Advanced Practice Roles Enhance CHF Management
Sara Paul (left) and Donna McCauley work closely at the Medical University of
South Carolina to transfer CHF patients from the inpatient to the outpatient
By Sara Paul, RN, MSN, FNP
and Donna McCauley, RN, MSN, CCRN
At the Medical University of South Carolina in Charleston, two advanced practice nurses work together to “seamlessly” transfer congestive heart failure (CHF) patients from the inpatient to the outpatient setting.
Sara Paul is a nurse practitioner (NP) in the outpatient congestive heart failure clinic, where patients are closely monitored to prevent complications leading to hospital readmission. Her role combines the medical management of CHF, including physical evaluation, diagnosis, and disease management, with the nursing component of patient education and telephone follow-up.
Donna McCauley is the continuum of care manager, who not only follows the heart failure patient during admission, but also develops appropriate discharge plans. As a clinical nurse specialist (CNS), she monitors the acute care stay of complex cardiac patients. She evaluates daily the care and outcomes of the patient’s hospitalization to ensure smooth progression throughout the acute management phase. During this phase, complex discharge needs are identified and communicated to the CHF nurse practitioner.
When a CHF clinic patient is admitted to the hospital, Paul and McCauley meet to share pertinent information about the patients and their family. Paul provides information about the patient’s medical history, medication profile, and psychosocial background.
At the completion of the acute care phase, McCauley collaborates with Paul to ensure that the patient’s needs are met. McCauley reviews the patient’s hospital course and discharge medications with Paul. In addition, she ensures that the patient is scheduled for an appointment at the CHF clinic, where patients are referred when they have questions or concerns after discharge.
This type of collaboration between these advanced practice nurses roles creates a foundation for providing optimal patient care through expert coordination of services. Mutual respect for one another’s role enhances communication and the continuum of care for the complex cardiac patient. Working together, the NP and the CNS improve patient outcomes by planning care, communicating patient information, and coordinating discharge needs and follow-up.
Sessions Tailored to Advanced Practice Nurses
Advanced practice nurses will find plenty of interest at the 1999 National Teaching Institute,™ scheduled for May 16 through 20 in New Orleans, La., beginning with preconference sessions and continuing into the Advanced Practice Institute.™
Among new features this year is the Fundamental Critical Care Support Course, developed by the Society of Critical Care Medicine and offered over a two-day period, May 15 and 16. This course is already filled.
Also offered as a preconference session is the Acute Care Nurse Practitioner (ACNP) Prep Class. Experts will provide an overview of relevant information listed in the ACNP test content outline. “Pharmaceuticals for the Nurse Practitioner: Interaction Challenges of Prescriptive and Alternative Therapies” is another preconference session that will be of particular interest to advanced practice nurses.
Throughout the API and NTI, advanced practice nurses will have approximately 50 concurrent sessions from which to choose. Among these are ticketed mastery sessions related to intubation, chest tubes, lumbar puncture, and the physiological approach to cardiac auscultation. These ticketed sessions are already filled. Refer to the schedule for the other advanced practice sessions.
In addition, the Advanced Practice Work Group will facilitate roundtable discussions on advanced practice topics.
A special API cocktail reception, which is sponsored by Hill-Rom, is also scheduled for May 18.
For more information or to register for the NTI, featuring the API, call (800) 899-AACN (2226), or visit the NTI Web site.
PRN Frequently Asked Questions: Hospitals Face Shortage of Critical Care Nurses
Q Do you have information about the current shortage of critical care nurses?
A A growing number of hospitals are experiencing a shortage of critical care nurses. Many hospitals that have open nursing positions are now offering incentives such as sign-on bonuses. At the same time, an increasing number of new graduate orientation programs and critical care internship programs are offered around the country.
What began as a scattered, regional issue is rapidly becoming a widespread phenomenon. The severest shortages are in areas requiring experienced nurses with highly specialized skills. The greatest need is for critical care nurses in specialized areas including cardiovascular ICUs, pediatric and neonatal ICUs, neuroscience ICUs, and catheterization labs.
AACN’s Registered Nurse Statistics fact sheet indicates that this trend has been building since the mid-1990s. For example:
• Almost 2 million RNs were employed in 1996; projections are that there will be almost 2.4 million RN jobs in 2006 (21% increase).
• Approximately 1.2 million RNs were employed in hospitals in 1996; projections are that there will be approximately 1.3 million RN hospital jobs in 2006 (7.4% increase).
• In 1996, the unemployment rate for RNs was less than 2%. (72% of entry-level nursing students with a bachelor’s degree graduated with jobs waiting; 85.7% of masters-level nurse practitioner students graduated with jobs waiting; and 94% of nursing students with a master’s degree graduated with jobs waiting.)
Career Development Services (CDS), an AACN and TravCorps alliance, reported in a survey conducted in Fall 1998 that trends in the requests for temporary or traveling critical care nurses have increased in every area of the country. The number of requests for traveling and per diem nurses closely reflects the number of nursing vacancies. The CDS survey reported the following trends by geographic area:
Forty-six percent of total needs were in critical care units. Large hospitals in New York, N.Y.; Boston, Mass.; Washington, D.C.; and Baltimore, Md., showed the greatest need. Smaller hospitals in New England showed an increased demand.
Some hospitals in larger urban areas now offer in-house training or internships for the first time in 10 years.
Virginia showed a decreased demand for critical care nurses, with some of the larger hospitals citing budgetary restrictions as the reason. The same was true for the Pittsburgh, Pa., area.
West/South Central States
Forty-nine percent of total needs were in critical care units. California, Arizona, and Texas showed an increased demand for experienced critical care nurses.
Forty-five percent of total needs were in critical care units. Florida showed record-breaking requests for experienced open-heart or cardiovascular ICU nurses. Needs in North and South Carolina, Ohio, Indiana, and Oklahoma had also increased.
Requests to fill open positions showed increases of 45% in adult critical care units, 50% in pediatric and neonatal critical care units, and 140% in emergency departments.
Additional information about CDS, an exclusive benefit for AACN members, is available at (888) AACN-JOB (222-6562), or on the AACN Web site at
For more nursing workforce and nursing career information, visit the AACN Web site at
http://www.aacn.org. Click on the “Practice” tab, then on the “Clinical Practice Links” icon and scroll down to the “Career/Professional Development” section.
The AACN fact sheet titled Registered Nursing Statistics provides additional information including the number and age of nurses in the United States, enrollment in nursing programs, and average salary ranges. This free resource is available in the “Practice” area of the AACN Web site at
http://www.aacn.org. From the “Practice” area, click on “Fact Sheets and Position Statements.” The fact sheet is also available through Fax-on-Demand at (800)AACN-FAX (222-6329). Request Document #5029.
Deadlines Near for 3 Research Grants
Deadlines are approaching for three nursing research grants that are available through AACN. Following is information about each grant.
Hewlett-Packard–AACN Critical Care Nursing Research Grant
This grant awards $30,000 for studies that are preferably related to the technological requirements of patient management in acute and critical care.
In addition, $2000 in travel expenses, an HP Vectra personal computer, HP LaserJet printer, and associated utility software is presented to the recipient of the grant. Eligible applicants must be AACN members and have an active RN license. The grant may be used to fund research that is associated with an academic degree.
Applications must be received by July 1, 1999. To obtain an application, visit the Hewlett-Packard Web site at
http://www.hp.com/go/healthcare. If you have additional questions, contact the Research Department at AACN, (800) 809-2273, ext. 335.
AACN Clinical Inquiry Grants
These grants provide up to $250 to support projects that will directly benefit patients and their families.
Funds will be awarded for projects that address one or more AACN research priority and that link to AACN’s vision of a healthcare system driven by the needs of patients and their families. To be eligible, the principal investigator must be an RN, an AACN member, employed in a clinical setting, and directly involved in patient care.
Applications must be received by July 1, 1999. To obtain an application, call (800) 899-AACN (2226).
American Nurses Foundation Research Grant
May 3, 1999, is the deadline to submit applications for the $3500 American Nurses Foundation (ANF) Research Grant, which is awarded annually to support research relevant to critical care nursing practice.
The grant, which is sponsored by AACN, is designed for beginning nurse researchers or experienced nurse researchers who are entering a new field of study. The principal investigator must be an RN who has obtained a baccalaureate or higher degree in nursing. The proposed study may be used to meet the requirements of an academic degree.
Applications are available from ANF by calling (202) 651-7298, or on the ANF Web site at
http://www.nursingworld.org/anf. Proposals must be received at ANF by May 3.
For additional information about nursing research grants that are available from AACN, call (800) 899-AACN (2226).
Have you encountered problems with the use of sodium chloride (preservative free) versus bacteriostatic sodium chloride (with benzyl-ETOH solution) for flushing of vascular access devices?
Contact Mary Rappaport, RN, MN, CNS, Clinical Nurse Specialist; phone, (602) 867-5716; fax, (602) 867-5657.
We are developing an outpatient prescheduled, synchronized cardioversion form, and would like to use a numerical score to assess recovery. Do you have a form you could share. Do you use the postanesthesia recovery (PAR) scale for Brevital (methohexital sodium) or the Aldrete score for Versed (midazolam hydrochloride)?
Contact Mary E. Thomas, RN, CCRN, Whitley Memorial Hospital, 353 N. Oak St., Columbia City, IN 46725; phone, (219) 244-6191, ext. 2456 or 2457; fax, (219) 248-6148; e-mail, Mary.Thomas@Parkview.com.
Ethics Is the Challenge Today
Editor’s note: Donna Kathryn Kruse, RN, MS, CCRN, is a nurse in the medical-surgery ICU at Sherman Hospital, Burlington, Ill. She was a recipient of a 1998 Excellence in Clinical Practice award. Included here are excerpts from the exemplar submitted in connection with the award nomination. For information about the annual Circle of Excellence recognition awards, call (800) 899-AACN (2226), or visit the Awards area of the AACN home page at http://www.aacn.org.
By Donna Kathryn Kruse
There are times when the challenges you face as a critical care nurse cause you to question society’s values as well as your own.
During my 10 years as a critical care nurse, I have been involved in numerous ethical discussions and decisions. However, one of the most disturbing cases involved Ken, a 37-year-old male patient who was admitted to our nine-bed medical-surgical ICU after an intentional morphine overdose.
Raised in a broken home, Ken faced many emotional issues and had been treated for paranoid behavior. Following his release from a six-week treatment program, Ken refused to take his medication. As a result, his behavior led to job terminations and marital problems.
Three days after his divorce was final, Ken attempted suicide by ingesting approximately 60 sustained-release morphine tablets and drinking an oral morphine solution. Ken had access to large quantities of morphine that were prescribed for his uncle, who was diagnosed with cancer. His girlfriend found him unconscious. The paramedics were unable to auscultate a blood pressure, and a lengthy resuscitation effort occurred in the emergency department. When Ken arrived in the ICU, he was intubated and placed on a mechanical ventilator, and required vasopressors.
This prolonged hypoperfused state sent Ken's liver and kidneys into shock. However, as a result of the treatments initiated, his organs made a remarkable recovery over several days. He was weaned off the vasopressors and required only minimal support from the ventilator. Ken was now withdrawing his extremities when he was exposed to noxious, painful stimuli. His electroencephalograms also showed increased activity. However, Ken did not wake up.
As I cared for Ken, I was able to bond with his family members and gain their trust. Although divorced, both his mother and father kept a vigil at his bedside. His mother blamed herself for her son’s problems, and his father searched for concrete answers to Ken’s condition.
The family began asking when Ken’s neurological status would improve and what type of recovery to expect. I reiterated the physicians’ prognoses and explained how neurological injuries differed from the other body insults that were improving. I then set up a patient care conference to facilitate dialogue between Ken’s family and the various physicians.
A nurse on a previous shift, who had not been involved in the ongoing care of Ken and his family, commented on the report that Ken’s condition had deteriorated and that “we should just let him go.” I disagreed, because I observed that Ken’s neurological assessment showed continued improvement. In addition to supporting the needs of the family members, I offered assistance and acted as their advocate in getting some of their financial and spiritual questions resolved.
Ken’s sister telephoned soon after that interaction with the other nurse. The sister was angry upon hearing that the morphine had been out of Ken’s system for days and that he would be in a persistent vegetative state. I was stunned when she said, “I want everything stopped and for Ken to be allowed to starve to death.” I began to probe for why her behavior had suddenly changed.
As I walked to Ken’s room, his father approached me. He was carrying an organ donation pamphlet and had questions about the procedure to donate organs. Bewildered, I asked if something drastic had happened. He answered, “No.” I explained to him that Ken was neither brain dead nor a candidate as a heart-beating organ and tissue donor.
Ken’s stepmother inquired about the hospital’s hospice facilities. I told her that the one inpatient hospice bed was reserved for someone whose death was imminent. However, I gave her a brochure.
I informed the neurologist of these conversations with the family and updated him on Ken’s status and gradual recovery. He asked whether Ken was a valuable member of society. I told him about Ken’s psychiatric history and inability to hold a job. The neurologist said that he would have no problem documenting that Ken was in a persistent vegetative state and withdrawing food and fluids. He asked me to record the surrogate information on the chart. However, the neurologist who made rounds the next day stated that Ken was not in a persistent vegetative state and that he would recover to the point of probably walking, talking, and feeding himself. He said that, in his opinion, Ken would probably lose only his higher cognitive abilities.
I was torn. I understood the family’s point of view as they began to realize the burden his long-term care might entail. However, I was a patient advocate, and Ken was improving.
Because the care conference to decide Ken’s fate was only two days away, I was uncomfortable in transferring him to the neuroscience unit. Although I had no further clinical ties to Ken, I explained my concerns to the ICU manager, who assured me she would check in on the conference. When I asked her later how the conference went, she said everyone else was present and that she deferred the conference over to the group.
Two days later, I learned that Ken had been sent to a hospice unit at a neighboring hospital. My heart sank. Ken had received the right to die—whether he wanted it or not. His suicide attempt could have been just a cry for help.
I realized that we can only learn from cases such as this. How much involvement is too much, and for whom do we advocate?
Competency Checklist Available on CD-ROM
Educators now have a convenient, easy-to-use tool to create checklists for competency assessment, cross training, and orientation. Available through Lippincott Williams & Wilkins, the AACN Critical Care Competency Checklist provides educators the 55 most important critical care skills in a computer-based checklist format. Each of these skills can be modified and customized to meet your facility needs. You can even create your own skills checklists! To order, call Lippincott Williams & Wilkins at (800) 527-5597. Request Item #0-683-40323-0. The price is $395.
Geriatric Corner: How Old Is Old?
How old would you be if you didn’t know how old you was?
I was recently asked to provide a definition of a “geriatric” patient. This request reminded me of just how difficult it is to apply sound nursing assessment, intervention, and evaluation skills when you really want a magic number. I hope this column reminds you to use your tools and not look for rules.
Chronological Versus Biological Age
Aging defies easy definition, at least in biological terms. Aging is more than the passage of time; it is the manifestation of biological events over a span of time. Most of us recognize an old person when we see one, and some of us are good at estimating chronological ages. However, subjective determinations based on appearances are frequently wrong. More importantly, age in years does not directly correlate to biological age.
• Hearts do not naturally weaken with age.
• Regular exercise and a low-fat diet will not slow aging.
• Middle-aged people who are slightly overweight live longer than do people who are very thin or very heavy.
• Curing cancer would add only two years to the life of the average 65-year-old. However, curing heart disease would add 14 years.
• Only 5% of people older than 65 years are in nursing homes.
• No human has lived—or can live—longer than 115 years.
A Problem-Oriented Approach
A distinguishing characteristic of caring for elderly people is the prominence of certain recurring clinical problems that can originate in various organ systems disorders. These problems can include anorexia, weight loss, fluid and electrolyte abnormalities, heat regulation disorders, syncope, gait disturbance, falls, immobility, confusion, incontinence, pain, sleep abnormalities, and pressure sores.
Because these presenting symptoms or syndromes often do not help identify the locus of a disease, a comprehensive evaluation is needed. Understanding age-dependent changes in associated organ systems is the path to successful nursing care for an older adult.
Asking patients what they were like before they were sick or developed a problem may provide clues that can help to determine the best plan of care. It may also provide clues to their biological age, function, expected age-dependent changes, and functional ability. This process is important, because knowing the clinical condition and comorbidities is critically important in determining how patients might respond to treatment or decision making.
Back to the Question
Although age 65 is chosen arbitrarily, it is the age most commonly used in the data and studies of older persons. However, many studies use younger people, but describe them as “old.” The issue is that we don’t have good data on the truly old, especially those over age 80. To define a patient group, you could apply the ranges of “young old” (65-74), “old” (75-84), and “oldest old” (>85), depending on how you want to break down the data.
A Positive Note
The actual designation of “old” may shift with changing retirement benefits and as Medicare and social security benefits edge upward. But, that’s another column.
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
1. Hayflick L. How and Why We Age. New York, NY: Ballantine Books; 1994.
2. Gallo JJ, Reichel W, Andersen LM. Handbook of Geriatric Assessment. Gaithersburg, Md: Aspen Publishers, Inc; 1995.
3. Luggen AS, ed. Core Curriculum for Gerontological Nursing. St Louis, Mo: Mosby-Year Book; 1996.
4. Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, NJ: Merck & Co, Inc; 1995.
5. Timiras PS, ed. Physiological Basis of Aging and Geriatrics. 2nd ed. Boca Raton, Fla: CRC Press, Inc; 1994.