Top anesthesia challenges, the field's future & how CRNAs will shape it — 5 Qs with AANA president

Certified registered nurse anesthetists will play a crucial role in tackling the biggest issues facing anesthesia in 2019, according to American Association of Nurse Anesthetists President Garry Brydges, DNP, CRNA.

Dr. Brydges told Becker's ASC Review about the trends, obstacles and opportunities on the horizon, how AANA is planning to confront them and the strategies it has already set in motion.

Note: Responses have been lightly edited for style.

Question: What are the biggest challenges in anesthesiology right now? What are the biggest concerns for CRNAs?

Garry Brydges: There are several critical challenges confronting anesthesia professionals today. The complexity of comorbidities, such as delirium, nausea and vomiting, in an aging population challenges CRNAs to use opioid-sparing techniques, regional anesthesia and other innovative methods to deliver patient care as safely as possible without lasting effects.

Pharmaceutical costs [are] a large issue with many factors. First, the cost of new emerging agents, such as intravenous acetaminophen or Sugammadex, are removed from hospital formularies because administrators often fixate on direct costs of drugs. But the focus should be on variable costs that impact patient outcomes and satisfaction, including length of hospital stay, 30-day readmission rates, postoperative nausea and vomiting, postoperative ileus, respiratory compromise and pain management. We need to focus our attention on increasing the quality of healthcare which, ultimately, translates to reduced variable costs.

Q: What major healthcare trends do you predict for 2019, and how is AANA preparing to address them?

GB: A major healthcare trend for 2019 will focus on reimbursement through MACRA. Most healthcare providers do not realize the impact MACRA will have on the fiscal stability of facilities, providers and local communities. To prepare CRNAs for the future, AANA is educating its members to address MACRA through the application of clinical practice techniques that translate into increased quality of care and patient satisfaction.

In 2019, AANA hopes to create a clear understanding of the value and quality CRNAs bring to patient care before, during and after surgery, which translates into superior patient outcomes.

Q: What role will CRNAs play in the future of anesthesia care?

GB: As the first anesthesia professionals, CRNAs have played a pivotal role in ensuring patient access to safe, cost-effective anesthesia care for nearly 150 years, and CRNAs will continue to play a major role in shaping the future of anesthesia care in the U.S. Reducing the cost of healthcare delivery continues to be a priority, and CRNAs will be a major stakeholder in the surgical experience. CRNAs will use their expertise to advance innovations in anesthesia care, including progressive techniques in regional anesthesia and multimodal opioid-sparing strategies. In addition, CRNAs will address gaps in healthcare delivery such as pain management, opioid addiction and access to care in rural America.

CRNA education is being expanded to include leadership and the business aspects of healthcare delivery — expertise that will allow CRNAs to lead healthcare organizations and address operational issues that challenge healthcare systems. CRNAs already make a positive impact on healthcare by lowering the cost of anesthesia services, improving anesthesia patient outcomes, increasing patient satisfaction, reducing length of stay and postoperative pain management requirements and increasing patient ambulation.

Q: Can you explain the new bipartisan opioid law and what AANA and CRNAs contributed to developing the legislation?

GB: The AANA was a major supporter of Section 3201 of the H.R. 6, SUPPORT for Patients and Communities Act, which increases the number of waivered health providers that can prescribe Medication Assisted Treatment— the use of medications along with counseling and behavioral therapies to prevent and treat opioid abuse. The legislation wisely authorizes CRNAs, clinical nurse specialists and certified nurse midwives to prescribe buprenorphine for a period of five years. In addition, the provision makes permanent this prescribing authority for physician assistants and nurse practitioners as was temporarily granted by the Drug Addiction Treatment Act of 2000.

Since opioids have been a mainstay of anesthesia practice for decades, it stands to reason CRNAs are experts in understanding the role and limitations of opioids in healthcare delivery. Through interdisciplinary collaboration, CRNAs are a major stakeholder in addressing the opioid crisis through Medication Assisted Treatment. CRNAs, like many other non-MD/DO healthcare professionals, continue to make major contributions to addressing the opioid crisis through this legislation.

Q: What is the Enhanced Recovery After Surgery pain management protocol, and how does it help patients avoid opioids?

GB: Enhanced Recovery After Surgery is a patient-centered, evidence-based pain management strategy employed by CRNAs to reduce the need for opioids, improve patient outcomes and reduce costs. ERAS uses robust patient communication and opioid-sparing techniques such as regional anesthesia, peripheral nerve blocks, nonpharmacologic approaches and non-opioid medications.

ERAS supports collaborative pain care between the patient, the CRNA and the entire care team. It also encourages patients to play an active role by expressing their own needs and concerns to help establish realistic goals for improved well-being and quality of life without dependence on opioids. This thorough assessment and treatment of pain not only reduces the need for opioids during and after surgery, but also decreases the risk of acute pain transitioning to chronic pain and the development of opioid dependency and abuse. New research has demonstrated the effectiveness of ERAS for women who have undergone lumpectomy, mastectomy and gynecological surgeries.

Garry Brydges, DNP, MBA, CRNA, ACNP-BC, has served in many capacities on his professional associations, including on boards of directors at the state and national levels. He is the Texas Association of Nurse Anesthetists' former president, and, most recently, AANA's president-elect.

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