ISA UPDATE
NEWS FOR THE IOWA SOCIETY OF ANESTHESIOLOGISTS
Officers
President
Patrick Allaire, MD
[email protected]
President-Elect
Joseph F. Cassady, Jr., MD
[email protected]
Secretary/Treasurer
David Haupt, MD
[email protected]
District Director
John Moyers, MD
[email protected]
Asst. District Director
James Becker, MD
[email protected]
President’s Letter
by Patrick Allaire, MD
As you read my second newsletter,
the first cool days of fall are setting
in over Iowa. This is a time of year
when we anticipate the start of
school, football games, harvest
and hunting seasons. It also marks
the time when we hold our national
ASA annual meeting. Presently,
your delegates and directors are
making plans to represent you at
the ASA House of Delegates in San
Francisco, October 13 – 16. Feel
free to contact these representatives if you have opinions about
issues to be discussed.
Iowa DHS Proposes Cut in Anesthesia
Fees for Medicaid in FY 2008-09
SEPTEMBER 2007 ISSUE
CMS Proposes Fee
Update for Anesthesia
By now, I hope every ISA
member has contacted CMS
in support of an anesthesia
fee increase. Preliminary
reports are that we will be
receiving this update…in
part, thanks to your efforts to
advocate on your own
behalf.
To those of you whom
responded to the ISA/ASA
call to action…
Thank-you.
The ISA has just become aware that Iowa DHS has proposed cutting Medicaid anesthesia fees to the
Medicare rate beginning in July 2008. DHS estimates that they would save about $1,000,000/yr. with
this strategy. Currently, Iowa Medicaid pays $27.15/unit. Under this proposal, that rate will be slashed
to the Medicare rate of $15.26. Your officers will be working feverishly on this issue. At present we
are formulating an action plan to include our lobby firm, the administrative team and the Iowa Medical
Society. It is certain that we will also require your involvement on this issue. I would request that every
anesthesia group pick a contact person whom I can communicate with to coordinate our response to
this proposal. Your local representatives can contact me at my e-mail listed above. There is a very
good chance our only remedy will be legislative…which means we will all have to be contacting our
local legislator to stop this.
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Iowa Board of Nursing re. Propofol Sedation
In June, the ISA leadership
was asked to provide testimony to the IBN on a proposal to
expand the R.N. scope of practice to include nurse administered propofol sedation. The
ISA was opposed to this action.
Attached you will find our prepared statement. Feel free to
use this document to help you
craft policy in your local hospital or clinic setting. A
September 13, 2007 ruling
from the IBN states, “Propofol
administration for operative,
invasive and diagnostic procedures is not within the nursing
scope of practice.” The board
will allow two exceptions to this
rule:
1) Ventilated patients in the
ICU on a propofol drip
2) Propofol administration by
CRNA’s
The board recognized that
there are several hospitals in
Iowa currently using propofol
for procedures. In order to
allow time for hospitals to
Iowa Board of Radiology Considers
CRNA use of Flouroscopy
In May, the IBR was asked to
consider granting privileges to
CRNA’s to supervise radiology
technicians in the administration of fluoroscopy for pain
management procedures (i.e.
epidural steroids, etc.). Dr.
Dana Simon was instrumental
in helping craft the ISA
response opposing this measure. He even represented the
ISA position at the IMS annual
meeting; successfully passing
a resolution defining pain management as the practice of
medicine. Therefore, IMS will
help ISA oppose further efforts
by IANA to legislate expanded
practice privileges in this area.
For now, this request has been
tabled by the IBR.
Wellmark Class Action Lawsuit
Wellmark and BCBS have
reached a settlement in
response to a class-action
case entitled Love vs. BCBS.
Detailed information can be
found on the IMS website.
While many of the concessions
granted in the settlement will
have only a small impact on
anesthesia practices in Iowa,
one point is worth noting.
Wellmark has agreed to allow
all physicians to terminate their
participation agreements with
only 120 days notice, instead
of the 1 year previously stipulated. This means that physicians that are contracted under
the 5-year anesthesia agreement now have the option of
exiting that contract prior to its
scheduled June 2009 expiration. Other significant concessions include Wellmark’s
agreement to publish bundling
rules, medical policies and fee
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revise their policies and communicate this ruling to the nursing staff, this ruling will go into
effect on 12/1/07.
ISA – PAC
The response to our last
newsletter’s request for state
PAC contributions was heartening. We received over
$4,000 in new PAC contributions in the last three months.
This brings our current PAC
fund for distribution to
$12,000. We will begin distributing these funds ahead of the
next election cycle when we
can leverage our contributions
the most. For those who have
not contributed yet, there is a
donation form enclosed. In a
relatively small state like
Iowa…any amount makes a
difference.
To those who have contributed…Thank-you.
schedules and their promise to
stop re-coding charges that
are submitted to them. They
also conceded that they will no
longer recoup money already
paid more than 18 months
after the initial payment. Also,
they
can
no
longer
request/require “most favored
nation” clauses, “all product” or
“gag” clauses in their contracts.
New Management Service as of October 1
After an extensive review of our
management service options,
the ISA board of directors has
decided to change our management company from IMS to
Diversified
Management
Services (DMS), a Des Moines
based professional association
management company. For our
members there will be several
positive changes under the
new management, including: a
dedicated telephone service,
redeployment of the ISA website with the capability of on-
line bill paying and PAC contributions, more detailed financial
accounting and greater sophistication of our meeting planning
and marketing. DMS is also
very experienced with legislative lobbying, which we will tap
into after our transition. For
now, we will continue to employ
the services of the Brown
Winnick law firm as our lobbyists. The scheduled transition
date will be October 1. Check
out the website (www.iasocanes.org). For contact infor-
mation use our website or the
new phone number listed
below for your membership
concerns.
Our annual ISA spring meeting
is scheduled for Saturday, April
5, 2008 at the Hotel Fort Des
Moines. Please plan to attend.
We have arranged several
nationally recognized speakers
whom I am sure you will be
very pleased with.
As you can see, it has been a
full summer. Your ISA officers
and directors have been working diligently on your behalf.
You can each do your part by
supporting your group members whom become involved
in ISA leadership and by contributing to the ISA – PAC so
that we have the capital necessary to lobby for your interests.
Feel free to contact any of the
officers, directors or delegates
with your concerns.
Save the Date - April 5, 2008
Kevin Kruse, CAE
Iowa Society of
Anesthesiologists
525 SW 5th Street, Suite A
Des Moines, IA 50309
Phone: 515-282-8192
Fax: 515-282-9117
Email: [email protected]
We’re Back On the Web! See us at: www.iasocanes.org
Statement on Propofol (Diprovan) Sedation by a Registered Nurse
Prepared by Patrick H. Allaire, M.D.
President – Iowa Society of Anesthesiologist (ISA)
The ISA and our parent organization, the American Society of Anesthesiologists (ASA), which represents 40,000 member physicians, are opposed to registered nurse administration of propofol. We
believe that patient safety is paramount and that this proposal would unnecessarily place Iowans at
risk.
(Continued)
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Statement on Propofol (Diprovan) Sedation by a Registered Nurse
Prepared by Patrick H. Allaire, M.D.
President – Iowa Society of Anesthesiologist (ISA)
The ISA and our parent organization, the American Society of Anesthesiologists (ASA), which represents 40,000 member physicians, are opposed to registered nurse administration of propofol. We
believe that patient safety is paramount and that this proposal would unnecessarily place Iowans at
risk.
A joint statement, issued April 14, 2004, by the ASA and AANA (American Association of Nurse
Anesthetists) regarding propofol administration reads,
“Whenever propofol is used for sedation/anesthesia, it should be administered only by
persons trained in the administration of general anesthesia, who are not
simultaneously involved in the surgical or diagnostic procedure. This restriction is
concordant with specific language in the propofol package insert, and failure to
follow these recommendations could put patients at increased risk of significant
injury or death.”
There are two major points which should prompt the board of nursing to deny this petition for R.N.
administration of propofol.
First, the risks that propofol may induce a state of general anesthesia,
necessitating that the practitioner be able to recognize and manage lifethreatening anesthetic complications, and second,
The lack of crucial evidence that it may be safely administered by clinicians
not trained in anesthesiology.
The first and foremost point is that propofol is a powerful anesthetic agent that can produce varying
levels of sedation along the continuum from sedation to general anesthesia. It is not possible to
predict how an individual will respond within this continuum. Because of propofol’s extremely rapid
onset and high potency, the desired level of sedation is easily and often exceeded. Wide variation
in individual response to a standard intravenous dose of propofol often causes a patient to enter an
unintended state of general anesthesia within as little as 30 seconds. There is also an impressive
20-fold variation among individuals in the rate of metabolism of propofol. It is imperative to note that
propofol has no antagonist or reversal medications, in contrast to benzodiazepines and narcotics,
the other sedatives that are currently administered by non-anesthesia trained personnel.
Due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonist agents, drugs such as propofol require special attention. This means that the clinician administering propofol must have the technical skill, knowledge and experience to instantaneously recognize and rescue a patient experiencing any of the sequelae of general anesthesia, which include
life-threatening respiratory and cardiovascular emergencies. Therefore, the practitioner should
have the education and training to manage the potential medical complications of sedation and
anesthesia. The practitioner should be proficient in recognizing and managing the often subtle
signs of adverse respiratory or cardiovascular events to prevent complications such as hypoxia,
hypoventilation, bradycardia, tachycardia, hypotension and hypertension.
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Failure to rescue has consistently been reported in the gastroenterology literature as a prominent
cause of poor outcomes. In particular, that literature shows greater rates of complications among
patients with imperfect health and patients who are older than 50. Some state health agencies are
also aware of the threat to patient safety. Between 2001 and 2004, no fewer than 38 deaths related to the performance of endoscopies in ASCs were reported to the Florida Health Care
Administration Board of Medicine.
All of the published studies regarding RN administration of propofol lack the statistical power to
establish the safety of propofol by non-anesthesiologists. The expected anesthesia mortality rate in
healthy patients is 1 in 300,000 cases. All of the studies combined, performed to date, regarding
RN propofol sedation do not encompass 300,000 patients. The number of cases required for statistical significance far exceeds that number. The truth is, this practice modality has not been studied
sufficiently to verify its safety for Iowans.
We have genuine concern that individuals, however well intended, who are not anesthesia professionals may not recognize that sedation and general anesthesia are on a continuum and thus deliver levels of sedation that are, in fact, general anesthesia without having the training and experience
to recognize this state and respond appropriately.
Privileges to administer general anesthesia, awarded by the facility in which the practitioner practices, are the best indicator of satisfactory training and experience in the use of propofol. We are
concerned that granting the petition would make it more likely that R.N.s will be directed to administer propofol in settings where no anesthesia personnel are available to render rescue airway or cardiovascular resuscitation when unintended general anesthesia is produced. Failure to “rescue”
these patients will have disastrous consequences as noted in the Florida experience.
Currently, anesthesia personnel whom are qualified to administer propofol (anesthesiologists and
CRNAs) receive between 2 and 5 years of advanced training in general anesthesia, airway management and cardiovascular resuscitation. We do not believe that a registered nurse or non-anesthesiologist can reproduce that level of experience or skill by attending a weekend course or a few
weeks of “hands on” training.
Because of safety concerns, the FDA has issued a “black box” warning published in the PDR
regarding propofol administration which reads,
“For general anesthesia or monitored anesthesia care (MAC) sedation, Diprivan
injectable emulsion should be administered only by persons trained in the admin.
of general anesthesia and not involved in the conduct of the surgical/diagnostic
procedure. Patients should be continuously monitored, and facilities for
maintenance of a patent airway, artificial ventilation, and oxygen enrichment
and circulatory resuscitation must be immediately available.”
For these multiple reasons and, most importantly, to ensure the safety of Iowans, this petition must
be denied.
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