NRAN 80526 Scope of Practice.pdf

Scope of Practice Standards of NRAN 80526 Nurse Anesthesia Casey Crow DNP, CRNA Practice Objectives Understand the history of nurse anesthesia practice Be familiar with the history of nurse anesthesia and evaluate how the history affects current practice and future politics Ana...

Scope of Practice Standards of NRAN 80526 Nurse Anesthesia Casey Crow DNP, CRNA Practice Objectives Understand the history of nurse anesthesia practice Be familiar with the history of nurse anesthesia and evaluate how the history affects current practice and future politics Analyze the professional organization and how it relates to our current and future practice Analyze the Scope of CRNA practice as outlined by the AANA Understand and evaluate the AANA Code of Ethics as it relates to CRNA practice and decision making Understand and evaluate the current Standards of Nurse Anesthesia Practice Scope of Nurse Anesthesia Practice Professional role Education, Accountability and Leadership Anesthesia practice Value and future of Nurse Anesthesia Practice Professional Role Advanced Practice Registered Nurses Licensed as independent practitioners May work autonomously or in collaboration with other health care providers Opt-out states All acuity levels Across the lifespan Variety of settings Surgical, obstetrical, diagnostic, therapeutic, pain management Clinicians, researchers, educators, mentors, advocates, administrators Opt-Out Education, Accountability and Leadership Becoming a CRNA Graduate from an accredited program Pass the National Certification Examination (NCE) Given by the National Board for Certification and Recertification of Nurse Anesthetists (NBCRNA) Professional Excellence Ongoing recertification (NBCRNA) Life-long learning Engagement in quality improvement Professional development Education, Accountability, and Leadership Scope of Practice Education Experience State and federal law Facility policy CRNAs responsible for actions and maintenance of clinical competence Critical thinking and ethical judgement required Question Is anesthesia a practice of nursing or medicine? Care vs Cure Anesthesia Practice Recognized nursing and medical specialty Same standard of care History October 16, 1846 Ether Day Dr. Morton Dentist Performed the first public ether demonstration in Boston, MA History History History History 1850s: Professional nursing Florence Nightingale Crimean War Nurses and nurse anesthetist were vital during the Civil War Nurse anesthetists began delivering anesthetics via open drop ether technique 150 years ago: crude exercise with no monitoring or equipment How did they monitor patients under anesthesia? History Nursing specialty before medical specialty Principle providers of anesthesia services from late 1870s until after WWII Nurse anesthetists had a crucial role in delivery of anesthesia in combat areas in every war Since WWI WWII 17 nurse anesthetists to every 1 physician anesthetist before and during WWII (1942) Panama Strike Only nurse anesthetists were sent with fighting forces Iraq War CRNAs were the largest group of anesthesia providers at forward positions History Sister Mary Bernard Alice Magaw First nurse anesthetists Most famous nurse anesthetist of 1877 19th century Not a physician so not recognized by the medical community History Agnes McGee First nurse anesthesia educational program St. Vincent's Hospital in Portland, OR 1909 1912-1920: 19 nurse anesthesia schools were opened Helen Lamb Founded School of Anesthesia Barnes, 1929 First endotracheal anesthetic in US History Formal, academic, MD anesthesia training developed after nurse anesthesia Dr. Ralph Waters: first medical academic anesthesia department 1927 Brought anesthesia into the realm of medical practice Had been a nursing practice Physicians reluctant to become anesthetists Money Physician anesthetists refused to acknowledge contributions of innovative nurse anesthetists Denial to nurse anesthetists of a just place in the literature of the field History Agatha Hodgins Paper at the biennial convention of the American Nurses Association Suggested nurse anesthetists organize into a “coherent and acting body.” 1931: National Association of Nurse Anesthetists (NANA) Cleveland, OH 1936: American Society of Anesthesiologists (ASA) History US: 3 challenges brought against nurse anesthetists for illegally practicing medicine Frank v South, 1917 Hodgins v Crile, 1919 Chalmers-Francis v Nelson, 1936 Found in favor of the nursing profession Premise that the surgeon was the person practicing medicine Montana Society of Anesthesiologists v Montana Board of Nursing, 2007 Reaffirmed CRNA practice Scope of Practice Unique role Physiologic support Monitoring Intervention Surgeon’s role: patient’s anatomy Anesthesia’s role: patient’s physiology “Our job is to keep patients alive while the surgeon does things that could kill them.” Dr. James Cottrell, as President of the ASA Scope of Practice Is anesthesia a diagnostic or a cure paradigm? “Ours is a role of physiologic support and monitoring and intervention. Ours is not a diagnostic and cure paradigm at all.” Scot Foster, CRNA Anesthesia = Support CRNAs enter the profession as critical care nurses Excel at intensive care and support Scope of Practice Continuously monitoring vital signs and other parameters of the patient’s physiology Quick to counteract untoward reactions that may threaten to occur Most vulnerable state a person can be in, their life is in your hands Intensely intensive care Balancing act Matching dosages of analgesics to levels of surgical pain Titrating drugs constantly throughout the case Requires constant vigilance Scope of Practice Numerous studies show anesthesia care by CRNAs to be safe and of high quality "...[T]he participation of Certified Registered Nurse Anesthetists (CRNAs) in delivery of anesthesia care would have ceased many years ago if there was evidence that this participation resulted in a less favorable outcome compared with anesthesia personally administered by an anesthesiologist." Robert Stoelting, MD Scope of Practice Greatest overlap within nursing and medicine Courts have upheld the concept of anesthesia practice of both physician and nurse anesthetists Politics Politics State Legislation No state in the US that requires supervision by an anesthesiologist 33 states do not have a physician “supervision” or “direction” requirement from CRNAs in nursing, medical laws or regulations 23 states do not require physician supervision or direction Taking into account state hospital licensing laws or regulations Neither JCAHO nor Medicare requires anesthesiologist supervision of CRNAs Scope of Practice Within the hospital Bylaws determined by each individual facility may require the supervision of CRNAs by an anesthesiologists in spite of state law Such restrictions have denied some patients access to the full scope of anesthesia services which should be available to them Restrictive CRNA practice bylaws are often not followed in the interest of patient care or for the greater operating room efficiency Not cost saving Code of Ethics for the Certified Registered Nurse Anesthetist Preamble AANA Code of Ethics is a guide for CRNAs to make ethical decisions in all practice roles Clinical practice, nurse anesthesia-related administrative, educational or research activities, or a combination of two or more of such areas of practice Consists of principles of conduct and professional integrity to guide decision making and behavior The CRNA’s ethical responsibility is primarily to the patient Also to the profession, other healthcare providers, self, and society The CRNA acknowledges, understands, and is sensitive to the vulnerability of the patient undergoing anesthesia, pain management, and related care The CRNA preserves the patient’s trust, confidence, and dignity Code of Ethics The CRNA has the personal responsibility to understand, uphold and adhere to these ethical standards of conduct. Deviation from the Code of Ethics occurs rarely in practice and any deviation must be supported by ethical decisional making, compelling reasons, and best judgement specific to the situation. The AANA recognizes the American Nurses Association (ANA) Code of Ethics as the foundation for ethical values, duties, and responsibilities in nursing practice. Code of Ethics Updated July 2018 1. Responsibility to Patients 2. Responsibilities as a Professional Competence and Responsibility in Professional Practice Leadership Clinical Practice and the Interdisciplinary Team Role Modeling and Education of Others The Profession 3. Responsibility in Research 4. Responsibility in Business Practices 5. Responsibility when Endorsing Products and Services 6. Responsibility to Society Code of Ethics for the Certified Registered Nurse Anesthetist by aanapublishing - Issuu Code of Ethics 1. Responsibility to Patients The CRNA respects the patient’s moral and legal rights, and supports the patient’s safety, physical and psychological comfort, and well-being. The CRNA collaborates with the patients and the healthcare team to provide compassionate, holistic, patient-centered anesthesia, pain management, and related care. Code of Ethics 1. Responsibility to Patients The CRNA: Code of Ethics 1. Responsibility to Patients The CRNA: Code of Ethics 2. Responsibility as a Professional As an independently licensed professional, the CRNA is responsible and accountable for judgments made and actions taken in his or her professional practice. Requests or orders by physicians, other healthcare professionals, or institutions do not relieve the CRNA of the responsibility for judgments made or actions taken. Code of Ethics 2. Responsibility as a Professional Competence and Responsibility in Professional Practice The CRNA: Code of Ethics 2. Responsibility as a Professional Competence and Responsibility in Professional Practice The CRNA: Code of Ethics 2. Responsibility as a Professional Leadership The CRNA: Code of Ethics 2. Responsibility as a Professional Clinical Practice and the Interdisciplinary Team The CRNA: Code of Ethics 2. Responsibility as a Professional Role Modelling and Education of Others The CRNA: Code of Ethics 2. Responsibility as a Professional The Profession The CRNA: Code of Ethics 3. Responsibility in Research The CRNA protects the integrity of the research process and the reporting and publication of findings: The CRNA adheres to the ethical principles of respect for persons, beneficence, and justice relevant to research involving human participants. Code of Ethics 3. Responsibility in Research The CRNA: Code of Ethics 3. Responsibility in Research The CRNA: Code of Ethics 4. Responsibility in Business Practices The CRNA, regardless of practice arrangement or practice setting, maintains ethical business practices in dealing with patients, colleagues, institutions, corporations, and others. Code of Ethics 4. Responsibility in Business Practices The CRNA: Code of Ethics 5. Responsibility when Endorsing Products and Services The CRNA may endorse products and services only when personally satisfied with the product’s service’s safety, effectiveness, and quality. The CRNA may not say that the AANA has endorsed any product or service unless the Board of Directors of the AANA has done so. The CRNA must not endorse any product or service when presenting content for an AANA- approved continuing education activity as this is a prohibited conflict of interest. Code of Ethics 5. Responsibility when Endorsing Products and Services The CRNA: Code of Ethics 6. Responsibility to Society The CRNA collaborates with members of the health professionals and others to improve the public health, including access to healthcare and anesthesia, pain management, and related care. Code of Ethics 6. Responsibility to Society The CRNA: Scope Governed by 4 general categories CRNA’s Experience give care: State statues and Preanesthetic preparation regulations Anesthesia induction, Institutional policy maintenance and emergence Post anesthesia care Perianesthetic and clinical support Scope CRNA scope of practice Performing and documenting preanesthetic assessment and evaluation Requesting consultations and diagnostic tests Informed consent Developing and implementing an anesthesia plan Selecting, obtaining, ordering and administering preoperative medications and fluids Scope CRNA scope of practice Performs anesthesia techniques Selecting, applying, and inserting appropriate non- invasive and invasive monitoring techniques Selecting, obtaining, and administering the anesthetics, drugs, and fluids to manage the anesthetic Scope CRNA scope of practice Managing a patient’s airway and pulmonary status Facilitating emergence and recovery from anesthesia Selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support Discharging the patient from PACU and providing post-anesthesia follow-up care Scope CRNA scope of practice Implementing acute and chronic pain management Responding to emergency situations Airway management, administering emergency drugs and fluids, BLS, ACLS, PALS Scope Additional responsibilities may include: Administration/management Scheduling, material management, supervision of staff, development of policy and procedure, etc. Quality assessment Data collection, trending, departmental review, committee meetings, problem solving, interventions, documents, etc. Educational Clinical and didactic teaching, in-services, supervision of residents (RRNAs/SRNAs) Research Committee appointments Interdepartmental liaison Nursing, surgery, obstetrics, PACUs, outpatient services Clinical/administrating oversight of other departments Respiratory therapy, OR, ICU, pain clinics, etc Anesthesia Practice Performance of history and physical Preanesthesia evaluation Informed consent Developing, initiating plan of care Selecting, ordering, prescribing, administering drugs Invasive line insertion, monitoring, maintenance Acute and chronic pain management Critical care Resuscitation Value and Future of Nurse Anesthesia Practice CRNAs practice Rural, urban, US military Primary providers in medically underserved areas, military and rural America Advocacy important to remove barriers and to increase access to care Standards Purpose: Assist profession in evaluating quality of care Provide a common base for practitioners to use in development of quality practice Assist the public in understanding expectations of practice Support and preserve basic patient rights Standards Students enrolled in nurse anesthesia educational programs practice according to the standards and guidelines of the Council on Accreditation of Nurse Anesthesia Educational Programs (COA). Standard I: Patient’s Rights Respect the patient’s autonomy, dignity, and privacy and support the patient’s needs and safety. Supporting AANA document: Code of Ethics for the Certified Registered Nurse Anesthetist Standard II: Preanesthesia Patient Assessment and Evaluation Perform and document or verify documentation of a preanesthesia evaluation of the patient’s general health, allergies, medication history, preexisting conditions, anesthesia history, and any relevant diagnostic tests. Perform and document or verify documentation of an anesthesia focused physical assessment to form the anesthesia plan of care. Supporting AANA document: Documenting Anesthesia Care, Practice and Policy Considerations. Standard III: Plan for Anesthesia Care After the patient has had the opportunity to consider anesthesia care options and address his or her concerns, formulate a patient-specific plan for anesthesia care. When indicated, the anesthesia care plan can be formulated with members of the healthcare team and the patient’s legal representative (e.g., healthcare proxy, surrogate). Supporting AANA documents: Documenting Anesthesia Care, Practice and Policy Considerations and Informed Consent for Anesthesia Care, Policy and Practice Considerations. Standard IV: Informed Consent for Anesthesia Care and Related Services Obtain and document or verify documentation that the patient or legal representative (e.g., healthcare proxy, surrogate) has given informed consent for planned anesthesia care or related services in accordance with law, accreditation standards, and institutional policy. Supporting AANA documents: Code of Ethics for the Certified Registered Nurse Anesthetist, Informed Consent for Anesthesia Care, Policy and Practice Considerations, and Reconsideration of Advanced Directives, Practice Guidelines and Policy Considerations. Standard V: Documentation Communicate anesthesia care data and activities through legible, timely, accurate, and complete documentation in the patient’s healthcare record. Supporting AANA document: Documenting Anesthesia Care, Practice and Policy Considerations. Standards of Care Documentation “If it ain’t documented, it ain’t done” Standard V Included in Standard II: document preanesthesia evaluation and physical assessment Included in Standard IV: document informed consent Accurate and timely documentation of pertinent information Allows to visualize trends Prevents negative interferences Documenting Anesthesia Care Practice and Policy Considerations Represents a detailed account of the anesthesia care Preanesthetic assessment/evaluation Informed consent Anesthesia services Postanesthesia care Legal document Formal record Referenced for reimbursement, quality improvement, review by external organizations Pertinent anesthesia-related information Accurate, complete, legible Documenting Anesthesia Care Practice and Policy Considerations Preanesthesia Overview of general health Medication history Allergies Health history and review Medical history of systems Preexisting conditions Physical exam Anesthesia history Relevant diagnostic test result Additional health issues ASA status Demographics: height, Anesthesia plan of care weight, VS, allergies Documenting Anesthesia Care Practice and Policy Considerations Documenting Anesthesia Care Practice and Policy Considerations Documenting Anesthesia Care Practice and Policy Considerations Informed consent Obtained after Anesthesia interview Discussion of plan Considerations, risks and benefits for each type of anesthesia and pain management Pt comorbid conditions Patient preference Patient has opportunity to ask questions and have concerns addressed Separate document than surgical consent Documenting Anesthesia Care Practice and Policy Considerations Anesthesia care documentation Name, ID number All anesthesia professionals involved in the patient’s care Immediate preanesthesia assessment and evaluation Changes in health status, NPO status Safety checks: equipment, drugs/gas supply Monitoring: oxygenation, ventilation, circulation, body temperature, skeletal muscle relaxation Airway management Drug administration: drug, dose, route, time Patient positioning: who positioned the patient, type of positioners IV fluid administration totals: blood products if applicable Lines inserted: techniques, locations, procedure Complications, adverse reactions, problems during anesthesia Patient status at end of anesthesia Documentation in timely and legible manner Documenting Anesthesia Care Practice and Policy Considerations Documenting Anesthesia Care Practice and Policy Considerations Postanesthesia Care Goal: ensure patient safety Prevent complications Restore the patients physiologic and psychological health Prior to transferring care PACU RN assesses patient Confirm the patient is stable Hand off report Documenting Anesthesia Care Practice and Policy Considerations Documenting Anesthesia Care Practice and Policy Considerations Postanesthesia Evaluation CMS: requires completion of postanesthesia evaluation within 48 hours after anesthesia State Law and facility policy Only after the patient is sufficiently recovered from the effects of anesthesia Documenting Anesthesia Care Practice and Policy Considerations Facility Discharge Detailed instructions Anesthesia care Pain management How to address concerns Pain, swelling, loss of sensation, nausea/vomiting, temp >101 Standard VI: Equipment Adhere to manufacturer’s operating instructions and other safety precautions to complete a daily anesthesia equipment check. Verify function of anesthesia equipment prior to each anesthetic. Operate equipment to minimize the risk of fire, explosion, electrical shock, and equipment malfunction. Supporting AANA document: Documenting Anesthesia Care, Practice and Policy Considerations. Standard VII: Anesthesia Plan Implementation and Management Implement and, if needed, modify the anesthesia plan of care by continuously assessing the patient’s response to the anesthetic and surgical or procedural intervention. The CRNA provides anesthesia care until the responsibility has been accepted by another anesthesia professional. Supporting AANA document: Documenting Anesthesia Care, Practice and Policy Considerations. Standard VIII: Patient Positioning Collaborate with the surgical or procedure team to position, assess, and monitor proper body alignment. Use protective measures to maintain perfusion and protect pressure points and nerve plexus. Standard IX: Monitoring, Alarms Monitor, evaluate, and document the patient’s physiologic condition as appropriate for the procedure and anesthetic technique. When a physiological monitoring device is used, variable pitch and threshold alarms are turned on and audible. Document blood pressure, heart rate, and respiration at least every five minutes for all anesthetics. Standard IX: Monitoring, Alarms a. Oxygenation Continuously monitor oxygenation by clinical observation and pulse oximetry. The surgical or procedure team communicates and collaborates to mitigate the risk of fire. b. Ventilation Continuously monitor ventilation by clinical observation and confirmation of continuous expired carbon dioxide during moderate sedation, deep sedation or general anesthesia. Verify intubation of the trachea or placement of other artificial airway device by auscultation, chest excursion, and confirmation of expired carbon dioxide. Use ventilatory monitors as indicated. Standard IX: Monitoring, Alarms c. Cardiovascular Monitor and evaluate circulation to maintain patient’s hemodynamic status. Continuously monitor heart rate and cardiovascular status. Use invasive monitoring as appropriate. d. Thermoregulation When clinically significant changes in body temperature are intended, anticipated, or suspected, monitor body temperature, use active measures to facilitate normothermia. When malignant hyperthermia (MH) triggering agents are used, monitor temperature and recognize signs and symptoms to immediately initiate appropriate treatment and management of MH. Supporting AANA document: Malignant Hyperthermia Crisis Preparedness and Treatment, Position Statement. Standard IX: Monitoring, Alarms e. Neuromuscular When neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery. Standard X: Infection Control and Prevention Verify and adhere to infection control policies and procedures as established within the practice setting to minimize the risk of infection to patients, the CRNA, and other healthcare providers. Supporting AANA document: Infection Prevention and Control Guidelines for Anesthesia Care and Safe Injection Guidelines for Needle and Syringe Use Standard XI: Transfer of Care Evaluate the patient’s status and determine when it is appropriate to transfer the responsibility of care to another qualified healthcare provider. Communicate the patient’s condition and essential information for continuity of care. Supporting AANA document: Patient-Centered Perianesthesia Communication, Practice Considerations Standard XII: Quality Improvement Process Participate in the ongoing review and evaluation of anesthesia care to assess quality and appropriateness to improve outcomes. Supporting AANA document: Patient-Centered Perianesthesia Communication, Practice Considerations Standard XIII: Wellness Is physically and mentally able to perform duties of the role. Supporting AANA documents: Professional Attributes of the Nurse Anesthetist, Practice Considerations, Patient Safety: Fatigue, Sleep, and Work Schedule Effects, Practice and Policy Considerations, Promoting a Culture of Safety and Healthy Work Environment, Practice Considerations, and Addressing Substance Use Disorder for Anesthesia Professionals, Position Statement and Policy Considerations Standard XIV: A Culture of Safety Foster a collaborative and cooperative patient care environment through interdisciplinary engagement, open communication, a culture of safety, and supportive leadership. Supporting AANA documents: Code of Ethics for the Certified Registered Nurse Anesthetist, Patient-Driven Interdisciplinary Practice, Position Statement, Professional Attributes of the Nurse Anesthetist, Practice Considerations, and Patient-Centered Perianesthesia Communication, Practice Considerations Standards of Care What is a standard of care? Definition of standard: “Something set up and established by authority, custom, or general consent as a model, example or rule for the measure of quantity, weight, extent, value, or quality.” Standards set the benchmark for expected behaviors. Standards of Care Customs and behavior of the members of the profession What others in the profession would do under similar circumstances If the profession has developed documents that reflect a consensus on how the profession is to be practiced, these documents will set the standard for judging individual transgressions. General accepted principles of patient care Expert witness Standards of Care Only members of a profession can establish standards Courts have delegated the setting of professional standards to members of the profession Conduct Developed through consensus and consideration of scientific evidence, and based on concept that adherence will provide positive outcomes Expert witness Provide testimony to assist judges, juries, and attorneys to understand the evidence and make factual determinations Refer to statements from a professional association Standards of Care Difficulty determining standard of care in healthcare Legislatures do not adopt detailed standards for professional practice Not just what everybody does, but what practitioners do that relate to quality outcomes Published professional practice documents Reflect consensus on practice Will set the standard for judging individual transgressions Standards of Care What about anesthesia procedures? Closed claim studies Pulse oximeters CO2 monitors Temperature monitors “Other standards” Improve “Quality of care” Documentation Documentation Documentation References Professional Practice Manual for the Certified Registered Nurse Anesthetist. American Association of Nurse Anesthetists, https://www.aana.com/practice/practice-manual Bankert, M. Watchful Care: A History of America’s Nurse Anesthetists. 1989. American Association of Nurse Anesthetists. National Board of Certification and Recertification for Nurse Anesthetists. The Continued Professional Certification (CPC) Handbook. https://www.nbcrna.com/docs/default-source/publications- documentation/handbooks/cpc_hb.pdf?sfvrsn=941c170c_8. Accessed March, 2018.