AACN News—October 1998—Practice

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Vol. 15, No. 10, OCTOBER 1998


Pediatric Critical Care Therapies and Trends Examined

The lack of solid evidence in a few areas of pediatric care was emphasized by Mary Fran Hazinski, RN, MSN, FAAN, during a lecture on “Trends and Controversies in Pediatric Care: at the 1998 National Teaching Institute™ in Los Angeles.

A clinical specialist at Vanderbilt University in Nashville, Tenn., Hazinski cited areas that need more study if treatment is to improve.

For example, according to Hazinski, inhaled nitric oxide (NO) is still used under research protocol, because the Federal Drug Administration (FDA) has not yet approved it for general use. Nitric oxide is increasingly used for pediatric patients with persistent pulmonary hypertension—especially for those with temporary primary pulmonary hypertension (PPH) following lung and heart transplants—and for patients with acute respiratory distress syndrome. It also reduces the need for extracorporeal membrane oxygenation (ECMO) in neonates with persistent pulmonary hypertension, she pointed out.

According to Hazinski, the FDA is awaiting the results of outcome data that document lower mortality rates in neonates treated with NO.

In a recent study of 37 newborn patients with PPH, who met ECMO criteria, 21 did not have NO available, and only 5 improved without ECMO. Of the 16 for whom the drug was available, 12 didn’t need ECMO therapy.

“NO reduces the need for ECMO, but this is considered an intermediate outcome, not a final outcome, so some data gathering is still under way to see if a case can be made,” Hazinski said. “Mortality is also low in both groups, so it’s difficult to show that NO improved survival.
Hazinski also reviewed the American Heart Association’s (AHA) new textbook content.

“The AHA is really trying to take a new approach to generating materials, delivering them in a timely fashion, and assisting in training,” she said.

The AHA’s plans for its February 2000 Jamboree include developing international resuscitation guidelines and common ways to teach them.

“We should all be able to look internationally for science to come up with common recommendations and ways of teaching,” Hazinski added.

The strict U.S. drug approval process has led to the AHA's use of findings generated from European trials in the guidelines. The AHA is committed to publishing new guidelines 90 days after the 2000 Jamboree, and to publishing textbooks 90 days after that.

“The AHA also listened to how we teach what we teach, and the message is that we need to simplify,” Hazinski said. “We need to do a better job preparing our instructors and make sure our courses are skill focused.”

Many instructors told a focus group that the courses mix CPR training, healthy-heart living, and information about stroke and antismoking.

“We were throwing everything at them but the kitchen sink,” Hazinski said.

In addition, the AHA is looking at the use of automated external defibrillators in children, an area that continues to raise many questions. Some of the devices, Hazinski said, incorrectly interpret pediatric rhythm. Vanderbilt University conducted a pilot study on 30 patients and found the specificity of the devices tested to be at 90%.

“We had two children with pulsable rhythms, and one of the three devices we tested said to shock them, and that’s worrisome.”


Grants Available for Nursing Research

AACN offers several grants to nurses for research that benefits patients and families or that link to AACN’s vision. Application materials may be obtained by calling (800) 899-AACN (2226). Following are grants for which application deadlines are approaching:

AACN Clinical Inquiry Grants
Up to $250 each is awarded for clinical research projects that will directly benefit patients and families. Funds will be awarded for projects that address one or more AACN research priorities and link with AACN’s vision.

To be eligible, the principal investigator must be an RN, a current AACN member, employed in a clinical setting, and directly involved in patient care. Funds will be awarded to projects that address one or more AACN research priorities and link to AACN’s vision.

Applications must be received by January 1, 1999.

Physio-Control-AACN Small Projects Grants Program
Three grants of up to $500 are awarded to qualified individuals to carry out projects that focus on aspects of acute myocardial infarction or resuscitation such as the use of defibrillation, synchronized cardioversion, invasive pacing, or interpretive 12-lead electrocardiogram. This award is sponsored by Physio-Control.

The principal investigator must be an active or affiliate member of AACN and not currently conducting another study funded by an AACN research grant. Examples of eligible projects include the development of patient education programs, continuous quality improvement projects, outcomes evaluation projects, and small clinical research studies.

Applications must be received by January 15, 1999.


More Thunder Project II Sites Return Data Collection Materials

An additional 22 Thunder Project´┐Ż II sites returned data collection materials between June 1, 1998, and August 28, 1998, bringing the total to 47. (See the July 1998 issue of AACN News for a list of the earlier sites and site coordinators.)

More than 200 sites across the United States and in Canada, Australia, and the United Kingdom are participating in the Thunder Project II, which is studying pain perceptions and responses of acutely and critically ill patients to 6 clinical procedures. The procedures are tracheal suctioning, nonburn wound care, drain removal, turning, femoral sheath removal, and central line placement. The study includes children aged 3 years and older as well as adults.

Following are the sites and site coordinators that have completed data collection since June 1:

St. Vincent Infirmary Medical Center
Little Rock, Ark.
Ann Manees,
RN, BSN, CCRN

Mercer Medical Center
Trenton, N.J.
Maureen O’Brien,
RN, MSN, CCRN, CNA

Abbott Northwestern Hospital
Minneapolis, Minn.
Sue Sendelbach,
RN, MS

Central Dupage Hospital
Winfield, Ill.
Mary Lyons,
RN, MSN

Vanderbilt University Medical Center
Nashville, Tenn.
Sarah Hutchison,
RN, BSN, CCRN

Meridia Hillcrest Hospital
Mayfield, Heights, Ohio
Veronica Sumodi,
RN, MSN, CCRN

Children’s Hospital
Los Angeles, Calif.
Nancy Blake,
RN, MN, CCRN, CNAA

Henry Ford Health System
Detroit, Mich.
Denise Adams,
RN, MSN, CCRN, CS

VA Medical Center
Denver, Colo.
Catherine Owens,
RN, BSN, CCRN

University of Minnesota Hospital & Clinics
Minneapolis, Minn.
Julie Sabo,
RN, MN, CCRN

Mercy Hospital Medical Center
Des Moines, Iowa
Joan Beard,
RN

Henry Ford Wyandotte Hospital
Wyandotte, Mich.
Charissa Bredow-Shawcross,
RN, MSN, CCRN

University of South Dakota
Vermillion, S.D.
Teresa Solberg,
RN, MSN, CCRN

Mount Carmel Health System
Columbus, Ohio
Stacey Erdelsky,
RN

Mayo Foundation Hospital
Rochester, Minn.
Ann Hotter,
RN, MSN, CCRN, CS

Mount Sinai Medical Center
Miami Beach, Fla.
Marye C. Barden,
RN, MSN, CCRN

Lawnwood Regional Medical Center
Fort Pierce, Fla.
Karen Deison,
RN

Catholic Medical Center
Manchester, N.H.
Maria Matsco,
RN

Immanuel Medical Center
Omaha, Neb.
Ann McPhillips,
RN, BAN, CCRN

VA Medical Center
Pittsburgh, Pa.
Karen Miller,
RN, BSN, CCRN

Marquette General Hospital
Marquette, Mich.
Susan Pragacz,
RN, MSN, CCRN, CS

Virginia Mason Medical Center
Seattle, Wah.
Shirley Storch-Sherman,
RN, BSN, CCRN

Geriatric Corner

Throughout the United Nations’ International Year of Older Persons, which was launched October 1, 1998, AACN News will feature information relevant to the care of older adults.

As the 21st century approaches, the older population is larger than it has ever been. This population is itself aging and changing in composition. People older than 85 years constitute the fastest-growing segment of the aged population. Its ethnic composition is changing as well; the African American segment of the older population is growing at a faster rate than other segments.

Because caring for older patients can be challenging. This feature is intended to provide you facts, references, resources, helpful hints, age-related physiological changes vs. pathological changes, and Internet resources as they relate to the older adult. There is a lot of talk about “age-specific competencies” with respect to Joint Committee on Accreditation of Healthcare Organizations (JCAHO) regulations and standards. We hope that integrating information about the aging patient into everyday practice will help you to support and improve the quality of care given to these patients.

Internet Resources
Following is a listing of Internet resources related to gerontological aspects of nursing care. Many of these resources are linked to other sites, providing a comprehensive data base for gerontologically sensitive and responsive nursing care.

International Year of the Older Person 1999
http://www.hcoa.org/iyop
Toll-free Numbers for Patient Support

Academic Journal Directory

Administration on Aging

Advanced Directives International
http://www.adiwills.com/index.html
Duke University Center for the Study of Aging and Human Development
http//www.geri.duke.edu
Gerontological Nursing Resources on the World Wide Web
http://www.usc.edu/isd/locations/science/gerontology/
The GeroWeb Virtual Library on Aging

Healthweb-Geriatrics and Gerontology

UTMB Center on Aging
http://www.utmb.edu/aging/index.html

For more information about the International Year of Older Persons or age-related care issues, contact AACN Clinical Practice Specialist Justine Medina, RN, MS, CCRN, at (800) 809-2273, ext. 401; fax, (949) 362-2020; e-mail, Justine.Medina@aacn.org.

References
1. Macfadyen D. International demographic trends. In: Kane RL, Evans JG, Macfadyen D, eds. Improving the Health of Older People: A World View. New York, NY: Oxford University Press; 1990:19-29.
2. Acello B. The Geriatric Survival Handbook. Aurora, Colo: Skidmore-Roth Publishing, Inc.; 1998.
3. Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. Whitehouse Station, NY: Merck & Co., Inc.; 1995.
4. Gallo JJ, Reichel W, Andersen LM, eds. Handbook of Geriatric Assessment. 2nd ed. Gaithersburg, Md: Aspen Publications, Inc; 1995.


Strategies Advanced Family-Center Care Philosophy

Although incorporating family-centered care into nursing practice can be a struggle, the outcome is worth the effort, according to Margo Halm, RN, MA, CCRN, CS, a clinical nurse specialist for Heart and Lung Services at United Hospital, St. Paul, Minn.

Speaking at the 1998 National Teaching Institute™ in Los Angeles, Halm urged nurses to spread the word about the benefits of family-centered care. She also provided tips to win over skeptical administrators and colleagues.

Drawing on the pioneering work of the Association of the Care for Children’s Health (ACCH), Halm is working to infuse the same philosophies into adult critical care units. She said the philosophy is grounded in several key points:

• Recognizing that the family is the constant in the patient’s life
• Being aware of family strengths and individuality, and respecting different methods of coping
• Encouraging and facilitating family-to-family support and networking
• Sharing complete and unbiased information about the patient’s care with family members on a continuing basis and in a supportive manner

• Incorporating the development needs of children and adolescents into healthcare systems
• Designing accessible healthcare delivery systems that are flexible, culturally competent, and responsive to family needs

The biggest challenge, Halm said, is convincing administrators and coworkers that adopting a family-centered care philosophy warrants the effort.

“There is a real need for us to help nurses who are trying to convince a small group of people that this will lead to better outcomes for families,” she said. “The ACCH has done a lot of training programs. We can use its work to introduce the concept through usual channels to get people on-board.

“We need to get people to realize why this is so important. We need to get people to look at the values in their own lives.”


InfoLink

Your acute and critical care sharing link

What kinds of outcome measures are you using to evaluate CVVH (continuous veno-venous hemofiltration) programs? Is anyone measuring outcomes that relate directly to the success or failure of a CVVH program?
Contact Dawn Beland,
RN, MS, CCRN, CS, Critical Care Educator, Hartford Hospital, 80 Seymour St., P.O. Box 5037, Hartford, CT 06102-5037; phone, (860) 545-5253; fax, (860) 545-5062; e-mail, dbeland@harthosp.org.

Does your hospital have a policy for securing an endoctracheal tube tape? I am looking for examples of procedures.
Contact Keena Carter,
RN, BSN, CCRN, via fax at (301) 981-1037.

Do You Have a Question?

Send your InfoLink questions to: AACN News, 101 Columbia, Aliso Viejo, CA 92656-1491; fax, (949) 362-2049; e-mail, aacnnews@aacn.org; or call (800) 809-2273, ext. 502, or (949) 362-2000, ext. 502 (outside the United States). Please include as much of the following information as possible: your name, mailing address, phone number, fax number, and e-mail address. InfoLink questions are published based on available space. You also can post InfoLink questions online. Go to http://www.aacn.org/aacn/aacnsite.nsf/htmlmedia/infolink_discussion.html.


Living With Ethical Dilemmas: The Art of Compromise

Debates about ethics have raged among philosophers and scholars for centuries. For nurses, doctors, and administrators, these philosophical debates give way to real-life decisions and dilemmas in the critical care setting.

Issues of values, informed consent, cost containment, futility, resource use, and competency are tackled daily. One of the biggest challenges facing nurses is balancing principle-based ethics and relationship-based ethics. Katherine Brown-Saltzman, RN, MA, a clinical nurse specialist in palliative care in the Department of Nursing at the University of California Los Angeles Medical Center, believes it is possible to integrate both.

Speaking on “Ethical Dilemmas: Moving from Principles to Practice” at the first Advanced Practice Institute™ earlier this year in Los Angeles, Brown-Saltzman said that ethical dilemmas are rarely resolved. Instead, she said, nurses and their colleagues must use the fine art of compromise.

The constant barrage of moral and ethical challenges can take a toll on any healthcare provider, she said. The key to overcoming that stress is to accept that moral and ethical ambiguity come
with the territory.

Keep lines of communication open, acknowledge difficult issues, and talk about these issues with colleagues, Brown-Saltzman advised. Ethics committees and consultants can go a long way toward easing stress.


Clinical Simulations on CD-ROM

AACN and Lippincott Williams & Wilkins announce the publication of Clinical Simulations in Neonatal and Pediatric Critical Care, a computer-based program of critical care case simulations on CD-ROM.

Patients and realistic healthcare situations are presented using interactive media to simulate commonly encountered neonatal and pediatric problems. Critically ill “virtual” pediatric patients provide an opportunity for learners to solve problems and determine priorities for care of the patient and family.

Using a case-study approach, the programs provide the advantages of clinical exposure, without posing a risk to actual patients. Each simulation gives the user the potential to earn 1 contact hour of continuing education credit.

The four cases presented involve meconium aspiration, respiratory distress syndrome, alterations in fluid and electrolytes, and alterations in neurological function.

For more information on this new, multimedia, interactive teaching tool that allows users to learn at their own pace, or to receive a 30-day preview, contact Lippincott Williams & Wilkins at (800) 527-5597.

AACN Clinical Issues Features Genetics

The November issue of AACN Clinical Issues: Advanced Practice in Acute and Critical Care will bring clinicians cutting edge information on genetics. Guest editors are Marilyn Sawyer Sommers, Carole Hetteberg, Carole Kenner, and Cindy Prows. The content is divided into “Foundations of Genetics,” “Application to Assessment and Management of Clinical Illness,” and “Issues in Research, Education, and Ethics.” The issue concludes with a comprehensive glossary of related terms.

To subscribe to AACN Clinical Issues or to order a single copy, call Lippincott at (800) 777-2295.