CRNAs’ Expert, Diverse Skills Indispensable During Public Health Crises

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By Melissa Ramirez Cooper
Director, AANA Public Relations & Communications

Samantha Heavrin, CRNA, MBA, was among one of the first to arrive in New York City to serve on the COVID-19 pandemic’s frontline of care. Assigned to work at The Mount Sinai Hospital on Madison Avenue, Heavrin had three “identities” for her computer sign-in: nurse, advanced practice nurse practitioner, and Certified Registered Nurse Anesthetist (CRNA).

“Later in my deployment, I was also given a fourth identity as respiratory therapist,” said Heavrin, a member of the American Association of Nurse Anesthetists (AANA) who is chief of anesthesia at an ambulatory surgery center in Louisville, Ky. Through her contract with AMSURG, Heavrin was part of about 200 Envision clinicians who deployed to the greater New York City area to provide care.

“At Mount Sinai, we did whatever was needed, and that was true for all healthcare workers across New York City,” she said. “Whether it was changing drips, running labs, getting materials, or turning a patient, all of us worked outside of our traditional roles.”

Heavrin said her entire anesthesia team took on multiple responsibilities. “There was so much to be done to care for patients impacted by COVID-19,” she said. “We also served on ‘proning’ teams, which is a process of turning patients onto their stomachs so they can take in oxygen better. It can be a difficult process to have intubated patients move onto their stomach, but it made a huge different for patients to oxygenate, and our proning teams were great.”

Throughout the pandemic, tens of thousands of CRNAs like Heavrin were readily available to serve. CRNAs are expert clinicians with advanced specialized skills in airway management, ventilator support, vascular volume resuscitation, and advanced patient assessment. Because of their diverse and unique skillset, CRNAs have been utilized as advanced care providers and regarded as vital members of the nation’s critical care workforce. During the COVID public health crisis federal and state governors have temporarily removed barriers to CRNA practice, enabling them to practice to the fullest extent of their education and training.

Alongside her colleagues at the hospital, Heavrin had friends deployed in other parts of the city. “One of my nurse practitioner friends worked in tents set up in Central Park. When we looked out the window, we could see these MASH-type units set up by the military to triage patients.”

Heavrin is thankful to her employer for the support services extended to clinicians, which included, among many things, traveling logistics, supplies of personal protective equipment, and mental health and wellness resources.

“When we left New York, we had to go into quarantine for two weeks. We were encouraged to do video calls and talk about our experiences with our clinician peers. We were also provided resources and information. It was during quarantine when we really processed our experience, talked and cried.”

Since returning home to Kentucky, Heavrin and her friends journaled about their time in New York and wrote a book chronicling their experiences.

“It Was Like Going Off to War”: CRNA Shares Experience of Working in NYC During Pandemic

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By Melissa Ramirez Cooper
Director, AANA Public Relations & Communications

When Jeremy Carlisle, CRNA, flew from Springfield, Ore., to New York City, he was struck by how few people were on his flight. “Maybe there were 15 of us on a 200-seat airplane.” Carlisle, a member of the American Association of Nurse Anesthetists (AANA), was on his way to serve on the COVID-19 frontlines of care.

With elective surgeries on hold, Carlisle was one among many Certified Registered Nurse Anesthetists (CRNAs) in the Portland area without patients. Still credentialed with AMSURG, a division of the national medical group Envision Healthcare, Carlisle received an opportunity to work in New York. Within three days of that call, he was en route to New York’s Mount Sinai Beth Israel Hospital, located in Manhattan's Lower East Side.

When Carlisle arrived, the hospital was determining the roles of each healthcare provider tending to patients impacted by the virus. “Given my experience in anesthesia and critical care, I was able to help provide care in the ICU.”

Since the start of the pandemic, tens of thousands of CRNAs have cared for critically ill patients. Their unique skills and expertise have allowed them to step forward in ways essential to addressing the virus that few others can, particularly in advanced airway and ventilation management, vascular volume resuscitation, and advanced patient assessment. During state emergencies, federal and state governors temporarily removed barriers to CRNA practice, further reinforcing the need to utilize CRNAs at the full extent of their education and training.

“When I first arrived, New York was experiencing some of its worst weeks statistically with the number of admissions and deaths,” said Carlisle. “Almost all of the patients at Beth Israel were COVID-19 patients.”

While healthcare teams were working relentlessly, “doing everything possible to care for patients,” said Carlisle. For him, the hardest part was “that patients didn’t have their family members to visit them or be with them at their bedside. We set up video calls and made other connections for patients and families.”

“I was in the military, and the situation in New York was somewhat like going off to war. It was going to the battlefield and wondering if you were going to come back,” said Carlisle. “The scale and intensity of the situation was different and unlike anything I had experienced,” he said.

“I asked God every day to help me, my family and my patients.”

“One story that continues to stay with me was a patient and her granddaughter, with whom I built a friendship. The granddaughter shared with me how grateful she was for the care we provided her grandmother,” recounts Carlisle.

“On one of the last days before I left, the granddaughter came to me and [offered to buy me] breakfast. I told her that it wasn’t necessary, but she told me to go have breakfast and to think about her and her family. I will never forget that. I will never forget the love she had for her loved ones.”

Patient Safety a Top Priority Amid COVID-19 Pandemic

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COVID-19 has had far-reaching impacts on our lives, with medical procedures and surgeries deemed “elective” and postponed in order to slow the virus’s spread. In reality, these procedures are far from optional: delaying medical interventions can result in increased health problems, such as later-stage cancer diagnoses.

Increased Patient Safety Measures to Combat COVID-19

In recent weeks, our ambulatory surgery centers (ASC) have resumed elective cases and implemented a number of protocols to ensure patient safety. These measures include:

  • Screening everyone who enters our surgery centers for COVID-19 symptoms
  • Taking the temperature of every person who enters our surgery centers
  • Requiring masks for all employees and patients
  • Enforcing social distancing guidelines
  • Requesting patient escorts remain in the car until patient is ready to go home
  • Increasing cleaning of high-touch surfaces throughout the day
  • Providing hand sanitizer and tissues

Learn more about all of the steps our ASCs are taking to keep patients safe.

Patients Feel Safe at Our Surgery Centers

Patients who have already returned to our ASCs have first-hand experience of the new protocols in action. Their feedback has been extremely positive, with reactions like:

“During this COVID-19 time, I was especially nervous about my procedure but was immediately greeted by the friendliest nurse around. She was very courteous and kept asking if I was fine. She prepared me for the procedure by carefully doing everything that needed to be done and listened to me. The rest of the staff was also very professional and took great care of my needs. Thank you all for a great experience that I hopefully won’t have to repeat for a while.” – San Antonio, April 2020

“Even during these crazy times, I was treated with the utmost respect, courtesy, and care. My doctor and her amazing team took the necessary steps to make sure I wasn’t put at greater risk during my procedure. They ensured all my questions were answered, and I was 100% ready going into and out of the procedure.” – Escondido, April 2020

“Every social distancing precaution that I have learned was practiced from the front entrance to the check-in desk to the exam rooms to my time with my doctor and my exit. They were all efficient and caring before the virus and that certainly was the case at this visit also.” –  Knoxville, May 2020

AMSURG Develops Toolkit to Guide Ambulatory Surgery Centers in Providing Safe, Quality Patient Care

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NASHVILLE, Tenn. – AMSURG, a division of Envision Healthcare and national leader in the management of ambulatory surgery centers (ASC), has developed guidelines to support the delivery of safe, quality outpatient care as communities begin resuming elective procedures during the COVID-19 pandemic.

“Quality patient care is always our top priority, and following clinical best practices, along with federal and local guidance, will help ensure the safety of our patients and clinicians as we resume elective procedures during this public health crisis,” said Dr. Chan Chuang, Chief Medical Officer of Envision and Co-President of AMSURG. “Ambulatory surgery centers are an integral part of the healthcare delivery system, providing quality care at a significantly lower cost and in a more convenient setting than many alternative care sites. The services we provide are essential in helping patients maintain their health and quality of life, and these procedures can be resumed safely in some communities.”

The guidelines developed by AMSURG clinical and quality leaders provide the organization’s network of more than 3,700 physicians and more than 250 ASCs with recommended processes to ensure clinician and patient safety. The best practices include:

  • Screening patients diligently. In addition to conducting a thorough patient screening for the appropriate elective procedure, ASCs are screening patients for COVID-19. All clinical staff members are also screened daily.
  • Educating patients. In addition to traditional pre-procedure education, AMSURG ASCs are educating patients on precautions the center is taking to protect patients and staff. Education also includes information about patients’ role in their health and well-being.
  • Implementing social distancing precautions. ASCs are scheduling more time between procedures to enable appropriate social distancing during patients’ care journeys and thoroughly clean treatment rooms and equipment.
  • Continuing to adhere to high clinical quality and safety measures. Clinicians and clinical staff are following strict clinical guidelines, including screening for COVID-19, using appropriate personal protective equipment and following stringent cleaning protocols.

Since the outbreak of COVID-19 in the U.S., AMSURG ASCs have complied with all local and federal guidelines and been a part of efforts to mitigate the spread of the virus and support patient care. Some centers have aligned with hospitals and state agencies to distribute critical resources like personal protective equipment and ventilators to areas of greatest need. Other centers have continued to provide essential care to patients – when it was medically necessary not to delay a procedure – including a colonoscopy to detect and remove cancerous polyps and urgent orthopaedic and retina procedures to improve patients’ quality of life.

Envision, along with AMSURG, has taken a leading position in responding to America’s call for COVID-19 care. The medical group’s actions to support clinicians, healthcare partners and patients include:

  • Mobilizing to meet the need for more physicians and advanced practice providers across the nation. Envision is providing support to 55 medical sites by deploying more than 500 clinicians to care for COVID-19 patients. Anesthesiologists and certified registered nurse anesthetists from the anesthesiology provider team are already on the ground to meet unprecedented demand for care. Clinicians will continue to be deployed to address surging hot spots across the country.
  • Securing more than 5 million items of PPE, including masks, face shields, gowns, and goggles to support Envision’s clinicians and hospital partners. This PPE is being delivered to areas of greatest need.
  • Treating every patient regardless of their ability to pay. Envision has committed to working with all parties to ensure no COVID-19 patient is burdened with unexpected costs. We will not send patients surprise medical bills and will work to ensure patients are only responsible for in-network cost-sharing.
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About AMSURG

AMSURG acquires, develops and operates ambulatory surgery centers (ASC) in partnership with physicians throughout the United States. As of January 1, 2020, AMSURG owned and operated 257 ASCs and one surgical hospital in 34 states and the District of Columbia with medical specialties ranging from gastroenterology to ophthalmology and orthopaedics. To learn more about AMSURG, a division of Envision Healthcare Corporation, visit www.amsurg.com.

About Envision Healthcare Corporation

Envision Healthcare Corporation is a leading provider of physician-led services and post-acute care, and ambulatory surgery services. The Company delivers physician services, primarily in the areas of emergency department and hospitalist services, anesthesiology services, radiology/tele-radiology services, and children’s services to more than 1,800 clinical departments in healthcare facilities in 45 states and the District of Columbia. Post-acute care is delivered through an array of clinical professionals and integrated technologies which, when combined, contribute to efficient and effective population health management strategies. As a market leader in ambulatory surgical care, the Company owns and operates 257 surgery centers and one surgical hospital in 35 states and the District of Columbia, with medical specialties ranging from gastroenterology to ophthalmology and orthopedics. In total, the Company offers a differentiated suite of clinical solutions on a national scale, creating value for health systems, payers, providers and patients. For additional information, visit www.envisionhealth.com.

Colonoscopy Aids Patient’s Health Outcome as COVID-19 Crisis Ensues

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On Friday, the Florida governor ordered all hospitals and ambulatory surgery centers to cease all elective surgeries due to COVID-19, leaving surgery centers like ours to decide which procedures are considered an emergency. Making these decisions are not easy for our physicians. Each decision is painstaking, having to determine the medical necessity of each procedure on a case-by-case basis.

COVID-19, the new invisible disease, arises in addition to another daily invisible disease – colon cancer. March is Colon Cancer Awareness Month and although this fight is understandably taking a back seat in its importance, it is still a very real killer.

Earlier this week, at Space Coast Endoscopy Center in Rockledge, Florida, a 37-year-old woman began showing somewhat benign symptoms of possible rectal cancer. Feeling that overlooking her symptoms and delaying a colonoscopy could mean dire consequences, our physician performed the procedure. Upon completion, our physician diagnosed her with rectal cancer. If our center were not open to proceed with her procedure, it may have been months before she had her colonoscopy, drastically changing her life story.

Colon Cancer Kills, Too

Colorectal cancer is the second-leading cause of cancer death among men and women combined in the U.S. There will be an estimated 147,950 new cases of colorectal cancer in 2020. 1 in 20 people will be diagnosed with colorectal cancer. 1 in 3 people are not up-to-date with colorectal cancer screening.

Symptoms of colorectal cancer may include

  • A persistent change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool
  • Rectal bleeding or blood in your stool
  • Persistent abdominal discomfort, such as cramps, gas or pain
  • A feeling that your bowel doesn’t empty completely
  • Weakness or fatigue
  • Unexplained weight loss

If you believe you are experiencing any of the following symptoms, it’s important for you to schedule an appointment with a gastroenterologist immediately.

How Our Center is Protecting Patients from COVID-19

Our staff continues to be diligent in keeping patients safe during this pandemic. Our center has implemented the following standards:

  • Prescreening Patients via the phone and text message
  • Screening our staff
  • Asking all patient caregivers to wait outside
  • Reassessing our patients and taking their temperatures upon entering our facility
  • Social distancing our patients in our pre/post procedure area
  • Wiping down our facility twice a day or more per the recommended CDC guidelines
  • Wearing N-95 masks per recommended NETEC and CDC guidelines
  • Waiving up-front payments for procedures unless a patient wants to pay

Yes, procedure numbers are approximately a quarter of our usual caseload, yet we continue to play a vital role in our community as we abide by local/state health department guidelines while readying ourselves to assist however we can. We remain connected with the local police and fire marshal, assuring them of our support as they are truly on the frontlines of this pandemic. We have also reached out to a local nursing home, where one of our staff members works aside from our center, providing an encouraging note and a prepackaged goodie for their patients if their diet permits. In continuing to give, we all feel truly blessed.

On National Doctors’ Day, AMSURG Celebrates the Role of ASCs During the COVID-19 Crisis

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March 30 is National Doctors’ Day, and AMSURG would like to thank the 3,700 physicians who practice in our more than 250 partner centers across the country. Every day, you partner with patients to prevent colon cancer, repair vision or improve their quality of life with orthopedic solutions. The important work you do to deliver high-quality, patient-centered has never made a bigger impact in the communities we serve than now in the midst of the COVID-19 crisis.

Ambulatory Surgery Centers (ASCs) play a valuable healthcare delivery role in this pandemic. As hospitals care for critical patients, ASCs can offer safe, high quality surgeries to patients who need emergent and urgent procedures.

AMSURG values its partnership with you and the work we do to ensure the continued safety of patients and physicians alike. With communities on high alert due to COVID-19, AMSURG is leveraging its resources to equip its center partners with clinical best practices to prepare for and protect patients from the virus.

“The commitment you show to your patients is awe-inspiring, but as your partner, we are equally committed to supporting our physicians,” Chan Chuang, AMSURG Co-President, said. “You do incredible work every day, and we will continue to support that work and ensure the safety of both physicians and patients,” added Teresa Sparks, AMSURG Co-President.

Happy Doctors’ Day. You are our Healthcare Heroes, and we are so proud to partner with you.

Help Us Celebrate Healthcare Heroes

We invite you to join us in celebrating Healthcare Heroes by posting a video of yourself thanking physicians for all that they are doing to maintain our country’s healthcare safety net during the COVID-19 crisis and use the #HealthcareHeroes hashtag.

Our organization is honored to celebrate the work of these men and women as they demonstrate a willingness to stand united in their commitment to patient safety and well-being. We thank you for everything you do to care for communities and help contain the spread of COVID-19.

GI Nurses: Advocates for Population Hesitant to Care for GI Health

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GI Nurses and Associates Week is March 22-28, and AMSURG is proud to recognize the work of GI nurses and associates at partner centers around the country.

Jimmy Dottolo, MSN, RN has served as center leader for the Louisiana Endoscopy Center in Baton Rouge, Louisiana, since 2010. Dottolo manages operations for a staff of more than 80 employees responsible for nearly 33,000 procedures a year.

A former emergency department nurse, Dottolo said his transition to GI nursing and the important role GI nurses play caring for the general population provided an eye-opening education. “GI nurses are advocates; we work with a population that is hesitant to take care of their GI health, so we are constantly working to educate and increase awareness that the GI diseases we see are detectable and preventable.”

GI nurses are vital to the delivery of quality care at AMSURG partner centers. “They are the first wave for patients at our centers; GI nurses prepare patients physically and emotionally for procedures, and it is their passion and knowledge that helps patients through the process,” AMSURG Regional Vice President, Operations Erik Hamnes said.

Passion is a shared trait among GI nurses and associates, many of whom have dedicated their lives to advocating for the necessity of potentially life-saving colorectal cancer screening procedures. Last year alone, AMSURG’s more than 180 endoscopy partner centers performed more than 600,000 colonoscopies.

Robi Rhodes, MSN, RN, is Director of Nursing for MGA GI Diagnostic and Therapeutic Center in Marrero, Louisiana. With three locations in the New Orleans Metropolitan area, MGA and its clinicians are responsible for over 2,000 colonoscopies a month.

Rhodes, who is responsible for overseeing the daily operations of 70 nurses and support staff, said misconceptions regarding digestive health – and the role GI nurses play – persist. “When I tell people that I’m a GI nurse, I still sometimes get that sort of ‘Wow, why did you go into that specialty?’ response,” Rhodes said. “But being a GI nurse, I understand how important the work we do is and how important gastrointestinal health needs to be for our population.”

“A lot of people still don’t understand the reality of things like colorectal cancer, so I’ve been able to use my profession as a conversation starter for discussing GI health with my friends and family,” Rhodes explained.

As a center leader, Rhodes works closely with AMSURG to ensure MGA meets the needs of its community. The operational and strategic support AMSURG provides, Rhodes said, has allowed both he and his clinicians to better focus on their patient population.

“I've talked to directors who operate independent centers, and something I always hear is that the responsibility is all on their shoulders,” Rhodes said. “But having AMSURG as a partner means they’re here to help me – whether it be with day-to-day operations, clinical questions or administrative support, you name it.”

Dr. Edward Esber and a Patient’s Family Promote Colonoscopies in the Battle with Colon Cancer

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AMSURG Partner Gastroenterologist, Edward Esber, M.D., FACG, FASGE, and the McCool family recently shared their story of battling colon cancer. Tracy’s husband, John, was diagnosed with stage four colon cancer in the fall of 2018. In hopes of encouraging others to take action now before it’s too late, Tracy is sharing the message of early screening. “Don't put off that colonoscopy… It’s not complicated, it’s a simple procedure and it really does save lives.”

Click here to view the complete video interview.

To learn more about Dr. Esber and the Digestive Health Center in Akron, Ohio, visit dhcakron.com.

Patient Safety Awareness Week: COVID-19 Preparation Through Our Culture of Safety

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The coronavirus disease 2019 (COVID-19) has communities on high alert, and AMSURG is equipping its more than 250 ambulatory surgery center partnerships with clinical best practices to prepare for and protect patients from the virus.

AMSURG values the ability to partner with clinicians and work as a community to ensure the delivery of high quality and safe patient care. In honor of Patient Safety Awareness Week from March 8-14, AMSURG is proud to recognize our ambulatory surgery centers (ASC) partners across the country and highlight their commitment to safety.

This past year, 12 of AMSURG’s partnering centers were among the pilot group of volunteers who participated in the first-ever Culture of Safety Survey offered to ASCs. The Agency for Healthcare Research and Quality (AHRQ) designed this survey to evaluate how each employee feels about the patient safety environment of their center.

The engagement and responsiveness of the participating centers presented an opportunity for Nina Goins, R.N., Vice President of Quality and Clinical Services for AMSURG, to analyze the data and to work individually with these ASCs to establish and share comprehensive best practices. “I truly believe in a learning culture,” Goins said. “We really value this initiative because it allowed us to learn more about our centers’ safety culture and how we can best support them.”

In a collaborative effort with center leaders and medical directors, Goins and her team developed action plans, identified areas of opportunity for improving patient safety and implemented effective change management strategies. Following the success of the survey, Goins plans to offer the Culture of Safety Survey to all partner centers in 2020.

The Culture of Safety Survey works to improve the quality of care and reduce the risk of complications that can harm both patient and clinician well-being. When it comes to addressing clinician’s concerns at our centers, Ginger Woodside, R.N., Director of Clinical Risk Management for AMSURG, focuses on improving situational awareness in addition to serving as the voice of support. “We are really focused on engagement because it is so important for these clinicians to have this safe space to talk,” Woodside said. “We want them to know that we are here; we are their resource.”

Looking towards the future, AMSURG will continue to pursue enhancements in patient care with culture- driven initiatives focused on community support and patient safety.

Learn how Envision Healthcare’s Patient Safety Organization is setting new standards and Envision Physicians Services is leveraging data and collaboration to improve patient outcomes through the links below.

Envision Healthcare Patient Safety News Story

Envision Physician Services Patient Safety News Story

Weston Outpatient Surgical Center Brings Total Joint Replacements to the Center

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Each year, more physicians and patients are choosing the ambulatory surgery center setting for total joint replacements. At-home recovery, lower costs and reduced risk of hospital-acquired infections are some of the drivers for this change in setting. In line with the trend, more of our centers are bringing total joint procedures to the facilities. Weston Outpatient Surgical Center in Weston, Florida, is one of the latest to begin performing total joint procedures.

“We made total joints a priority at the center, and with preparation, we were able to perform four procedures in the fourth quarter of 2019,” explained Estella “Stella” Castoreno, Center Leader at Weston. “I am a recent hire at Weston and bring several years of experience in total joints. I made a stretch goal for myself to bring joints to Weston Outpatient Surgical Center as my first quarter initiative.”

Pairing Stella’s own experience with a highly motivated staff, Weston established a special total joints committee to begin the preparations for the new procedures. “We had many comprehensive meetings with the staff, equipment representatives and surgeon. We also created a dictionary with a list of questions and responses so that every person involved in the procedures would be aligned with the overall goals and objectives in joint procedures. The staff, physicians and vendors aligned with one vision.”

Another factor in preparing to bring total joints to the center is ensuring the patients are right for the setting. A pre-telephonic assessment of the patient history and living accommodations were a top concern for the committee. The patients must meet the criteria for an outpatient joint. While there is a significant focus on patient selection, having a high-caliber orthopedic surgeon is even more important. Stella, said, “A successful joint program requires the right patient and right surgeon.”

Preparing for total joints at the center also required the commitment of every member of the 80+ person team. In addition to the special committee that focused on the new procedures, the staff not directly involved in total joints significantly helped by maintaining operations for the center’s regular volume, 600 cases annually.

As a new leader at the center, the preparation for the total joint procedures was also Stella’s time to get better acquainted with her staff and surgeons. “I approached it as taking it back-to-basics. We went through mock procedures with every bit of equipment and supplies needed for the case.  I even included the vendor representative in our mock case,” Stella said. “One of our techs played the role of patient. We had a lot of fun preparing for the procedures.”

“I encouraged the staff to see themselves as travel agents. Our patients expect to get through the joint replacement journey and back home refreshed with even more pep in their step,” explained Stella.

Weston’s first total joint patient had an opportunity to tour the center and meet every person who would interact with the case, from the billing office, registration clerk, nursing staff (pre-admission testing, pre-op, PACU and O.R.), scrub technicians, anesthesia team, physical therapist and administrator. This helped ensure the patient was comfortable when returning on the day of surgery.

Stella encourages centers considering adding total joints to make it relatable to the staff and to consider the three pillars — patient, staff and physician.

  • Patient – Personalize the goal with the patient. A great question is “What did you like to do prior to your knee weakness (walk the mall, plant flowers, etc.)?” Keep in mind, patient(s) don’t measure their quality of life by “ambulating 20 feet.”
  • Staff – To be successful, you must have complete buy-in from everyone at the center. Procedures can become transactional, so we must always take on the opportunity with the goal of creating exceptional experiences for the patients.
  • Physician – A highly skilled, reputable surgeon is just as important. Encourage surgeons to transition to outpatient by using the patient criteria screen tool in an acute care setting.

With four successful total joint replacements completed, Weston plans to continue to expand its total joint procedures. “We thank Dr. Mario Berkowitz, Dr. Alexander Bertot and Dr. Thomas Riley for trusting us to care for your patients. It is a great honor,” Stella concluded.

To learn more about the Weston Outpatient Surgical Center, visit https://westonoutpatient.com.