Jackie Rowles, MBA, CRNA, ANP-BC FAAPM, FAAN Meridian Pain Group

Transcription

1 Jackie Rowles, MBA, CRNA, ANP-BC FAAPM, FAAN Meridian Pain Group

2 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

3 Improving the quality of life by reducing physical and emotional suffering.

4 Team of providers working together in the provision of treatment and services

5 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

6 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

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

8 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:

9 80% 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:

10 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: 13-19

11 Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research --June 29, 2011 Much of the chronic pain experienced by Americans isn't treated correctly, in part because doctors are not taught in medical school how to help patients manage pain Chronic pain, a condition that affects more than 116 million Americans and costs the U.S. between $560 and $635 billion annually in medical treatment and lost productivity

12 Calls for a cultural change in order to prevent, assess, treat and understand all types of pain and laid out a blueprint for providing relief from pain. Directs the Department of Health and Human Services to develop a plan to increase awareness about pain and its health consequences; improve how pain is assessed in the healthcare setting and how treatment of pain is paid for by the federal government; and to address disparities in how different groups of people experience pain

13 The report recommends healthcare providers engage in continuing education programs, and that licensure, certification, and recertification should include assessment of providers' knowledge of pain management

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

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18 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

19 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?

20 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

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22 Injection of a local anesthetic and/or steroid Injection around nerves, joints, muscles, tendons Spinal cord stimulation Intrathecal pump implantation Radiofrequency ablation

23 May be diagnostic May be therapeutic May be both!

24 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.!

25 Anesthesia is defined as the relief of PAIN

26 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

27 We are trained in the evaluation and treatment of pain We are trained in peripheral and regional blockade many of these procedures are the same ones utilized in the treatment of non surgical related pain

28 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

29 Pain Management is specifically addressed in the AANA Document Scope and Standards for Nurse Anesthesia Practice.

30 CRNAs practice according to their expertise, state statutes and regulations, and institutional policy.

31 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.

32 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.

33 The state of Louisiana is the only state who has declared interventional pain management the practice of medicine. However there are constant challenges in other states.

34 The management of pain is the central component of total anesthesia care. Recognizing the individual patient's right to the treatment of acute and chronic pain, nurse anesthetists acknowledge that it is their professional and ethical responsibility to participate in the management of pain.

35 By virtue of education and individual clinical experience, CRNAs possess the necessary knowledge and skills to employ therapeutic, physiological, pharmacological, interventional, and psychological modalities in the management of acute and chronic pain.

36 CRNAs adhere to a total patient care philosophy directed at the promotion and maintenance of health and well being with special emphasis on providing rapid and effective alleviation of pain

37 Recognized as qualified providers of anesthesia and anesthesia related services, CRNAs demonstrate competencies that promote safe, effective access to pain management and anesthesia care. drafted in 1994, revised 2002, reviewed 2005

38 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

39 Spinal mediated pain Joint pain Myofascial pain Post surgical pain Malignancy Post-traumatic pain Bone pain Nerve pain

40 Physical Evaluation and Assessment Pharmacological treatment Injection Techniques Intralaminar Epidural Injections Regional Blocks Peripheral Nerve Blocks Stellate Ganglion (?)

41 Advanced Physical Assessment Advanced Pharmacology Injection Techniques Transforaminal Epidural Injections Nerve root injections Facet injections Medial nerve branch blocks Sacroiliac Joint Injections

42 Discography Spinal Cord Stimulation Rhizotomy Intrathecal pump implantation Sympathetic blocks: stellate ganglion, thoracic, lumbar, hypogastric

43 Anatomy Physiology Pharmacology Pathophysiology ANESTHESIA techniques, evaluation and treatment. of patient s response to PAIN

44 Our training makes us VERY VALUABLE team members of the Integrative Pain Management Team In both the acute and chronic pain treatment settings

45 Very helpful for pain clinic work Some states CRNAs have PA Does causes scrutiny within some state medical societies

46 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, the discrepancy in payment for services in different states caused many issues which were successfully addressed in the 2012 CMS ruling which took effect on Jan. 1, 2013

47 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

48 Acute deemed OK by our critics Chronic area being targeted as medical practice Challenge that interventions/blocks are dangerous Key point made that CRNAs are not trained in chronic pain. Statements that chronic pain is disease process requiring medical diagnosis/treatment and often state CRNAs can t be trained

49 LA lawsuit 11/07 Ruling 2/08 and Appeal Appeals Ruling 12/23/08 Rumor of MDAs volunteering as expert witnesses against CRNAs

50 LA IA NE OK AL TN MO others

51 There are many patients with pain who need good care 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. ALL providers need more training in pain management as pointed out by the IOM report!

52 The FTC has issued letters against proposed actions to regulate CRNAs out of pain practice AL Oct TN April 2011 MO March 2012

53 Nurse Anesthesia Schools My SRNA experience More formal COA curriculum? Basic pain mgt vs. Advanced Procedures directly transferable Specialty training and credentialing/certification

54 First course 10/2008 Held twice yearly, May and October Added one day Advanced Physical Assessment course beginning in May 2013 Now offering Basic and Advanced courses, and cadaver dissection Hoping to serve as a template for other specialty training (cardiovascular, obstetrics, pediatrics)

55 Post Master s Certificate in Advanced Pain Management began in rd class started Feb with 12 students

56 AANA Scope of practice Anesthesia definition AANA Position Statement on Pain Management Fluoroscopy use training Credentialing Hospitals, ASCs, offices

57 Multidisciplinary, inclusive society Has raised visibility and credibility Believe Pain mgt is every providers responsibility Currently one credentialing exam for all providers Advanced diplomat exam 10/2014 for MD, Dos and planned later for all prescribers Board of Directors CRNA position Encourage more CRNAs to join

58 ASPMN.org For RNs 30 CEUs in last 3 yrs (15 in pain) RN-C is credential Credentialing via the ANA

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60 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

61 Preliminary report published September 2010 Hardcopy final report available Jan There were eight final recommendations

62 Nurses should practice to the full extent of their education and training Recommendation number one: REMOVE SCOPE OF PRACTICE BARRIERS

63 US Congress dubbed as the decade of pain National Pain Care Policy Act and VA Pain Act

64 Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research

65 Established a national ruling concerning CRNA pain services who is able to provide and be reimbursed First became a problem when two Medicare Contract Agencies who denied CRNA reimbursement and this affected 18 states Proposed rule published July 6, 2012 Comment period ended September 4, 2012 Agency reviewed comments and issued a final policy on Nov. 2nd Took effect Jan

66 HHS/NIH National Pain Strategy Workgroups Part of Affordable Care Act Result of IOM report Oversight panel and 5 workgroups Two workgroups have been appointed

67 Education and Training workgroup Margaret Faut Callahan, PdD, FAAN Dean of Nursing at Marquette University Public Health: Care, Prevention, Disparities Jackie Rowles, MBA, CRNA, ANP-BC, FAAPM, FAAN Pain Practitioner

68 NBCRNA is in the development stage of a specialty certification exam in Non Surgical Pain Management. Group working on exam questions currently Go to the NBCRNA website for updated info

69 Chronic pain is a national problem Managing chronic pain is difficult The management of chronic pain is not owned by one discipline Collaboration and use of multiple modalities have been shown most effective in the management of chronic pain syndromes CRNAs are well positioned to add value to the pain management team

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