AACN News—August 1999—Practice

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Vol. 16, No. 8, AUGUST 1999

Priorities Guide Research Agenda

By Jacqueline Fowler Byers, RN, PhD
Chair, 1998-99 Research Work Group

New research priorities designed to provide direction for AACN and its members into the next millennium have been announced.

The new priorities were developed over the last two years by the 1997-98 and 1998-99 AACN Research Work Groups. The goal was to identify broad areas of interest and concern to AACN members, patients and families. The priorities can be used to identify and address gaps in knowledge and research used in critical care practice.

The new AACN research priorities are part of the Research Work Group’s mission, which seeks to meet the needs of patients and families through a research agenda that promotes the creation of cultures of inquiry and data-driven practice. The AACN research agenda supports research generation (Do), dissemination (Share) and utilization (Use). Future efforts will focus on developing user-friendly tools to assist AACN members in their quest for data-driven practice.

Nominal group technique was used to identify important, unanswered critical care practice questions. The questions were then grouped into broader categories through consensus.

Lifespan and outcomes are integral themes for each of the research priorities.

The priorities identified were further validated by surveying a sample of staff nurses, who are AACN members. They were asked not only to identify their important practice questions, but also to rank the importance of the proposed priorities to their practice. No new categories emerged from the survey, nor were any of the proposed priorities invalidated. A review of more than 3,000 practice questions received by the AACN Practice Resource Network (PRN) further supported the new priorities.

Following are the new research priorities:
• Effective and appropriate use of technology to achieve optimal patient assessment, management or outcomes
• Creation of a healing, humane environment
• Processes and systems that foster the optimal contribution of critical care nurses
• Effective approaches to symptom management
• Prevention and management of complications

Members of the 1997-98 Research Work Group were Dorrie Fontaine (chair), RN, DNSc, FAAN, Mary Kracun, RN, PhD, CCRN, (board liaison), Anne Wojner, RN, MSN, CCRN, (board liaison), Jacqueline Byers, RN, PhD, Susan Fowler, RN, MN ,CCRN, CNRN, CS, Anna Gawlinski, RN, DNS, CCNS, CCRN, CS, NP, Bradi Granger, RN, MSN, Jessica Palmer, RN, MSN, and Therese Richmond, RN, PhD, CRNP, FAAN. Members of the 1998-99 Research Work Group were Jacqueline Byers, RN, PhD, (chair), Stephanie Woods, RN, PhD, CCRN, (board liaison), Diane Carroll, RN, PhD, Mae Ann Fuss, RN, MSN, CCRN, Jessica Palmer, RN, MSN, Kristine Peterson, RN, MS, CCRN, Pamela Poppelwell, RN, and Therese Richmond, RN, PhD, CRNP, FAAN.

The Research Work Group members challenge each of you to use the new research priorities to help identify practice questions in your setting, and to guide your performance improvement and research projects.

In addition to guiding critical care research and research utilization, the priorities will be used to guide the AACN research grants program and the research awards.

Oct. 1, 1999, Deadline to Apply for Research Grants

Several grants to fund research that is relevant to critical care nursing practice are available through AACN. The deadlines to submit proposals for three of these grants are approaching.

Sigma Theta Tau-AACN Critical Care Grant

Cosponsored by AACN and Sigma Theta Tau, this grant awards up to $10,000 to support research relevant to critical care nursing practice.

The principal investigator must be an RN, with preference given to members of AACN or Sigma Theta Tau. The proposed study may be used to meet the requirements of an academic degree.

Proposals must be received by Oct. 1, 1999.

AACN Data-Driven Clinical Practice Grant
Six awards of up to $1000 each are presented each year under this grant.

To be eligible, research must be focused on stimulating the use of patient-focused data or previously generated findings to develop, implement and evaluate changes in critical care nursing practice.

The principal investigators must be RNs and current AACN members. They may not be using another AACN research grant to conduct research. Proposed studies may be used to meet the requirements of an academic degree.

Applications must be received by Oct. 1, 1999.

AACN Critical Care Research Grant
This grant awards up to $6000 for studies that support one of AACN’s research priorities. (See related article above.)

The principal investigator must be an RN and current AACN member. The proposed study may be used to meet the requirements of an academic degree.

Proposals must be received by Oct. 1, 1999.

To obtain a grant application, call (800) 899-AACN (2226) or Fax On Demand at (800) 222-6329 and request #1013. For more information about AACN research grants and projects that have been funded, visit the “Research” area of the AACN Web site at http://www.aacn.org.

ACNPs Need Roles That Are Well-Defined

Reconfiguration of advanced practice nursing has led to the evolution of the acute care nurse practitioner (ACNP) role, a position that is being shaped by innovative advanced practice practitioners in acute care settings.

However, defining the role of the ACNP continues to be elusive because of unanswered questions and debate about the scope of practice, education and

Stacey B. Gross, RN, MSN, ACNP, and Maria Fe Mangila, CS-FNP, addressed the issue at the 1999 National Teaching Institute™ in New Orleans, La. Their presentation was titled “The Acute Care Nurse Practitioner: Is the Role Being Utilized to the Fullest?”

Gross and Mangila discussed the procedures ACNPs should be allowed to perform as well as the impact of their role on registered nurses, physician assistants and physicians. For example, ACNPs can perform a complete history and physical exam; order and interpret diagnostic tests; and evaluate subjective and objective data.

Gross said nurse practitioners have experienced an identity crisis as the demographics have changed. Of the approximately 2.5 million RNs currently practicing in the United States, 160,000 are included under the umbrella category of advanced practice nurses. Included are nurse practitioners, clinical nurse specialists, certified nurse anesthetists and certified nurse midwives.

Mangila noted that the number of educational courses has increased to accommodate this increasingly popular role. The number of educational tracks increased from 210 in 1990 to 527 in 1995.

Gross reviewed strategies to overcome barriers and resistance to implementing the advanced practice role in a healthcare facility. In acute care settings, she noted, ACNPs are employed to save costs. The best approach is to establish a clear job description outlining the ACNP function; a well-defined credentialing and privileging process; and a strong relationship between nurse practitioners and physicians.

Practice Resource Network: Protocol Decreases Problems With Nosocomial Infection

Q How can we decrease our hospital’s rate of nosocomial pneumonia?

A Nosocomial infections are responsible for increased recovery time, morbidity and mortality of hospitalized patients. The annual cost of nosocomial infections is staggering. In an article titled “Reducing Nosocomial Pneumonia in Critical Care” (for continuing education credit information, see page 7), Cheryl McKay RN, MSN, reported that in 1991 nosocomial infections were directly linked to more than 80,000 deaths at a cost approaching an estimated $10 billion. Hospital-acquired pneumonia (HAP) is defined as pneumonia occurring more than 48 hours after admission. McKay stated that the rate of HAP is as high as 10 cases per 1000 admissions, with a 20-fold increase among patients on mechanical ventilation. HAP has a mortality rate of 30%, the highest of all nosocomial infections, and prolongs hospital stays by as much as seven to nine days per patient.”

The team at McKay’s hospital developed a protocol involving the use of objective scoring tools, early nutrition, aggressive ventilation and rotation therapy (40� rotation or greater to each side using a specialty bed). Because of the protocol, the HAP rate decreased by 43% within one year. The team’s approach targeted high-risk trauma, neurosurgical and other critically ill patients. It reported that the length of an ICU stay decreased by one day and that the number of ventilator days decreased by 20%.

This innovative protocol was originally presented in October 1998 at the Showcase for Innovation and Best Practices. The conference was sponsored by the Best Practice Network, a group of 30 healthcare associations, including AACN and the American Nurses Association, that are dedicated to sharing and encouraging innovative clinical practices.

More information about this protocol, the Best Practice Network and other practice information from the Showcase for Innovation and Best Practice Conference can be found on the Best Practice Network Web site ().

The full text of the article, which offers continuing education credit, can be accessed through the “Earn CE” area of the AACN Web site (http://www.aacn.org) and scroll to the “Respiratory” section. The original article, which was published as a supplement to the February 1999 issue of RN Magazine, was developed and produced by RN Magazine under an educational grant from KCI Therapeutic Services Inc., in cooperation with the Best Practice Network.

You Can Make a Difference One Life at a Time

Editor’s note: Kelly Johnston, RN, MSN, CCRN, a staff nurse in the Medical ICU at the Ann Arbor Veterans Administration Medical Center, Ann Arbor, Mich., received a 1999 Excellence in Caring Practices Award. Following are excerpts from the exemplar Johnston submitted in connection with her award, which is part of AACN’s Circle of Excellence recognition program. For more information about Circle of Excellence awards, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org and click on “awards.” The deadline to apply for Circle of Excellence awards for 2000 is Sept. 1, 1999.

By Kelly Johnston

J.D. was 57 years of age, married and the father of an 11-year-old son when he presented at our emergency department with persistent abdominal and back pain. He had severe end-stage chronic obstructive pulmonary disease (COPD), and was oxygen- and steroid-dependent. This diagnosis had resulted in multiple intubations. He had a significant anxiety disorder, which added to the complexity of his condition.

While in the emergency room, J.D. reacted adversely to lorazepam and meperidine hydrochloride, which led to severe agitation, tachypnea and cyanosis. He was intubated and transferred to our medical ICU (MICU), where his four-month stay presented many challenges.

On admission, J.D. had expressed that he did not want to be on a ventilator for more than two weeks. If he was unable to be weaned within that time, he wanted ventilatory support withdrawn.

After many failed attempts at weaning, we discussed a tracheostomy with J.D. and his wife. They agreed. Even though J.D. had not wanted to be on a ventilator for longer than two weeks, they hoped he would be able to go home on a ventilator after the tracheostomy.

However, two days after the tracheostomy, J.D. was not moving his lower extremities and had lost bowel and bladder function. A magnetic resonance imaging scan revealed a T5 to T6 spinal lesion, which had most likely resulted from steroid-induced osteopenia. An emergency spinal cord decompression was required. One week later, J.D. underwent a second surgery for spinal column stabilization via rod replacement. Now, despite the original plan for short-term mechanical ventilation therapy, we had to develop a plan for the transition period from recovery to long-term care.

Attaining an acceptable functioning level and optimum quality of life, as defined by J.D., presented additional challenges. The interdisciplinary team had to explore plans to wean this highly anxious man off the ventilator as well as to create strategies for dealing with the unexpected spinal surgery and lower extremity paralysis. Throughout this process, I thought about the heart-wrenching life and death discussions I had had with J.D. and his wife, the most difficult of which was when J.D. was angry because I wouldn’t “pull the plug” on his ventilator.

One of my greatest challenges presented when the orthotic representative needed to make a plaster cast of J.D. for spinal stabilization. We had to place him for about 30 minutes in a flat, supine position—a position that is not well-tolerated when on a ventilator.

In preparing to wean J.D. from the ventilator, I worked closely with the psychiatric nurse practitioner, psychiatric team and staff, as well as with J.D. and his wife. Despite education, anxiolytics and reassurance, J.D. remained extremely anxious. We tried a
variety of pharmaceutical agents without success. We tried alternative therapies such as relaxation audio and video tapes. At J.D.’s request, we read the 23rd Psalm many times a day, which seemed to help him relax.

When J.D.’s wife mentioned how much he missed their cat, I decided to try pet therapy. Unfortunately, the cat could not be brought into the unit, because J.D. contracted vancomycin-resistant enterococcus infection, which required that he be isolated temporarily.

The staff continued to think of diversions that might decrease J.D.’s anxiety. A staff member’s son, who had a back injury that required him to wear a brace similar to J.D.’s, visited to discuss how he coped with the brace. When I discovered that J.D. restored classic cars as a hobby, I brought photographs from a local classic car show and invited a friend of mine who also restores classic cars to visit.

I worked with the speech therapist to try a Passy Muir on the ventilator to improve communication. However, because of his anxiety and underlying lung disease, J.D. was not able to use it effectively. His love of computers led me to involve the speech therapy department in setting up a “talking computer,” which would repeat the words he typed. This created excitement when J.D. was able to communicate with his family and the staff through the computer.

Despite all this, J.D. was not able to wean from the ventilator. Our challenges were complicated further by his immobility, end-stage lung disease, urosepsis and nosocomial infections as well as J.D.’s and his wife’s opposition to long-term maintenance on the ventilator.

Many times, J.D. expressed ambivalence about staying on the ventilator vs. having treatment withdrawn. After numerous heartfelt discussions with J.D. and his wife, he decided to continue active care to become stronger and be able to wean from the ventilator.

Time passed and, with little or no improvement, the goals changed from short-term weaning to coming to grips with long-term ventilation. Although J.D. was ventilator dependent, he was hemodynamically stable, making it difficult to justify continuing the high intensity MICU care. J.D. and his wife adamantly opposed his entering a nursing home and wanted to pursue his care at home on a ventilator. At this point, the medical ethics committee was consulted.

Among the issues brought forth at the ethics conference was the feasibility of hospice care. Although J.D.’s life-span prognosis met hospice guidelines, his ventilator was a management barrier. We therefore investigated alternatives for home care. Other issues focused on safety and the need for high-level, 24-hour skilled nursing and respiratory care.

Who would provide the care? Would the family be able to assume responsibility for the majority of his care?

These concerns prompted lively discussions among the interdisciplinary team members. This was our first experience with sending a patient home on a ventilator and, because home care was at the other end of the spectrum from ICU nursing, our problem-solving approaches forced us to look outside our comfort zone as we broke new ground in developing a unique plan of care for J.D.

In preparing for J.D.’s discharge, the hospital team developed individual teaching sheets that contained clear objectives and criteria to help the family safely meet J.D.’s multiple needs. We worked with the physicians, home health team, ventilator company, respiratory department, occupational therapy, physical therapy, dietitian, speech therapy department, chaplain services, ethics committee, social services, psychiatric team, parish nurse and pharmacy service. Everyone went the extra mile.

To prepare for J.D.’s return home, his wife had a wall removed so that a hospital bed and equipment could be moved into J.D.’s living room. She also had a ramp built and the home was rewired to meet safety requirements for the medical equipment.

After four months of challenges, J.D. finally went home. One significant outcome that showed the commitment to his total care was that J.D. had developed no decubitus ulcers in spite of his paralysis, fragile skin and incontinence.

I am proud of the way that all the staff demonstrated creativity and expertise in addressing the complex needs of J.D. and his family. The staff listened to and respected J.D.’s wishes.

Some of us visited his home to reinforce teaching, answer questions, and provide support and reassurance. I cannot describe how I felt when I saw how peaceful J.D. was. It made all the risks worthwhile. Going home was the “best medicine” for J.D.

We stretched our “rubberbands” and extended our ICU to J.D.’s home. This was a wonderful opportunity for all of us to go outside the “box” and truly advocate for his wishes.

Working with J.D., his family, the interdisciplinary team, the community and numerous volunteers solidified my belief that people do make a difference—one life at a time.

Geriatric Corner: The Year in Review

In celebration of the United Nations’ International Year of Older Persons 1999

In September, the United Nations designated 1999 as the International Year of Older Persons. Caring for older patients can be challenging for any nurse. To celebrate the designation and ease these nursing challenges, the “Geriatric Corner” column was introduced to address facts, references, resources, helpful hints and Internet links related to the care of the older adult in acute or critical care units.

Your comments, e-mails and suggestions indicated this information was valuable and enhanced your practice. Although the United Nations’ International Year of Older Persons 1999 officially ends in September 1999, we will continue to publish useful, age-related information in the “Geriatric Corner” each month. If you have specific age-related practice questions you would like featured, contact AACN Clinical Practice Specialist, Justine Medina, RN, MS, at (800) 394-5995, ext. 401; fax, (949) 448-5520; e-mail, Justine.Medina@aacn.org. We would also love to hear about changes you might have made to your practice as a result of reading the “Geriatric Corner.”

Our participation in the Specialty Nursing Activities Partnership Program for Care of Older Adults (SNAPP) with the John A. Hartford Foundation-Institute for Geriatric Nursing is now linked under “Continuum of Care” in the “Practice” area of the AACN Web site at http://www.aacn.org. This partnership makes practice information, resources and up-to-date aging references easily accessible to AACN members, with a goal of promoting best practices in the care of the older adult.

All of the “Geriatric Corner” columns can be found in AACN News online. Simply search by keyword for “Geriatric Corner” from the AACN Web site and choose the issue you want.

Following are the topics covered:
• Internet Aging Resources (October 1998)
• Congestive Heart Failure in the Elderly (November 1998)
• Sleep (December 1998)
• Depression (January 1999)
• Accidental Hypothermia (February 1999)
• Decubitus/Pressure Ulcers (March 1999)
• Chronological vs. Biological Age (April 1999)
• Specialty Nursing Activities Partnership Program for Care of Older Adults (May 1999)
• Adverse Drug Reactions (June 1999)
• Alcohol Use and Abuse (July 1999)

Abstracts Invited for NTI 2000 in Orlando, Fla.

Research, research utilization and creative solutions abstracts are being accepted for the National Teaching Institute™ in 2000 in Orlando, Fla. Sept. 1, 1999, is the deadline to submit abstracts.

Up to three research abstract awards and one research utilization abstract award will be selected to receive the AACN Research Abstract Award, part of AACN’s Circle of Excellence recognition program.

This award recognizes research abstracts that display outstanding scientific merit and particular relevance to critical care nursing.

Award recipients receive $1000 toward NTI expenses.

Other abstract presenters receive a $75 reduction in registration to the NTI, which is scheduled for May 20 through 25.

To obtain abstract forms or for more information about Circle of Excellence grants and awards, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org and click on the “Research” area.

Vox Populi: Staffing and Patient Classification

How are periods of low census or overstaffing handled at your facility? Select all that apply.

Use mandatory time off 35.7%
Use voluntary time off 67.9%
Use the time to complete projects or committee work 38.6%
Float nurses to other areas 75.7%
Other 2.9%

What is the minimum staffing requirement for your unit when the census drops to 1 or 2 patients?

Two RNs 78.3%
One RN and one aide 1.7%
One RN and another licensed caregiver (e.g., LPN, MD, RT) 2.6%
One RN and another staff member (e.g., secretary, monitor technician, housekeeper) 7%
One RN who can access assistance via a notification system (e.g., call bell, intercom) 2.6%
No minimum standards 1.7%
Other 6.1%

Source: Volunteers in Participatory Sampling—a demographically representative sample of AACN members; 1998.

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