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Research Corner
Myth vs. Reality: Oral Care in the
Critically Ill
Mary Jo Grap
By Cindy Munro, RN, PhD, ANP, Associate
Professor, Virginia Commonwealth University School of Nursing
and Mary Jo Grap, RN, PhD, ACNP, Research
Work Group
Myth: Oral care is not a high priority in
critically ill patients.
Reality: Oral care, a key component of nursing
care, is primarily considered a patient comfort intervention. In fact, a study
of oral care practices found that, on a scale of 1 to 100, ICU nurses ranked the
importance of oral care as 54.
However, oropharyngeal colonization is
associated with several systemic diseases, including cardiovascular disease,1
chronic obstructive pulmonary disease2-4 and, in the ICU setting,
ventilator-associated pneumonia.5 The need to treat nosocomial pneumonia, which
ranks second in morbidity and first in mortality among nosocomial infections,6
adds five to seven days to hospital stay and billions of dollars to healthcare
costs.7,8 A critical risk factor for the development of VAP is colonization of
the oropharynx.9,10
Within 48 hours of hospital admission, the
composition of the oropharyngeal flora in critically ill patients undergoes a
change to predominantly gram-negative organisms, constituting a more virulent
flora that includes potential VAP pathogens.11,12 The microorganisms are
concentrated in dental plaque, which serves as a reservoir for pathogens.13
Dental plaque in ICU patients has been shown to be colonized by respiratory
pathogens, such as methicillin-resistant staphylococcus aureus and pseudomonas
aeruginosa, which can lead to VAP.5
Previous research indicates that vigorous oral
hygiene is necessary to reduce oral colonization of pathogenic organisms.9
Although toothbrushing is effective in reducing the number of oral
microorganisms and is more effective in plaque removal and gingival stimulation
than foam swabs,14 it is not uniformly used in nonintubated patients and used
even less in intubated patients.15 Hydrogen peroxide, which is frequently
used,15 does remove debris. However, it may cause superficial burns if not
diluted carefully. Lemon and glycerine swabs initially stimulate saliva
production, but are acidic, which not only causes irritation and decalcification
of the teeth, but may also result in rebound xerostomia,16-18 a dryness of the
mouth caused by an abnormal reduction in the amount of saliva secreted.
Foam swabs are effective for stimulation of
mucosal tissues, but ineffective in plaque removal15,17,18,19-21 and are
unlikely to reduce the risk of VAP.22
Although data are available concerning
appropriate oral care in healthy adults, evidence-based protocols for oral care
for critically ill patients are not available. However, studies are under way to
identify the best oral care methods for critically ill patients.
Summary
Evidence-based oral care practices for the
critically ill have yet to be defined. Until these data are available,
procedures with known deficiencies, such as the exclusive use of foam swabs,
should be avoided. Oral care should not be performed by quickly swabbing the
mouth. Instead, consistent and frequent oral care, using a toothbrush and
toothpaste at least three times a day, should be a priority, especially when the
patient is intubated.
References
1. Fowler EB, Breault LG, Cuenin MF. Periodontal
disease and its association with systemic disease. Mil Med. 2001;166:85-89.
2. Scannapieco FA, Papandonatos GD, Dunford RG.
Associations between oral conditions and respiratory disease in a national
sample survey population. Ann Periodontol. 1998;3:251-256.
3. Scannapieco FA, Mylotte JM. Relationships
between periodontal disease and bacterial pneumonia. J Periodontol.
1996;67:1114-22.
4. Scannapieco FA. Role of oral bacteria in
respiratory infection. J Periodontol. 1999;70:793-802.
5. Scannapieco FA, Stewart EM, Mylotte JM.
Colonization of dental plaque by respiratory pathogens in medical intensive care
patients. Crit Care Med. 1992;20:740-745.
6. Tablan OC, Anderson LJ, Arden NH, Breiman RF,
Butler JC, McNeil MM. Guideline for prevention of nosocomial pneumonia. The
Hospital Infection Control Practices Advisory Committee. Am J Infection Control.
1994;22:247-292.
7. Fagon JY, Chastre J, Hance AJ, Montravers P,
Novara A, Gibert C. Nosocomial pneumonia in ventilated patients: a cohort study
evaluating attributable mortality and hospital stay. Am J Med. 1993;94:281-288.
8. Craven DE, Steger KA, Barat LM, Duncan RA.
Nosocomial pneumonia: epidemiology and infection control. Intensive Care Med.
1992;18:S3-S9.
9. Fourrier F, Duvivier B, Boutigny H,
Rourrel-Delvallez M, Chopin C. Colonization of dental plaque: a source of
nosocomial infections in intensive care unit patients. Crit Care Med.
1998;26:301-308.
10. Garrouste OM, Chevret S, Arlet G, Marie O,
Rouveau M, Popoff N et al. Oropharyngeal or gastric colonization and nosocomial
pneumonia in adult intensive care unit patients. A prospective study based on
genomic DNA analysis. Am J Respir Crit Care Med. 1997;156:1647-1655.
11. Abele-Horn M, Dauber A, Bauernfeind A,
Russwurm W, Seyfarth-Metzger I, Gleich P et al. Decrease in nosocomial pneumonia
in ventilated patients by selective oropharyngeal decontamination (SOD).
Intensive Care Med. 1997;23:187-195.
12. Johanson WG, Jr., Seidenfeld JJ, de los
Santos R, Coalson JJ, Gomez P. Prevention of nosocomial pneumonia using topical
and parenteral antimicrobial agents. Am Rev Respir Dis. 1988;137:265-272.
13. Gipe B, Donnelly D, Harris S. A survey of
dental health in patients with respiratory failure. Am J Res Crit Care Med.
1995;151:A340.
14. DeWalt EM. Effect of timed hygienic measures
on oral mucosa in a group of elderly subjects. Nurs Res. 1975;24:104-108.
15. Grap MJ, Munro C, Ashtiani B, Bryant S. Oral
care interventions in critical care. Am J Crit Care. 2002;11:293.
16. Adams R. Qualified nurses lack adequate
knowledge related to oral health, resulting in inadequate oral care of patients
on medical wards. J Adv Nurs. 1996;24:552-560.
17. Holmes S. Nursing management of oral care in
older patients. Nurs Times. 1996;92:37-39.
18. Aronovitch SA. Oral care and its role in WOC
nursing. J Wound Ostomy Continence Nurs. 1997;24:79-85.
19. Buglass EA. Oral hygiene. Brit J Nurs.
1995;4:516.
20. Moore J. Assessment of nurse-administered
oral hygiene. Nurs Times. 1995;91:40-41.
21. Pearson LS. A comparison of the ability of
foam swabs and toothbrushes to remove dental plaque: implications for nursing
practice. J Adv Nurs. 1996;23:62-69.
22. Munro CL, Grap MJ, Hummel R, Elswick RK,
Sessler C. Oral health status: effect on VAP. Am J Crit Care. 2002;11:280.
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Practice Resource Network
Q:
I am interested in participating in research
activities through AACN. How can I get involved?
A:
AACN has three volunteer opportunities that focus specifically on research and
the advancement of critical care nursing science. AACN�s other volunteer
activities offer opportunities for nurses who are experienced in evidence-based
practice. The specific research opportunities include:
� The Research Work Group articulates and
provides recommendations to promote multidisciplinary and collaborative,
research-based practice along the continuum of care. Its members review research
grant awards; select the NTI Research and Creative Solutions Abstract award
winners; participate in the identification and development of research
resources; and complete the selection of the Distinguished Research Lecturer.
� The Research Grant Review Panel reviews and
evaluates proposals and awards AACN large grants. The group provides the
framework in which the comprehensive review of all grant submissions is
accomplished.
� The Research and Creative Solutions Abstracts
Review Panel reviews and rates abstracts submitted for AACN�s annual National
Teaching Institute. The final scores are forwarded to the Research Work Group
for use in award selection.
Review Panels
First-time volunteers are encouraged to
volunteer for either of the two review panels. Although neither of these groups
require grant work experience, it is preferred for the Research Grant Review
Panel.
The work of these committees is organized around
the submission deadlines: generally fall and spring for the grants and Sept. 1
for the abstracts. Although the workload varies according to the number of
submissions, an average of between 10 and 20 hours per year is required of the
volunteers.
No travel for face-to-face meetings is required
for members of these review panels. They conduct their work via phone or online
discussion databases, as well as by using electronic forms in some cases. Thus,
members must have Office 97 version or higher for compatibility with Excel, Word
and Internet access.
Work Group
The Research Work Group, on the other hand,
requires considerably more time and involvement. This opportunity is geared to
AACN members who are researchers, educators or clinical nurses who regularly use
evidence and research in their daily work.
The group meets face-to-face once for a two-day
weekend meeting in August and subsequently via two to three conference calls
during the year. Although the workload depends on the group assignments each
year, the time required of volunteers is generally between 40 and 60 hours each
year, including the weekend meeting. Research Work Group members are also
required to have Office 97 version or higher.
Applications Accepted
The application process for volunteer
opportunities began Dec. 1. Applications are due March 1 for terms effective
July 1 through June 30.
For additional information about the various
committees or for a volunteer application, see the center section of this issue
of AACN News or visit the AACN Web page at
http://www.aacn.org >
Membership > Volunteer Opportunities.
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Grants
AACN offers a variety of small and large
research grants. Jan. 15 is the deadline for three of these grants:
Philips Medical Systems-AACN Outcomes for
Clinical Excellence Research Grant
This new grant, funded by Philips Medical
Systems, will award $100,000 every three years to support studies that center on
improved outcomes or system efficiencies in the care of acutely or critically
ill patients. Research conducted with this grant may apply to any age patient in
any clinical environment, but must relate directly to at least one of AACN�s
research priorities. The grant will be awarded for the first time at AACN�s 2003
National Teaching Institute and Critical Care Exposition, May 17 through 22 in
San Antonio, Texas.
Clinical Inquiry Grant
This grant supports multiple awards of $500
each, up to $5,000 annually, for clinical research projects that directly
benefit patients or families. Interdisciplinary projects are especially invited.
AACN End-of-Life/Palliative Care Small
Projects Grant
This grant funds two grants of $500 each for
projects focusing on end-of-life or palliative care outcomes in critical care.
Due Feb. 1
Feb. 1 is the deadline for the following grants:
Datex-Ohmeda-AACN Research Grant�Sponsored
by Datex-Ohmeda, this grant provides up to $5,000 to support research by a
critical care nurse addressing the issue of nutritional assessment in the
critically ill patient.
AACN Critical Care Grant�This
grant awards up to $15,000 to support research focused on one or more of AACN
research priorities. The proposed research may not be used to meet the
requirements of an academic degree.
AACN Mentorship Grant�This
grant awards up to $10,000 to support research done by a novice researcher
working under the direction of a mentor with expertise in the area of proposed
investigation. The novice researcher will be the principal investigator and will
receive the award. The novice researcher may be conducting the research to meet
requirements for an academic degree, but the mentor may not. The mentor may not
be a mentor on an AACN Mentorship Grant in two consecutive years.
AACN Certification Corporation Research
Grant�Sponsored by AACN Certification Corporation, this grant awards up to four
awards of $10,000 each for studies related to certified practice.
Due March 1
March 1 is the deadline for the following grant:
Evidence-Based Clinical Practice Grant�This
grant awards $1,000 to cover direct project expenses, such as printed materials,
small equipment and supplies. Eligible projects can include research utilization
studies, CQI projects and outcome evaluation studies. Collaborative projects are
encouraged.
To find out more about AACN�s research
priorities and grant opportunities, visit the AACN Web site at
http://www.aacn.org >
Membership > Awards, Grants, Scholarships. The grants handbook is also available
from AACN Fax on Demand at (800) 222-6329 (Canada call 949-448-7315), Request
Document #1013.
The Power of One: Voluntarism Is Important
in Informed Consent Process
By Jacqueline Fowler Byers, RN, PhD, CNAA
Ethics Work Group
AACN�s Synergy Model emphasizes the unique,
holistic patient and nurse characteristics that are intertwined to promote a
positive healing interaction. Relevant patient characteristics include
vulnerability, complexity and participation in decision making. Pertinent nurse
characteristics include advocacy and moral agency, caring practices,
collaboration, systems thinking and response to diversity. Several of these
factors must be considered in the informed consent process.
Voluntarism is one of three required elements of
informed consent. The other two are full disclosure of pertinent information,
and the capacity to understand and make a decision. Voluntarism means making an
independent choice based on the full disclosure of information, including
treatment alternatives.
External factors, which may come from family,
friends or healthcare providers, can threaten voluntarism. The actions of others
regarding the patient�s informed consent decision making may be based on the
ethical principle of beneficence, or trying to do what is best for the patient.
Potential threats to voluntarism include manipulation, coercion, emotion-laden
appeals or rational persuasion. Loved ones may employ these tactics because they
believe that they know what is best for the patient. Healthcare providers may
act accordingly, knowingly or unknowingly. A provider might believe strongly
that a certain treatment or end-of-life decision is �right� for the patient,
which can result in a manipulation of how the pertinent information is presented
to persuade the patient toward a certain choice.
Ethically, this is a slippery slope toward
unethical practices, depending on the degree of lack of objectivity in the
presentation of information. In the case of clinical research, the promise of
free medical care or �cutting edge� treatment may be coercive to the indigent or
less educated patient. Patients may also hold healthcare providers in such high
esteem that the patient will defer to the provider�s suggestions.
The Synergy Model allows the nurse to evaluate
voluntarism in informed consent from a holistic perspective. First, patient
characteristics are evaluated. Have all the necessary steps been taken by the
healthcare team to protect the patient�s socioeconomic, cultural and physiologic
vulnerabilities? Does the patient realize that appropriate care will continue to
be provided, even if he or she declines a certain treatment or research
protocol? After listening to loved ones and healthcare providers, has the
patient had the time to independently evaluate the situation and make a decision
based on their complex situation and values?
Meeting the legal and ethical requirements in
the critical care setting is challenging. As moral advocate, the nurse must
ensure that the patient or his or her surrogate is making a voluntary decision
free from external influences. The nurse can collaborate with the healthcare
team to ensure that the entire process of informed consent meets all required
elements and is culturally and ethically sensitive to the patient�s needs.
Key Contributors to Voluntarism in Informed
Consent
� Pertinent information is provided to the
patient.
� Information is free of bias or pressure.
� Information is provided in a caring, sensitive
manner.
� Information is presented in a language and
vocabulary level that the patient can understand.
� The patient is assured that the treatment or
research trial decision will not affect his or her access to needed healthcare.
� Steps are taken to ensure that the patient is
protected from his or her socioeconomic, cultural and physiologic
vulnerabilities.
� Adequate time is allowed for the patient to
process the provided information, ask any questions and independently make a
decision.
To Learn More
1.http://
www.indiana.edu/~poynter/sas/res/ic.pdf
- Pedroni JA, Pimple KD. A Brief Introduction to Informed Consent in Research
With Human Subjects. Bloomington, Ind: Indiana University; 2001.
2.http://
www.peds.ufl.edu/ethics_course/Ethics,%20Informed%20Consent.htm
- Ethics Course for Pediatric Residents: Informed Consent. University of
Florida.
3.http://www.aacn.org
- #120902, Nursing & the Law (5th edition) and #400849, Patient/Family:
Conference Guide Pocket Reference.
CNS and NP Roles Collaborate in Service
Line Model
By Mary Tierney, RN, MSN, CCRN, CNS, ANP-C
Advanced Practice Work Group
Healthcare models have evolved to address
today�s changing managed care and cost-containment issues. For example, the
service line management model seeks to reduce healthcare costs, as well as to
improve marketing of services, process development and the quality of patient
care.
The traditional and modified approaches are
often designed for procedural, interventional or surgical services in the
management of comprehensive diseases in certain populations. They typically have
common clinical care missions with a mechanism for integrating services across a
multidisciplinary continuum.
Advanced practice nurses provide clinical
competence and expertise to meet the complex and challenging demands of patient
care delivery within a service line. Collaboration between clinical nurse
specialists and nurse practitioners is the perfect match for service line
management.
The first step toward collaboration is defining
roles. As expert clinicians, researchers, educators and consultants, both the
CNS and the NP have key partnerships with other APNs, physicians, nurse managers
and staff.
The CNS typically affects nursing practice
through mentoring, role modeling, changing system processes and influencing
patient and family care management through direct care. The NP typically focuses
on making clinical decisions related to complex patient problems encountered in
the acute care setting. Both develop programs, tools and procedures to improve
healthcare for patients.
Working together, the CNS and NP can collaborate
to promote quality care within a service line. An example of APN collaboration
is the development of a cardiovascular service line. By applying the nursing
process, APNs assess, plan, implement and evaluate cardiovascular services
across a multidisciplinary and multidepartmental framework. Objectives and goals
are defined and accomplished within an established timeline.
A multidisciplinary team is key to the success
of a cardiovascular service line. As a change agent, the CNS who has program
development expertise can establish and manage the team structure through
objectives, goals and desired outcomes. Typical cardiovascular service line
teams include members from critical care, surgery, the catheter lab, the ICU,
telemetry, cardiac rehabilitation, nutritional services, education, home care,
diagnostics, and physical and occupational therapies, as well as administrative
staff. The team members are responsible for developing processes that provide
continuity of quality care with reduction in duplication of services.
The CNS monitors the team progress and outcomes
with the department managers and the service line NP. The cardiovascular NP
provides direct patient care to complex patients within the service line to
ensure that the flow of care is timely and efficient. Included are making daily
rounds, taking history and physicals, writing orders, monitoring and ordering
diagnostic tests, evaluating medications, doing procedures and collaborating
with surgeons, cardiologists, primary care physicians and other consultants.
The CNS and NP work together to identify and
intervene in complex patient problems to improve patient care within the service
line. As clinicians, they role model clinical expertise and assist staff to
increase their knowledge, skills and confidence. As educators, they provide
evidenced-based practice through staff education and training for all
disciplines. As researchers, they monitor quality indicators and develop methods
to assist in cost containment and efficiency in care delivery. As consultants,
they assess, develop and plan for needs and services of complex cardiovascular
patients in collaboration with department managers and staff.
Mary Tierney is the cardiovascular services
manager and nurse practitioner at Longmont United Hospital, Longmont, Colo.
Across the Continuum of Care: Many Factors
Dictate Progressive Care Resource Needs
Editor�s note: A section of the following
article was omitted from the October 2002 issue of AACN News. The article is
reprinted here in its entirety.
By Susan Helms, RN, MSN, CCRN
Progressive Care Task Force
Determining the resources needed to support and
enhance the delivery of care to critically ill patients in the progressive care
unit requires assessment of the patient population, environment and available
technology.
One helpful tool when setting up a PCU is to
first establish admission, discharge and transfer criteria. This criteria can
guide the selection of resources and technology needed to care for the defined
patient population and support cost justification for resources that may be
requested.
The admission and discharge criteria should be a
multidisciplinary, descriptive tool that explains the level of patient acuity
that will be accommodated in the PCU. Defining and describing standards, the
environment and staff responsibilities are other tools that may be useful in
planning the unit.1
The Patient Population
Because the PCU design may be based on a
specific patient population, assessment of the population to be served and the
level of nursing vigilance that will be required must be a central focus when
gathering resources for PCUs. Questions to answer include: How often and what
types of vital signs need to be monitored? Will multiparameter monitoring, such
as hemodynamics, oxygen saturations and ventilator weaning status, be needed?
Will patients require frequent mobilization to other units or departments for
procedures or tests? How many and what types of staff are needed?
For example, patients who have progressed to
stable critical states may be considered capable of withstanding transport off
the unit for scans, x-rays or procedures. Moving patients from department to
department when equipment is not portable places a burden on PCU nurses and
their efforts to maintain a consistent level of care. When a patient is moved,
relevant data can be missed or misplaced, which increases the risk of medical
errors, as well as the administrative time that may be necessary to manually
transcribe information obtained during the patient�s transport. In addition,
staff may be required to travel with the patient, taking them away from their
patient assignments.
The Physical Environment
PCUs often have many structural constraints
because, historically, they have been remodeling projects used to meet
institutional specific needs for expansion. Thus, the PCU staff should be
actively involved in providing insight into how the physical environment can
best be arranged.
For example, construction should consider the
rehabilitation aspect of patient care, while allowing for nursing vigilance. If
units are not properly planned, they may be too small to provide the service
that is required, or too large, creating the possibility that low-risk patients
will be inappropriately admitted.2
Studies and systems analyses that estimate
procedural times, travel times and emergency response times are important in
assessing the physical layout of units and the patient care requirements. For
example, does the unit layout allow for timely acquisition of critical
information and access to patients? Planning the placement of emergency
equipment, medications and documentation stations should take into account the
safe proximity of the nurse to the patient and the equipment needed for
surveillance. When the changing physical environment is extremely limited,
technology may be the answer.
The Technology
When choosing technological resources, assess
how they will enhance patient care. For example, PCU staff say that patient
mobility and accessibility to patient information are two major causes of
anxiety. Defining the level of mobility will help determine the type of
monitoring devices chosen. Will patients require cardiac monitoring and
emergency equipment during transport? Will patients be better served with
telemetry or stationary monitoring capabilities?
Today, technological advances in telemetry
systems allow nurses to monitor patients as they move around the hospital. These
systems can transmit multiple data sets, such as heart rate, multilead ECG and
pulse oximetry. This information can be viewed at the central nurses� station.
The systems can also be integrated into small, hand-held receivers, which can
display a preview of the rhythm and alert the nurse to high-level alarms. Some
telemetry systems allow for remote, centralized patient monitoring with rapid
and secure nurse notification systems.
At the same time, computerization is changing
the way healthcare is practiced and communicated. Some facilities have moved
from paper-heavy charts to paperless, computerized documentation. Because
patients in progressive care are in various stages of critical care recovery,
timely access to information, including patient history and radiology and test
results, is important.
Successful information systems enhancements in
the PCU can also reduce unnecessary or redundant paperwork and administrative
work. Integrating information systems allows PCU nurses to fully utilize patient
data, which improves not only productivity and workflow at the point of care,
but also patient outcomes. Nurses who have instant access to the information
they need can make better-informed decisions about patients� needs without
leaving the point of care.
As hospitals move to networked environments, all
patient care information from the ambulance to the hospital room is being linked
to create a single data source. Collaboration among critical care units is
imperative when making changes in how information and data flow. Hospital
administrators, PCU clinicians, and medical and nursing leadership may want to
consider forming a task force that explores both clinical concerns and
administrative understanding of the facility�s strategic framework. For example,
unilateral changes in monitors in one unit without the knowledge of the others
may adversely impact standardization of staff training, supplies, biomedical
support and data transfer into the electronic medical record.3
As patients move across the continuum of care,
having a strong structure, competent staff, an easily accessible physical
environment and technology that enhances workflow are becoming standard in the
PCU. With adequate assessment and planning, this environment becomes an
effective way to develop a quality outcome stay for patients on their way to
recovery.
References
1. Berke WJ, Ecklund MM. Progressive Care
Series, Part 1: Progressive care units continue to grow in numbers as the
patient acuity gap between medical/surgical care narrows. Nurs Manage. February
2002;32:26-29.
2. Keenan SP, Massel D, Inman KJ, Sibbald WJ. A
systematic review of the cost-effectiveness of noncardiac transitional care
units. Chest. 1998;113:173-177.
3. Halpern NA, Pastores SM. Technology
introduction in critical care: just knowing the price is not enough! Chest.
1999;116:1092-1099.
In the Circle: Award Recognizes Clinical
Nurse Specialists
The following are excerpts from exemplars
submitted in connection with the Oridion-AACN Excellent Clinical Nurse
Specialist Award. Part of the AACN Circle of Excellence recognition program,
this award is sponsored by Oridion Medical to honor CCNS-certified nurses who
demonstrate the key components of advanced practice nursing. In addition, the
recipients illustrated how they have been a catalyst for successful change.
Recipients were provided complimentary registration, airfare and hotel
accommodations for the 2002 NTI in Atlanta, Ga.
Karen K. Giuliano, RN, MSN, CCRN, CCNS
Atkinson, N.H.
Philips Medical Systems
and Boston College School of Nursing
LO. Jr. was admitted to our trauma ICU after
sustaining severe traumatic injury in a motor vehicle accident. His father, who
owned a trucking company, had lost control of the vehicle in which they were
riding. After attempting to control the bleeding at the scene, the trauma team
transferred L.O. Jr. to our trauma ICU.
L.O. Sr. was also admitted, but to the neurology
observation unit. However, he wanted to see his son. I explained the situation,
answered questions and then brought him and other family members to L.O. Jr.�s
bedside.
We all realized that L.O. Sr. needed this time
with his son, and the flurry of the resuscitation quieted briefly as he moved
close enough to touch his son and tell him how much he loved him. The feeling of
a father�s desperation was shared by all of us who were present as L.O. Sr.
watched for a response from his son.
Recognizing that father and son should not be
separated during this critical time, we unofficially admitted L.O. Sr. into an
ICU bed where he was able to observe the resuscitation effort. Every nurse and
physician in the ICU that day worked together to ensure that the full range of
patient and family needs were met.
Roberta Kaplow, RN, PhD, CCNS, CCRN
Atlanta, Ga.
Nell Hodgson Woodruff School of Nursing
Emory University
As Scott was admitted to the ICU, providing me
his medical history in detail, he struck me as extraordinary. Battling Hodgkin�s
disease and aggressive therapy, he had developed pulmonary fibrosis.
Although visitation during �nonvisiting hours�
was unheard of at the time, Scott�s parents were at his bedside almost
continuously. My co-primary nurses and I met with the manager and agreed that
having Scott�s parents nearby was best. However, some staff expressed concern.
In an effort to dispel this concern, I performed a literature search to find
empirical support. The studies supporting open visitation were presented in a
journal club.
Over the next few weeks, Scott�s status
deteriorated. His lungs stiffened, and ventilating him was challenging. Despite
aggressive management, it became apparent that Scott would not survive.
I organized a meeting with the intensivist. The
parents seemed to accept Scott�s impending death as well as could be expected.
However, they didn�t discuss Scott�s condition in front of him. In a graduate
course, I had learned that, though children were rarely told that they were
dying, they usually knew. Having cared for Scott, I felt he knew. I told his
parents, and we explored their concerns about telling him. They agreed that they
should. When the parents returned to Scott, his mother asked him, �Do you know
you are dying?� He nodded he did and wrote, �I knew awhile ago, but I didn�t
want to upset you.�
Scott eventually died peacefully with his
parents by his side. I believe I helped Scott�s family prepare for and cope with
his death. Caring for Scott facilitated my role as a change agent. The open
visitation policy for Scott�s family provided the stimulus for an ongoing
evaluation of policies.
Sepsis Education Program Now Available in
CD-ROM Format
Grant Underwrites Purchase Fee
Identification and Management of the Patient
With Severe Sepsis,� AACN�s national sepsis education program for nurses, is now
available in a self-paced CD-ROM format. Funded by an unrestricted educational
grant from Eli Lilly and Company, this program is sponsored by AACN and is
accredited for 5.0 contact hours of CE credit for single users.
Narrated by clinical expert Barbara McLean, RN,
MN, CCRN, CCNS-NP, FCCM, the new program offers clinicians a comprehensive view
of the latest information on the diagnosis and care of patients with severe
sepsis.
The 170-page, audio/slide CD-ROM study guide
includes pathophysiology of severe sepsis; identification of acute organ system
dysfunction; antibiotics, source control and monitoring in severe sepsis,
including investigational and new approved therapies; hemodynamic, ventilatory,
renal and other aspects of care; and nursing care of patients with severe
sepsis. Case studies are also included in the presentation.
To order this program for only the $7.50
shipping and handling fee, call (800) 899-2226 and request Item #004060.
Quantities are limited.
Get a Rebate on a Palm Device from PDA
Center
Purchase a Palm handheld device through the AACN
PDA Center and receive a $50 mail-in rebate. This special rebate offer is good
through Feb. 1 when you purchase either a Palm M515 or Palm M130 device. For
details, simply visit the PDA Center online at
http://www.aacn.org.
But, that�s not all. Through Jan. 31, AACN will
include the new �Laboratory Values� electronic pocket reference for Palm OS free
of charge with the purchase of any handheld device that runs the Palm OS system.
AACN also now offers six new electronic versions
of the popular laminated clinical references for Palm OS. Recently released are
the �Hemodynamic Management� and �Critical Care Assessment� pocket
references.
Start building your library of electronic
resources that will be available from your PDA at the touch of a stylus.
If you want help in determining which PDA device
is best suited for you, a tutorial titled �Handheld Devices for Healthcare
Practitioners,� is now available in the PDA Tutorials section of the PDA Center.
Public Policy Update
The Issues
1. Patient Safety�Experts Recommend Alcohol
Solutions in New Hand-Washing Guidelines
2. ICU Study�Intensive Care Specialists Save
Lives
3. Healthcare Quality�IOM Report Calls for
Federal Government to Play Lead Role
4. HIPAA Privacy Rule�HHS Office Releases New
FAQs
5. Value of Nursing�Study Finds Benefit of Nurse
Follow-Up Care
Patient Safety
Background: Researchers have concluded that
waterless, alcohol-based antiseptics used by hospital healthcare workers are
more effective germ killers than soap and water. In unveiling new hand-washing
guidelines, the Centers for Disease Control and Prevention also said that use of
alcohol-based antiseptics has proved to save time for nursing staff, as well as
staff involved in emergency situations, and has resulted in better adherence to
hand-washing guidelines.
Saying that good hand-hygiene saves lives, CDC
Director Julie Gerberding recommended that hospital workers wear gloves when
they possibly could come in contact with blood or other bodily fluids. However,
Elaine Larson, a nurse who is associate dean for research at the Columbia
University School of Nursing, said that waterless antiseptics are not cleaning
agents, because they do not remove surface dirt, and that hand washing with
regular soap is still the best approach to daily hygiene.
ICU Study
Background: A study published recently in the
Journal of the American Medical Association found that employing intensivists
could reduce death rates by 30%. Although only 10% of hospitals employ such
experts, the researchers estimated that 162,000 more lives could be saved every
year if intensivists were on the staffs of all ICUs.
According to one of the researchers, Derek Angus
of the Department of Critical Care Medicine at the University of Pittsburgh
School of Medicine, staffing ICUs with physicians specifically trained in
critical care medicine can also conserve resources. Intensivists can help reduce
inappropriate ICU admissions, prevent complications that increase length of stay
and recognize opportunities for prompt discharge, he said.
Angus noted that, despite the estimated $180
billion annual investment the 6,000 ICUs in the United States represent, there
is no standard model for how an ICU should be staffed or organized.
Healthcare Quality
Background: In its highly anticipated third
report on healthcare quality, titled the �Future of the Public�s Health in the
21st Century,� the Institute of Medicine called on the federal government to
play a lead role in developing clinical standards and taking other major steps
to improve quality in the industry. The IOM recommended that the six federal
healthcare programs�Medicare, Medicaid, the State Children�s Health Insurance
Program, the Defense Department�s Tricare, the Veterans Health Administration
and the Indian Health Services�develop standard performance measures to help the
industry�s multiple �stakeholders.�
The industry has struggled without �clear,
consistent signals� on how to assess and improve quality, the report said. �The
current set of activities has not closed the quality gap and is unlikely to do
so in the future,� said Gilbert Omenn, MD, chairman of the IOM committee that
produced the report. Additional information on the report is available online at
http://www.nap.edu/books/0309086221/html/.
HIPAA Privacy Rule
Status: Responding to questions and comments
submitted to its Web site, the Health and Human Services Office for Civil Rights
has released a new set of �Frequently Asked Questions� about the HIPAA Privacy
Rule. OCR also posted an unofficial version of the complete regulation text of
the modified Privacy Rule. The FAQs and the unofficial text are available at the
OCR Web site at
.
Value of Nursing
Background: A study published in the October
issue of the American Heart Journal found that post-heart bypass patients are
more likely to control their cholesterol and lower their risk of more heart
disease if they receive follow-up care from a nurse. The study from the Johns
Hopkins University School of Nursing included 228 men and women. Following heart
bypass surgery, all received standard care, such as information and instructions
for diet, activity, and monitoring pulse and temperature.
The study found that 65% of the people in the
nurse care management group lowered their cholesterol to recommended levels,
compared to 35% in the other group. Those who received follow-up by a nurse also
reported healthier diet and exercise habits. The study is available online at
http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=home&id=hj.
Elections 2002: Healthcare Issues
Important, But Not Priority in New Congress
The results of the November elections will bring
a reorganization of leadership and committees on Capitol Hill. According to the
Wall Street Journal, Republican lawmakers, who will assume control of both the
House and Senate in the 108th Congress, will likely use their �substantially
increased power� to �change the national debate� on healthcare and enact
market-based reforms. Following are some of the issues expected to be affected:
Bush Agenda
President Bush hopes that Republican lawmakers
will address a large part of his agenda, including a number of healthcare
proposals related to issues such as patients� rights legislation, a ban on human
cloning and an increase in funds for community health centers.
New Leadership
Senate Minority Leader Trent Lott (R-Miss.) will
likely assume the position of Senate majority leader, and Sen. Judd Gregg (R-N.H.)
is expected to become chair of the Senate Health, Education, Labor and Pensions
Committee.
Prescription Drugs
Republican lawmakers also hope to address a
Medicare prescription drug benefit and a ban on �partial-birth� abortion. In
addition, they have said that they plan to address a Medicare provider
�give-back� bill.
Sen. Charles Grassley (R-Iowa), who will likely
be chair of the Senate Finance Committee, which has jurisdiction over Medicare
legislation, said that his agenda next year will include a prescription drug
benefit bill. The legislation, which GOP lawmakers may propose as part of a
larger Medicare reform bill, could focus on low-income beneficiaries.
Pharmaceutical companies predict that their contributions to GOP candidates will
place an industry-supported prescription drug benefit on the �fast track� to
approval next year. In addition, the Republican-controlled Congress may try to
block legislation to increase access to generic treatments, a move that would
benefit brand-name pharmaceutical companies.
Patients� Bill of Rights
Several health insurance analysts predicted that
the patients� rights bill �is dead� next year, and health insurers hope that GOP
lawmakers will consider tax credits to help low-income employees and small
businesses purchase health insurance. However, the �narrow margin� of GOP
control in the Senate�51 Republicans, 47 Democrats, one Independent and one
still undecided seat�may limit the ability of Republicans to move their
healthcare legislation through Congress. In addition, increased federal budget
deficits may impact the Republican healthcare agenda by preventing the passage
of significant legislation.
Healthcare Interests
Incoming members of the 108th Congress include
several new House members with health backgrounds, both in policy and in medical
practice. Two freshman members are practicing obstetrician/gynecologists and one
is a practicing psychologist. Michael Burgess, MD, a Republican elected to
Texas� 26th district, currently is chief of obstetrics at Lewisville Medical
Center. A second obstetrician newly elected to the House, Phil Gingrey, MD, will
represent Georgia�s 11th district, also as a Republican. Also among incoming
Republican House members with healthcare backgrounds is Pennsylvania State Sen.
Tim Murphy, a practicing psychologist. Another state legislator moving to the
House with healthcare interests is Dennis Cardoza (D), taking over Rep. Gary
Condit�s seat in California�s 18th district. Florida State Sen. Ginny
Brown-Waite (R), moving to the House after defeating Democratic Rep. Karen
Thurman in the 5th district, also campaigned heavily on healthcare issues and
was endorsed by the AMA.
AACN Online Quick Poll
Is providing oral care a high priority in your
practice?
Yes 78%
No 22%
Number of Responses: 594
The AACN Online Quick Poll is a voluntary survey
on a variety of topics and is not scientifically projectable to any other
population. AACN presents these surveys to give our users an opportunity to
share their opinions on particular topics. Participate by visiting the AACN Web
site at
http://www.aacn.org.
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