Improving the quality of life by reducing physical and emotional suffering. Jackie Rowles, CRNA MBA MA FAAPM Pain Care by Meridian Health Group

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1 Jackie Rowles, CRNA MBA MA FAAPM Pain Care by Meridian Health Group Participants will have an understanding of: Suitability of CRNAs for pain management practices Hallmarks and components of Integrative Pain management CRNA Training/Roles as Effective Pain Management Team members Challenges to CRNA pain practice Improving the quality of life by reducing physical and emotional suffering. 1

2 Team of providers working together in the provision of treatment and services with the goal of getting each patient to the highest level of functioning possible for their condition(s). Anesthesia providers Physiatrists Internists/Family Physicians Nurses, APNs Physicians Assistants Accupuncturists Exercise physiology Neurology And others! Psychiatrists Psychologists Physical therapists Occupational therapists Podiatrists Sleep specialists Massage therapists Chiropractors Orofacial pain Decrease pain (acute or chronic) Improve quality of life Maximize activity levels, home and work Allow for rehabilitation Improve sleep Improve mood, ability to cope 2

3 Decrease reliance on medications Improve functional status Improve relationships Get patients back to work, or keep them working! 3

4 About one fourth of U.S. adults report low back pain in the past 3 months The proportion of physician visits attributed to back pain has changed little in the past decade. Spine 2006; 23: % of the population will suffer from back pain sometime during their lives 80-90% of reported cases of low back pain will resolve within 6 weeks. Those who suffer with back pain have healthcare costs 50-60% higher than those who do not. Spine 1995; 20: Spine 1987; 12: J Pain Symp Manage 1997; 13: Recurrence rates: as high as 65-85% Is the most common cause of disability in population <45 yrs. Old Rate of those returning to work: 50% if off for 6 months 25% if off for 12 months 0% if off for 2 years Spine 2008; 33: Am Rheum Disease 1998; 58:

5 Physical Assessment clinic visits Consultation services Medication Management some have prescriptive authority Procedural Sedation for other providers Injection and Interventional Services 5

6 Advanced physical assessment Detailed medical/surgical history Detailed treatment history Review of imaging studies Review of medication use Review of alternative therapies: accupuncture, herbs, massage Detailed review of pain severity/type/location/frequency aggravating factors/alleviating factors onset/duration/description/ related to accident or injury? Review of any other testing information: labs, EMG Psychological exam Litigation involved? 6

7 Perform further assessment Request further testing as needed Assess patient support system Formulate treatment plan with team Discuss plan with patient/family, obtain buy in Initiate plan with treatment team Evaluate response to treatment plan, modify plan with team members/patient as needed Injection of a local anesthetic and/or steroid Injection around nerves, joints, muscles, tendons Spinal cord stimulation Intrathecal pump implantation Radiofrequency ablation 7

8 May be diagnostic May be therapeutic May be both! Interventional therapies are thought to work best in combination with other treatment modalities such as: psychology/physical therapy/ot/ activity modification/medication/ podiatry/massage/etc.! Anesthesia is defined as the relief of PAIN 8

9 Pain Management is incorporated in all that we do Pre- op/intra- op/post- op or PACU Obstetrical Post Anesthesia Pain Service (Hospital based) Hospital/ASC /office pain practices We are trained in the evaluation and treatment of pain We are trained (or can be further trained) in peripheral and regional blockade many of these procedures are the same ones utilized in the treatment of non surgical related pain Courses which have didactic and cadaver stations to offer training in advanced physical assessment, pharmacological pain agents, fluoroscopy and radiation safety, and interventional pain procedures 9

10 Pain Management is specifically addressed in the AANA Document Scope and Standards for Nurse Anesthesia Practice. CRNAs practice according to their expertise, state statutes and regulations, and institutional policy. Organized Medicine in the US has brought forth challenges to CRNAs in chronic pain practices stating their belief the management of chronic pain is the practice of medicine. 10

11 As well as challenges to use of fluoroscopy for needle placement, or guidance, as well as suitability of CRNAs in the performance of spinal injection procedures for chronic pain. First adopted by the AANA BOD in June 1994 Revised June 1997, February 2005, and August 2010 Four paragraphs 16 reference citations Educates as to the prevalence of pain Discusses components of pain; the role of healthcare providers in treating pain; reviews history of CRNA services, practice, training as related to the management of pain; provides rationale for CRNA pain management scope of practice. 11

12 Providing acute and chronic pain management and treatment is within the professional scope of practice of CRNAs. CRNAs employing pain management techniques is neither new nor unusual and has long been a part of CRNA practice. By virtue of education and individual clinical experience, a CRNA possesses the necessary knowledge and skills to employ therapeutic, physiological, pharmacological, interventional, and psychological modalities in the management of acute and chronic pain. The AANA believes that it is incumbent upon the individual CRNA to assure his or her competency when delivering anesthesia services, including pain management and treatment. KEY to provision of care Especially specialty care Meeting graduation requirements and passing certification exams demonstrate basic competency levels Almost all specialization requires further training, study, and experience for ANY Provider 12

13 The Council on Accreditation (COA) standards mandate nurse anesthesia programs provide content within, but not limited to, the following areas: anatomy, physiology, pathophysiology, pharmacology, and pain management AANA Position Statement on Pain Management Spinal mediated pain Joint pain Myofascial pain Post surgical pain Malignancy Post- traumatic pain Bone pain Nerve pain Physical Evaluation and Assessment Pharmacological treatment Injection Techniques Intralaminar Epidural Injections Regional Blocks Peripheral Nerve Blocks Stellate Ganglion 13

14 Advanced Physical Assessment Advanced Pharmacology Injection Techniques Transforaminal Epidural Injections Nerve root injections Facet injections Medial nerve branch blocks Sacroiliac Joint Injections Discography Spinal Cord Stimulation Rhizotomy Intrathecal pump implantation Sympathetic blocks: stellate ganglion, thoracic, lumbar, hypogastric First course in October 2008 Subsequent courses 5/2009, 10/2009, 5/2010, and 10/2010, 5/2011 and 10/2011 Hoping to serve as a template for other specialty training (cardiovascular, obstetrics, pediatrics) 14

15 Anatomy Physiology Pharmacology Pathophysiology ANESTHESIA techniques, evaluation and treatment. of patient s response to PAIN Our training makes us VERY VALUABLE team members of the Integrative Pain Management Team In both the acute and chronic pain treatment settings Very helpful for pain clinic work Some states CRNAs have Prescriptive Authority Does causes scrutiny within some state medical societies as some physicians are not supportive of this 15

16 CRNAs are, and have been for many years, recognized by the US Government, and private insurance companies, as qualified providers for pain management as evidenced by payment for services billed Unfortunately, there is some discrepancy in payment for services in different states in the US Procedure Fluoroscopy fee Local Medicare Carriers differ E&M codes problematic for some TF ESIs, other procedures under current Medicare scrutiny for overuse of billing codes Acute deemed OK by our critics. It is hard to argue against the fact that anesthesia practice includes the management of acute pain! Chronic pain treatment is the area being targeted as organized medicine declares it is medical practice 16

17 There are many patients with pain who need good care and not enough pain specialists to treat them CRNAs work very well as members of a team CRNAs have valuable training in pain processes, pathophysiology, patient assessment, pharmacological care, urgent/emergent care, etc. and can make a positive impact in patient care! Nurse Anesthesia Schools My SRNA experience More formal COA curriculum? Basic pain mgt vs. Advanced Procedures directly transferable Specialty training and credentialing/certification AANA Scope of practice Anesthesia definition AANA Position Statement on Pain Management Fluoroscopy use training Credentialing Hospitals, ASCs, offices 17

18 pain- Case discussions, information on pain meetings, etc. Used as a resource for CRNA pain practitioners Multidisciplinary, integrative, inclusive society Has raised visibility and credibility Believe Pain mgt is every providers responsibility One credentialing exam for all providers (physicians, nurses, chiropractors, massage therapists, etc.) Board of Directors CRNA position Encourage more CRNAs to join ASPMN.org For RNs 30 CEUs in last 3 yrs (15 in pain) RN- C is credential available via examination Credentialing is via the American Nurses Association 18

19 United States Congress dubbed as the decade of pain Passed House of Representatives and sent to Senate This act includes the establishment of: Institute of Medicine Conference on Pain Pain research at National Institutes of Health. Pain care education and training. Public awareness campaign on pain mgt Sent a letter of support for the National Pain Care Act which was signed by the AANA President to represent the 40,000 AANA members AANA also supported Veteran s Affairs pain act with a letter of support 19

20 Institute of Medicine of the National Academies A nonpolitical health care advisor to Congress Paired with Robert Wood Johnson Foundation for a two year study that developed a set of national recommendations with the goal of transforming the future of nursing. Visit to view the report Preliminary report published September 2010 Hardcopy final report available Jan There were eight final recommendations 20

21 Nurses should practice to the full extent of their education and training Recommendation number one: REMOVE SCOPE OF PRACTICE BARRIERS Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends actions for the following entities: Congress State Legislatures Centers for Medicare and Medicaid Services Office of Personnel Management Federal Trade Commission and Antitrust Division of the Department of Justice Work together effectively with your colleagues Educate all decision makers concerning CRNA practice Keep your ear to the ground Stay involved in your state and national associations Communicate concerns to state/national leaders Establish rapport with decision makers Donate to your state and AANA PAC Keep the patient first Most of all, be the best practitioner you can be LEAD BY EXAMPLE 21

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