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  • Kentucky ASA Misinformation About Opt Out: Reality Check



    Today the KSA (Kentucky Society of Anesthesiologists) Released a press release and email blast to their members attacking the recent Opt Out by the Kentucky Governor Beshear. As expected it is full of misinformation, inaccuracies and bold face lies. We here at nurse-anestheisa.org have put together a response. At the bottom you can find the actual letter and talking points by the KSA. Here is our reply with sections of the KSA response in quotes:


    IMMEDIATE ACTION: Urge Governor Beshear to Oppose Opting-Out of the Federal Physician Supervision Patient Safety Standard
    This is certainly NOT a standard and in fact it is simply a billing requirement for the hospital to bill medicare part A not the CRNA to bill medicare part B. CRNAs have been working autonomously without MDAs for over a century and not a shred of evidence exists which shows, with any metric studied, that independent CRNA practice increases M&M. Clearly this isnt a standard and in fact since CRNAs work autonomously in all states (opt out or not), and they are the experts in anesthesia when working with a surgeon (just as an MDA is when working with a surgeon). This is independent practice and happens everywhere in the USA everyday, sans MDA.

    No standard just mythology.

    Patient Safety: Despite improvements in outcome, anesthesia remains dangerous. CRNAs lack the education and training to practice independently. Twelve years of medical education is irreplaceable, and its role in providing safe care cannot be underestimated. This amounts to more than 10,000 hours of clinical education and training during their medical school and residency training. In comparison, nurse anesthetists complete 6- 7 years of education: four years of college, two - three years of nurse anesthetist training. This amounts to only between 500-720 hours of nursing education and training. CRNAs lack the medical judgment to recognize and respond to an emergency should an anesthetic complication arise.
    Not even one part of this statement is actually true. Lets go through it since it is so inaccurate.

    Despite improvements in outcome, anesthesia remains dangerous.


    Lets put this into perspective...

    Due to our advances over the past 25 years or so, almost unique in healthcare enterprises, anesthesiology is now approaching the “six sigma performance” grail of an ultra-safe organization (3.4 defective outcomes per million opportunities). No other clinical specialty even comes close. The aviation industry performs between six and seven sigma. (. National Strategy for Quality Improvement in Health Care. Report to Congress. March 2011. U.S. Department of Health & Human Services. & Agency for HealthCare Research And Quality (AHRQ) 2000, Mary & Brown 2002).

    Chance of dying as a result of pregnancy in the USA or Western Europe = 5-10 deaths per 100,000 live births (0.005-0.01%) (Chang 2003, Hill 2001).


    Chance of dying as a result of general anesthesia alone = somewhat less than 11-16 deaths per 100,000 persons, depending upon general health of the persons (0.01-0.016%) (Lienhart 2006, Arbous 2001).


    Chance of dying due to complications resulting from the operation of removing the womb (hysterectomy) = 120 to 160 deaths per 100,000 operations (0.12-0.16%) (Bachmann 1990, Loft 1991).


    Chance of dying due to complications resulting from the operation of removing the gallbladder = 150 to 1400 deaths per 100,000 operations, depending upon health and technique of operation (0.15-1.4%) (Feldman 1994, Hannan 1999).


    Chance of dying due to complications resulting from the operation of removing the large bowel for cancer = 800 to 5000 deaths per 100,000 operations, depending upon health and technique of operation (0.8-5.0%) (Nelson-2006).

    So there goes that statement.

    Twelve years of medical education is irreplaceable, and its role in providing safe care cannot be underestimated.


    Yes, it costs 10X as much to have the same outcomes based on all evidence and data as well as an extra 4 years. Does not make alot of sense. Additionally. Other physicians are not qualified to give anesthesia yet they have 9 of those same years (4 pre med, 4 med school, 1 internship) so clearly only the last 3 matter with regard to anesthesia and safety. During this time the Physician has to learn everything the RN already comes with related to patient care plus anesthesia.

    Lastly, the author ignores the min 1 year critical care experience and the average of 3 years that SRNAs have before anesthesia school. One cannot UNDERESTIMATE the importance of actual EXPERIENCE with sick patients throughout the continuum of a severe illness. Right?

    nurse anesthetists complete 6- 7 years of education: four years of college, two - three years of nurse anesthetist training. This amounts to only between 500-720 hours of nursing education and training.


    Apparently with all that extra education math still eludes the authors from the KSA.

    Here is the time requirement in a local BSN program:

    Clinical rotations for the BSN Nursing program are held at some of the Valley's most reputable hospitals and healthcare facilities. Students spend approximately 1,000 hours total in the skills/simulation lab and in a variety of clinical settings providing care to people of all ages to meet program outcomes.

    That is just the clinical time.

    Total Degree credits for BSN = 123

    A credit hour is the amount of time that you spend in class each week. If it's a 3 credit class, that means you spend 3 hours PER WEEK in the classroom, which gives you the 3 credit hours. That is 15 hours of real time for every credit hour.

    So the didactic in a full on BSN program here is 1845 hours ALONE not including the study time.

    So, JUST to become an RN = 2845 hours.

    One year full time as an RN is 52 weeks - 2 weeks vacation = 50 weeks x 40 hrs per week (assuming no OT) = 2000 hours of clinical practice

    Add the fact that the average applicant has 3 years that is an average of 6000 hours of clinical practice ALONE.

    Now to the CRNA portion.

    My program was 74 credit hours over a 36 month period. That is 1100 hours of DIDACTIC time alone.

    Clinical for me was counted only for the time of cases. I did over 1000 cases which came to just over 2200 hours of CASE time alone. If i was to count all the other time in clinical doing pre ops, floor intubations an codes, in the trauma room, on call, in PACU or just at the facility i could EASILY 2.5 X this time to 5500 hours.

    So lets review for the math impaired from the KSA.

    TOTAL Clinical time Required: 1000 (to be an RN), + 2000 (as an RN) + 2200 in CRNA clinical = 5200 HOURS alone.

    Total average clinical time = 1000 (to be an RN) + 6000 (3 years as an RN) + 5500 in CRNA clinical = 12500 HOURS of clinical ALONE.

    Total Didactic time = 2845 hours (to be an RN) + 1100 hours to be a CRNA = 3945 didactic hours alone.

    TOTAL MINIMUM didactic + clinical time to be a CRNA = 9145 hours.

    TOTAL AVERAGE didactic + clinical time to be a CRNA = 16445 HOURS.

    So, i have no idea where the writer from the KSA gets this statement.


    An opt-out would eliminate the medical judgment and skills provided by physicians, thereby jeopardizing the health and safety of the citizens of Kentucky. Kentucky citizens deserve the highest quality of care possible.


    Really? A couple of major problems with this statement.

    1) Medical judgement is not the sole domain of physicians and never has been.

    2) The "standard" and "quality" of care is the same for CRNAs as it is for MDAs.

    2) There is no evidence that CRNAs working independently of MDAs has EVER been any less "safe" for patients and a litany of data shows CRNAs are equally as safe.

    No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians
    Health Aff August 2010 29:81469-1475;

    Needleman/Minnick OB Anesthesia Study in Health Services
    Research
    [Needleman, J, Minnick, AF. “Anesthesia Provider Model, Hospital
    Resources, and Maternal Outcomes.” Health Services Research.
    November 2008. DOI: 10.1111/j.1475-6773.2008.00919x.]

    Simonson OB Anesthesia Study in Nursing Research
    [Simonson, DC, Ahern, MM, Hendryx, MS. “Anesthesia Staffing and
    Anesthetic Complications During Cesarean Delivery.” Nursing
    Research. 2007; 56:9-17]

    Pine Study in the AANA Journal
    [Pine, M, Holt, KD, Lou, YB. “Surgical Mortality and Type of
    Anesthesia Provider.” AANA Journal. 2003; 71:109-116.]

    Bechtoldt Study
    [Bechtoldt, Jr, AA. “Committee On Anesthesia Study. Anesthetic-
    Related Deaths: 1969-1976.” North Carolina Medical Journal.
    1981;42:253-259.]

    Forrest Study
    [Forrest, WH. “Outcome — The Effect of the Provider.” In: Hirsh, R,
    Forrest, WH, et al., eds. Health Care Delivery in Anesthesia. Philadel-
    phia: George F. Stickley Company. Chapter 15. 1980:137-142.]

    Minnesota Department of Health Study

    In 1994, the Minnesota Department of Health (DOH), as mandated
    by the state Legislature, studied the provision of anesthesia services
    by CRNAs and anesthesiologists. The department reached four con-
    clusions, including the following:
    There are no studies, either national in scope or Minnesota-
    specific, which conclusively show a difference in patient
    outcomes based on type of anesthesia provider. [page 23,
    DOH study.] [emphasis added]

    Centers for Disease Control

    In 1990, the federal Centers for Disease Control (CDC) considered un-
    dertaking a multimillion-dollar study regarding anesthesia outcomes.
    Following a review of anesthesia data from a pilot study issued by the
    CDC and the Battelle Human Affairs Research Centers, however, the
    CDC concluded that morbidity and mortality in anesthesia was too low to
    warrant a broader study. The pilot study, published on December 1,
    1988, was titled, “Investigation Of Mortality and Severe Morbidity
    Associated With Anesthesia: Pilot Study.” The pilot study stated that:
    To obtain regional estimates of rates of mortality and severe
    morbidity totally associated with anesthesia with a precision of
    about 35% a nationwide study consisting of 290 hospitals
    should be selected. This size study would cost approximately
    15 million dollars spread over a 5-year period.

    National Academy of Sciences Study

    This study was mandated by the U.S. Congress and performed by the
    National Academy of Sciences, National Research Council. The re-
    port to Congress stated: “There was no association of complications of
    anesthesia with the qualifications of the anesthetist or with the type of
    anesthesia.” [House Committee Print No. 36, Health Care for American
    Veterans, page 156, dated June 7, 1977.]

    Nurse Anesthetist Professional Liability Premiums

    Based on a comparison of 1988 data from St. Paul Fire and Marine In-
    surance Company, at the time the country’s largest provider of liability
    insurance for CRNAs (but no longer providing liability coverage for
    healthcare professionals), and 2004 data from CNA Insurance Com-
    pany, currently the largest insurer of CRNAs, insurance premiums for
    nurse anesthetists have decreased nationally a total of 39 percent in
    that time span. (This pertains to claims-made coverage, typically for
    self-employed CRNAs.) The premium drop is detailed in the appendix
    titled, “Nurse Anesthetist Professional Liability Premiums: Premium
    Changes from 1988 to 2004,” found at the back of this booklet. The
    appendix details premium information for CRNAs, both on a state-by-
    state basis and nationally.


    The decrease in CRNA malpractice insurance premium rates demon-
    strates the superb anesthesia care that CRNAs provide. The rate drop
    is particularly impressive considering inflation, an increasingly com-
    bative legal system, and generally higher jury awards.

    And i hope the KSA isnt dumb enough to quote the Silber study again cause:

    "HCFA/CMS Affirms that Study Not About CRNA Practice
    In the anesthesia rule published in the January 18, 2001, Federal Reg-
    ister by HCFA/CMS, the administration dismissed all claims by ASA
    and the Pennsylvania study research team that the study examined
    CRNA practice and was relevant to the supervision issue. HCFA/CMS
    stated the following:
    •  “We have also reviewed a more recently published article by Dr.
    Silber (July 2000) and colleagues from the University of Penn-
    sylvania. This article also is not relevant to the policy determina-
    tion at hand because it did not study CRNA practice with and
    without physician supervision, again the issue of this rule. More-
    over, it does not present evidence of any inadequacy of State
    oversight of health professional practice laws, and does not pro-
    vide sound and compelling evidence to maintain the current Fed-
    eral preemption of State law.” [p. 4677]
    •  “One cannot use this analysis to make conclusions about CRNA
    performance with or without physician supervision.” [p. 4677]
    •  “Even if the recent Silber study did not have methodological prob-
    lems, we disagree with its apparent policy conclusion that an
    anesthesiologist should be involved in every case, either per-
    sonally performing anesthesia or providing medical direction of
    CRNAs.” [p. 4677]"

    The IOM Future of Nursing Report found HERE advocating removal of barriers to CRNA practice by the IOM/ RWJF

    So there goes that line of BS.

    Opting-Out Rejects the Health Care Community’s Push for Physician-Led Team Care: A physician-led health care team (like the Anesthesia Care Team) is a proven model to provide high quality, cost-effective care. Opting out rejects this model by authorizing nurse anesthetists to practice independently.
    What community? Who said there was a "push" for this? Where is the evidence? In fact its just the opposite, there is an expansion of CRNA only practice (tuns of evidence for that) and this is only about protecting MDAs market share/control. All available evidence (see above) indicates that CRNAs provide the same high quality, (more) cost effective care which is just as safe.

    Additionally in regards to cost effectiveness....

    Medicare Part B and most public and private health plans reimburse for CRNA services through a
    number of different modalities, including nonmedically directed CRNA services and CRNA services
    medically directed by an anesthesiologist.


    Nonmedically directed CRNA services represent an important value to patients, ensure a high
    quality of anesthesia service indistinguishable from more costly practice modalities, and create savings
    by comparison with medically directed services even though both are reimbursed identically under
    Medicare Part B.


    Let’s suppose there are four identical cases. In Case A, anesthesia is delivered by a nonmedically
    directed CRNA; in Case B, by a CRNA medically directed at a 4:1 ratio by an anesthesiologist oversee-
    ing the four simultaneous cases; in Case C, by a CRNA medically directed at a 2:1 ratio; and in Case
    D, by an anesthesiologist who personally performs the anesthesia service. Further suppose that the
    annual compensation of the anesthesia professionals involved approximates national market condi-
    tions: $158,000 for the CRNA (AANA 2009 Practice Profile Survey) and $410,000 for the anesthesiol-
    ogist (MGMA 2009 Physician Compensation and Production Survey).


    Under the Medicare program and most private payment systems, in all four cases the anesthesia pro-
    fessionals are reimbursed the same. However, the annualized labor costs for each modality vary
    widely. The annualized anesthesia labor cost for Case A equals $158,000 per year; for Case B, it is
    $158,000 + (0.25 x $410,000) or $260,500 per year; and for Case C, it is $158,000 + (0.50 x
    $410,000) or $363,000 per year. Finally, for Case D the annualized cost equals $410,000 per year.
    So if Medicare reimburses at the same rate for nonmedically directed and medically directed CRNA
    services, who bears the additional labor cost associated with medical direction by an anesthesiologist?
    Typically it is shifted onto hospitals and other healthcare facilities, and ultimately passed along to
    patients, premium payers, and taxpayers. With a considerable fraction of the 32 million anesthetics
    provided by CRNAs being “medically directed,” it is reasonable to assume that the additional costs of
    this medical direction are substantial. In the instances where a health plan, unlike Medicare, reim-
    burses for medically directed anesthesia services at a higher rate than for nonmedically directed CRNA
    services, the modest payment differential rarely approaches the large additional costs associated with
    medically directed services. In the interest of ensuring patient access to safe, cost-effective anesthesia
    care, delivering and billing for anesthesia services using the nonmedically directed CRNA model is far
    more prudent than using the costly medical direction model.

    Educational Costs


    The educational cost to prepare CRNAs is significantly less than the cost to prepare anesthesiologists.
    Becoming a CRNA usually takes a minimum of seven to eight years (including a year of acute care
    nursing experience); becoming an anesthesiologist usually takes 12 years.


    According to a 1996 paper titled “Health educational costs, provider mix, and healthcare reform: A
    case in point—nurse anesthetists and anesthesiologists” by Ira Gunn, CRNA, MLN, FAAN, it cost
    approximately 10 times more to educate one anesthesiologist compared with one nurse anesthetist.
    Put another way, approximately 10 CRNAs could be educated for the cost of one anesthesiologist.
    Given that the cost of education in the United States has steadily increased over the last 14 years, it is
    safe to assume that it is still approximately 10 times more expensive to prepare one anesthesiologist
    than it is to prepare one CRNA.


    Additionally, CRNAs enter the workforce and start providing patient care four years sooner than
    anesthesiologists, another benefit to the overall healthcare system.


    Opting-Out Will Not Improve Rural Access: An opt-out would not resolve any perceived access problems. Data does not exist to show that nurses move to the rural areas when laws are amended to authorize independent practice. In fact, the Institute of Medicine and American Medical Association research show that physicians and nurses all tend to work in the same large urban areas. In fact, former AANA President Wanda Wilson reported in AANA’s NewsBulletin that there is a “greater supply of CRNAs in metropolitan areas and a lack of supply in rural areas….”
    Really? Yet over 70% of all rural anesthesia is done by CRNAs.... go figure.

    Of the anesthesia care provided in rural hospitals, 70% is provided by CRNAs, and 37% of nurse anesthetists practice in towns with fewer than 50,000 residents.

    Garde JF Report of the Executive Director. AANA NewsBulletin.
    December 2000;54(11):11-14.


    Prescription Drug Abuse Could Increase: Prescription drug abuse is an enormous issue for Kentucky. Allowing CRNAs to practice independently may expand the number of “pill mills” in Kentucky as seen in other states. This would negatively impact the implementation of the landmark legislation battling prescription drug abuse, House Bill 1, which was signed last week.


    I dont even know where to start with this...
    wait yes I do...

    Florida is one of 2 states in the entire country which does not allow Nurse Practitioners to prescribe scheduled substances. They state that no NP is qualified to do so. Interestingly enough Florida, the state where only PHYSICIANS can prescribe narcotics, is also prescribing 10X more oxycodone than providers in every other state in the country combined.

    Reference HERE

    In conclusion, an opt-out would have dangerous ramifications to the patients of Kentucky and jeopardize Kentucky’s ability to deliver quality medical care. For these reasons, I strongly urge opposing an opt-out of the federal physician supervision patient safety standard.


    In conclusion, the KSA apparently has no interest in providing actual data for their claims and has chosen to ignore ALL the avaliable evidence/data which universally opposes their statements. Their statement is little more than baseless anti-competitive fear mongering.



    Kentucky Society of Anesthesiologist Letter- call for action
    Please call and leave a message. It will take you 2 minutes to do and can be anybody from any state.

    As many of you may have already heard, the Governor has signed an opt-out letter. KSA has worked diligently and successfully for more than a dozen years with three (3) different Governor's against opt-out. Last year, the KY Hospital Association joined the nurse anesthetists in lobbying the Governor to opt out. KSA has been in regular dialogue with the Governor’s Office; we have asked them for a formal meeting, and we have asked for the letter to be rescinded. We have also spoken with ASA staff today about our options and will be exploring all of them.

    At this point, I encourage you to call the Governor’s Office at (502) 564-2611 and register your opposition to this action. You should have gotten the call to action from the ASA, but in case you want to review the key points, I have attached that to this e-mail. A little noise goes a long way in Frankfort. Please let your voices be heard. When you call, ask to leave a message for the Governor. If you have a personal relationship with the Governor or any member of his staff, please ask to speak directly with him/her. I have attached talking points for you to use. Please let us know if you receive any feedback.

    Thank you.

    Sincerely,
    Heidi M Koenig, MD
    President, Kentucky Society of Anesthesiologists

    IMMEDIATE ACTION: Urge Governor Beshear to Oppose Opting-Out of the Federal Physician Supervision Patient Safety Standard


    Governor Beshear is considering opting-out of the federal patient safety standard requiring nurse anesthetists to be supervised by a physician. Please call him immediately at (502) 564-2611 and urge him to oppose an opt-out.* Here are several talking points for your call:


    An opt-out would not be in the best interest of the state citizens of Kentucky for the following reasons:


    Patient Safety: Despite improvements in outcome, anesthesia remains dangerous. CRNAs lack the education and training to practice independently. Twelve years of medical education is irreplaceable, and its role in providing safe care cannot be underestimated. This amounts to more than 10,000 hours of clinical education and training during their medical school and residency training. In comparison, nurse anesthetists complete 6- 7 years of education: four years of college, two - three years of nurse anesthetist training. This amounts to only between 500-720 hours of nursing education and training. CRNAs lack the medical judgment to recognize and respond to an emergency should an anesthetic complication arise.


    An opt-out would eliminate the medical judgment and skills provided by physicians, thereby jeopardizing the health and safety of the citizens of Kentucky. Kentucky citizens deserve the highest quality of care possible.


    Opting-Out Rejects the Health Care Community’s Push for Physician-Led Team Care: A physician-led health care team (like the Anesthesia Care Team) is a proven model to provide high quality, cost-effective care. Opting out rejects this model by authorizing nurse anesthetists to practice independently.


    Opting-Out Will Not Improve Rural Access: An opt-out would not resolve any perceived access problems. Data does not exist to show that nurses move to the rural areas when laws are amended to authorize independent practice. In fact, the Institute of Medicine and American Medical Association research show that physicians and nurses all tend to work in the same large urban areas. In fact, former AANA President Wanda Wilson reported in AANA’s NewsBulletin that there is a “greater supply of CRNAs in metropolitan areas and a lack of supply in rural areas….”
    Prescription Drug Abuse Could Increase: Prescription drug abuse is an enormous issue for Kentucky. Allowing CRNAs to practice independently may expand the number of “pill mills” in Kentucky as seen in other states. This would negatively impact the implementation of the landmark legislation battling prescription drug abuse, House Bill 1, which was signed last week.


    In conclusion, an opt-out would have dangerous ramifications to the patients of Kentucky and jeopardize Kentucky’s ability to deliver quality medical care. For these reasons, I strongly urge opposing an opt-out of the federal physician supervision patient safety standard.
    Comments 16 Comments
    1. WA_Gas_Passer's Avatar
      WA_Gas_Passer -
      Please tell me you sent this to the Governor of KY and the President of KY anesthesia society. Please???
    1. Doug Ramey's Avatar
      Doug Ramey -
      I agree, send this to KY's Governor, & while you are at it, send it to all of the previous 16 opt-out Governor's... and the remaining 12 opt-out eligible state's Governors!
    1. JoshCRNA's Avatar
      JoshCRNA -
      Quote Originally Posted by CO_Gas_Passer View Post
      Please tell me you sent this to the Governor of KY and the President of KY anesthesia society. Please???
      Seriously!
    1. fredbenny's Avatar
      fredbenny -
      Who was the fact checker on this article????
    1. fredbenny's Avatar
      fredbenny -
      I meant the KSA article not the forums article.
    1. Bob Gauvin's Avatar
      Bob Gauvin -
      Excellent job Nurse-Anestheisia.org. Strong work!
    1. neopusher's Avatar
      neopusher -
      Quote Originally Posted by Bob Gauvin View Post
      Excellent job Nurse-Anestheisia.org. Strong work!
      +1
    1. Ruspantine's Avatar
      Ruspantine -
      Simply another attempt to discredit CRNA's and the excellent anesthesia performance we provide daily. I find it interesting that in my past 25 plus year experience, that OR nurses as well as surgeon's and their family members specifically request a CRNA to administer their anesthetic, moreso than an anesthesiologist on the same staff
    1. davegasser's Avatar
      davegasser -
      Now y'all see what we have been dealing with for all of these years. However, I'm sure the fight has just begun. Nice reply, Mike. If you'd like to send this to the BOD of KyANA email me privately. Dr. Koenig IS a complete id--t though.
    1. MmacFN's Avatar
      MmacFN -
      Hey Dave Sure. Sent it away. Ill email you.

      Quote Originally Posted by davegasser View Post
      Now y'all see what we have been dealing with for all of these years. However, I'm sure the fight has just begun. Nice reply, Mike. If you'd like to send this to the BOD of KyANA email me privately. Dr. Koenig IS a complete id--t though.
    1. gregsto's Avatar
      gregsto -
      Be sure to read this item for a discussion on why the CMS supervision requirement is a now absurd regulation which should be removed:

      http://lawmedconsultant.com/3356/ky-...on-requirement
    1. Kenethesia's Avatar
      Kenethesia -
      I absolutely love this. Thank you to the individual/individuals who took the time and effort to construct this.
    1. MmacFN's Avatar
      MmacFN -
      You are welcome

      Quote Originally Posted by Kenethesia View Post
      I absolutely love this. Thank you to the individual/individuals who took the time and effort to construct this.
    1. yourbuddy's Avatar
      yourbuddy -
      Well done!
    1. C-wick's Avatar
      C-wick -
      Very nice.
    1. beard's Avatar
      beard -
      Nice!
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