AACN News—December 2002—Practice

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Vol. 19, No. 12, DECEMBER 2002


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?

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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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