor in anesthesia? (3)

-V/S
-Physiologic parameters
-Adjusting anesthetic
*
The best monitor in the OR is the anesthetist
*

What is "intensely intensive care"?

Anesthesia

What have been found by numerous studies regarding anesthetic care provided by CRNAs?

CRNAs are safe and provide high quality care WITHOUT physician supervision

Who is Robert Stoelting?

An esteemed MD in the anesthesia world who supports that CRNAs are just as good as MDAs in providing anesthesia care to individuals

Do standards of anesthetic care differ between the AANA and ASA?

Nope... they are the same, but just different wording

No where within nursing and medicine is there a greater overlap then in the field of ____

anesthesiology

What is the oldest nursing specialty?
-What preceded medical specialty?

NURSE ANESTHESIA!!!

When did anesthesiologists come into profession?

After WWII
-CRNAs were the sole provider of anesthesia from the late 1870s until after WWII
-CRNAs played a crucial role in the delivery of anesthesia in combat areas in every war

T/F There were more anesthesiologists than CRNAs in WWII, Vietnam and the Panama strike?

False!
WWII= 17:1 CRNA to anesthesiologist
Vietnam= 3:1
Panama strike= CRNA only

How many states require
anesthesiologist
supervision of CRNAs?

0

How many states require some
physician
supervision for CRNAs?

17

How many states do not require physician supervision for CRNAs?

33

Does JCAHO or Medicare require anesthesiologist supervision of CRNAs?

No

What does Medicare require? How do certain states get around that?

Medicare requires physician supervision of CRNAs UNLESS you are in an opt out state

How many states have selected to opt-out of the physician supervision of CRNAs?

17
(yet no increase in the number of patients dying!)

What is most limiting to the CRNA scope of practice?

Individual facility bylaws
-Can require supervision of CRNAs
-These restrictions denied some patients access to full scope of anesthesia practices

What are restrictive CRNA practice bylaws done in the interest of?

Control
(NOT in the interest of patient care or OR efficiency)

What are the 7 code of ethics established by the AANA?

1. Responsibility to our Patients
2. Competence
3. Responsibilities as a Professional
4. Responsibilities to Society
5. Endorsement of Products and Services
6. Research
7. Business Practices

-Preserving human dignity
-Respecting the moral and legal rights
-Supporting safety and well being
...fall under which code of ethics?

Responsibility to our Patients

What are involved in the support of patient safety and well being? (5)

-Provide quality care
-Protect patient from harm (our primary priority)
-Avoid conflicts between personal integrity and patient rights
-Protect patient from incompetent/impaired health care professionals
-Do not deceive or violate the trust of the patient

To remain competent as a CRNA, what three things must one maintain?

1. RN license
2. State advanced practice statutory or regulatory requirements
3. Recertification

What 2 other things are also involved in promoting competency of the CRNAs?

-Life long learner
-Quality improvement activities (must attend 2 professional education activities)

What are professional responsibilities?

-Judgments and actions as a licensed professional
-Professional practice standards
-Contribute to the profession and body of knowledge
-Conduct, integrity, and dignity of the profession as a whole

Why do CRNAs collaborate?

To promote highly competent, safe, quality care

T/F The AANA has never endorsed any product or service

True

When should a CRNA endorse a product/service?

Only when personally satisfied with the product, quality, service

How do we protect integrity of the research process?

-Evaluates research
-Conducts ethical research
-Participates in research activities

How do CRNAs maintain ethical business?

Contractual obligations (whether verbal or written commitment) are consistent with professional standards of practice

What are the four general categories in which cRNAs give care?

1. Preanesthetic preparation
2. Anesthesia induction, maintenance, and emergence
3. Postanesthesia care
4. Perianesthetic and clinical support

What are the Scope of nurse anesthesia practice? (11)....LONG

1. Preanesthesia assessment and evaluation
-Request consultations
-Order diagnostic tests
-Obtain informed consent
2. Develop and implement an anesthesia plan
-Select, obtain, and administer preoperative medications and fluids
3. Anesthesia techniques wit

What are the additional responsibilities of the CRNAs?

- Administration/management: scheduling, staff supervision, managerial management, policy development, procedure guidelines
-Quality assessment: data collection/trending, committee meetings
- Education: academic or clinical settings
- Research
- Committee

What should students practice according to when in clinical?

The standards and guidelines of the Council of Accreditation of Nurse Anesthesia Education Programs (COA)

Why did the AANA develop Standards of Care for nurse anesthesia practice? (3)

1. Offers guidance for us and institutions as to what nurse anesthesia practice is
2. Addresses responsibilities of quality anesthetic practice
3. Calls for collaboration with other healthcare providers

Why do we have the standards of care?
(4)

1. Assist us to evaluate the quality of care provided by all practitioners...QUALITY IMPROVEMENT
2. Provides a common base for development of quality of anesthetic practice
3. Assist the public in understanding what to expect from the practitioner...HOLD

What must we do when there is a deviation from the AANA standards?

DOCUMENT any deviation and state reason for deviation

What are standards?

Authoritative statements that describe the minimum rule and responsibility for which we are accountable

What govern standards of care? (3)

o Your expertise
o State statues and regulations
o Institutional policy - can restrict scope of practice

Are AANA position statements and guidelines considered standards of care?

No

What must be ensure when performing preanesthesia assessment?

Relevant tests obtained and reviewed

Why does informed consent require a qualified professional?

Informed consent requires explanation of risks vs. benefits of different options, therefore requiring a CRNA/MDA not a nurse

T/F Informed consent can be written, verbal or implied?

True
(Implied in an emergency situation)

What must be explained to the pt with anesthesia informed consent?

1. Risks
2. Benefits
3. Options
*Document informed consent such as "discussed benefits and risks of GETA versus subarachnoid block. Patient agreed to GETA

What is considered when developing a patient specific plan for anesthesia care?

-Comorbidities
-Surgical procedure
-Surgeon's preference
-Pt's preference

What should be turned on and audible in ALL patients when any physiologic monitoring device is used?

-Variable pitch and low threshold alarm
-Do NOT silence an alarm (they are there for a reason)

How do we verify intubation?

-
EtCO2
-Chest rise and fall
-Breath sounds
-Visualize the tube going thru the cords

How do we verify ventilation?

-EtCO2
-Peak inspiratory pressures

How do we monitor oxygenation continuously?

-Pulse Ox for ALL patients
-Color of mucous membrane, skin, blood
-ABGs if necessary

How do we monitor CV status continuous?

-ECG for ALL patients q5min (lead II and V5)
-Obtain VS q3min and record VS q5min
-Listen to heart sounds with precordial stethoscope (esp. in peds)

In what populations are continual monitoring of body temp important?
-What type of body temp measurement should we use?

1. Peds
2. Anybody who is receiving an agent that can trigger MH (therefore always monitor temp when using VAs or SCh)
-Use core temp

What must we monitor if using NMBAs for a surgical case?

Neuromuscular function and status to assess depth of blockade and degree of receovery

Is it important to assess patient positioning and protective measures?

Yes

What is the hallmark of safe anesthesia care?

Vigilance

What are some synonyms for vigilance?

Alertness
Attention
Watchfulness

Who determines when a pt can be discharged from the PACU?

CRNAs/anesthesiologists

What is the definition of a standard?

-Established by authority, custom or general consent
-Set up as an example or rule (measure of quality, extent, value or quantity)
-Serves as benchmark for what is expected behavior of the professional

Who is responsible for developing standards of care?

Members within the profession (us!)

How do we as a profession develop standards of care? (2)

Must develop standards based on 1) consensus and 2) scientific evidence of positive patient outcomes

What's the purpose of an expert witness?

-Provide testimony
-Make factual determination

What's important to remember if you become an expert witness?

Refer to professional association statements (refer to the literature or standards of care)

What standards of care (numbers) is documentation mentioned?

Standard VI
Standard VIII
(Also I, II and V, but he did not point that out in class)

What are the purposes of proper charting?

-Facilitates comprehensive patient care
-Allows for retrospective review
-Legal docs in courts

What is the basic core of info that must be documented?

1. Pt ID
2. Provider info, credentials
3. Equipment checks
4. Minimal monitors
5. Techniques ("as requested by surgeon")
6. Meds- ALWAYS!
7. Intake and output
8. Procedural data

T/F One should use a trailing zero in documentation?

False
("Always lead / never follow")