AANA Journal April 2013 Volume 81 Number 2 : Page92

PRACTICE NEWS Michael Neft, CRNA, DNP, MHA, LTC(ret), USA Jihan A. Quraishi, RN, MS Ewa Greenier, MPH, MBA A Closer Look at the Standards for Nurse Anesthesia Practice As part of its ongoing work, the AANA’s Practice Com-mittee reviewed the Scope and Standards for Nurse Anesthesia Practice, particularly focusing on the Stan-dards for Nurse Anesthesia Practice. Revisions and updates were made to the standards to ensure clarity and reflect current anesthesia practice. This article high-lights several of the important revisions made to the Standards for Nurse Anesthesia Practice, specifically focusing on the importance of documentation, updates to Standard V–Patient Monitoring, and changes to other documents affected by the updates. This is not an exhaustive discussion of all changes made to the docu-ment. The updated Standards for Nurse Anesthesia Practice are presented in their entirety. Keywords: Documentation, nurse anesthesia practice, patient monitoring, practice committee, standards of practice Background As part of the AANA’s evidence-based process, the Practice Committee reviewed the Scope and Standards for Nurse Anesthesia Practice . Due to the robust nature of this document, priority review was given to the Standards for Nurse Anesthesia Practice , which were reviewed in a quantitative literature analysis approach. The final version of the Standards for Nurse Anesthesia Practice was approved by the AANA Board of Directors in January 2013. Future work on the Scope for Nurse Anesthesia Practice will be con-ducted using a qualitative approach by the Practice Committee. The original composition of the document included eleven standards with corresponding interpretive language. The committee’s goals were to ensure that the standards reflect current standards of practice and to add clarity to the document. Most revisions enhance the clarity of the standards without substan-tially changing their meaning. The end result is a more streamlined and updated set of standards, with minimal interpretive language. The updated Standards for Nurse Anesthesia Practice are available on the public side of the AANA’s website (www.aana.com), under Resources > Professional Practice > Professional Practice Manual. arching principle that applies to all of the standards. Accurate, complete, legible, and timely documentation on a patient’s anesthesia record ensures a written testimony of the occurrences of the case and allows for monitoring of quality. Standard V–Patient Monitoring The most substantive change to the standards was in Standard V, which focuses on patient monitor-ing. Standard V is the only standard which retained an interpretation section. The interpretation contains additional guidance for Certified Registered Nurse Anesthetists (CRNAs) regarding monitoring. Particularly, the interpretation indicates that “Consistent with the CRNA’s professional judgment, additional means of monitoring the patient’s status may be used depend-ing on the needs of the patient, the anesthesia administered, or the sur-gical technique or procedure being performed.” The monitoring stan-dards set out in Standard V are the What Are the Changes to the Standards? Documentation Documentation has always played a vital role in nurse anesthesia practice. The importance of docu-mentation is emphasized throughout the standards. The preamble high-lights that there may be times when an exceptional patient-specific deviation from a standard occurs, such as the inability to obtain patient informed consent in an emergency situation. The patient-specific reasons for the deviation are to be noted on the patient’s anes-thesia record. Documentation of a deviation from a standard is an over-92 AANA Journal „ April 2013 „ Vol. 81, No. 2 www.aana.com/aanajournalonline

Practice News

Michael Neft, CRNA, DNP, MHA, LTC(ret), USA Jihan A. Quraishi, RN, MS Ewa Greenier, MPH, MBA

A Closer Look at the Standards for Nurse Anesthesia Practice

As part of its ongoing work, the AANA's Practice Committee reviewed the Scope and Standards for Nurse Anesthesia Practice, particularly focusing on the Standards for Nurse Anesthesia Practice. Revisions and updates were made to the standards to ensure clarity and reflect current anesthesia practice. This article highlights several of the important revisions made to the Standards for Nurse Anesthesia Practice, specifically focusing on the importance of documentation, updates to Standard V–Patient Monitoring, and changes to other documents affected by the updates. This is not an exhaustive discussion of all changes made to the document. The updated Standards for Nurse Anesthesia Practice are presented in their entirety.

Keywords: Documentation, nurse anesthesia practice, patient monitoring, practice committee, standards of practice

Background

As part of the AANA's evidence-based process, the Practice Committee reviewed the Scope and Standards for Nurse Anesthesia Practice. Due to the robust nature of this document, priority review was given to the Standards for Nurse Anesthesia Practice, which were reviewed in a quantitative literature analysis approach. The final version of the Standards for Nurse Anesthesia Practice was approved by the AANA Board of Directors in January 2013. Future work on the Scope for Nurse Anesthesia Practice will be conducted using a qualitative approach by the Practice Committee.

The original composition of the document included eleven standards with corresponding interpretive language. The committee's goals were to ensure that the standards reflect current standards of practice and to add clarity to the document. Most revisions enhance the clarity of the standards without substantially changing their meaning. The end result is a more streamlined and updated set of standards, with minimal interpretive language. The updated Standards for Nurse Anesthesia Practice are available on the public side of the AANA's website (www.aana.com), under Resources > Professional Practice > Professional Practice Manual.

What Are the Changes to the Standards?

Documentation

Documentation has always played a vital role in nurse anesthesia practice. The importance of documentation is emphasized throughout the standards. The preamble highlights that there may be times when an exceptional patient-specific deviation from a standard occurs, such as the inability to obtain patient informed consent in an emergency situation. The patient-specific reasons for the deviation are to be noted on the patient's anesthesia record. Documentation of a deviation from a standard is an overarching principle that applies to all of the standards. Accurate, complete, legible, and timely documentation on a patient's anesthesia record ensures a written testimony of the occurrences of the case and allows for monitoring of quality.

Standard V–Patient Monitoring

The most substantive change to the standards was in Standard V, which focuses on patient monitoring. Standard V is the only standard which retained an interpretation section. The interpretation contains additional guidance for Certified Registered Nurse Anesthetists (CRNAs) regarding monitoring. Particularly, the interpretation indicates that "Consistent with the CRNA's professional judgment, additional means of monitoring the patient's status may be used depending on the needs of the patient, the anesthesia administered, or the surgical technique or procedure being performed." The monitoring standards set out in Standard V are the minimum requirements established for patient monitoring. As a CRNA monitors a patient's status throughout a case, additional techniques (eg, use of precordial stethoscope, spirometry) may be used at the discretion of the CRNA as an additional means of monitoring to ensure patient safety. Noteworthy changes to Standard V subsections include the update of the ventilation, cardiovascular, thermoregulation, and neuromuscular monitoring standards.

Ventilation

The ventilation standard underwent one major conceptual change. Given the patient safety implications that sedation may have on patients, the ventilation monitoring standard now states "during moderate or deep sedation, continuously monitor for the presence of expired carbon dioxide." Overall, continuous ventilation monitoring requires vigilance by means of observational and quantitative assessments. Quantitative methods should also be used to confirm carbon dioxide (CO2) in the expired gas, which assumes that ventilation and perfusion are appropriately matched. Measurement of CO2 assists in determining the adequacy of ventilation, verifies tracheal intubation, identifies esophageal intubation, alerts anesthesia professionals when a patient has been disconnected from the breathing circuit, and supports the diagnosis of circulatory problems.1-3

Sedation occurs on a continuum depending on the patient status and pharmacologic response to a drug; therefore, it is often difficult for a clinician to determine when a patient may transition from moderate to deep sedation. Several randomized control studies investigating the use of end tidal carbon dioxide (ETCO2) monitoring during moderate or deep sedation showed that ETCO2 monitoring was critical in determining whether clinicians could identify respiratory depression.4-6 The researchers determined that an absolute ETCO2 change from baseline greater than 10% would identify twice as many hypoxic patients, indicating that patients who develop hypoxia have preceding ETCO2 changes.5,6 Similar findings in the pediatric population were also identified.7,8 When administering moderate and deep sedation, a CRNA shall monitor for the presence of expired carbon dioxide as a patient safety measure unless a patient-specific circumstance, procedure or technology invalidates this monitoring technique. If a patient-specific exception to the ability to monitor should occur, the deviation to the standards must be documented on the patient's medical record.

Cardiovascular

During the standards review process, the cardiovascular monitoring standard was rephrased to add clarity and reflect current practice. The standard states to "Continuously monitor cardiovascular status via electrocardiogram. Perform auscultation of heart sounds as needed. Evaluate and document blood pressure and heart rate at least every five minutes." Anesthesia professionals must be concerned about circulation and cardiac function during procedures. At a minimum every patient undergoing anesthesia should have continuous electrocardiogram (ECG), and arterial blood pressure measurements with heart rate monitored and evaluated every 5 minutes.9 Additional cardiovascular monitoring techniques should be used at the discretion of the anesthesia professional depending on surgical and/or patient need or risk factors. Anesthesia professionals must be prepared to deal with anesthesia related complications such as arrhythmias, myocardial ischemia, intraoperative hypotension, and hemodynamic alterations.

Thermoregulation

Both general and regional anesthesia cause thermoregulatory changes and heat imbalance compromising both thermoregulatory compensation and/or impairing central and peripheral thermoregulatory control. The thermoregulation standard was further clarified to denote that temperature monitoring applies to all populations "when clinically significant changes in body temperature are intended, anticipated, or suspected." All patients should be assessed for risk factors for hypothermia, depending on skin exposure in relation to environmental temperatures, patient characteristics, procedure, and anesthesia used. As such, the determination of temperature monitoring is multi-factorial. Passive or active warming interventions should take place contingent upon procedure and at the discretion of the anesthesia professional and surgical team.

Neuromuscular

The neuromuscular monitoring standard was also refined to state "when neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery." The use of neuromuscular blocking agents (NMBAs) has been shown to be associated with a statistically significant increase in hypoxic events after extubation, reintubation, and unplanned ICU admission.10 The use of NMBAs has also been associated with complications such as postoperative residual curarization (PORC). The impact of PORC may lead to prolonged intubation times, muscle weakness, and respiratory complications.11,12 In literature reviews, several authors noted that residual paralysis, following a neuromuscular blockade as indicated by a train-of-four ratio of 0.7 to 0.9, is associated with upper airway muscle weakness leading to impaired pharyngeal function, airway obstruction, and possible risk for aspiration and hypoxia.12-15 The authors suggest that managing neuromuscular block is an essential patient safety strategy.

Additional Documents Affected

Three documents in the Professional Practice Manual for the Certified Registered Nurse Anesthetist quote the standards. The Postanesthesia Care Standards for the Certified Registered Nurse Anesthetist, Standards for Office Based Anesthesia Practice, and Guidelines for the Management of the Obstetrical Patient for the Certified Registered Nurse Anesthetist were updated to reflect the approved standards. Edits were only made to the documents if they were warranted due to a standards revision.

An update was made to the Postanesthesia Care Standards for the Certified Registered Nurse Anesthetist to clarify that Standard VII is not specific to postanesthesia care, but includes all transfers of the responsibility of care for the patient from the CRNA to another qualified healthcare provider.

The Standards for Office Based Anesthesia Practice were updated with all of the approved standards. Given the revisions to several of the monitoring standard subsections, application to office practice of Standard V was expanded to state "Minimum monitors in the office based setting include: pulse oximetry; electrocardiogram; blood pressure; O2 analyzer when O2 is delivered through the breathing system of the anesthesia machine; end-tidal CO2 when administering general anesthesia; a monitor for the presence of expired carbon dioxide when administering moderate or deep sedation; a body temperature monitor when clinically significant changes are intended, anticipated, or suspected; and peripheral nerve stimulator as indicated when administering neuromuscular blocking agents."

Lastly, the standards were updated in the appendix of the Guidelines for the Management of the Obstetrical Patient for the Certified Registered Nurse Anesthetist. No additional changes were made to the remainder of this document.

All three of these documents will be reviewed in their entirety and revised accordingly in the future based on their prioritization schedule for the Practice Committee.

Final Version of the Standards for Nurse Anesthesia Practice

These standards are intended to:

1. Assist the profession in evaluating the quality of care provided by its practitioners.

2. Provide a common base for practitioners to use in their development of a quality practice.

3. Assist the public in understanding what to expect from the practitioner.

4. Support and preserve the basic rights of the patient.

These standards apply to all anesthetizing locations and may be exceeded at any time at the discretion of the CRNA. Although the standards are intended to promote high-quality patient care, they cannot ensure specific outcomes. The CRNA should consider the integration of new technologies into current anesthesia practice.

There may be exceptional patient-specific circumstances that require deviation from a standard. The CRNA shall document any deviations from these standards (eg, emergency cases for which informed consent cannot be obtained, surgical interventions or procedures that invalidate application of a monitoring standard) and state the reason for the deviation on the patient's anesthesia record.

Standard I

Perform and document a thorough preanesthesia assessment and evaluation.

Standard II

Obtain and document informed consent for the planned anesthetic intervention from the patient or legal guardian, or verify that informed consent has been obtained and documented by a qualified professional.

Standard III

Formulate a patient-specific plan for anesthesia care.

Standard IV

Implement and adjust the anesthesia care plan based on the patient's physiologic status. Continuously assess the patient's response to the anesthetic, surgical intervention, or procedure. Intervene as required to maintain the patient in optimal physiologic condition.

Standard V

Monitor, evaluate, and document the patient's physiologic condition as appropriate for the type of anesthesia and specific patient needs. When any physiological monitoring device is used, variable pitch and threshold alarms shall be turned on and audible. The CRNA should attend to the patient continuously until the responsibility of care has been accepted by another anesthesia professional.

a. Oxygenation

Continuously monitor oxygenation by clinical observation and pulse oximetry. If indicated, continually monitor oxygenation by arterial blood gas analysis.

b. Ventilation

Continuously monitor ventilation. Verify intubation of the trachea or placement of other artificial airway devices by auscultation, chest excursion, and confirmation of expired carbon dioxide. Use ventilatory pressure monitors as indicated. Continuously monitor end-tidal carbon dioxide during controlled or assisted ventilation and any anesthesia or sedation technique requiring artificial airway support. During moderate or deep sedation, continuously monitor for the presence of expired carbon dioxide.

c. Cardiovascular

Continuously monitor cardiovascular status via electrocardiogram. Perform auscultation of heart sounds as needed. Evaluate and document blood pressure and heart rate at least every five minutes.

d. Thermoregulation

When clinically significant changes in body temperature are intended, anticipated, or suspected, monitor body temperature in order to facilitate the maintenance of normothermia.

e. Neuromuscular

When neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery.

f. Positioning

Monitor and assess patient positioning and protective measures, except for those aspects that are performed exclusively by one or more other providers.

Interpretation.

Continuous clinical observation and vigilance are the basis of safe anesthesia care. Consistent with the CRNA's professional judgment, additional means of monitoring the patient's status may be used depending on the needs of the patient, the anesthesia being administered, or the surgical technique or procedure being performed.

Standard VI

Document pertinent anesthesia-related information on the patient's medical record in an accurate, complete, legible, and timely manner.

Standard VII

Evaluate the patient's status and determine when it is safe to transfer the responsibility of care. Accurately report the patient's condition, including all essential information, and transfer the responsibility of care to another qualified healthcare provider in a manner that assures continuity of care and patient safety.

Standard VIII

Adhere to appropriate safety precautions as established within the practice setting to minimize the risks of fire, explosion, electrical shock and equipment malfunction. Based on the patient, surgical intervention or procedure, ensure that the equipment reasonably expected to be necessary for the administration of anesthesia has been checked for proper functionality and document compliance. When the patient is ventilated by an automatic mechanical ventilator, monitor the integrity of the breathing system with a device capable of detecting a disconnection by emitting an audible alarm. When the breathing system of an anesthesia machine is being used to deliver oxygen, the CRNA should monitor inspired oxygen concentration continuously with an oxygen analyzer with a low concentration audible alarm turned on and in use.

Standard IX

Verify that infection control policies and procedures for personnel and equipment exist within the practice setting. Adhere to infection control policies and procedures as established within the practice setting to minimize the risk of infection to the patient, the CRNA, and other healthcare providers.

Standard X

Participate in the ongoing review and evaluation of anesthesia care to assess quality and appropriateness.

Standard XI

Respect and maintain the basic rights of patients.

Conclusion

This article highlights several of the important revisions made to the Standards for Nurse Anesthesia Practice. This was not an exhaustive discussion of all changes made to the document. Significant time and effort was put forth to ensure that all standards are pertinent and reflective of current literature and anesthesia practice. All CRNAs and student nurse anesthetists are strongly encouraged to familiarize themselves with the updated standards and incorporate them into their practice. CRNAs have a history of providing high quality, safe and effective anesthesia care to their patients and these standards will continue to reinforce those principles. Any questions regarding these standards can be directed to the AANA's Professional Practice Division at practice@aana.com or (847) 655-8870.

REFERENCES

1. Nagelhout JJ, Plaus KL, eds. Nurse Anesthesia. Fourth ed. St Louis: MO: Saunders; 2010.

2. McFadyen G. Update in Anaesthesia. Respiratory gas analysis. The Journal of the World Federation of Societies of Anaesthesiologists. Dec 2008;24(2):170-173. http://update.anaesthesiologists.org/wp-content/uploads/file/Update%2024,2.pdf. Accessed February 1, 2012.

3. Thompson JE, Jaffe MB. Capnographic waveforms in the mechanically ventilated patient. Respir Care. Jan 2005;50(1):100- 108; discussion 108-109.

4. Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: a randomized, controlled trial. Ann Emerg Med. Jan 2007;49(1):1-8.

5. Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation with propofol: a randomized, controlled trial. Ann Emerg Med. Jul 2008;52 (1):1-8.

6. Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. Mar 2010;55(3):258-264.

7. Kannikeswaran N, Chen X, Sethuraman U. Utility of endtidal carbon dioxide monitoring in detection of hypoxia during sedation for brain magnetic resonance imaging in children with developmental disabilities. Paediatr Anaesth. Dec 2011; 21(12):1241-1246.

8. Lightdale JR, Goldmann DA, Feldman HA, Newburg AR, DiNardo JA, Fox VL. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics. Jun 2006;117(6):e1170-1178.

9. Brodsky JB. What intraoperative monitoring makes sense? Chest. May 1999;115(5 Suppl):101S-105S.

10. Henneman JP, Martinez EA, Ehrenfeld JM, Eikermann M. The use of intermediate acting neuromuscular blocking agents is associated with increased postoperative respiratory complications. ASA Abstract. October 16, 2011.

11. McGrath CD, Hunter JM. Update in Anaesthesia. Monitoring of neuromuscular block. The Journal of the World Federation of Societies of Anaesthesiologists. Jun 2009;25(1):42-46. http://update.anaesthesiologists.org/wp-content/uploads/2009/10/Update-251-2009.pdf. Accessed February 1, 2012.

12. Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in the postoperative period. Minerva Anestesiol. Mar 2006;72(3):97-109.

13. Kopman AF. Neuromuscular monitoring: old issues, new controversies. J Crit Care. Mar 2009;24(1):11-20.

14. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. Jul 2010;111(1):120-128.

15. Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology. Apr 2010;112(4):1013-1022.

AUTHORS

Michael Neft, CRNA, DNP, MHA, LTC(ret), USA, is an assistant professor, assistant director, coordinator of clinical education, and DNP coordinator for the nurse anesthesia program at the University of Pittsburgh. He has been the chair of the AANA Practice Committee since fiscal year 2011.

Jihan A. Quraishi, RN, MS, is a research analyst in the AANA's Research Division.

Ewa Greenier, MPH, MBA, is a professional practice specialist for the AANA, providing staff support for Practice Committee activities.

Read the full article at http://digitaleditions.sheridan.com/article/Practice+News/1363288/153253/article.html.

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