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Digital Issues

N.J. CRNAs Must Be Supervised

CRNAs can legally practice without physician supervision in 16 states, but New Jersey is not about to join their ranks anytime soon.

A state appeals court last week upheld the New Jersey Department of Health's regulation requiring an anesthesiologist to be present during induction, emergence and any critical change in status when an advanced practice nurse/anesthesia (APN/A) administers general or major regional anesthesia, conscious sedation or minor regional blocks.

The law at issue "did not grant APNs authority to administer anesthesia without supervision," writes the court, which says anesthesia administration falls under the umbrella of medical practice. The health department "is not regulating the practice of APN/As or the nursing profession. Rather, it is regulating the practice of administering anesthesia in a hospital setting."

The department is in a position to determine differences in practitioners' education, training and skill to establish anesthesia staffing regulations, the court continues. "Requiring the availability of an anesthesiologist to handle complications beyond the expertise of APN/As is a reasonable exercise of DHSS's regulatory authority and will better protect patients."

The American Society of Anesthesiologists and the New Jersey State Society of Anesthesiologists applauded the ruling , which follows legal arguments in October.

"Anesthesiologists are highly skilled physicians who have significantly longer and more extensive training than nurse anesthetists," says NJSSA President Mordechai Bermann, MD. "We are able to make split-second medical decisions in the operating room. The ruling will help protect the quality of health care in our state."

However, the evidence backing the decision's determination of quality is questionable, says Jay Horowitz, CRNA, of Quality Anesthesia Care Corp. in Sarasota, Fla.

"There's no bona fide science to suggest a poorer result without this mandate, and there are peer-reviewed studies to suggest otherwise," he says. "No other state has such a requirement. CRNAs are fully credentialed anesthesia providers who are held to the same safety standards and overall standards of care as anesthesiologists.

"To depict them as assistants to anesthesiologists contradicts state and federal regulations for practice and reimbursement, CRNA practice in the military and within the Veterans Administration system," he continues. "Although anesthesia may be the practice of medicine when provided by doctors, it's well documented in the law that, when provided by nurses, it is the practice of nursing."

Stephanie Wasek

The Importance of Longer Colonoscopy Withdrawal Times

Widely accepted colonoscopy quality measures recommend aiming for a withdrawal time of 7 minutes, but researchers suggest that longer withdrawals actually result in higher adenoma detection rates.

The withdrawal time guideline, they note, doesn't take insertion times into account. The researchers, from the Mayo Clinic in Scottsdale, Ariz., have observed that difficult endoscope intubations not only lengthen insertion times, they tend to demand careful examination on the way back out — but often lead physicians to cut their withdrawals short.

For a study presented at the American College of Gastroenterology's annual meeting, Mayo's Erika Boroff, MD, and her colleagues reviewed reports from nearly 1,800 colonoscopies performed by 20 physicians over the course of a year. The mean insertion time was 11.6 minutes and the mean withdrawal time was 12.3 minutes. The research team found that adenoma detection rates were lower when insertion times were longer than withdrawal times, but that they increased by 8% for every minute that withdrawal time exceeded insertion time.

As a result of this finding, and data suggesting that most physicians remove polyps during withdrawal, researchers stress the importance of allowing sufficient time during colonoscopy scheduling to enable adequate examination and action in withdrawals.

David Bernard

Should Surgical Preps Be Sterile?

Mandating the sterility of surgical prep products will not necessarily lower surgical site infection risks, clinical experts and observers told an FDA committee at a public hearing last week.

Prep manufacturers in particular claimed that requiring the antiseptic products to be sterile would be an undue and perhaps unnecessary burden, according to a published account of the hearing.

Other attendees, including physicians and policy analysts, pointed out that the true sources of surgical site infections are hard to pinpoint, and one manufacturer's representative says no current data link non-sterile products to infections or sterile products to safer, more effective skin antisepsis.

FDA researchers have noted, however, that nosocomial infections associated with contaminated antiseptic products may be more common than indicated by manufacturers' reports and medical literature. They report in the New England Journal of Medicine that the non-sterility of preps increases the possibility of microbial contamination during manufacture or use.

The public hearing's commentators argued that more stringent sterility standards on prep products would force manufacturers to overhaul their current production processes, an expensive and disruptive requirement that could negatively impact caregivers without much benefit to patient care.

Instead, they say, educational efforts should be employed to explain the proper use of prep solutions, while the FDA enforces its current manufacturing regulations to prevent product contamination.

Daniel Cook

InstaPoll: Are You Counting Propofol as a Daily Count?

Propofol might soon be classified a controlled substance. Is your facility already in the habit of counting it daily as well as witnessing any waste? Tell us in this week's Outpatient Surgery Magazine InstaPoll.

The patient comes first for 86% of the 398 facility managers who answered last week's poll about always doing what's best for the patient, even if that comes at the expense of the facility or physician. Only 9% of respondents said their facility doesn't always do what's best for the patient.

Dan O'Connor

News & Notes

  • Compounding crackdown continues Surprise inspections have shuttered another 3 compounding pharmacies in Massachusetts as the state's pharmacy registration board and public health department step up their efforts to regulate the plants, according to the Boston Globe. The paper also reports that the board has added 3 new members to diversify and potentially provide better oversight.
  • Protecting patient data The federal Department of Health and Human Services has launched a website addressing the need to safeguard patients' medical records when they are accessed through mobile devices such as laptop computers, tablets and smartphones. The educational website describes the possible risks and the steps providers can take to secure private data.
  • What to do with blue wrap? Recycle it, says Mid Coast Hospital of Brunswick, Maine. The hospital used to discard the mountains of wrap it collected, according to a local news report. But now it's partnered with its waste collection service to send the wrap to a company that melts it down into pellets, which become the reusable raw material for park benches, garbage cans and other plastic products.