Q&A
FAQs
FREQUENTLY ASKED QUESTIONS:
1) How do I make sure that all my numbers add up?
In order for all your numbers to add up before we send your transcript to the NBCRNA, the following should be reconciled:
A) Total Anesthesia Cases = sum total of Patient Physical Status, or
B) Total Anesthesia Cases= sum total of these methods of anesthesia:
General anesthesia administration + Regional administration anesthesia (epidural anesthesia, spinal anesthesia, and PNB anesthesia) + Monitored anesthesia care anesthesia
2) How should I count for a peripheral nerve block for patients under general anesthesia?
This can be tricky since for that particular patient we can ONLY count either a General anesthesia or Regional management in order to get the Total Anesthesia Cases correct. So, you can count this case as General anesthesia with all the required elements checked off.
Then on an another Typhon entry, mark the box
“Do NOT count this case towards my “Total Anesthesia Cases”
requirement and do not show in missing information list”
and continue to check the boxes appropriate for Regional management
and administration.
3) How is OB management defined by the Council?
The Council defines OB management as it entails to patient assessment, insertion of epidural catheter, possibly ordering /starting the epidural infusion, or titration of the epidural infusion.
4) What is the distinction between trauma and emergency?
Say if the patient fell and obtained a fracture, then will be brought to the operating room, will that be counted as a trauma or an emergency case?
Trauma is generally considered from an accident (motor vehicular) or gunshot but not from a fall. Trauma is considered when an acute bodily injury is known, but a fall from a Wal-Mart parking lot may not necessarily be traumatic.
Nonetheless, it is also possible that a traumatic injury (open fracture) can become an emergency. At any rate, it can only be counted as one in order to be logged in.
An emergency case is that case that cannot wait and should be done within 6 hours of occurrence (bleeding post op, incarcerated bowel that has to be brought from the ED to the OR), while an urgent surgery needs to be done within 6-24 hours of occurrence-needs to be done but not life threatening.
5) What constitutes invasive line insertion/placement? Can you count the skill even if you failed to insert or place the catheter but initially attempted the skill?
As long as you were actively involved in the activity, like sterile draping and inserting an IV, arterial line, SAB or epidural, but were unsuccessful, you can still COUNT that skill.
6) When doing an endotracheal intubation alone but not the surgical
case, you are required to log an ASA number when you count the skill. However, this will be counted as part of the total anesthesia cases which is a different number when you add general anesthesia + regional management + monitored anesthesia care.
There might be a discrepancy in the Total Anesthesia Cases due to counting of the ASA status with performing a skill (intubation or regional block) but not the case, it is OKAY. You need to log in the skill and if Typhon asks for the ASA status, then so be it.
7) What does Intrathoracic mean?
Intrathoracic means an invasive entry into the thoracic cavity that involves sternotomy and opening the chest or potential bypass or use of anticoagulant. Cardiac catheterization or electrophysiology ablation procedures do not count as open hearts.
8) What about ablation via femoral catheter?
Ablation should be counted under VASCULAR.
9) What does Total Hours of Anesthesia Time mean?
Example: You are in the OR from 6:00 am until 4:00 pm (10 hours). Your 7:30 case is delayed and does not start until 9:00. The case lasts 3 hours and then you go to lunch. Two other cases scheduled for your room get switched to another room so as not to be delayed. You wait around for a case coming from the emergency room but it never gets there. In the meantime, you do some pre and postop rounds. Only the 3 hours when you delivered anesthesia count as hours of anesthesia time for that day.
10) Anatomic categories
This category is confusing since there is an overlap of anatomical and surgical categories.
Example: You administer anesthesia for 2 vascular cases – one carotid endarterectomy and one aorto-bifemoral graft. Take credit for 2 vascular cases, 1 neck, 1 under intra-abdominal, and 1 under extremities.
Example: One night during your obstetric rotation, you administer anesthesia for 2 emergency c-sections and 1 vaginal delivery. You can take credit for 3 obstetrical interventions, 2 c-sections, one vaginal delivery, 2 intra-abdominals, 1 under perineal and 2 emergencies. Also, don’t forget that vaginal deliveries are done in the lithotomy position.
Example: While you are on call, a trauma victim with multiple blunt and penetrating injuries comes to the OR. You spend the night doing a craniotomy, tracheotomy, exploratory laparotomy, and ORIF of a femur. Count all of the following categories for this patient: intra-abdominal, extremities, head-intracranial, neck and emergency.
11) Methods of anesthesia
Count each type of anesthetic technique use once, e.g., general or
regional. Inductions are either by IV or by mask. Inhalation inductions through a tracheotomy do not count as mask inductions. Hint: The number of IV and mask inductions should usually equal the number of general anesthetics.
12) Airway management
Airway management is counted as either mask, endotracheal, or LMA. “Mask management” means the entire case was managed with bag and mask ventilation, such as the case in bilateral myringotomy tube placement. Mask management does not mean masking the patient prior to intubation. “Endotracheal intubation” means that you performed the intubation yourself.
13) What does TIVA mean?
Total IV anesthesia” means a general anesthetic in which no volatile agent is used. N2O is OK.
14) What does Emergence mean?
“Emergence” means that you awakened the patient and/or extubated. Note that patients whose airways are managed with LMAs or face masks also require emergence from anesthesia.
15) Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) refers to surgical procedures where the surgeon infiltrates local anesthesia and the anesthesia staff provides monitoring and/or sedation. This category does not include sedation given to a patient whose primary anesthetic was a regional block.
16) What is Moderate or Deep Sedation?
Moderate sedation refers to a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by minimal tactile stimulation. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate.
Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and when spontaneous ventilation may be inadequate.
17) What does Regional Management mean?
“Management” means you cared for a patient who received a regional block. This includes scenarios in which you administer the block or do not place the block. “Actual administration” means that you performed the regional technique yourself.
Example: You are in the cystoscopy room for 4 cases, all of which are scheduled for spinals. You are only able to perform two of the blocks, but manage all of the cases. Count these cases as two spinals actually administered and four regional blocks managed.
18) Invasive monitoring techniques
Includes arterial lines, central venous access and pulmonary artery
catheters. These categories are similar to the regional and intubation categories – if you perform the procedure, count it as insertion/placement and monitoring. If you don’t place the catheter, only count it as monitoring. Don’t forget to count CVP monitoring when you have a PA catheter. If you attempt to place a central line or arterial line, but are not successful, still count the attempt. It may take several attempts until you get it, but these are blind techniques and require practice. Each attempt is a valuable learning experience.
Simple models and simulated experiences maybe used to satisfy this requirement. However, insertion of peripherally inserted central catheters (PICC) does not meet the requirements for central line placement.
19) How can I capture the numbers for CVP Monitoring?
Capturing this requirement has always been a challenge given that the monitoring number requirement far exceeds the insertion requirement. Exhaust all opportunities for actual CVP monitoring intraoperatively.
20) What about procedures in Interventional Radiology?
Procedures performed in interventional radiology can be classified according to the appropriate body system and procedure type, e.g., declotting an arteriovenous fistula with local anesthesia and IV sedation would be classified as vascular, extremity and MAC. With advancements in interventional radiology, many highly invasive procedures are being performed there with and without general anesthesia. If you perform anesthesia for a case like intracranial aneurysm coiling by carefully inducing the patient, using TIVA or inhalation agent, an endotracheal tube, and have all the vasoactive gtts set up as you would in the OR, count this case as an intracranial case as well.
What should be included under the box for Pain management?
Pain management encounters include but are not limited to the following:
Initiation of epidural or intrathecal analgesia.
2. Facilitation or initiation of patient controlled analgesia.
3. Initiation of regional analgesia techniques for postoperative pain or other nonsurgical pain conditions including but not limited to plexus blocks, local anesthetic infiltration of incisions, intercostal blocks, etc.
4. Adjustment of drugs delivered, rates of infusion, concentration or dose parameters for an existing patient controlled analgesia or patient controlled epidural analgesia.
5. Pharmacologic management of an acute pain condition in postanesthesia care unit.
6. Trigger point injections.
7. Electrical nerve stimulation.
Call experience - Call is a planned clinical experience outside the normal operating hours of the clinical facility, for example, after 5 PM and before 7 AM, Monday through Friday, and on weekends. Assigned duty on shifts falling within these hours is considered the equivalent of an anesthesia call, during which a student is afforded the opportunity to gain experience with emergency cases. Although a student may be assigned to a 24-hour call experience, at no time may a student provide direct patient care for a period longer than 16 continuous hours.
Clinical hours - Clinical hours include time spent in the actual administration of anesthesia (i.e., anesthesia time) and other time spent in the clinical area. Examples of other clinical time would include in-house call, preanesthesia assessment, postanesthetic assessment, patient preparation, operating room preparation, and time spent participating in clinical rounds. Total clinical hours are inclusive of total hours of anesthesia time; therefore, this number must be equal to or greater than the total number of hours of anesthesia time.
Reasonable time commitment - A reasonable number of hours to ensure patient safety and promote effective student learning should not exceed 64 hours per week. This time commitment includes the sum of the hours spent in class and all clinical hours (see Glossary, “Clinical hours”) averaged over 4 weeks. Students must have a 10-hour rest period between scheduled clinical duty periods (i.e., assigned continuous clinical hours). At no time may a student provide direct patient care for a period longer than 16 continuous hours.
Clinical supervision - Clinical supervision of students must not exceed (1) 2 students to 1 CRNA, or (2) 2 students to 1 anesthesiologist, if no CRNA is involved. The CRNA and/or anesthesiologist are the only individual(s) with responsibility for anesthesia care of the patient, and have responsibilities including, but not limited to: providing direct guidance to the student; evaluating student performance; and approving a student’s plan of care. There may be extenuating circumstances where supervision ratios may be exceeded for brief periods of time (e.g., life-threatening situations); however, the program must demonstrate that this is a rare situation for which contingency plans are in place (e.g., additional CRNA or anesthesiologist called in, hospital diverts emergency cases to maximize patient safety). Clinical supervision must be consistent with the COA Standards (i.e., clinical oversight is the responsibility of a CRNA or anesthesiologist only). The program is responsible for ensuring its clinical supervision requirements are consistent with the COA Standards and that students are aware of these requirements and know who is supervising them in the clinical area.
Counting clinical experiences - Students can only take credit for a case where they personally provide anesthesia for critical portions of the case. A student may only count a procedure (e.g., central venous catheter placement, regional block, etc.) that he or she actually performs. Students cannot take credit for an anesthetic case if they are not personally involved with the management of the anesthetic or only observe another anesthesia provider manage a patient’s anesthetic care. Two learners should not be assigned to the same case, except when the case provides learning opportunities for 2 students, and 2 anesthesia providers are necessary due to the acuity of the case. The program will need to justify any deviation from this requirement.
Credentialed expert - An individual awarded a certificate, letter, or other testimonial to practice a skill in an institution is a credentialed expert. The credential must attest to the bearer’s right and authority to provide services in the area of specialization for which he or she has been trained. Examples are: a pulmonologist who is an expert in airway management, an emergency room physician authorized by an anesthesia department to assume responsibility for airway management, or a neonatologist who is an expert in airway management.
Pain management, acute - Acute pain management involves the treatment of pain of recent onset arising from a discrete cause, e.g., postoperative pain. Acute pain may result from both surgical and nonsurgical origins. The experience of acute pain can initiate a cascade of emotional, physical, and/or social reactions.
Pain management, chronic - Chronic pain management involves the treatment of persistent pain or discomfort that continues for an extended period of time (usually involving durations greater than 3 to 6 months). Chronic pain may result from both surgical and nonsurgical origins. Some chronic conditions cause pain that may come and go for months or years or that may cause acute increases in the pain level. Persistent pain in certain circumstances becomes a disease with complex causal interactions of biological and psychological factors and not just a symptom.
Pain management encounters - Pain management encounters are individual one-on-one patient interactions for the express purpose of intervening in an acute pain episode or a chronic pain condition. Pain management encounters must include a patient assessment before initiating a therapeutic action.