IN THIS ISSUE:
ANESTHESIOLOGY 2015
“LEADERS IN PERIOPERATIVE MEDICINE” TO MEET IN SAN DIEGO
F1RSTAnalytics: Real-Time Insight at Your Fingertips
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F1RSTAnalytics – The information you need, provided in a way you can use it. 255 West Michigan Avenue, Jackson, MI 49201 888-242-1131 ext. 4113 • info@anesthesiallc.com • www.anesthesiallc.com
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President Frederick Campbell, M.D. Cedar President-Elect John LaGorio, M.D. Norton Shores
TAB LE OF CO NT ENT S P R E S I D E N T’ S ME SSAGE ................................................................. 4 DIRECTOR’S REPORT............................................................................ 6
Secretary-Treasurer Michael Danic, D.O. Redford
E N H A N CE D R ECO VE RY P RO GRAM
Immediate Past President Sam Talsma, M.D. Ann Arbor
A CA S E O F M ARI J UAN A ASSO CI ATE D ACUTE M YO CARDI AL
Communications/ Public Relations Committee Ali Jaffer, M.D. Dominic Monterosso, D.O. Managing Editor Hillary Walilko Cover Photography Courtesy: goodfreephotos.com Contact for advertising information: Hillary Walilko MSA 120 N. Washington Sq., Suite 110A Lansing, MI 48933 Phone: 517.346.5088 Fax: 517.371.1170 email: walilko.h@gcsionline.com The Ventilator is published four times annually by GCSI Association Services. It is funded by the Michigan Society of Anesthesiologists and with advertising revenues. The Michigan Society of Anesthesiologists is a nonprofit, statewide organization. No part of this publication may be reproduced without permission of the publisher and MSA. All article submissions will be considered for publication and accepted at the approval of the Editor and the Communications/Public Relations Committee. We reserve the right to edit submissions for accuracy, clarity, and length.
Summer 2015
TE A M B U I LD I N G P RO CE SS..............................................8
I N FA R CTI O N I N THE AB SE N CE O F CO RO N ARY ARTE RY D I S E A S E . . . . . . . . ........................................................... 1 0 CALENDAR OF EVENTS ..................................................................... 16 RESIDENT REVIEW: 2015 AMERICAN SOCIETY OF ANESTHESIOLOGISTS LEGISLATIVE CONFERENCE................................. 18 THE MICHIGAN OPIOID SAFETY SCORE (MOSS): A NOVEL ASSESSMENT TOOL FOCUSED ON SAFE DELIVERY OF OPIOIDS................................................................ 20 LEGISLATIVE CORNER ........................................................................ 22
INDEX TO ADVERTISERS Anesthesia Business Consultants....................................... IFC MedComm Billing Consultants.......................................... 15 Merrill Lynch........................................................................ 15 Paragon Service.................................................................... 17 University of Michigan Health System..................................7
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PRESIDENT’S MESSAGE
Frederick Campbell M.D. President
PHYSICIANS, NURSES, AND ANESTHESIOLOGIST ASSISTANTS:
COMPETITION IN THE WORKPLACE
P
hysicians in general, and anesthesiologists in particular, have encountered “turf” challenges from competing clinicians over the years.
As a resident almost forty years ago in a training program composed of allopathic residents and attendings, I recall the arrival of the program’s first osteopathic resident. There was some skepticism, likely based in part on our ignorance and bias, as to whether the D.O. would be as knowledgeable and skilled as his M.D. peers. We allopathic residents quickly learned that this “newbie” was a very capable physician. The group practice in which I work today is composed of both allopathic and osteopathic anesthesiologists and we can’t be distinguished from one another except by our identification badges. Though not equivalent in anesthetic knowledge and skill, the “dabblers and poachers” from other specialties seeking credentials to provide deep sedation at sites outside the operating room are more recent competitors for certain parts of anesthesia practice.
Recently, many anesthesiology groups, small and large, private and academic, have been confronted by RFPs from their hospitals and must compete with the group from across town or the national mega-group to maintain their franchise. For years anesthesiologists in small rural hospitals have faced competition from the nurse anesthetistonly practice model. Several have been displaced when single-minded hospital administrations opt for a leaner surgical services budget. The leaderships of the American Association of Nurse Anesthetists and the Michigan Association of Nurse Anesthetists have sought the authority for nurse anesthetists to practice independent of anesthesiologists (and other qualified supervising physicians) throughout the state. The advocacy by MANA, on behalf of the Michigan Health and Hospital Association, for Senate Bill 320, now under consideration in the state’s Senate Health Policy Committee, is the nurses’ current effort to take the place of physician anesthesiologists. Further deliberation by the committee on SB 320 is not anticipated until the summer legislative recess has ended.
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Nurse anesthetists have largely been immune from competition for their role as mid-level providers of anesthesia services. They have essentially been the sole mid-level anesthesia providers across Michigan. While Certified Anesthesiologist Assistants (CAAs) are prevalent in several states, their number in Michigan has been low. Many of the employed nurse anesthetists in my practice were aghast that we would invite CAAs to interview for new positions. The reaction from some was frankly hostile and the visceral antipathy expressed baffling. Did our intention to interview CAAs violate a sense of entitlement to the exclusive mid-level provider role or threaten the nurses’ economic security? A volatile reaction would be justified if CAAs posed a serious economic threat to the nurse anesthetists. However, CRNAs outnumber CAAs by about 25 to one in the United States and by a far greater amount in Michigan. There are 114 nurse anesthesia training programs in the U.S., only 10 Anesthesiologist Assistant programs, and no AA training programs yet exist in Michigan. This does not constitute a serious threat to most Michigan nurse anesthetists presently working.
I heard some of the mischaracterizations that AANA spokespersons have stated at various state legislative hearings at which CAA licensure has been debated. One of those claims is the background and training of CAAs, and by extension their clinical performance, is inferior to that of nurse anesthetists. This is not the experience of hospitals and groups across the country that employ these mid-level practitioners, nor the experience of the two Michigan practices that currently include CAAs. Our practice’s nurse anesthetists are quality people and talented professionals. In the end I anticipate their biases will be tempered by interaction and experience with CAAs and their fears alleviated by their continuing role as the state’s most prevalent mid-level providers. They will discard their unfounded attitudes and find CAAs to be worthy colleagues.
Introduction of more CAAs into Michigan practices could end the virtual monopoly of the nurse anesthesia profession in the state, though by shear numbers the nurses are likely to predominate as mid-level providers. It is ironic that AANA and MANA are actively competing for the place of physician anesthesiologists while their members object so strenuously to the introduction of another provider into Michigan anesthesiology practices. Therein lies the dissonance within the nurse anesthetists’ professional organizations. The politically active leadership promotes competition with physician anesthesiologists at the same time individual working nurse anesthetists feel threatened by the addition of CAAs into the state’s anesthesia workforce. As I listened to the objections of our practice’s nurse anesthetists to our consideration of CAAs, Summer 2015
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DIRECTOR’S REPORT
ANESTHESIOLOGY 2015:
‘LEADERS IN PERIOPERATIVE MEDICINE’ TO MEET IN SAN DIEGO Kenneth Elmassian D.O. ASA Director, Michigan Chairman, ASA Committee on Communications
I
f you are like me, the American Society of Anesthesiologists’ premier annual meeting, October 24- 28, can be somewhat intimidating…. there is so much to do. It’s like drinking from the proverbial firehose, with educational events galore. Each year, the ASA keeps improving the format with the goal of making the event a user friendly experience. This year ANESTHESIOLOGY 2015 annual meeting will offer 600 educational sessions that cross 10 clinical tracks, 1,200 e-poster sessions and 1,100 medically challenging cases. We expect to welcome more than 15,000 attendees from over 90 countries to sunny San Diego. It truly is the most comprehensive anesthesia-related educational event in the world There are very good reasons why San Diego is known as “America’s Finest City”. And there are just as many reasons why the ANESTHESIOLOGY 2015 annual meeting this October is going to be the most exciting, diverse and intelligently designed annual meeting yet. ASA’s foremost priority is meeting its members’ needs, and the programming you’ll experience in San Diego is based on extensive member feedback – you spoke, and we’re delivering what you asked for. Here are just some of the ways we’ve enhanced the ANESTHESIOLOGY 2015 annual meeting: • Keynote lectures have been scheduled earlier in the morning to help kick off your day and facilitate easier scheduling of your activities. • Improved meeting flow with concurrent sessions running in 60, 90 or 120 minute format, allowing attendees to participate in more sessions and claim full CME.
• New self-study program to increase your knowledge and competence in several clinical areas. • New, innovative problem-based learning discussion interactive sessions in a 90-minute format, including Best of Abstracts and Medically Challenging Case presentations. • More networking and information-sharing opportunities. New this year is the “Charitable Networking Event: An International Tasting Reception”. There will also be new, dedicated break and lunch times so you can explore the Connection Center to meet attendees, ASA staff, exhibitors and corporate supporters. • Free Wi-Fi throughout the San Diego Convention Center. • A separate, dedicated mobile application for Poster Sessions, Medically Challenging Cases and Poster Discussions. • Improved subspecialty programming and increased subspecialty society participation. • A new mobile application with scheduling features and personal session itineraries. The Whole Meeting @ Your Fingertips…Once again this year, educational grids, the Meeting Guide, Scientific Abstracts and Exhibit Guide will be available only in PDF format, offering immediate access on your laptop, tablet or phone. Find these publications online at goanesthesiology.org/guides. Also, check out all of the meeting’s international resources at goanesthesiology.org and clicking on “Attend” then “International Resources”. Resident and Medical Student Programming…The ANESTHESIOLOGY® 2015 annual meeting offers a packed schedule of education and social events for residents and medical students, including sessions on oral board prep, job hunting, critical care
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training, finance, and navigating residency in the era of health care reform. Be sure to check out two new sessions: A Day in the Life of an Anesthesiologist and Things I Wish I Knew Before Residency. Advocacy…Visit the ASA Advocacy Booth to discuss and share current political, legislative, regulatory, policy and state issues impacting the practice of anesthesiology. With the ever-changing health care environment and volume of new legislation and regulations, now is the time to enhance your knowledge of important advocacy issues. Stop by the booth to talk with experts on hot topic issues such as: • Political Affairs • Medicare Physician Payment • Perioperative Surgical Home • Scope of Practice • Practice Management • PPACA implementation • CMS regulations • Coding and payment issues • State legislation and regulations • Pain Medicine • Grassroots • Any other questions you might have
ASA Governance…Of course, while all these activities are taking place in the foreground, the ASA House of Delegates [412 voting members] will be meeting and deliberating issues related to the science of anesthesiology and advancing improvements to patient safety and quality care. The basis of those discussions will be heard at the Midwest Caucus meetings, of which Michigan is a member, and at the four Reference Committees of the House of the Delegates [Administrative Affairs, Professional Affairs, Scientific Affairs, and Finance], where every ASA member is welcome to attend and be heard. In addition, Michigan has a Director, and ten ASA Delegates representing you and your practice at the House of Delegates, where too, James D. Grant, MD, ASA Treasurer, will be nominated to serve as 1st Vice President of the ASA. This will be a particularly exciting year for the profession and for the State of Michigan. I hope you will join us. If you have any questions, you can contact me or the office of the Michigan Society of Anesthesiologists. Learn more at goanesthesiology.org
2015 MOCA® Simulation Courses at the University of Michigan Course information and registration available at: http://anes.med.umich.edu/main/programs/moca.html For additional information, contact Dr. Lauryn Rochlen at 734-936-4280 or rochlenl@med.umich.edu. Summer 2015
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ENHANCED RECOVERY PROGRAM TEAM BUILDING PROCESS Ali Sabbagh, M.D. Vinay Pallekonda, M.D. Bhavesh Amin, MSIII George McKelvey, Ph.D. Detroit Medical Center/ Wayne State University Detroit, MI
Weekly ERP meeting attendees at the DMC
M
argaret Mead is quoted ‘never doubt that a small group of thoughtful committed people can change the world, indeed, it is the only thing that ever has’ and our small group was determined to prove this. Enhanced Recovery Program (ERP) initiatives are aimed at implementing series of bestpractice, evidence-based interventions throughout the perioperative period of surgical care. As the Affordable Care Act begins to integrate into the US health care systems, these systems are evolving to provide higher quality and safer care. Multiple U.S institutions have implemented an ERP, however no institution, as yet, have implemented an ERP process involving multiple specialties in an inner city setting, which represents a specific health care challenge that the Detroit Medical Center (DMC) wishes to confront.
In light of ongoing US healthcare changes moving toward the concept of the Perioperative Surgical Home, multidisciplinary teamwork is vital in order to provide coordinated care and reduced healthcare costs with the focus on quality and safety. The Anesthesiology department at DMC is committed to coming out from “behind the curtain” in order to demonstrate that anesthesiologists can make a significant difference to all levels of perioperative care. We, as anesthesiologists in this changing healthcare climate must be determined to prove that we are vital in facilitating safe, efficient quality care for the surgical patient throughout the entire surgical experience. Our vision in the ERP process was to knock down some of the silo’s that are built in the hospital setting. To allow transparency throughout the perioperative process so that a multidisciplinary team can demonstrate the path to a quality, safe and successful surgical experience.
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Early Goal Directed Therapy regional meeting, Troy Michigan, June 24th 2015 Hosted by the Detroit Medical Center ERP Team
At the Detroit Medical Center, the Anesthesiology and General Surgery departments in tandem, headed the DMC ERP initiative with generous guidance from the Michigan Surgical Quality Collaborative. Initially the ERP concept was discussed with a multidisciplinary team. This initial meeting generated great interest and enthusiasm, and a small research team was subsequently assembled to conduct a literature search regarding current ERP data. Rapidly, many DMC departments joined the ERP multidisciplinary team comprising of members from administration, nursing, therapy services, pharmacy, social work and case management, and surgical and anesthesia services. For all DMC ERP sites, to enhance communication, specific leaders or “champions” were chosen to represent all members of each specific health care discipline. Collaboration as a multidisciplinary team in order to standardize the ERP processes so that a system wide approach for perioperative care could be taken in our DMC inner city hospitals. Initially, DMC ERP meetings began with roughly ten people. Within 6 weeks, the weekly meetings were drawing on average, forty DMC ERP members representing all the collaborating disciplines. To spread the word about the DMC’s new approach to the ERP we collaborated with other hospitals across Michigan and neighboring states and organized and hosted a regional Early Goal Directed Therapy conference which boasted over two hundred and fifty attendees, included seventy five members from the DMC. As the ERP initiative moves forward, we believe that we have avoided the majority of potential organizational and institutional barriers due to our innovative and collaborative process. To illustrate this progress, a survey was sent out to all stakeholders (147 people) presented with the ERP implementation process, which consisted of five questions. Ninetytwo stakeholders responded within the time frame allotted. • Approximately 55% of respondents had not Summer 2015
previously heard of ERP prior to our team building process. • All (100%) respondents answered ‘yes’ when asked if they liked the ERP multidisciplinary approach. • 97.8% of respondents agreed that the ERP team building process was organized. • 93.3% of respondents identified our approach as efficient. • 84.4% of respondents replied they would be confident in taking our team building process to other institutions interested in starting an ERP. Effective health care processes are designed to assist and guide productivity and quality. We believe that the DMC ERP group has designed a simplified, manageable ERP team building process allowing us to more easily identify and address any potential barriers to ERP implementation. As our ERP journey continues, we are confident that the ERP initiative will assist our health care colleagues in a collaborative, efficient and safe manner of improving perioperative patient care.
REFERENCES: 1. Kalogera E., MD, Bakkum-Gamez JN, MD, Jankowski CJ, MD, et al; Enhanced Recovery in Gynecologic Surgery. Obstet Gynecol. 2013 August;122(201):319-328 2. Miller TE, Thacker JK, White WD, et al; Enhanced Recovery Study Group. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014;118(5):1052-1061 3. Greco M, Capretti G, Beretta L, et al. Enhanced recovery program in colorectal surgery: a metaanalysis of randomized controlled trials. World J Surg. 2014;38(6):1531-1541.
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A CASE OF MARIJUANA ASSOCIATED ACUTE MYOCARDIAL INFARCTION IN THE ABSENCE OF CORONARY ARTERY DISEASE Lakshman Gollapalli, M.D. Aashish J. Kumar, M.D. Rudram Muppuri, M.D. Detroit Medical Center/ Wayne State University Detroit, MI
ABSTRACT Cannabis smoking is the most common substance of drug abuse among young adults in the Western world. Ongoing controversy remains about the causal relationship between marijuana use and adverse cardiovascular events. We report a case of a 37 year old male who developed marijuana associated MI during induction of general anesthesia for an elective surgery. We present this case to highlight vasculotoxic effect of marijuana on the cardiovascular system. With the legalization of marijuana in several states across the country, a thorough preoperative evaluation is required in order to ensure optimal care is delivered, and to avert potential crisis that may unfold. Among illicit substance use disorders, marijuana use disorders are reaching epidemic proportions in the western world.1 Controversy remains regarding causal association between marijuana use and adverse cardiovascular events.2 In patients with established coronary artery disease, marijuana smoking has been shown to act as trigger of acute myocardial infarction for several hours following its use. However, in the absence of obvious coronary artery disease, marijuana use has been reported to cause acute myocardial infarction in few case reports worldwide.3-8 However, almost all of them had relied on either coronary angiogram or stress test to diagnose coronary artery disease, which are inaccurate in documenting coronary artery disease burden.9,10
Here we report a case of acute myocardial infarction in association with recent marijuana use in a relatively healthy young patient where coronary artery disease was exclusively ruled out through computed tomography coronary angiogram (CTCA). CASE DESCRIPTION A 37-year-old African American gentleman was scheduled for elective surgical exploration and possible orchiectomy of a testicular mass. He has no past medical problems and never had past surgeries. Preoperative vitals were stable, physical examination was normal. Patient received 2mg of midazolam IVP in preoperative holding area. In the operating room, standard ASA monitors were attached. During induction of anesthesia, patient received fentanyl 100 mcg IV, lidocaine 100 mg IV, followed by propofol 200 mg IV and succinylcholine 100 mg IV. Patient developed non-sustained tachyarrhythmia, which was interpreted as ventricular tachycardia on tele monitor by anesthesia team (telemetry strips or electrocardiogram were unavailable). Additional 100mg IV lidocaine was bloused and EKG changes revealed ST segment elevation with sinus bradycardia and hypotension. Ephedrine 20 mg IV was given to treat hypotension. Patient was intubated with endotracheal tube size 8 mm OCETT and anesthesia maintained with isoflurane 0.4 MAC. Patient became stable, with normal EKG and blood pressure. He was extubated in the operating
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room and he regained full consciousness. He denied chest pain and any symptoms and was transferred to the recovery unit. On careful questionnaire, it was revealed that patient was a habitual marijuana user for 20 years and consumed marijuana just prior to coming to the hospital for the elective procedure.
DAYS
TROPONIN (NG/ML)
CK-MB (NG/ML)
DAY 1
0.44
20
DAY 2
5.7
22
DAY 3
1.23
6
DAY 4
0.80
3
DAY 5
0.10
showed normal systolic and diastolic dysfunction, no wall motion abnormality, normal left ventricular wall thickness and no other structural abnormality. EKG gated high-resolution (0.6mm collimation, 500 ms gantry rotation time)
64-slice computed tomography coronary Figure 1: Trend of cardiac enzymes (Troponin and CKangiogram (CTCA) MB [Immunoassay]) during hospitalization Subsequent work revealed no luminal up showed elevated abnormality, normal troponin and urine drug screen was positive for coronary vessel wall without evidence of any marijuana. Initial troponins and CK-MB were plaque (Figure 3). 0.44 ng/mL and 20 ng/mL respectively then peaked to 5.70 ng/mL and 22 ng/mL respectively. Figure 3: Computed tomography coronary (Figure 1) angiogram images showing no discernible coronary artery disease in the lumen or vessel Immediate EKG showed non-specific flat 0.5 wall. (Red arrow: Left main coronary artery; mm ST segment depression in V4-V6 (Figure 2a), Black arrow: Right coronary artery; White arrow: which resolved on second day. (Figure 2b) Aortic valve) The patient was treated for NSTEMI with aspirin, plavix, beta-blocker, statins and intravenous heparin as per American College of Cardiology/ American Heart Association guidelines. Subsequent EKG showed no significant ST changes. 2D echocardiogram done the second day
Coronary calcium score was calculated to be zero, suggesting no presence of plaque, and less than 5% chance of having heart disease, and very low risk of a heart attack.18,19 Given the history of undiagnosed testicular mass suspicious for malignancy, pulmonary embolism as a plausible
Figure 2a: Immediate EKG showed non-specific flat 0.5 mm ST segment depression in V4-V6
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Figure 2b: Normal EKG on day 2
cause of troponin elevation was considered. However, no evidence of pulmonary embolism was found on CTCA and subsequently on lung ventilation-perfusion technetium scan. Throughout the hospital stay, patient remained asymptomatic, vital sign were stable and no other complications observed. Patient troponin and CK-MB trended to normal and heparin was discontinued. Patient was discharged home on the fourth day to follow up with oncology.
anginal threshold and may act as a trigger of acute myocardial infarction for several hours following its use.2 More importantly, several case reports of myocardial infarction in close proximity to marijuana use in otherwise healthy individuals or those with low cardiovascular risk have also been reported, even in the absence of established coronary artery disease.3-8 Ischemia work up showing no evidence of coronary artery disease was done by coronary angiogram in majority of the cases.4,5,8
Marijuana is not only the most prevalent (4%) illicit drug being used in the USA, but also had incidence of more substance disorder (DSMIV marijuana abuse or dependence) in 20012002 than in 1991-1992, affecting mainly younger generations.1 Cannabis is derived from the plant Cannabis sativa and its effect is primarily mediated by the activation of cannabinoid receptors, which are present in brain, heart, blood vessels, spleen and immune system.11 Marijuana use has been associated with acute cardiovascular events (myocardial infarction, ventricular tachycardias), primary cerebrovascular events (including transient ischemic attacks, cerebrovascular accidents) and peripheral vascular events (renal infarction and peripheral arteritides).12 In patients with established coronary artery disease, marijuana smoking has been shown to significantly lower
In two cases,6,7 a treadmill stress test was negative for inducible ischemia and in other,3 autopsy revealed no evidence of atheromatous coronary artery disease. Our case is unique for two reasons: Patient had been asymptomatic (denied any chest pain) throughout the hospital course emphasizing that marijuana use may be associated with asymptomatic myocardial infarction, not making the patient to seek medical care; Coronary artery disease was ruled out exclusively by CTCA, which showed no intra luminal stenotic disease or any nonobstructive coronary plaques in the vessel wall. Myocardial infarction frequently develops from angiographic non obstructive lesions9 and since angiography only defines vessel lumen and not cross-sectional vessel wall morphology,10 role of conventional coronary angiogram in ‘excluding’ coronary artery disease is limited.
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Figure 3: Computed tomography coronary angiogram images showing no discernible coronary artery disease in the lumen or vessel wall. (Red arrow: Left main coronary artery; Black arrow: Right coronary artery; White arrow: Aortic valve)
As earlier case reports were relied mainly on coronary angiogram to exclude coronary artery disease, ambiguity remained in interpreting the results. The diagnostic potential of computed tomography coronary angiography (CTCA) surpasses coronary angiography because it allows not only the detection of significant coronary stenosis but also the presence of non-obstructive coronary plaques.113Proposed mechanisms by which marijuana might contribute to the development of myocardial infarction include: catecholamine excess related increase in heart rate and cardiac workload; impaired oxygen supply to the heart secondary to increased blood carboxyhemoglobin levels; marijuana smoking induced oxidant gases resulting in cellular stress which may potentiate cardiovascular risk through Summer 2015
activation of platelets; increased oxidized LDL formation; enhanced factor VII activity; and inflammatory response induction.2 During cannabis smoking there is a dose dependent increase in heart rate which peaks in 30 min after smoking and increase in blood pressure when supine and orthostatic hypotension. [14,15] Delta-9 tetrahydrocannabinol (THC) concentration reaches peak even before the end of smoking, which induce activation of human platelets in vitro. This has also been postulated as a possible mechanism for an increased risk of MI. [16] Also cannabis smoking increases carboxyhaemoglobin levels and results in decrease oxygen carrying capacity. [17]
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In our case, proposed mechanism of myocardial infarction would be demand ischemia from tachyarrhythmia, coronary vasospasm or potentiated hypotensive response to anesthetic medications secondary to recent marijuana use, in conjunction with administered anesthetic medications. Therefore, recent marijuana use may have potentiated the effects of anesthetic medication. Marijuana associated myocardial infarction can occur in absence of symptoms due to analgesic properties of THC. Marijuana use can also be associated with myocardial infarction, even in the absence of coronary artery disease, further strengthening the notion that marijuana has a vasculotoxic effect on cardiovascular system. With the legalization of marijuana in several states across the country, its use and abuse has increased significantly. Anesthesiologists and the surgical team should be well aware of the potential cardiovascular risks associated with marijuana use and general anesthesia. A thorough preoperative evaluation is required in order to ensure optimal care is delivered, and to avert potential crisis that may unfold.
REFERENCES 1. Compton, W.M., Grant B.F., Colliver J.D., Glantz M.D., Stinson F.S., Prevalence of marijuana use disorders in the United States: 1991-1992 and 20012002. Jama, 2004. 291(17): p. 2114-21. 2. Aryana, A. and M.A. Williams, Marijuana as a trigger of cardiovascular events: speculation or scientific certainty? Int J Cardiol, 2007. 118(2): p. 141-4.
7. McLeod, A.L., C.J. McKenna, and D.B. Northridge, Myocardial infarction following the combined recreational use of Viagra and cannabis. Clin Cardiol, 2002. 25(3): p. 133-4. 8. Podczeck, A., K. Frohner, and K. Steinbach, Acute myocardial infarction in juvenile patients with normal coronary arteries. Int J Cardiol, 1991. 30(3): p. 359-61. 9. Ambrose, J.A., Tannenbaum M.A., Alexopoulos D., Hjemdahl-Monsen C.E., Leavy J., Weiss M., Borrico S., Gorlin R., Fuster V., Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol, 1988. 12(1): p. 56-62. 10. Topol, E.J. and S.E. Nissen, Our preoccupation with coronary luminology. The dissociation between clinical and angiographic findings in ischemic heart disease. Circulation, 1995. 92(8): p. 2333-42. 11. Baker, D., Pryce G., Giovannoni G., Thompson A.J., The therapeutic potential of cannabis. Lancet Neurol, 2003. 2(5): p. 291-8. 12. Caldicott, D.G., Holmes J., Roberts-Thomson K.C., Mahar L., Keep off the grass:marijuana use and acute cardiovascular events. Eur J Emerg Med, 2005. 12(5): p. 236-44. 13. Schoenhagen, P., White R.D., Nissen S.E., Tuzcu E.M., Coronary imaging: angiography shows the stenosis, but IVUS, CT, and MRI show the plaque. Cleve Clin J Med, 2003. 70(8): p.713-9. 14. Beaconsfield, P., J. Ginsburg, and R. Rainsbury, Marihuana smoking. Cardiovascular effects in man and possible mechanisms. N Engl J Med, 1972. 287(5): p. 209-12. 15. Johnson, S. and E.F. Domino, Some cardiovascular effects of marihuana smoking in normal volunteers. Clin Pharmacol Ther, 1971. 12(5): p. 762-8.
3. Bachs, L. and H. Morland, Acute cardiovascular fatalities following cannabis use. Forensic Sci Int, 2001. 124(2-3): p. 200-
16. Deusch, E., Kress H.G., Kraft B., KozekLangenecker S.A. (2004), The procoagulatory effects of delta-9-tetrahydrocannabinol in human platelets. Anesth Analg, 2004. 99(4): p. 1127-30, table of contents.
4. Charles, R., S. Holt, and N. Kirkham, Myocardial infarction and marijuana. Clin Toxicol,1979. 14(4): p. 433-8.
17. Hollister, L.E., Health aspects of cannabis: revisited. Int J Neuropsychopharmacol, 1998.1(1): p. 71-80.
5. Choi, Y.S. and W.R. Pearl, Cardiovascular effects of adolescent drug abuse. J Adolesc Health Care, 1989. 10(4): p. 332-7.
18. Annika Schuhbaeck; Thomas Zimmer; Michaela Mitschke; Mohamed Marwan; Stephan Achenbach; Jasmin Schmid, J Am Coll Cardiol. 2014;63(12_S):. doi:10.1016/S0735-1097(14)61268-7
6. Collins, J.S., Higginson J.D., Boyle D.M., Webb S.W., Myocardial infarction during marijuana smoking in a young female. Eur Heart J, 1985. 6(7): p. 637-8.
19. Thomas Gerber, Christopher M Kramer, Diagnostic and prognostic implications of coronary artery calcification detected by computed tomography, uptodate.com, June 2014
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Your World is Complicated As a Health Care Provider, it’s often one challenging thing after another: :: Proper documentation and coding of the procedures you perform
:: Ensuring your billed amounts are paid thoroughly and completely
:: Capturing that documentation in an Electronic Health Record compatible with your external constituencies
:: Understanding how YOUR PRACTICE will fit into the world of the Affordable Care Act
:: Billing those coded procedures in a timely, efficient and complete manner
:: Taking care of your patients
This is just a sampling of the issues you face every day. ALL are important to remaining viable in today’s challenging healthcare environment.
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CALENDAR OF EV ENTS
2015 September 17 MSA BOARD MEETING LANSING, MI
September 24 – 25
MICHIGAN SURGICAL QUALITY COLLABORATIVE CONFERENCE LIVONIA, MI
November 21 -22 ASA QUALITY MEETING ROSEMONT, IL
Visit www.mymsahq.org for current events and training opportunities.
October 24 – 28 ASA ANESTHESIOLOGY 2015 SAN DIEGO, CA
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New & Refurbished Anesthesia Equipment
Refurbished Passport 2
Refurbished Cardiocap/5
Refurbished Mindray Spectrum
New Mindray Passport 8 & 12
Video Stylet Only $499 each
Masimo Pronto SpHb Spot-Check
Masimo EMMA EtCO2 & RR
Masimo Root w/ EtCO2 & Multigas
S/5 Aestiva SPECIAL $12,900
Refurbished Fabius GS
New Mindray A3/DPM6
Refurbished S/5 Avance
Regional Biomedical Service In-house Biomedical Repairs New and Refurbished Vaporizers Vaporizer Pole Mounts Gas Fittings and Hoses- All Types Anesthesia Accessories Oxygen Sensors Heine Laryngoscopes Oral Surgery Analgesia Units
Refurbished GE Aespire/7900
800-448-0814
Summer 2015
Paragon Service www.ParagonService.com
SPECIAL Paragon/Penlon $8,900
Fax 734-429-3197
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RESIDENT REVIEW:
2015 AMERICAN SOCIETY OF ANESTHESIOLOGISTS LEGISLATIVE CONFERENCE Krystal Weierstahl, D.O. Henry Ford Hospital Department of Anesthesiology Detroit, MI
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s Anesthesiology residents, most of our time has been devoted to clinical duties, learning, and studying. As a result, our knowledge of outside events suffers. I attended the 2015 American Society of Anesthesiologists Legislative Conference held May 4-6 in Washington D.C., as a Michigan resident representative from Henry Ford Hospital. As the conference began, I became aware of the current issues in the field of Anesthesiology potentially affecting the future of our profession and safety of our patients.
The visits to Congress served to educate our legislators on current ASA topics. As a resident new to legislation, my fellow residents and I were able to see experienced members of MSA discussing three current issues. The three main issues in discussion were veteran healthcare, rural health care access, and screening colonoscopies. The first issue discussed was the protection of our nation’s veterans’ healthcare. The Department of Veterans Affairs Office of Nursing Services proposes to move forward with a new policy handbook, the VHA Nursing Handbook. The proposed handbook would mandate the VA to provide anesthesia care using nurse anesthetists without physician supervision;
The conference started with two days of educating and informing attendees on current issues. A final day was devoted to visiting with members of the Senate and the House of Representatives at Capitol Hill. The Michigan Society of Anesthesiologists (MSA) compiled a group to attend this annual event. This year’s Michigan delegation consisted of current MSA board members, MSA pastpresidents, and residents from several hospitals across Michigan. The residents included: Dr. Natasha Smolcic, M.D., Beaumont Hospital; Dr. Rashad Albeiruti, M.D., University of Michigan; Dr. Tyler McCulloch M.D., Detroit Medical Center; and Dr. Travis Bailey, D.O., McLaren Greater Lansing The group with Representative Dr. Dan Benishek (R-1) and myself.
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MSA Residents with Senator Gary Peters: (l to r) Tyler McCulloch, Krystal Weierstahl, Rashad Albeiruti, Sen. Peters, Natasha Smolcic, Travis Bailey, and Lindsay Straight
this would abandon the current physician-led, team-based surgical anesthesia care model. The ASA supports the Frontlines to Lifelines Act, a legislation proposal that would improve veteran healthcare access and continue to protect teambased surgical anesthesia care. A second issue discussed was rural healthcare access. In rural facilities, hospitals have low patient volumes and Medicare payments. The anesthesia rural “pass-through� program was created as an incentive for anesthesia providers to practice in the rural settings. With this program, hospitals can use Medicare Part A funds, instead of Part B to incentivize anesthesia providers to practice in this setting. However, the current law does not apply to physician anesthesiologists. A bi-partisan Medicare Access to Rural Anesthesiologist Act of 2013 would reform the rural access to allow hospitals to employ physician anesthesiologists. The last issue discussed was screening colonoscopies. With Medicare, preventative service cost-sharing requirements for patients are eliminated. A screening colonoscopy is considered a preventative service. However, if during a colonoscopy a polyp is found and removed, the screening colonoscopy is now considered diagnostic or therapeutic. This means a patient would have to share cost Summer 2015
for this screening. The new legislation being proposed is the Removing Barriers to Colorectal Cancer Screenings Act. This would prevent all cost-sharing, if a screening colonoscopy was transitioned to diagnostic or therapeutic. These three issues are currently being taken to our Congressman. Nevertheless, there are many more matters surrounding the field of anesthesia. The ASA website www.asahq.org/ advocacy has further tools and information to learn more and stay informed. As a resident it is often difficult to see past our daily activities of training and learning. However, after this conference I realized how key these issues are, and how our involvement is needed to continue to protect the future of our field and safety of our patients.
REFERENCES: 2015 American Society of Anesthesiologists Legislative Conference The American Society of Anesthesiologists Website. www.asahq.org/advocacy
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THE MICHIGAN OPIOID SAFETY SCORE (MOSS):
A NOVEL ASSESSMENT TOOL FOCUSED ON SAFE DELIVERY OF OPIOIDS Branden Yaldou, MD Joshua Hozella, MD Roy Soto, MD Department of Anesthesiology and Perioperative Medicine Beaumont Health Royal Oak MI
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one are the days focused on treating pain as a number. In the twenty years since the American Pain Society initially declared pain to be the “fifth vital sign”, pain therapy has evolved to a delivery system focused on patients’ interpretation of a rating scale. Often treating pain with opioids, this rating-scale driven practice has resulted in increased adverse events prompting The Joint Commission to release its only Sentinel Event Alert of 2012. The Alert outlined opioidrelated harm and focused on the continuing problem faced in managing patients’ pain. It further delineated risk factors for adverse events and made recommendations for education and training, appropriate patient monitoring, effective tools and processes, and use of safer technologies. By describing these means to reduce complications and improve the safety of pain management, the Alert outlines the basics for development of an evidence-based roadmap for improving patient satisfaction and reducing cost. These conclusions were supported in similar publications demonstrating the need for sedation assessment prior to opioid use. The Alert and others also support factors such as pre-therapy health risk and respiratory rate, may further improve safe delivery of opioids in the clinical setting. Together, these findings incited the development of a single point of care tool integrating a proven sedation assessment scale with health risk and respiratory rate, effectively identifying patients at risk for opioid-related harm.
THE MICHIGAN OPIOID SAFETY SCORE The Michigan Opioid Safety Score (MOSS) was developed to incorporate patient risk, respiratory rate, and sedation into one bedside score that could be used to improve patient safety during inpatient opioid therapy (see Figure 1). Scoring is based on a summation of risk data with objective bedside measures of over-sedation taking precedence over a patient’s subjective report of pain. RISK ASSESSMENT Patients are initially scored based on health risk. These include four risk categories, or groups: 1. Snoring/obesity/sleep apnea history 2. Site of surgery (abdominal/thoracic) and anesthesia time (if >3 hours within 24 hours of MOSS assessment) 3. Concomitant sedative use (if within 2 hours of MOSS assessment) 4. Advanced age as well as current smoking history Patients are assigned points based on risk group, with a maximum possible score of two. Some patient risks may change over time (depending on concomitant sedatives and time from anesthetic exposure), while others (e.g., weight, age) will be static. RESPIRATORY RATE A respiratory rate of ≥10 breaths/minute yields no
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Michigan Opioid Safety Score (MOSS)
Roy Soto, M.D.
points on the MOSS assessment, while a rate <10 breaths/minute generates two points.
RISK STRATIFICATION MOSS= Health Risk (maximum of 2 points) + RR Score +/- mPOSS STOP modifier (Possible score 0 – 4 with possible STOP modifier)
Circle point score if any criteria apply to patient
A) Health Risk
STOP MODIFIER
Group 1
Based on a modified POSS (sedation) score, patients receive a STOP modifier if they are excessively sedated, drift off to sleep during conversation, or are difficult to arouse. Note that no points are assigned for sedation per se, and assessments are made subjectively by nurses at the point of care, that is, when the patient (or family member/care provider) ask for pain medications.
Group 3
Group 2
Group 4
Age > 75 Smoker
MOSS Score (Total Points)
1
1 1 1
If points total for this section is >2, enter “2” for MOSS Score here: B) Respiratory Rate Respiratory Rate ≥ 10
0
Respiratory Rate < 10
2
Add points from this section to MOSS Score above and enter here: C) Modified Pasero Opioid-Induced Sedation Scale (mPoss): STOP Modifier Excessively sedated, drifts off to sleep, difficult to arouse or unarousable
STOP
If STOP is circled for this section, enter “STOP” for MOSS Score and follow guidelines below
STOP
STOP
SCORING 4
Risk factors plus respiratory rate generate a score of 0-4, with the STOP modifier overriding the numeric score (see Figure 1).
OSA Snoring BMI>40 Abd/Thor surgery Anesthesia time >3hr (within 24hr of assessment) Concomitant sedatives received within 2 hours
CAUTION
3 2
CONCERN
1 SAFE 0 Form completed by:
MOSS INTERPRETATION
Stop all opioids Notify primary physician Institute increased levels of monitoring Consider anesthesia/pain consultation Ensure multimodal analgesia delivered Consider reversal agents (naloxone or flumazanil as appropriate) Decrease opioid dose Increase levels of monitoring Ensure multimodal analgesia delivered Increase opioids as needed with special attention Consider increased levels of monitoring Ensure multimodal analgesia delivered Safe to proceed with further opioid dosing Ensure multimodal analgesia delivered
Signature: _____________________________________ Date: _____________ Time: _______
MOSS INTERPRETATION • Safe: Patients may receive continued opioid therapy. • Concern: Patients should be identified during nursing handovers, as at-risk patients that may need to be monitored more closely on the clinical unit than those deemed safe. • Caution: Opioids should be decreased and levels of monitoring increased. This may necessitate transfer to an intensive care or stepdown unit, or the need for continuous pulse oximetry, respiratory rate, or capnographic monitoring on the clinical unit. • STOP: Opioids should be discontinued immediately, primary care providers should be notified, and patients should be monitored/treated aggressively to prevent hypoventilation, hypercapnea, hypoxemia, apnea, and death. MULTIMODAL ANALGESIA Each step in the MOSS interpretation table includes comments regarding multimodal analgesia. This is present to ensure that patients never receive opioid-only pain treatment regimens, and that patients ideally receive non-opioid analgesics, such as acetaminophen and a nonsteroidal antiinflammatory drug, on a continuous basis when opioid orders are active. Summer 2015
Figure 1
Sedation assessment tools require continuous improvement to maximize benefits while decreasing risks. MOSS was developed to include sedation assessment and factors that put patients at risk of experiencing adverse events from the medications used to treat pain. A MOSS assessment provides more concise treatment decisions by taking into account medical history, concurrent sedative use as well as respiratory and sedation status. This tool can be used as a practical and accessible method for providers to move beyond treating pain as number and tailoring treatment for each individual patient. MOSS was developed in part through collaboration with the Michigan Health and Hospital Association’s Keystone Center. The tool has been adopted for use in hospitals around the state and plans for outcome studies post-implementation are underway. Since its inception, the MOSS was featured in the June 2015 issue of The Journal of PeriAnesthesia Nursing and abstracts have been presented at federally funded national conferences. A study of tool validation will be presented at this year’s ASA Conference in San Diego. For more information about the MOSS, feel free to contact the authors: Branden Yaldou, MD at branden.yaldou@beaumont.org; Joshua Hozella, MD at joshua.hozella@beaumont.org; and Roy Soto, MD at roy.soto@beaumont.org. 21
LEGIS LATIVE CORNER
MICHIGAN LEGISLATURE The Legislature has entered an in-district summer work recess, which extends through September 7th. Because of the failure of Proposal 1, the road funding ballot proposal, the current primary focus here in Lansing has been on how to fund Michigan’s transportation infrastructure moving forward through a combination of either new revenue or future budget cuts. Michigan Gov. Rick Snyder has spent the past three years urging the state Legislature to increase longterm road funding by at least $1.2 billion a year. Lawmakers sent Proposal 1 to the statewide ballot, but voters resoundingly rejected the bloated sales tax measure in May. The state House and Senate have since approved competing road funding plans, but Republican majorities in their respective chambers are currently at odds over a proposal to generate new revenue through higher fuel taxes. Both the House Plan and the Senate Plan rely heavily on the redirection of existing General Fund dollars to roads, which will likely negatively impact certain legislative priorities. The House Plan specifically targets economic development dollars in the MEDC, while the Senate Plan leaves the MEDC alone directly. However, the specific cuts from the Senate for the redirected dollars remain unidentified. The revenue increases in the Senate Plan are uniform among all payers with the exception of the $38 million diesel parity increase. However, both plans index the gas tax to inflation. Based on the two principles of equity and sustainability, the House Plan tends to negatively impact future budgets, and is questionable in its sustainability. The Senate Plan shares the same risks through its cut model, though provides some larger measure of sustainability through its increased revenue. The House Democrats have also released a road package that differs greatly from the one Speaker Cotter (R-Mount Pleasant) has in mind, including: a 3 percent increase, from 6 to 9 percent, in the Corporate Income Tax; a decrease in weight limits for commercial vehicles; an increase in registration fees for trucks; and the renegotiation of the Michigan Economic Growth Authority. According
Legislative Corner is a regular feature, written by Marcia Hune and Chris Iannuzzi, Governmental Consultant Services, Inc.
to House Democrats, the plan will protect middle class families in the state, while increasing the taxes paid by businesses. These plans will continue to be discussed throughout the upcoming weeks here in Lansing and all parties are optimistic a deal can be reached. The Legislature is scheduled to be in session in mid-August to continue the debate as the roads are currently eclipsing all other topics in Lansing. LEGISLATION ON SUPERVISION AND SCOPE OF NURSE ANESTHETISTS In May, as anticipated, Senate Majority Leader Floor Leader Senator Mike Kowall (R-White Lake) introduced a new version of the nurse anesthetist legislation for this session. Senate Bill 320 is much broader than other language we’ve seen in the past, as it includes the following provisions: • The bill would remove the physician supervision requirement for nurse anesthetists • It would allow them to develop a plan of care, which would permit them the ability to diagnose unsupervised • Allow nurse anesthetists to be responsible for addressing patient emergencies that arise during the implementation of the plan of care • Would allow them to prescribe controlled substances (schedules 1-5) unsupervised • Allows the nurse anesthetists to practice in a facility licensed under Article 17 of the Public Health Code (ie. Nursing home, home for the aged, mobile dental facility) or in ANY OTHER MEDICAL SETTING - this is not just limited to hospitals.
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â&#x20AC;˘ The nurse anesthetist would be able to deliver anesthesia/analgesia services performed for operative, obstetrical, interventional, or diagnostic purposes during the pre-, intra-, and post-operative periods. Both the Michigan Association of Nurse Anesthetists (MANA) and the Michigan Health and Hospital Association (MHA) are again supporting this issue. In a recent meeting with the sponsor, MANA, MHA, MSA, and the Michigan State Medical Society (MSMS), the MHA expressed publicly that their end goal is to change state law to allow for the federal opt-out.
midwives, certified nurse practitioners, and clinical nurse specialists-certified. Sen. Shirkey worked with the Michigan State Medical Society (MSMS) and the MSA on our concerns with the legislation, as well as the concerns of other physician groups, and substitute language was adopted that will require APRNs to be part of a Patient Care Team led by a physician. The bill was considered in the Senate Health Policy Committee for testimony only a number of times before being voted to the floor of the full Senate. However, discussions continue on that particular bill as the nurses have expressed their opposition to the patient care team language that is now in the legislation.
The MSA has shared draft language with the sponsor and other stakeholders on the issue that would instead keep intact a physician led anesthesia team model, similar to the patient care team language that was eventually included in Senate Bill 68 on the issue for the advanced practice registered nurses (APRNs).
GCSI continues to work diligently to be the eyes, ears, and representatives of the Michigan Society of Anesthesiologists in Lansing, as we advocate for policies that ensure the safety of patients. If members have questions, please do not hesitate to contact Marcia Hune or Chris Iannuzzi at hune.m@ gcsionline.com or iannuzzi.c@gcsionline.com.
The Senate Health Policy Committee held one hearing on Senate Bill 320 and in the meantime, GCSI and members of the MSA continue to discuss our concern with regard to patient safety under the bill with lawmakers in the State Senate and House of Representatives, as well as members of Governor Rick Snyderâ&#x20AC;&#x2122;s Administration. Many MSA members have contacted their lawmakers in opposition to Senate Bill 320. We appreciate the outreach and encourage all members to have conversations with their representatives and senators about the patient safety concerns with removing physician supervision and expanding the scope of nurse anesthetists. GCSI and your MSA Legislative Committee remain vigilant in advocating on behalf of anesthesiologists and physician supervision in regard to this legislation. LEGISLATION TO EXPAND THE SCOPE OF CERTAIN ADVANCED PRACTICE NURSES The new chairman of the Senate Health Policy Committee, Senator Mike Shirkey (R-Clarklake), introduced Senate Bill 68 dealing specifically with an expansion of scope for certain advanced practice registered nurses (APRNs) to include certified nurse Summer 2015
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