AACN News—December 1999—Practice

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Vol. 16, No. 12, DECEMBER 1999


Geriatric Corner: AACN Honored for Efforts to Promote Best Practices in Geriatric Nursing

AACN was selected as one of two recipients of the first Hartford Institute for Geriatric Nursing/Nursing Organization Liaison Forum (NOLF) Award, which was established to recognize organizations that demonstrate exemplary efforts in disseminating geriatric best practice information to their membership.

The award was accepted by AACN President Anne W. Wojner, RN, MSN, CCRN, during NOLF’s annual meeting in November 1999 in Washington, D.C. The award is part of the Hartford Institute Specialty Nursing Activities Partnership Program (SNAPP) for Care of Older Adults initiative, which was established more than a year ago.

AACN’s participation in the SNAPP program has provided AACN with additional informational resources, tools and support. In addition, the institute is linked directly to AACN’s Web site at http://www.aacn.org. Click on the "Practice Resource Network" under "Departments"; then "Clinical Practice Links" and "Continuum of Care." This partnership makes practice information, resources and up-to-date aging references readily available to AACN members in an effort to promote best practices in the care of older adults.

The Hartford Institute for Geriatric Nursing/Nursing Organization Liaison Forum (NOLF) Award will now be presented annually. Also honored in 1999 was the American Society of Ophthalmic Registered Nurses.
AACN will continue to provide age-related practice information in this monthly "Geriatric Corner" column. Is there a specific topic or concern that you would like featured? Contact AACN Clinical Practice Specialist Justine Medina, RN, MS, at (800) 394-5995, ext. 401; fax, (949) 448-5520; email, Justine.Medina@aacn.org with your suggestions. We would also like to hear about any changes that you made to your practice because of information presented in the “Geriatric Corner.”



Make a Difference, One Patient at a Time

The Starfish Flinger
As the old man walked the beach at dawn, he noticed a young man picking up starfish and flinging them into the sea. Catching up to the youth, he asked why he was doing this. The answer was that the stranded starfish would die if left until the morning sun. "But the beach goes on for miles and there are millions of starfish," countered the other. "How can your effort make any difference?" The young man looked at the starfish in his hand and threw it to safety in the waves.
"It makes a difference to this one," he said.
--Author Unknown


By Beth A. Glassford, RN, MS
Chairperson, Ethics Integration Work Group

The starfish story exemplifies the power that each of us has—the power of one. Each of us has the ability to make a difference.

As critical care nurses, we must consider our impact on the ethical decision making of our patients, families and fellow healthcare professionals. We must realize that we can make a difference, whether it be for the family we support in making the decision to remove a loved one from a ventilator or for the mother who decides to donate her young son’s organs. We are going to touch the lives of these people, and we can support them as they examine their values and make the toughest ethical decisions of their lives.

If just one critical care nurse today helps the starfish to safety, we can make a difference.

Conference Focuses on Nursing Research

More than 400 nurses, researchers and scholars attended the International Nursing Conference, titled "Better Health Through Nursing Research," in September 1999 in Washington, D.C.

AACN was among 21 nursing associations that sponsored the conference, which focused attention on the most critical and often controversial areas affecting health and patient care in the next century. Findings were presented at the conference on such areas as the nursing shortage, patient confidence in healthcare, fatigue in the adult, working population, eating disorders, and anger, hostility and moods in teenagers.

"We were very pleased to help sponsor this important conference," said Dorrie K. Fontaine, RN, DNSc, FAAN, associate dean at the Georgetown University School of Nursing, Washington, D.C., and a member of the AACN Board of Directors. "The research and papers presented are crucial to the well-being of patients and patient care in this country."

"We’re delighted that the American Association of Critical-Care Nurses has helped to host such an important gathering of nationally and internationally recognized nurse researchers and scholars," said William L. Holzemer, RN, PhD, FAAN, professor at the University of California-San Francisco and conference cochair. "These are critical times in healthcare. The new findings, once implemented, will help improve the quality of the healthcare patients receive."

Practice Resource Network: Frequently Asked Questions

QMy hospital is revising its policies and procedures. How do protocols, patient care guidelines and critical pathways differ?

AFollowing are a couple of resources that might help to define the differences more clearly, including an excerpt from the printed practice standards document that describes structured care methodologies. This is the most concise definition we have. The source is Outcomes Management by AACN President Anne W. Wojner, RN, MSN, CCRN, a module of the AACN clinical leadership program.

Another resource is the Agency for Health Care Policy and Research’s (AHCPR) Clinical Practice Guideline Development, which was an ACHPR program note in its Publication 93-0023 in 1993. This document provides the following nationally used definitions for protocols, guidelines, etc.:

Structured Care Methodology and Characteristics

Algorithm
--Useful in the management of high-risk subgroups within the cohort. May be “layered--on top of a pathway to highly control care practices that are used to manage a specific problem.
--Binary decision trees that guide stepwise assessment and intervention
--Intense specificity; no provider flexibility
--May use analytical research methods to measure cause and effect

Critical Pathway
--Represents a sequential, interdisciplinary, minimal practice standard for a specific patient population
--Provides flexibility to alter care to meet individualized patient needs
--Abbreviated format, broad perspective.
--Phase- or episode-driven
--Ability to measure cause-and-effect relationship between pathway and patient outcomes prohibited by lack of control; changes in patient outcome are directly attributable to the efforts of the collaborative practice team

Guideline
--Broad, research-based practice recommendations
--May or may not have been tested in clinical practice
--Practice resources helpful in the construction of structured-care methodologies
--No mechanism for assuring practice implementation

Order Set
--Preprinted provider orders used to expedite the order process, once a practice standard has been validated through analytical research
--Complements and increases compliance with existing practice standards
--Can be used to represent the algorithm or protocol in order format

Protocol
--Prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort
--Multifaceted; may be used to drive practice for more than one discipline
--Broader specificity than an algorithm; allows for minimal provider flexibility by way of treatment options
--May be “layered--on top of a pathway to control care practices that are used to manage a specific problem
--May use analytical research methods to measure cause and effect

If you have a practice question, call the Practice Resource Network at (800) 394-5995, ext. 217, or visit the Practice Resource Network--area under "Departments"--on the AACN Web site at http://www.aacn.org.

Survival Is Not the Only Measure of Impact

Debra Broach, RN, BSN, CCRN, CNRN, is a staff nurse in the neurological ICU at Clarian Health Methodist Hospital, Indianapolis, Ind. She received a 1999 Excellence in Clinical Practice Award. Following are excerpts from the exemplar that Broach 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 www.aacn.org and click on "awards-" under the "Departments" area.

By Debra Broach

Mr. C. had emigrated alone to the United States to build a better life for his wife and child, who he planned to send for later. However, while making a delivery for the restaurant he had established, he sustained a fractured femur and a severe head injury during an automobile crash.

He had been admitted to my neurological ICU during the night shift. A computed tomography of Mr. C.’s head showed a small subdural hematoma with some shift of intracranial contents, a skull fracture and probable shearing injury. However, the neurosurgeon did not consider him a candidate for surgery.

He was placed on a ventilator and an intracranial pressure (ICP) monitor was inserted. He required sedatives and vasopressors to maintain his cerebral perfusion pressures and vital signs. He was mostly unresponsive, lacked cerebral function and postured to pain only.

After receiving report, I accompanied Mr. C’s cousin and a friend to his room. Because the cousin spoke little English, the friend translated as I explained the purpose of each machine and described Mr. C.’s condition and treatments. The language barrier compounded an already distressing situation. When Mr. C.’s friend had to leave for work, I asked for the names of other interpreters who could be used throughout Mr. C.’s stay.

When I learned that Mr. C.’s wife and child were not in the country, I asked a social worker to evaluate the situation and what might be done to at least bring his wife to him.

Throughout the day, Mr. C.’s condition deteriorated. He became hyperthermic and more sensitive to suctioning and turning. I determined the optimal position for his head on the bed and planned his care to provide breaks between treatments. However, I could see that he was becoming less responsive to the treatments, because it took longer for his ICP levels to decrease. His ECG was now showing signs of ST-segment elevation, which suggested that he had also had a cardiac contusion.

When Mr. C.’s cousin returned, I called for the interpreter. I explained Mr. C.’s worsening condition and that comatose patients can be aware of their surroundings, and encouraged the cousin to talk to Mr. C. and touch him. I felt it was important that Mr. C. should not feel alone.

As Mr. C.’s condition continued to worsen, few options remained. When Mr. C.’s uncle and brothers arrived, I asked the interpreter, the neurosurgeon, the chaplain and the social worker to discuss the situation with the family. The social worker discussed ways in which Mr. C.’s wife could be brought to the United States quickly.

Later, one of Mr. C.’s brothers approached the bedside and, crying, with his hands in a praying position, he repeated the word “hallelujah.--I asked if he wanted to go to a place of worship, and he said he did. The unit secretary located one in the telephone directory.

When I left the shift, I was uncertain of Mr. C.’s outcome. Selfishly, I was saddened and angry that he was not responding to treatment. Replaying the day’s events in my mind, I wondered if I could have done more for him. Our team was providing excellent care. Although I knew that the odds were against him, I wanted my patient to improve, to provide a happy ending for his family and for me. However, as I lay awake that night, I was reminded that nurses must be willing to give their “all--to their patients and expect nothing in return.

During the night, Mr. C. developed diabetes insipidus and continued to develop worsening intracranial hypertension. He died the next day, without his wife at his side. There just had not been enough time.

I know that my colleagues and I did everything possible for this man. I know that, sometimes, our best efforts fail to achieve the results we desire. I believe that we, as nurses, give a piece of ourselves to our patients. Even though my patient did not survive, I know that I had an impact on his life. I gave him a chance to survive by giving him the best of myself, my knowledge and my skills.

Having that kind of impact as a nurse is an honor.

Grants Fund Research Related to Critical Care Nursing Practice

Following are nursing research grants for which application deadlines are approaching. For application materials, call (800) 899-AACN (2226) or visit the AACN Web site at www.aacn.org. Click on "Research" under the "Departments" area. For more information, call the AACN Practice and Research Department at (800) 809-2273.

Clinical Inquiry Grants
Funded by an anonymous donor, this grant awards up to $250 each for clinical research projects that will directly benefit patients or their families. Funds are awarded to projects that address one or more AACN research priorities and link with AACN’s vision.

The principal investigator must be an RN, a current AACN member, employed in a clinical setting and directly involved in patient care.

Applications must be received by Jan. 1, 2000.

Small Projects Grants

Sponsored by Medtronic/Physio-Control Corporation, this grant supports projects that focus on aspects of acute myocardial infarction and resuscitation. Up to $500 will be awarded to projects selected.

Eligible projects can include patient education; staff development or competency-based educational programs; continuous quality improvement or outcomes evaluations; and small research studies.

Applicants must be an active or affiliate member of AACN and not currently conducting another study funded by an AACN research grant.

Applications must be received by Jan. 15, 2000.

Critical Care Research Grant
This grant provides for one award of up to $15,000 to a nurse investigator who is actively involved in acute and critical care nursing practice. The study selected must be relevant to critical care nursing practice.

The principal investigator must be both an RN and a current AACN member. The proposed study may not be used to meet the requirements for an academic degree.

Proposals must be received by Feb. 1, 2000.

Mentorship Grant

Cosponsored by AACN and Mallinckrodt Inc., this grant awards up to $10,000 to a novice researcher to work with an experienced research mentor on a study that is relevant to critical care nursing practice.

The novice research applicant, who must be an RN and current member of AACN, should have only limited or no experience in the area proposed for investigation. The research funded may be used toward an academic degree.

The mentor must have research expertise in the area proposed for study by the novice researcher. The mentor cannot be designated as a mentor on another AACN mentorship grant for two consecutive years and cannot be conducting the research toward an academic degree.

Proposals for this grant must be received by Feb. 1, 2000.

AACN Certification Corporation Research Grant

These grants, funded by AACN Certification Corporation, provide up to $10,000 each for four studies related to certified practice. Examples of eligible projects are studies that focus on continued competency; the Synergy Model; the value of certification as it relates to patient care or nursing practice; and credentialing concepts. The proposed research may be used to meet the requirements of an academic degree.

Although AACN members are encouraged to apply for this grant, AACN membership is not required. However, if all other factors are equal, AACN member applications will be given preference.

Proposals must be received by Feb. 1, 2000.

AACN Data-Driven Clinical Practice Grant
This grant provides six awards of up to $1,000 each year for studies that stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute or critical care nursing practice.

The principal investigator must be both an RN and a current AACN member, and cannot be currently conducting a study funded by another AACN research grant. Proposed studies may be used to meet the requirements of an academic degree.

Applications must be received by March 1, 2000.

Point-of-Care Testing Has Positive Impact on Patient Care

Point-of-care testing has produced positive results at Baystate Medical Center, Springfield, Mass., where a formal program has been used in the 24-bed medical-surgical ICU since April 1997.


Coordinated by Karen K. Giuliano, RN, MSN, CCRN, ANP, the point-of-care testing system allows certain blood tests to be done at the bedside instead of having to send blood to the lab for testing. The system is now used in the operating room, ambulatory surgery, dialysis unit, ICU, neonatal ICU and cardiovascular ICU.

The results have been measured according to turn-around time, blood utilization and nursing satisfaction.

According to Giuliano, the turn-around time on stat orders has decreased from 27 minutes to four minutes when analyzing arterial blood gases, from 55 minutes to four minutes for hemoglobin and hematocrit, and from 60 minutes to four minutes for fluids and electrolytes.

In addition, the quantity of blood needed for testing has decreased dramatically, which has resulted in a corresponding decrease in the number of transfusions needed for medical patients, whose only source of blood loss had been due to phlebotomy.

Finally, nursing satisfaction with the new system when compared to the old system has markedly improved, Giuliano said.

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