AACN News—July 1999—Practice

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Vol. 16, No. 7, JULY 1999


Best Practice Network Advisory Board Looks to Future

Members of the Best Practice Network Advisory Board are (from left, front row) Mary Kingston, Ben Lutz, Joanne Krumberger, Marybeth Partington, Joan Shaver and Elizabeth Bridges, and (from left, back row) Elsie Nolan, Anne Santa-Donato, Judy Hartman, Stephanie Woods, Bill Peruzzi, Kris Hartigan, Christy Price, Laurie McNichol, Lenore Harris and Brenda Dawes. Members who are not pictured are Rita Munley Gallagher and Lisa Lund Fitzer.

Developing strategies for the year 2000 was the focus for the Best Practice Network Advisory Board when it met in April 1999 in Chicago, Ill.

The Best Practice Network began in 1996 with grassroots “summit” meetings between healthcare opinion leaders and leaders of more than 40 professional nursing associations. Today, 32 multidisciplinary association partners collaborate to provide resources and opportunities that foster the development of best practices to improve the health of patients and communities.

Each year, the associations that form the Network’s Circle of Vision send representatives to the advisory board meeting. AACN was instrumental in bringing the original partners together and continues to facilitate the work of the advisory board.

Key Meeting Highlights
Past AACN President Joanne Krumberger, RN, MSN, CCRN, who serves as advisory board facilitator, began the advisory board meeting by tracing the origins of the Best Practice Network and highlighting key developments. She articulated three key roles for the advisory board members: as fiduciaries, responsible for the finances of the Network; as liaisons with their own associations; and as ambassadors for other healthcare organizations.

Mary Kingston, RN, MN, Best Practice Network director, presented an overview of the Best Practice Network Web site. She highlighted the new sections, which are designed to encourage user participation. She also reported that Web site traffic has tripled in the last year.

In addition, Kingston shared results of user surveys showing that 75% rank the Web site as “very good” to “excellent” when compared with other sites. Users recommended development of additional activities on how to benchmark and find best practices, more news of healthcare innovations, and more sharing of best practices, articles and clinical protocols.

The Showcase for Innovation and Best Practices, a conference presented by the Best Practice Network in October 1998, was also discussed. The conference, which presented innovative concepts, benchmarking techniques and examples of best practices in a multidisciplinary context, received positive evaluations and comments by participants. Seeking to extend this type of learning experience to more professionals in diverse healthcare environments, a draft proposal was presented to include content related to best practices in each association partner’s annual national conference. This could either take the form of a preconference on best practices or a series of concurrent sessions. The proposal envisions that, by the year 2001 or 2002, these conference events would evolve into a fellowship program for cultivating best practices.

The Executive Summary Report provoked discussion on the best ways to finance the Best Practice Network in the future. Several options will be explored, including foundation or grant opportunities and the inclusion of corporate partners on the advisory board. A two- to four-year business plan will be developed, emphasizing sustainability and interorganizational collaboration. In the interim, a one-year transitional plan was approved.

Finally, the board reviewed the concepts expressed in the mission statement of the Best Practice Network, which were revised to better describe the current vision of the Network’s purpose. (See statement below)

The Impact for AACN
Advisory board members from each association indicated a strong belief that the Best Practice Network offers an innovative approach to meaningful healthcare transformation.

Noting that the pace of healthcare change will continue to accelerate, Krumberger said that innovative approaches for delivering high quality care will become even more important in achieving patient outcomes and organizational improvements.

“The Best Practice Network provides the forum for ‘real time’ access to innovative practices and an opportunity to dialogue about solutions to problems,” said Krumberger. “Quality will be what distinguishes the best healthcare systems and clinicians.”

A key value of the Network is the sharing of information, which leads to the development, dissemination and broad application of best practices. Former AACN Board Member Stephanie Woods, RN, PhD, CCRN, emphasized the leadership role of AACN members in this area.

“Strategically, there is a role for AACN members to lead in the generation of best practices in areas that are known to be high risk, high cost and low revenue,” she said. “That information could further validate the value of nursing, especially critical care nursing.”

AACN Treasurer Elsie Nolan, RN, MS, CS, added that AACN’s role is essential in cultivating best practices to assure that relevant clinical topics are addressed and measures are taken to find and disseminate best practices in critical care.

“As clinicians, we must scrutinize our practice, learn from others and integrate those best practices to improve care for our patients,” she said.

Participation Is the Key
At the heart of the Best Practice Network is the Web site, which offers a wide selection of activities and opportunities to learn more about what is working and what is not in healthcare today. Because of the participation of the association partners, the Best Practice Network Web site provides users the ability to connect with almost 1 million clinicians and specialty-focused professionals.

Each association partner has many members who are active in professional practice and who have demonstrated an interest in learning new, resource-efficient, improvement-oriented processes to share or incorporate into their practices. However, the continuing success and vitality of the Web site depends on the members of each partner association actively participating and sharing their expertise, successful programs and best practices.

A Message to AACN Members
AACN members not only have important information to offer their colleagues by participating in the Best Practice Network, but they also can learn something valuable to incorporate into their practice by visiting the Web site. You are encouraged to share your expertise and knowledge by submitting a best practice or program that is working well in your own practice environment. Every time you leave your footprints on the Web site, it becomes more relevant and content-rich.

This is an extraordinary opportunity to reshape healthcare and create a global learning center dedicated to best practices. Join us at and see why AACN has invested leadership talent and resources into creating this initiative.

For more information or to obtain a Best Practice Network Project Guide and Application Kit, contact Mary Kingston at (800) 809-2273, ext. 403; e-mail, mkingston@best4health.org.

The Mission

The Best Practice Network is a nonprofit, multidisciplinary consortium of healthcare professionals, healthcare associations, providers of healthcare products and services, and concerned consumers of healthcare services. It is dedicated to providing resources and opportunities that foster the development of best practices that improve the health of patients and communities while contributing to the development of efficient and robust healthcare systems. The Network is committed to creatively engaging healthcare professionals as essential participants in the process of healthcare improvement.
The Best Practice Network accomplishes this by:
• Showcasing healthcare innovations and best practices as models for improving and reshaping care delivery in local healthcare environments
• Providing educational resources and venues for the exchange of ideas and information about benchmarking and the development of best practices.
• Presenting challenging viewpoints and encouraging dialogue on current trends that are shaping healthcare.

• Providing Internet-based opportunities for Network participants from all regions, disciplines and professions to inspire each other, learn from each other and collaborate in the development and dissemination of best practices.
The broader vision of the Best Practice Network is that, by fulfilling its goals, it will contribute to the creation of an efficient and sustainable system of health and wellness, built on the best professional practices, that earns the trust and enhances the quality of life of patients and communities.

The Inner Voice Truly Makes a Difference

Editor’s note: Melissa A. Fulbright, RN, of Brownsburg, Ind., received a 1999 Excellence in Caring Practices Award, which is part of AACN’s Circle of Excellence recognition program. Fulbright is a critical care nurse in the medical-surgical ICU at Clarian Health Methodist Hospital, a level 1 trauma center in Indianapolis, Ind. Following are excerpts from the exemplar Fulbright submitted in connection with her award. 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 Melissa A. Fulbright

Dealing with life and death situations always seems easier when the patient is elderly and has lived a full life. It is never easy when the patient is young and just starting out in life.

My first experience in caring for a teenager will live in my memory forever.

At 19, Mark was transferred to my unit from an outlying hospital because of pulmonary complications. As I received report from the transferring nurse, my heart sank. Mark had been involved in a work-related forklift accident, which caused a C1 spinal fracture, leaving him a ventilator-dependent quadriplegic.

I was stunned when Mark greeted me with a huge smile as I entered his room. This teen, trapped motionless in a halo brace, with a tracheostomy and on a ventilator, spoke volumes with his bright eyes and cheerful smile. I was drawn by the warmth and spirit of hope in this room.

Over the next few days, Mark’s positive attitude motivated me to try to find ways to help him live as complete a life as possible. I was determined that Mark would be exposed to all the support and technology he needed to maximize his functionality so that he would not lose hope, as some quadriplegics do. He was also eager to try anything that might help his situation.

I enlisted the aid of his family. Mark’s mother and father were anxious to be involved in his care. In the first few weeks, we forged a strong bond as Mark endured multiple bronchoscopies for pulmonary complications. However, the daily chest x-rays showed little improvement. Soon, Mark began to feel depressed.

Over time, I learned that Mark had two young children and a fianc´┐Że. He had not seen them for several weeks. I worked with the unit management and Mark’s mother to arrange visits by his children, which made a tremendous difference in Mark’s mood.

Mark’s lungs finally showed signs of improvement, and we began to focus on normalizing his life. Mobility and communication were our primary targets. Our options were limited, because of the ventilator and Mark’s inability to use his hands. If he could speak, he would be able to communicate his needs and have a voice in his plan of care.

I collaborated with the pulmonologist and the respiratory therapist to explore options that would help Mark regain his voice. We finally found a special tracheostomy, which allowed Mark to talk by moving his head.

Once Mark was able to speak, I spent hours sitting and listening to him. Hearing him talk about how lucky he was to be alive renewed my desire to help him return to some kind of normal life. He told me he had not been outside since his accident three months earlier. Working again with the respiratory therapist, I was able to use a transport ventilator to take

Mark outside for almost 30 minutes. I am not sure who was more scared that first time, Mark or me. We made an outing part of our daily plan. With the help of another nurse and a respiratory therapist, we were able to arrange for Mark to join his family outside for a picnic and to watch fireworks on the Fourth of July.

When the time came for Mark to leave for rehabilitation, I knew he was scared. I worked with the care coordinator to prepare him and his family for the transition. We encouraged them to focus on what they had learned about his care and potential functionality. The day he left was exciting. We planned to stay in touch through visits and arranged for progress reports.

I was not prepared when Mark was readmitted to our unit with a vertebral artery bleed that had showered emboli and left him blind. My heart sank. Mark had lost three of his five senses.

Dismayed to see how depressed Mark was, I realized we had to act quickly to help him regain a more positive perspective about his situation. We checked his pupils hourly and, by the end of the third day, were encouraged to find that some of his sight was returning. However, he had also developed a space disorientation because of the bleed and felt as if he was falling and floating. I reassured him that he was not going to fall out of bed.

We used light sedation for several days to help Mark regain his sense of equilibrium. I spent numerous hours trying to help Mark’s parents cope with his hallucinations. When Mark regained his sight and the hallucinations stopped, our focus again shifted to returning him to rehabilitation.

However, because of negative experiences at the rehabilitation center, Mark’s parents were reluctant for him to go back. We struggled to find alternatives, but Mark’s parents finally decided they wanted to take him home. I worked with the care coordinator to develop a discharge plan that would be acceptable to everyone.

I provided Mark and his parents an outline of what they would need to know before Mark could be released. Although his parents had been somewhat involved in his care, they still had a lot to learn and I began to involve them in Mark’s care on a daily basis. I addressed basic issues of bathing, positioning and airway management. With the help of in-house resources, I tackled the more complex issues of nutrition, bowel and bladder control, infection control and ventilator management. To ensure that the teaching schedule would not be interrupted, I came to work on my days off.

One of Mark’s concerns was his sexuality, so I asked the physicians about the possibility of a suprapubic catheter, which was inserted shortly before he was discharged.

When the day arrived for his discharge, I encouraged Mark to remain active in his homecare decisions. A home health agency had been contracted to provide round-the-clock nursing care, and I encouraged him to continue to use his “voice” to communicate his likes and needs.

The care coordinator and I remained in contact with Mark and his parents, but on a more social than medical level as they became more comfortable with the home care staff.

This experience has given me a new perspective on nursing and my ability to meet patient needs. I learned first-hand about the benefits of being a strong patient advocate and helping the patient be in control of his care. Although technology can play a huge part in supporting a patient’s life, it is the inner “voice” that can truly make a difference for a meaningful outcome. The effort of helping Mark find his “voice” was repaid many times over.

New Standards for Practice Available Online

AACN’s recently revised “Standards for Acute and Critical Care Nursing Practice” are now available online on the AACN Web site at http://www.aacn.org. They can be viewed by clicking on the “Practice/PRN” area and then “Fact Sheets and Position Statements.”

The standards will be available in print later this year. Clinical practice tools in the form of definitions, explanations of the theoretical framework, implications for clinical practice, clinical practice scenarios and references will be included in the printed version.

The revisions to the 1989 “Standards for Nursing Care of the Critically Ill” were made after the AACN Board of Directors formed a Practice Standards Task Force in 1998. The task force evaluated each standard of care and standard of professional performance for relevance to and inclusion of acute and critical care nursing competencies.

The statements were revised to better articulate the professional expectations of competent acute and critical care nursing practice. In addition, the measurement criteria, which detail how nurses meet each standard, were evaluated and revised as necessary to reflect the unique aspects of acute and critical care nursing.

These “Standards for Acute and Critical Care Nursing Practice” also reflect the key concepts of the AACN Mission, Vision, Values, and Ethic of Care, scope of practice and Synergy Model.

Because clinical nursing practice can vary according to the setting in which the nurse is employed, the “Standards for Acute and Critical Care Nursing Practice” were developed to describe the practice of the nurse who cares for an acutely or critically ill patient, no matter where that patient is cared for within the healthcare environment.

Standards are defined as authoritative statements that describe a level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged. These standards are written to establish an example of the roles and responsibilities expected of the practitioner by the profession at large. Included are both standards of care, which prescribe a competent level of nursing practice, and standards of professional performance, which articulate the roles and behaviors expected of nursing professionals.

Practice Resource Network: Follow Protocols for PA Catheter Line and Site Care

Q:What are the latest evidence-based recommendations for pulmonary artery (PA) catheter line and site care?

A:The following recommendations are from the research-based protocol for practice titled Pulmonary Artery Pressure Monitoring, which was published by AACN in 1998.
PA catheters and introducers should be changed at least once every five days. Clinical studies in one or two different populations or situations (Level V) support this recommendation

The PA catheter insertion site should be changed if positive cultures (microbial infection or colonization) are obtained from the tip of a previous catheter specimen. Clinical studies in a variety of populations and situations (Level VI) support this recommendation.

PA hemodynamic flush systems (flush solutions, tubing, disposable transducer and stopcocks) should be changed every 72 hours. Clinical studies in one or two different populations or situations (Level V) support this recommendation.

Do not use antimicrobial ointment on PA catheter insertion sites. Use of polyantibiotic ointment without fungicidal properties may increase the rate of candida colonization. Clinical studies in one or two different populations or situations (Level V) support this recommendation.

More information about these and other practice recommendations is available in the Pulmonary Artery Pressure Monitoring protocol (Item # 170702) which is a part of the Protocols for Practice Series titled Hemodynamic Pressure Monitoring. This series contains a set of four protocols: Arterial Pressure Monitoring, Pulmonary Artery Pressure Monitoring, SvO2 Monitoring and Cardiac Output Monitoring.

The protocols are excellent resources for updating your hospital’s policy and procedures. Each protocol contains practice recommendations along with levels of evidence, annotated bibliography articles and an extensive reference list. In addition, each protocol contains information regarding the technology, accuracy and precision, related occupational hazards, ethical considerations and competency considerations.

Protocols are available for continuing education credit (AACN, category A). Individual protocols are $11 for AACN members ($14 nonmembers), plus shipping and handling. The Hemodynamic Monitoring Series (Item #170700) with binder is $42 for AACN members ($54 nonmembers), plus shipping and handling. To order, call (800) 899-AACN (2226), or visit the AACN Online bookstore at http://www.aacn.org.

Other Protocols for Practice are Care of the Mechanically Ventilated Patient, Creating a Healing Environment and Noninvasive Monitoring.

Research Conference Set for September, 1999

Better Health Through Nursing Research,” is the theme for the National Nursing Research Conference, scheduled for Sept. 15 through 18, 1999, in Washington, D.C. The State of the Science Congress is cosponsored by AACN and 18 other nursing organizations. Additional information on the congress as well as a registration form are available online at http://www.nursingworld.org/aan/nnrc.htm.

Geriatric Corner: Just a Little Brandy at Bedtime

The prevalence of alcohol abuse in older adults is estimated to be about 5%, but may be considerably higher among elderly patients.

Numerous factors, including stereotypes of alcoholics and the aged, conspire to make this disease difficult to detect in older persons. Concern about alcohol consumption in the elderly relates not to changing patterns of use, demographics or society, but to physiologic changes that accompany aging and pose problems if alcohol is consumed regularly.

Given the relatively complete absorption of alcohol, the smaller volume of distribution and increased organ dysfunction, older adults who drink alcohol regularly are subject to more toxic effects.

Secondary Physical and Psychiatric Problems
• Malnutrition may result from chronic alcohol use, especially in heavy drinkers.
• Cirrhosis is one of the eight leading causes of death in the over-65 population.
• Osteomalacia may develop in the chronic alcoholic, because of decreased Vitamin D metabolism due to compromised hepatic function.
• Cardiomyopathies and atropic gastritis can develop from long-term alcohol use.
• Decline in cognitive status may be the most frequent and serious problem. Chronic alcohol abuse may lead to a decline in memory and information processing, though intelligence may remain relatively unaffected.

An addiction and tolerance potential is high, due to the relatively “quiet” use of alcohol over many years that desensitizes the individual and his or her family to these problems. The addiction may not be realized until the person is in a setting where alcohol is not readily available.

The Role of the Critical Care Nurse
Evaluation for alcohol use problems should accompany history and evaluation of an older person with functional impairment, seizures, falls, cognitive impairment, depression, anxiety, insomnia and adverse reactions to medications.

Initial questions should include what kind of alcohol is consumed and how often the patient drinks (i.e., continually or in binges). While tolerance for binges decreases with age, guilt or concern about drinking becomes less common, and the patient may not recognize a connection between new symptoms and decades of alcohol consumption.

Assessment Tools
Among the brief measures of alcohol abuse are the four-item CAGE, the 10-item AUDIT, and the 24-item MAST-G. Of these assessment tools, the CAGE can be easily committed to memory:
• Has the patient ever felt the need to Cut down on drinking?
• Has the patient ever felt Annoyed by criticism of his or her drinking?
• Has the patient ever felt Guilty about drinking?
• Has the patient ever taken a morning drink (Eye-opener)?

Two affirmative answers to the CAGE questions are said to be suggestive of alcoholism. The other two tools are more specific and more sensitive, especially to items about amount consumed and problems related to alcohol consumption.

The secondary problems and potential interactions with other agents, especially benzodiazepines, may lead the older patient to central nervous system depression and are a major clinical concern. By the time a clinician suspects chronic alcohol use, the patient may already be exhibiting increased anxiety, agitation, sleep problems, nausea, weakness and cognitive changes.

When alcohol use has been determined to be a contributing factor, detoxifying the older patient may be planned using laboratory data and then tailoring the treatment accordingly.

Over the last year, this column has looked at many specific problems. We hope that you now have a better understanding that one of the distinguishing characteristics of caring for your older patients is that there is a prominence of certain recurring clinical problems that can originate in various ways. We hope that you have learned new ways to help in caring for those critically ill older adults.

The United Nations’ International Year of Older Persons will officially end in September 1999. For more information, contact AACN Clinical Practice Specialist, Justine Medina, RN, MS, CCRN, at (800) 394-5995, ext. 401; fax (949) 448-5520; e-mail: Justine.Medina@aacn.org.

Suggested Reading
1. Brody JA. Aging and alcohol abuse. J Am Geriatr Soc.
1982; 30:123-126.
2. Widner S, Zeichner A. Alcohol abuse in the elderly:
review of epidemiology, research, and treatment. Clin
Gerontol. 1991; 11:3-18.
3. Curtis JR, Geller G, Stokes EJ, Levine DM, Moore RD.
Characteristics, diagnosis, and treatment of alcoholism in
elderly patients. J Am Geriatr Soc. 1989;37:310-31.
4. Mayfield DG, McLeod G, Hall P. The CAGE
questionnaire: validation of a new alcoholism screening
instrument. Am J Psychiatry. 1974;131:1121-1123.
5. Ewing JA. Detecting alcoholism: the CAGE
questionnaire. JAMA 1984;252:1905-1907.
6. US Department of Health and Human Services.
Screening and brief intervention. In: Eighth Special
Report to the U.S. Congress on Alcohol and Health from
the Secretary of Health and Human Services. September
1993. Washington, DC: US Department of Health and
Human Services, Publication Health Service, National
Institutes of Health, National Institute on Alcohol Abuse

and Alcoholism, 1993:297-317.
7. Babor TF, Grant M. From clinical research to secondary
prevention: international collaboration in the develop-
ment of the Alcohol Use Disorders Identification Test
(AUDIT). Alcohol Health Res World. 1989; 13:371-374.
8. Blow FC, Brower KJ, Schulenberg JE, Demo-Dananberg
LM, Young JS, Beresford TP. The Michigan Alcoholism
Screening Test-Geriatric Version (MAST-G); a new
elderly-specific screening instrument. Alcohol Clin Exper
Res. 1992; 16:372.
9. Beresford TP. Alcoholism in the elderly. Int Rev
Psychiatry. 1993;5:477-483.
10. Bressler R, Katz MD. (1993). Geriatric Pharmacology.
New York, NY: McGraw-Hill, Inc. 1993.
11. Gallo JJ, Reichel W, Andersen, LM. Handbook of
Geriatric Assessment. Gaithersburg, MD. 1995. Aspen
Publishers, Inc.
12. Abrams WB, Beers MH, Berkow R (Eds). The Merck
Manual of Geriatrics, 2nd edition. Whitehouse Station,
NJ: Merck & Co. Inc; 1995.

Sept. 1, 1999, Deadline to Submit NTI Research and Creative Solutions Abstracts for 2000

Sept. 1, 1999, is the deadline to submit research, research utilization and creative solutions abstracts for the National Teaching Institute,™ scheduled for May 20 through 25, 2000, in Orlando, Fla.

Abstract presenters receive a $75 reduction in NTI registration fees.

In addition, 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.

Following is information about the abstracts that will be accepted:

Research and Research Utilization
These abstracts can focus on any aspect of critical care nursing research including reports of research studies or reports of research utilization. Only abstracts of completed projects will be accepted.

Abstracts reporting research studies must address the purpose; background and significance; methods; results; and conclusions.

Accepted abstracts will be designated either as an oral presentation or as a poster presentation.

Creative Solutions
These abstracts focus on specific strategies and practice innovations that are used by nurses to solve difficult, unique or interesting problems in patient care, nursing practice, nursing management, or nursing education. The creative solution must have been implemented, with outcomes evaluated.

Abstracts must address the purpose of the project and description of the creative solution, as well as evaluation and outcomes.

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.

Infolink

Do you have or would you be interested in helping put together a pamphlet on cerebral aneurysms for patients’ families. I would like to include information about what families can expect in the ICU setting.
Contact Marcia A. DePolo, RN, CCRN, CNRN, TNCC, ONC, 5301 Rolling Road, Springfield, VA 22151; phone, (703) 978-7410.

Does your facility have a protocol or guideline for the removal of pulmonary artery catheters by staff RNs? I am also interested in finding out what other institutions are doing in regard to training and validating competency.
Contact Anne Mitchell, (619) 532-9072; fax, (619) 532-9091.

We are developing a policy/procedure for nurses inserting enteral feeding tubes with a stylet. Do you have a policy or procedure you could share? Are nurses certified to perform this procedure? If so, how?
Contact Aneta Helmer, RN, BSN, CCRN, Good Samaritan Hospital, 375 Dixmyth Ave., 7AB M/SICU, Cincinnati, Ohio 45220; phone, (513) 872-2697; fax, (513) 872-4997.

I am requesting information about establishing a weight- and age-based heparin protocol for AMI (acute myocardial infarction) patients. Our current heparin protocol is based strictly on PTT (partial thromboplastin time) levels at periodic intervals, which poses a problem for obtaining and maintaining therapeutic levels, especially for very small, large or elderly patients.
Contact
MNibert@aol.com.

Do you give the calcium channel blocker Cardene only intravenously via a central catheter? If given peripherally, do you have a policy in place that requires changing peripheral sites every 12 to 24 hours to avoid vein irritation?
Contact Marylyn Kajs-Wyllie, RN, MSN, CCRN, Neuroscience Clinical Nurse Specialist, P.O. Box 4039, St. David’s Healthcare Partnership, Austin, TX 78765-4039; phone, (512) 407-4313; e-mail,
kajswylliemr@columbia.net.