AACN News—August 2000—Practice

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Vol. 17, No. 8, AUGUST 2000


Circle of Excellence: AACN Multidisciplinary Team Award


The AACN Multidisciplinary Team Award is part of the AACN Circle of Excellence recognition program. Up to three awards are given each year, with $2,500 earmarked to fund projects. In addition, individual recipients are recognized publicly and presented a personalized plaque. Following are excerpts from exemplars submitted by recipients of the awards for 2000:

Surgical Trauma ICU
Mission Hospital Regional Medical Center
Mission Viejo, Calif.


In June 1997, the trauma team at Mission Hospital Regional Medical Center was challenged to examine the care being provided to the critical neurotrauma population.
Although Mission has been a designated trauma center in Orange County, Calif., since 1980, the surgical-trauma ICU team members acknowledged that current practices differed from the AANS Severe Traumatic Brain Injury Guidelines published in late 1995.

A multidisciplinary team established an ambitious process that was designed to translate the new scientific guidelines into clinical practice. A retrospective chart review of severe TBI patients with Glasgow Coma Scale (GCS) between 3-8 in the previous three-and-a-half years revealed that 26% had a good outcome to moderate disability (GCS 4-5); 30% had severe disability to persistent vegetative state (GCS 2-3); and 43% died (GCS 1).

Following the initial review, a task force compared current practice against proposed changes and developed new hospital-based clinical guidelines. Every aspect of caring for the severe TBI patient—from admission through rehabilitation—was examined. The result was a series of algorithms with established outcomes at every phase of the patient’s hospital course.

Nearly every aspect of care during the ICU phase has changed. The surgical ICU nurses, physicians, pharmacists and respiratory therapists now share congruent goals and maintain regular communication. Chaplains and social workers bring an added dimension by providing for the spiritual, emotional and psychosocial needs of the patients and their families. Keeping the team abreast of each patient’s progress during the weekly trauma rehabilitation rounds ensures the patient’s transition to the surgical and acute rehabilitation units.

Two years after integrating the changes in practice, the team evaluated prospectively collected data to determine outcomes for the severe TBI population. The results were that 70% had a good outcome to moderate disability (GCS 4-5); 15% had severe disability to persistent vegetative state (GCS 2-3); and 15% died (GCS 1).

These outcomes confirmed to the team that the changes in practice and intense cooperation make a difference for their patients. The team has evolved and become synergistic with each patient and family.

Heart Failure Quality Support Team
University of Virginia Health System
Charlottesville, Va.

The Heart Failure Quality Support Team (QST) at the University of Virginia Health System first convened in January 1997. Over the last three years, the multidisciplinary team organized and conducted multiple projects aimed at improving the care of patients with heart failure in the inpatient and outpatient settings.

In the acute and critical care settings, the QST focused on the clinical management of patients and staff education. The development of a clinical pathway and guidelines for the use of IV inotropes resulted in more consistent and cost effective care. Since implementation of the pathway, the average length of stay has decreased, total costs have declined, weights are obtained daily, and the use of ACE inhibitors in appropriate patients is 100%.

The QST focused on several projects to improve patient and staff education. Education of staff has included review of pathophysiology, pharmacological management and sessions on physical assessment using a mannequin with simulated heart sounds. The QST also participated in a research study that evaluated a method for patient education. The patient education materials were revised based on the results of the study. Education extends beyond hospitalized patients and the QST offers public programs about heart failure. Recently the QST developed an article for the local newspaper on heart failure.

Because many patients with heart failure receive home health services, the QST developed an outpatient pathway for them. In addition to the home health pathway, the QST conducted a research study to compare patients receiving no home health services to those receiving home health services for nine weeks and 24 weeks.

In summary, the work of the QST illustrates the importance of converging various healthcare providers to achieve comprehensive outcomes. The work of this multidisciplinary team represents a sustained and inclusive approach with accomplishments ranging from inpatient, to home health, to outpatient and community settings.


Children’s Services Bereavement Group
Charleston Area Medical Center-Women and Children’s Hospital
Charleston, W. Va.
This project was born out of the knowledge that better support for grieving families was needed in our pediatric ICU, as well as the close relationship we had with several parents of chronically ill children.

We began by benchmarking for the latest information about bereavement programs, and meeting with other nurses. We also surveyed the general staff’s perceptions of the bereavement process. After the information was compiled, a committee was formed to decide what our institution needed. From these beginnings, we established a program that includes some of the following features:

• Hand/footprint kits that are available in all units for parents, and at times grandparents, of a dying child.
• Memory boxes that are put together for families. In addition to containing a lock of hair, arm bracelet or other mementos the families desire, a special verse card and a
pebble” with a butterfly imprint are provided.
• Parents are given information packets that include a list of available resources, as well as reading materials.
• Cards of sympathy that are sent to the parents of a child who has died. In addition, “thinking of you” cards are sent at special times during the first year after a child’s death.
• Memory trees, bearing cards stating that we hope their “memories grow with this tree” are presented to parents.

The program has attracted broad support. A memory walk and a park memorial, where parents can have the name and the date of their child’s death inscribed, were planned as a result of our efforts. Some families ask that donations be sent to the group in their child’s name, in lieu of flowers.

The deadline to submit nominations for this and other Circle of Excellence awards for 2001 is Sept. 1, 2000. For more information, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org. Click on “Awards.”

Application Deadlines Near for Nursing Research Grants

Several grants to support research relevant to critical care nursing practice are available from AACN. The deadlines to submit proposals for some of these grants are approaching. Following is information about these grants:

Agilent Technologies-AACN Critical Care Nursing Research Grant

Cosponsored by Agilent Technologies and AACN, this grant supports research conducted by a critical care nurse.

The total award of $35,000 includes $33,000 for research and $2,000 for travel expenses associated with presentations of the study findings. The recipient may use up to $3,000 of the research award to purchase a personal computer, utility software and printer to support the study. Computer-related expenses should be included and justified in the project budget.

The grant is intended to support a well-defined, well-described research project. The award selection will be based upon the scientific merit of the project; scientific and professional background of the applicant; adequacy of facilities and resources available for the research; originality; and potential benefits to the care of critically ill patients.

The preferred topic for this grant is the information technology requirements of patient management in critical care. Because this grant is intended to support research that has direct clinical application to critical care nursing practice, proposals for basic science or animal studies are not eligible. Reviewers’ comments will not be provided to applicants.

To be eligible, the applicant must be both an RN and an active AACN member. The grant can be used to fund research associated with an academic degree.
Proposals must be received by Sept. 1, 2000.

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

Funds are available for new projects, projects in progress or projects required for an academic degree as long as all other project criteria are met. Collaborative projects involving interdisciplinary teams, multiple nursing units, home health, subacute and transitional care, other institutions or community agencies are encouraged.

To qualify for an AACN Data-Driven Clinical Practice Grant, the principal investigator must be a regular or affiliate member of AACN and not currently conducting a study funded by an AACN research grant

Applications must be received by Oct. 1, 2000.

AACN Clinical Practice Grant
This $6000 grant supports research that focuses on at least one of AACN’s clinical research priorities.

The principal investigator must be both an RN and a current member of AACN. Research conducted in fulfillment of an academic degree is acceptable.

Proposals must be received by Oct. 1, 2000.

AACN-Sigma Theta Tau Critical Care Grant

This $10,000 grant, which is cosponsored by AACN and Sigma Theta Tau International, funds research that is relevant to critical care nursing practice.

The principal investigator must be an RN. The proposed study may be used to meet requirements of an academic degree.

Proposals must be received by Oct. 1, 2000.

To obtain application materials and instructions, call (800) 899-AACN (2226), or visit the “Research” section of the AACN Web site at http://www.aacn.org.

Geriatric Corner: Try This: Best Practices in Nursing Care of Older Adults

More than a year ago, the John A. Hartford Foundation Institute for Geriatric Nursing established the Specialty Nursing Activities Partnership Program (SNAPP) for Care of Older Adults. This collaboration is part of an effort to promote best practices in the care of the older adult and to share resources with nurses who care for acute and critically ill older adults.

Following is a tool from the January posting of the Try This: Best Practices in Nursing Care to Older Adult series, which appears monthly on the institute’s Web site at http://www.nyu.edu/education/nursing/hartford.institute. The site can also be accessed through the AACN Web site at www.aacn.org. Click on “Practice Resources,” then “Clinical Practice Links,” “Gerontology” and “John Hartford Foundation Institute for Geriatric Nursing.”

Assessing Pain in Older Adults
By Ellen Flahaerty, RN, MSN, GNP
Why: Studies on pain in older adults (65 years of age or older) have demonstrated that 25 to 45% of older people who live in a community setting have chronic pain. Between 45 and 85% of nursing home residents also report pain that is often left untreated. Although research strictly focusing on pain in older adults is minimal, studies involving younger participants have illustrated associations between pain and depression. In addition, increased pain has resulted in decreased socialization, impaired ambulation and increased healthcare utilization and costs. Because older adults are reluctant to report pain, nurses must be proactive in screening and assessing pain.

Best Tool: No objective measure or biological marker of pain exists. Simply worded questions and tools that can be easily understood are the most effective, because older adults frequently encounter numerous factors, including sensory deficits and cognitive impairment. Subjective tools such as the Faces Pain Scale (Figure 1) and the Visual Analogue Scales (VAS) (Figure 2) are highly effective in assessing pain in older adults. The VAS is a straight, horizontal 100mm line, which is anchored with “no pain” on the left and “worst possible pain” or “pain as bad as it could possibly be” on the right. Older adults are asked to choose a position on the line that represents their pain. The Faces Pain Scale depicts facial expressions on a scale of 0-6, where 0=smile and 6=crying grimace. The patients are asked to choose a face that represents how the pain makes them feel.

Target Population: Both the VAS and Faces Pain Scale are used with older adults. Studies have shown that 86% of nursing home residents could complete at least one of these pain scales. These pain scales could also easily be used with patients who, for example, are unable to speak because of endotracheal intubation.
Reliability and Validity: Studies comparing simple pain intensity measures have demonstrated high reliability and validity using the VAS and Faces Pain Scale with older adults.

Strengths and Limitations: These simple, yet effective pain assessment tools are easy to administer and provide a method to evaluate not only the presence of pain, but also the effectiveness of treatment. However, these assessment tools should not replace extensive medical history-taking and physical exams, which may lead to the determination of etiologies of pain.

Suggested Reading
American Geriatrics Society. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons. Am Geriatr Soc. 1998; 46:635-651.
Closs SJ. Pain and elderly patients: A survey of nurses’ knowledge and experiences. Adv Nurs. 1996; 23:237-242.
Herr KA, Mobility PR. Comparison of selected pain assessment tools for use with the elderly. Appl Nurs Res. 1993:6:39-46.

Do you have an age-related care story or idea? AACN wants to provide a vehicle for the sharing of information that can enhance practice for all members who provide care to the older population. Send information to AACN Clinical Practice Specialist, Justine Medina, RN, MS, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 448-5520; e-mail, Justine.Medina@aacn.org, or call (800) 394-5995, ext. 401.

Submit NTI Abstracts by Sept. 1, 2000

Sept. 1, 2000, is the deadline to submit applications research and research utilization abstracts or creative solutions abstracts for presentation at AACN’s National Teaching Institute and Critical Care Exposition in 2001 in Anaheim, Calif.

Presenters of selected abstracts receive a $75 reduction in NTI registration fees. All other expenses are the responsibility of the presenter, who can be either the first author or a designate of the author.

NTI 2001 is scheduled for May 19 through 24.

To obtain abstract forms, call (800) 899-AACN (2226), or visit the research area of the AACN Web site at http://www.aacn.org.

Vox Populi: Online Quick Poll

Are you currently pursuing, or do you intend to pursue further education?

Yes 77%
No 15%
Don’t Know 8%

Number of Responses: 1,891

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. Participate by visiting the AACN Web site at http://www.aacn.org.

Circle of Excellence: AACN Multidisciplinary Team Award

The AACN Multidisciplinary Team Award is part of the AACN Circle of Excellence recognition program. Up to three awards are given each year, with $2,500 earmarked to fund projects. In addition, individual recipients are recognized publicly and presented a personalized plaque. Following are excerpts from exemplars submitted by recipients of the awards for 2000:

Surgical Trauma ICU
Mission Hospital Regional Medical Center
Mission Viejo, Calif.
In June 1997, the trauma team at Mission Hospital Regional Medical Center was challenged to examine the care being provided to the critical neurotrauma population.
Although Mission has been a designated trauma center in Orange County, Calif., since 1980, the surgical-trauma ICU team members acknowledged that current practices differed from the AANS Severe Traumatic Brain Injury Guidelines published in late 1995.

A multidisciplinary team established an ambitious process that was designed to translate the new scientific guidelines into clinical practice. A retrospective chart review of severe TBI patients with Glasgow Coma Scale (GCS) between 3-8 in the previous three-and-a-half years revealed that 26% had a good outcome to moderate disability (GCS 4-5); 30% had severe disability to persistent vegetative state (GCS 2-3); and 43% died (GCS 1).

Following the initial review, a task force compared current practice against proposed changes and developed new hospital-based clinical guidelines. Every aspect of caring for the severe TBI patient—from admission through rehabilitation—was examined. The result was a series of algorithms with established outcomes at every phase of the patient’s hospital course.

Nearly every aspect of care during the ICU phase has changed. The surgical ICU nurses, physicians, pharmacists and respiratory therapists now share congruent goals and maintain regular communication. Chaplains and social workers bring an added dimension by providing for the spiritual, emotional and psychosocial needs of the patients and their families. Keeping the team abreast of each patient’s progress during the weekly trauma rehabilitation rounds ensures the patient’s transition to the surgical and acute rehabilitation units.

Two years after integrating the changes in practice, the team evaluated prospectively collected data to determine outcomes for the severe TBI population. The results were that 70% had a good outcome to moderate disability (GCS 4-5); 15% had severe disability to persistent vegetative state (GCS 2-3); and 15% died (GCS 1).
These outcomes confirmed to the team that the changes in practice and intense cooperation make a difference for their patients. The team has evolved and become synergistic with each patient and family.

Heart Failure Quality Support Team
University of Virginia Health System
Charlottesville, Va.
The Heart Failure Quality Support Team (QST) at the University of Virginia Health System first convened in January 1997. Over the last three years, the multidisciplinary team organized and conducted multiple projects aimed at improving the care of patients with heart failure in the inpatient and outpatient settings.

In the acute and critical care settings, the QST focused on the clinical management of patients and staff education. The development of a clinical pathway and guidelines for the use of IV inotropes resulted in more consistent and cost effective care. Since implementation of the pathway, the average length of stay has decreased, total costs have declined, weights are obtained daily, and the use of ACE inhibitors in appropriate patients is 100%.

The QST focused on several projects to improve patient and staff education. Education of staff has included review of pathophysiology, pharmacological management and sessions on physical assessment using a mannequin with simulated heart sounds. The QST also participated in a research study that evaluated a method for patient education. The patient education materials were revised based on the results of the study. Education extends beyond hospitalized patients and the QST offers public programs about heart failure. Recently the QST developed an article for the local newspaper on heart failure.

Because many patients with heart failure receive home health services, the QST developed an outpatient pathway for them. In addition to the home health pathway, the QST conducted a research study to compare patients receiving no home health services to those receiving home health services for nine weeks and 24 weeks.

In summary, the work of the QST illustrates the importance of converging various healthcare providers to achieve comprehensive outcomes. The work of this multidisciplinary team represents a sustained and inclusive approach with accomplishments ranging from inpatient, to home health, to outpatient and community settings.

Children’s Services Bereavement Group
Charleston Area Medical Center-Women and Children’s Hospital
Charleston, W. Va.
This project was born out of the knowledge that better support for grieving families was needed in our pediatric ICU, as well as the close relationship we had with several parents of chronically ill children.

We began by benchmarking for the latest information about bereavement programs, and meeting with other nurses. We also surveyed the general staff’s perceptions of the bereavement process. After the information was compiled, a committee was formed to decide what our institution needed. From these beginnings, we established a program that includes some of the following features:

• Hand/footprint kits that are available in all units for parents, and at times grandparents, of a dying child.
• Memory boxes that are put together for families. In addition to containing a lock of hair, arm bracelet or other mementos the families desire, a special verse card and a
pebble” with a butterfly imprint are provided.
• Parents are given information packets that include a list of available resources, as well as reading materials.
• Cards of sympathy that are sent to the parents of a child who has died. In addition, “thinking of you” cards are sent at special times during the first year after a child’s death.
• Memory trees, bearing cards stating that we hope their “memories grow with this tree” are presented to parents.

The program has attracted broad support. A memory walk and a park memorial, where parents can have the name and the date of their child’s death inscribed, were planned as a result of our efforts. Some families ask that donations be sent to the group in their child’s name, in lieu of flowers.

The deadline to submit nominations for this and other Circle of Excellence awards for 2001 is Sept. 1, 2000. For more information, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org. Click on “Awards.”

Application Deadlines Near for Nursing Research Grants

Several grants to support research relevant to critical care nursing practice are available from AACN. The deadlines to submit proposals for some of these grants are approaching. Following is information about these grants:

Agilent Technologies-AACN Critical Care Nursing Research Grant

Cosponsored by Agilent Technologies and AACN, this grant supports research conducted by a critical care nurse.

The total award of $35,000 includes $33,000 for research and $2,000 for travel expenses associated with presentations of the study findings. The recipient may use up to $3,000 of the research award to purchase a personal computer, utility software and printer to support the study. Computer-related expenses should be included and justified in the project budget.

The grant is intended to support a well-defined, well-described research project. The award selection will be based upon the scientific merit of the project; scientific and professional background of the applicant; adequacy of facilities and resources available for the research; originality; and potential benefits to the care of critically ill patients.

The preferred topic for this grant is the information technology requirements of patient management in critical care. Because this grant is intended to support research that has direct clinical application to critical care nursing practice, proposals for basic science or animal studies are not eligible. Reviewers’ comments will not be provided to applicants.

To be eligible, the applicant must be both an RN and an active AACN member. The grant can be used to fund research associated with an academic degree.
Proposals must be received by Sept. 1, 2000.

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

Funds are available for new projects, projects in progress or projects required for an academic degree as long as all other project criteria are met. Collaborative projects involving interdisciplinary teams, multiple nursing units, home health, subacute and transitional care, other institutions or community agencies are encouraged.

To qualify for an AACN Data-Driven Clinical Practice Grant, the principal investigator must be a regular or affiliate member of AACN and not currently conducting a study funded by an AACN research grant

Applications must be received by Oct. 1, 2000.

AACN Clinical Practice Grant
This $6000 grant supports research that focuses on at least one of AACN’s clinical research priorities.

The principal investigator must be both an RN and a current member of AACN. Research conducted in fulfillment of an academic degree is acceptable.

Proposals must be received by Oct. 1, 2000.

AACN-Sigma Theta Tau Critical Care Grant

This $10,000 grant, which is cosponsored by AACN and Sigma Theta Tau International, funds research that is relevant to critical care nursing practice.

The principal investigator must be an RN. The proposed study may be used to meet requirements of an academic degree.

Proposals must be received by Oct. 1, 2000.

To obtain application materials and instructions, call (800) 899-AACN (2226), or visit the “Research” section of the AACN Web site at http://www.aacn.org.

Geriatric Corner: Try This: Best Practices in Nursing Care of Older Adults

More than a year ago, the John A. Hartford Foundation Institute for Geriatric Nursing established the Specialty Nursing Activities Partnership Program (SNAPP) for Care of Older Adults. This collaboration is part of an effort to promote best practices in the care of the older adult and to share resources with nurses who care for acute and critically ill older adults.

Following is a tool from the January posting of the Try This: Best Practices in Nursing Care to Older Adult series, which appears monthly on the institute’s Web site at http://www.nyu.edu/education/nursing/hartford.institute. The site can also be accessed through the AACN Web site at www.aacn.org. Click on “Practice Resources,” then “Clinical Practice Links,” “Gerontology” and “John Hartford Foundation Institute for Geriatric Nursing.”

Assessing Pain in Older Adults
By Ellen Flahaerty, RN, MSN, GNP
Why: Studies on pain in older adults (65 years of age or older) have demonstrated that 25 to 45% of older people who live in a community setting have chronic pain. Between 45 and 85% of nursing home residents also report pain that is often left untreated. Although research strictly focusing on pain in older adults is minimal, studies involving younger participants have illustrated associations between pain and depression. In addition, increased pain has resulted in decreased socialization, impaired ambulation and increased healthcare utilization and costs. Because older adults are reluctant to report pain, nurses must be proactive in screening and assessing pain.

Best Tool: No objective measure or biological marker of pain exists. Simply worded questions and tools that can be easily understood are the most effective, because older adults frequently encounter numerous factors, including sensory deficits and cognitive impairment. Subjective tools such as the Faces Pain Scale (Figure 1) and the Visual Analogue Scales (VAS) (Figure 2) are highly effective in assessing pain in older adults. The VAS is a straight, horizontal 100mm line, which is anchored with “no pain” on the left and “worst possible pain” or “pain as bad as it could possibly be” on the right. Older adults are asked to choose a position on the line that represents their pain. The Faces Pain Scale depicts facial expressions on a scale of 0-6, where 0=smile and 6=crying grimace. The patients are asked to choose a face that represents how the pain makes them feel.

Target Population: Both the VAS and Faces Pain Scale are used with older adults. Studies have shown that 86% of nursing home residents could complete at least one of these pain scales. These pain scales could also easily be used with patients who, for example, are unable to speak because of endotracheal intubation.
Reliability and Validity: Studies comparing simple pain intensity measures have demonstrated high reliability and validity using the VAS and Faces Pain Scale with older adults.

Strengths and Limitations: These simple, yet effective pain assessment tools are easy to administer and provide a method to evaluate not only the presence of pain, but also the effectiveness of treatment. However, these assessment tools should not replace extensive medical history-taking and physical exams, which may lead to the determination of etiologies of pain.

Suggested Reading
American Geriatrics Society. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons. Am Geriatr Soc. 1998; 46:635-651.
Closs SJ. Pain and elderly patients: A survey of nurses’ knowledge and experiences. Adv Nurs. 1996; 23:237-242.
Herr KA, Mobility PR. Comparison of selected pain assessment tools for use with the elderly. Appl Nurs Res. 1993:6:39-46.

Do you have an age-related care story or idea? AACN wants to provide a vehicle for the sharing of information that can enhance practice for all members who provide care to the older population. Send information to AACN Clinical Practice Specialist, Justine Medina, RN, MS, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 448-5520; e-mail, Justine.Medina@aacn.org, or call (800) 394-5995, ext. 401.

Submit NTI Abstracts by Sept. 1, 2000

Sept. 1, 2000, is the deadline to submit applications research and research utilization abstracts or creative solutions abstracts for presentation at AACN’s National Teaching Institute and Critical Care Exposition in 2001 in Anaheim, Calif.

Presenters of selected abstracts receive a $75 reduction in NTI registration fees. All other expenses are the responsibility of the presenter, who can be either the first author or a designate of the author.

NTI 2001 is scheduled for May 19 through 24.

To obtain abstract forms, call (800) 899-AACN (2226), or visit the research area of the AACN Web site at http://www.aacn.org.

Vox Populi: Online Quick Poll

Are you currently pursuing, or do you intend to pursue further education?

Yes 77%
No 15%
Don’t Know 8%

Number of Responses: 1,891

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. Participate by visiting the AACN Web site at http://www.aacn.org.

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