The following is a response from the AANA regarding Anesthesiologists denegrating CRNAs in the wake of the Nevada endoscopy scandal. Please use the information to address concerns that may come from patients, surgeons or the public.
AANA added new reply to NV issue
Reality Check: The Truth Behind the Distortions
*AANA NewsBulletin,* April 2008
People in Glass Houses Shouldn't Throw Stones
Since Alice Magaw first provided anesthesia care for the surgical patients
of Dr. Charles Mayo, nurse anesthetists have enjoyed an outstanding
relationship with and built a sterling reputation among physicians with whom
they work. Unfortunately, over the years some anesthesiologists and other
physicians, and the organizations that represent them, have distorted facts
in order to discredit CRNAs and even to create fear in the general public
about anesthesia care provided by CRNAs. The AANA has never hesitated to
rebut these attacks, using the truth as its primary weapon of defense.
*The purpose of the "Reality Check" column is to present misinformation
about CRNAs that has appeared in a public forum, to state the facts, and to
empower CRNAs to address these issues with their patients, healthcare
colleagues, and employers and payers, should the need arise.*
*AANA members may use this column as necessary: Post to state association
websites, reprint in state association newsletters, use as background or
support materials for a meeting, etc. *
*If you have questions, comments, or suggestions for future columns, please
contact Christopher Bettin, AANA Senior Director of Communications, at* *
cbettin@aana.com* <../mail?view=cm&tf=0&ui=1&to=cbettin@aana.com>*.*
*
*
*Distortion*
When it comes to infection control, all healthcare professionals work in
glass houses. Any CRNA, anesthesiologist, or other healthcare professional
who does not strictly adhere to accepted standards and guidelines for safe,
aseptic injection practices puts their patients at terrible risk.
Recently, at the Endoscopy Center of Southern Nevada run by Dr. Dipak Desai,
an outbreak of hepatitis C was attributed to the reuse of syringes which
contaminated single-use vials of medication that was then given to multiple
patients (Nevada State Health Division investigation report). Five nurse
anesthetists were implicated and turned over their nursing licenses pending
further investigation.
Almost immediately stones began to fly, thrown by members of the medical
community.
The American Society of Anesthesiologists (ASA) posted on its website (*
www.asahq.org* <http://www.asahq.org/>) a press release titled, "ASA
Encourages Patients to Ask for An Anesthesiologist," which goes out of its
way to tell the public that anesthesiologists were not involved in the
hepatitis C outbreak at the Endoscopy Center. In the release, ASA President
Jeffrey Apfelbaum, MD, says, "Before undergoing any procedure involving
sedation or general anesthesia, patients need to be aware of what type of
anesthesia they will be receiving and most important—who will administer
their anesthesia."
In an article in the *Las Vegas Sun* (March 9), Dr. Christopher Millson, a
Las Vegas-based anesthesiologist, was reported to have said that "an
independent anesthesiologist would have gone 'toe to toe' with Desai and
prohibited the dangerous injection practices."
And in an interview with Nevada columnist Jon Ralston, Dr. Ed Kingsley,
president of the Nevada State Medical Association, said, "I think there is
more likelihood that if this had been an MD anesthesiologist, that would not
have taken place." (*Las Vegas Sun*, March 10)
*Selective Memories
*In the wake of the stone throwers' comments, a new idiom was easily spun
off of the old: "People in glass houses who decide to throw stones should
not have selective memories."
In formulating their opinions for public consumption, the stone throwers
either didn't consider or disregarded the following:
- "In 1995, Rosenberg et al. surveyed 2,530 anesthesiologists, a
10-percent random sample of ASA members, to assess whether anesthesiologists
are adhering to infection control guidelines, including protecting their
patients from exposure to infectious diseases. Alarmingly, 39 percent of
anesthesiologists reported reusing syringes from one patient to another." (
*ASA Newsletter*, December 2002)
- In 2002, at the AANA's request, Cooper Research, Inc., of
Cincinnati, Ohio, conducted a telephone survey of anesthesiologists, other
physicians, CRNAs, other nurses, and oral surgeons to determine provider
attitudes and practices concerning reuse. Three percent of the
anesthesiologists who responded indicated they reuse needles and/or syringes
on multiple patients; the other provider types reported reuse at 1 percent
or less for each group.
- In October 2007, Dr. Kamal Tiwari, an anesthesiologist, was accused
of reusing syringes on an unspecified number of patients at a surgery center
in Bloomington, Ind. At least two tested positive for hepatitis C.
- In November 2007, reports surfaced out of Long Island, N.Y., that
anesthesiologist Harvey Finkelstein, MD, was under investigation by the New
York State Department of Health for allegedly reusing syringes to draw up
medicine from multi-dose vials and exposing thousands of patients to
blood-borne pathogen infection.
Although these nationally publicized incidents involving anesthesiologists
occurred less than six months prior to the Nevada incident involving CRNAs,
the ASA release, Dr. Millson, and Dr. Kingsley called into question the
safety of CRNAs and assured the public about anesthesiologist safety, as
though nothing had previously happened.
*The Perils of Stone Throwing
*Almost as soon as Dr. Kingsley's words had left his mouth, the glass house
of the stone throwers took a direct hit and shattered into a million pieces.
On March 11, in an article titled "Another violation, many clinics:
Anesthesiologist admits risky practice," the *Las Vegas Sun* reported that
Dr. Scott Young, an anesthesiologist working at a gastrointestinal clinic in
Las Vegas, had been observed by health inspectors reusing syringes and
potentially contaminated vials of medication on multiple patients.
According to the Statement of Deficiencies and Plan of Correction sent by
the State of Nevada Health Division to the clinic's administrator (*
http://health.nv.gov/docs/gdcslsod.pdf*<http://health.nv.gov/docs/gdcslsod.pdf>),
"The anesthesiologist was asked what the process was when he went from a
used Propofol vial to a new patient. The anesthesiologist stated that he
would change the needle and reuse the same syringe."
In the same March 11 *Las Vegas Sun* article, Dr. Millson offered a
half-hearted defense of Dr. Young's actions: "…while Young was not following
the recommended practices, his case appears much different from what
occurred at the Endoscopy Center of Southern Nevada, because Young was
injecting into a 'high-port' IV line, relatively far from the patient's
vein, minimizing the risk of blood backflow. In comparison, the Endoscopy
Center patients' injections were occurring in IV ports at the arm, he said.
Also, Millson said, while it's not recommended to reuse Propofol, the
likelihood of its hosting infection is extremely slim if the vial is
consumed swiftly."
Brian Labus, senior epidemiologist for the Southern Nevada Health District,
responded to Dr. Millson's remarks in the article by pointing out that the
risk to patients would have been about the same at both clinics. "They're
single use items, plain and simple," Labus told the newspaper.
To leave no doubt in the minds of CRNAs or any other provider reading this
column: injecting with a used syringe or from a contaminated medication vial
into a high port on an IV line is not safe practice. Blood backflow is blood
backflow, so don't consider doing it. Further, if the "likelihood" of
something is "extremely slim"—such as swiftly consumed Propofol hosting
infection—then it is still greater than zero and far too big a risk to take
with your patients.
*The Public Trust
*Although it is disappointing that members of the medical community put the
AANA in a position of having to play the "who did what when" game, the AANA
remains focused on correcting this deadly infection control problem for the
sake of all patients. Any time a nurse anesthetist, anesthesiologist, or
other healthcare professional reuses a syringe or needle, or improperly uses
medication vials, patients are put at risk. The *AANA Infection Control
Guide*<http://www.aana.com/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=732>
clearly
states: "*Properly dispose of all needles and syringes after use. Do not
reuse needles and syringes. Once used, all needles and syringes are
contaminated. They are single use items*." Guidelines published by the
American Society of Anesthesiologists (ASA) are just as clear.
It is incumbent upon all anesthesia professionals to do their utmost to
follow safe injection and infection control practices. If the goal of
anesthesiologists and CRNAs truly is to ensure the safety and well-being of
our patients, then the anesthesiologists would do well to leave the stones
on the ground and join us in focusing on the task at hand. The public is
best served by a focus on the "what" of infection control (the healthcare
practices that will improve care) rather than "who" provides the healthcare
(the type of professional delivering the care).
