Could Your Patient be Taking Uber or Lyft Post-Anesthesia? A New Era for Transportation Policy and Practice Considerations.

PURPOSE: The purpose of this project was to examine nurse anesthetists' practice and encounters with ambulatory surgery patients experiencing transportation difficulties after the provision of anesthesia. DESIGN: A mixed method approach was used. METHODS: An eleven-item questionnaire was disseminated nationally to 2,827 Certified Registered Nurse Anesthetists (CRNAs) practicing in the outpatient setting. The survey consisted of multiple-choice questions and open text for qualitative assessment. Questions focused on frequency of encounters with patients experiencing transportation difficulties post-anesthesia and policies for rideshare options. FINDINGS: A total of 43% of responding CRNAs work in a clinical practice setting in which patients have the option of being discharged using rideshare (Uber/Lyft) but only if accompanied by an adult. Issues emerged around patient safety when using a rideshare service for discharge postanesthesia. CONCLUSIONS: The proliferation of rideshare options may provide increased access to surgical services in the outpatient anesthesia care setting. Practice considerations associated with transportation policies for postanesthesia patients in the era of rideshare services are warranted.

Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness.

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

Answering the call to address chronic pain in military service members and veterans: Progress in improving pain care and restoring health.

Chronic noncancer pain (CNCP) in military and veteran populations mirrors the experience of chronic pain in America; however, these two populations have unique characteristics and comorbid conditions such as traumatic brain injuries, postconcussive syndrome, posttraumatic stress disorder, and behavioral health disorders that complicate the diagnosis and treatment of chronic pain. Military members and veterans may also be stigmatized about their conditions and experience problems with integration back into healthy lifestyles and society as a whole following deployments and after military service. The military and veteran health care systems have made chronic pain a priority and have made substantial strides in addressing this condition through advances in practice, education, research, and health policy. Despite this progress, significant challenges remain in responding to the wide-spread problem of chronic pain. The purpose of this article is to: (a) examine the state of CNCP in military and veteran populations; (b) discuss progress made in pain practice, education, research, and health policy; and (c) examine research, evidence-based practice guidelines, and expert consensus reports that are foundational to advancing pain care and improving health for military service members and veterans with CNCP. In addition, recommendations are proposed to address this widespread health problem through the expanded use of advanced practice registered nurses, the implementation of models of care, and use of national resources to educate health care providers, support practice, and promote effective pain care.

Postgraduate nurse practitioner residency programs: supporting transition to practice.

The 2010 Institute of Medicine report The Future of Nursing recommended residency programs for nurses. The number of such postgraduate residencies for nurse practitioners (NPs) is increasing in community settings; still, the Institute of Medicine's recommendation departs from the tradition of direct entry into practice after the completion of a formal nursing program. Research shows that residencies support NPs' transition to practice, but very few data support their impact on patient care. Postgraduate residencies are controversial, and the authors of this Commentary discuss the naming, funding mechanisms, and possible mandating of these programs.The authors believe that residencies should not be mandated but encouraged for new NPs and for those moving to new clinical settings. Team-based residencies provide both an opportunity to improve collaboration and a model of patient-centered care.

Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing.

OBJECTIVE: To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing. DATA SOURCES: State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey. STUDY DESIGN: Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states. DATA COLLECTION: Secondary data sources. PRINCIPAL FINDINGS: Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001). CONCLUSIONS: Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.