AACN News—May 2002—Practice

AACN News Logo

Back to AACN News Home

Vol. 19, No. 5, MAY 2002


In the Circle: Award Recognizes Innovative Collaboration


Editor�s note: The following excerpts are from exemplars submitted in connection with the 2001 Innovision Award, a part of AACN�s Circle of Excellence recognition program. This award recognizes initiatives and programs that innovatively and collaboratively meet the needs of families of the acute and critically ill. Up to three awards, with $2,500 earmarked to fund projects, are granted to partnerships that include an AACN member, a healthcare provider organization and a community group. In addition, individual recipients are given public recognition and a personalized plaque.


Clinical Ethics Center
Dearborn, Mich.
Oakwood Healthcare Systems, OHMC-D Guild
Critically ill patients must often depend upon others to make healthcare decisions on their behalf. An advance directive can provide guidance about a patient�s wishes for medical treatment and relieve some of the decision-making burden. With the support of the Oakwood Hospital and Medical Center Guild, the Oakwood Healthcare System and its Clinical Ethics Center were able to develop several initiatives to enhance the completion of advance directives.

Under this initiative, an innovative advance directive education packet and program titled �My Voice�My Choice� was designed to lead individuals through the steps of preparing a durable power of attorney for healthcare that would be grounded in their own personal, cultural and spiritual values and beliefs. To date, more than 3,000 educational packages have been distributed, with translation into Arabic in progress. More than half of those who attended the program have completed an advance directive, and program evaluations have been positive. A 20-minute videotape was produced as a companion piece to the education packet, enhancing its use as a self-instructional program.

A public service announcement titled �What If� was produced to stimulate the public thinking about medical treatment choices and to seek more information about advance directives. The announcement, produced in both English and Arabic, aired on local television stations and will air on the new in-patient television network.

A project was also initiated to raise awareness of the Michigan Home Do-Not-Resuscitate Act. Home DNR forms and educational brochures were developed to promote awareness of the individual�s resuscitation wishes and avoid unwanted resuscitation.

These projects support patient autonomy in medical decision making, encourage individuals to �use their voice before they lose their choice,� demonstrate respect for individual values and beliefs, and promote the welfare of the individual and community by honoring the expressed wishes of the patient.


Surgical-Trauma ICU and TBI Team 2000
Mission Viejo, Calif.
Mission Hospital Regional Medical Center
Using the latest technology and interventions, critical care nurses provide skilled nursing care for their patients. Coupled with this is the human side of caring. The need to provide holistic care to our patients requires nurses to partner with others, including healthcare providers and patients� families.
Patient outcomes for our severe, traumatic brain injury patients have been greatly enhanced by using a new protocol. Feedback from the families of patients regarding the transition of care from the ICU to other settings led us to realize that an opportunity for improvement in meeting their needs existed.
In May 2000, representatives of the ICU, surgical unit, acute rehabilitation, physical therapy, occupational therapy, speech therapy, respiratory therapy, social work, chaplain, pharmacy, physicians, and four former patients and families volunteered to explore the three care phases of hospitalization: the ICU, the transition from the ICU to the surgical unit and rehabilitation. As goals and projects were identified, teams were established around four areas of focus.
Team 1 developed clinical guidelines for assessing and managing agitation, as well as an agitation scale.
Team 2 focused on physical environmental issues. Strategies to enhance patient safety were developed by devising alternatives to traditional restraints, using private rooms and agitation-reduction measures, appropriate staffing ratios, and sitters. The team also worked on structuring the environment to facilitate communication between disciplines by developing signage to indicate patient sleep and wake cycles and stop-and-go alerts for families and staff and by placing large, dry-erase boards in the TBI rooms in all three units.
Team 3 focused on continuity of care by establishing primary nurses for the TBI patients, educating nurses on special issues related to these patients, establishing weekly patient care conferences, allowing for liberal family visits and presence, and formalizing the transition process of patients from the ICU to the surgical unit to acute rehabilitation.
Team 4 concentrated on support of families and education. Activities included developing a family education book, complete with explanations on the protocol, equipment, disease process and procedures. In addition, the team added family lockers, sleep chairs and computers for Internet access.
The work by staff members and patients/families culminated in a change of culture within the institution. The team has recognized that caring for critical TBI patients encompasses the skills of an entire hospital and that families are valued members of that team.


Marsha Fecht, RN
Marcella L. Rogan, RN, BSN
Spinal Cord Injury Team
Indianapolis, Ind.
Clarion Health Partners-Methodist Hospital
Our 25-bed, level one, trauma neurological critical care unit receives 80 spinal cord injury patients per year, with only 25% having deficits. After attempts to research care of the acute SCI patient failed, an SCI team was established. Our mission statement is that we will establish a multidisciplinary system designed to meet the needs of SCI individuals through innovation and excellence in care, education, research and service. Our population of concern is the SCI patient at or above C6 level.
A packet of information was developed for distribution to the patient and family members. This packet included a letter concerning their stay on our unit, as well as articles on both the anatomy of the spinal cord and common questions regarding this type of injury. In addition, a resource list of not only staff members but also local and national organizations is available. To track our progress, an evaluation form was also placed in the packets.
Our group has not only grown, but also been able to share our knowledge with others. We spoke at a conference in Chicago, and presented a poster at the national convention of the American Association of Spinal Cord Injury Nurses. We also planned a case review for the Clarian Health National Neurological Conference in Indianapolis.


The Power of One: Understanding the Rules and Effecting Change

By Carol A. Puz, RN, BSN, CCRN
AACN Board Liaison
Ethics Work Group

As the healthcare paradigm shifts, we see major changes in the way nursing care is delivered to patients. For example, the use of unlicensed assistive personnel continues to increase as budget constraints and the availability of licensed personnel tighten. If we are to effect change, we must be proactive in understanding the rules and reaching beyond our current ways.

Are you familiar with the nurse practice act in your state? Do you know how to access this information? What are your state�s rules and regulations governing the use of UAPs? What are your hospital�s rules and regulations governing the scope of practice for UAPs or licensed practical nurses?

Because many states have no rules and regulations to govern the scope of practice for UAPs, their hospitals can freely determine what this role will encompass. In these cases, the delegation responsibility of RNs to ensure that the needs of patients and families are met is elevated. There are commonly accepted rules mandating that delegated activities involve certain �rights,� including right task, right circumstance, right person, right communication and right feedback.1 Using the �right� approach promotes the principle of beneficence, which is a moral obligation to promote good and prevent or remove harm, and to promote the welfare, health and safety of society and individuals in accordance with beliefs, values, preferences and life goals.

AACN�s mission, vision and values are framed within an ethic of care, which is a moral orientation that acknowledges the interrelatedness and interdependence of individual systems and society. An ethic of care respects individual uniqueness, personal relationships and the dynamic nature of life. Essential to an ethic of care are compassion, collaboration, accountability and trust. Within the context of interrelationships of individuals and circumstances, traditional ethical principles provide a basis for deliberation and decision making.2

Here�s an example of how you can put all this into practice:

You have reported on duty to find an assignment of four patients to be covered by you, the RN, an LPN and an unlicensed patient care technician. Your first reaction is to question how you will be able to handle this assignment and deliver safe care. You wonder how or what you can delegate appropriately to your team member, and about your moral obligation to your coworkers, your patients and their families.
Of the four patients, one and two are orally intubated and on ventilators. Their secretions are moderate, and both are on propofol. Patient three has a pulmonary artery line, and patients one, two and four have triple lumen CVPs. Patient two is on heparin and dobutamine. Patients three and four are on IV fluids at a keep open rate and are receiving IV antibiotics. These two patients are alert and oriented x 3. None of the patients have open wounds. Does this sound doable?

It may be helpful to use the Synergy Model to define the characteristics of these patients. Patients one and two are minimally resilient and patients three and four are moderately resilient. All four are highly vulnerable and moderately stable. Patients one and two are not able to participate in their care, though patients three and four have a moderate participation level.

This means that you may be able to delegate more of the care tasks for the two fairly stable patients to the UAP. What are your hospital�s rules regarding LPNs and IV therapy? Can you delegate some of this work? After the initial assessment of all the patients, you may want to delegate the most stable ones to the LPN to complete.

Your clinical decision making around meeting the needs of these patients is crucial. The synergy that results when patients� needs and characteristics are matched with the nurse�s competencies will afford the best outcomes. Remember that the American Nurses Association Code of Ethics for Nurses states that �the nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse�s obligation to provide optimum patient care.�3

By delegating the appropriate tasks to your team members, you are accountable for the care that is provided. However, you are also responding as an advocate and a moral agent to these patients. You must trust your team members to ensure patient safety. If you believe an issue in your area of practice involves an ethical decision related to clinical practice, you may want to ask the following series of questions4:

� What is the ethical dimension of the issue?
� Who is involved?
� Are there benefits as well as burdens?
� Have there been similar care issues?
� What have others said about the issue?
� What do the organizational policies say about the issue?
� What is your comfort level with the decision?

To find an ethical conclusion to the foregoing example, you can apply these questions. For example, the ethical and legal dimension of the issue is the fact that you are the only RN for these four patients and may not be able to delegate some of the care to your coworkers because it is out of their scope of practice. Who is involved? In addition to you, the LPN and the UAP, the patients are first and foremost the center of the issue. The benefits are in the fact that there are three of you to care for the patients; the burden is in the fact that some of the care required is outside the scope of practice of the LPN and the UAP. If you are unaware whether there have been similar care issues, you should definitely seek out the answer to this question. Ask your other coworkers if they have been faced with this issue and, if so, how they handled the situation. Then, develop a plan that can be adapted if this circumstance arises again. Familiarize yourself with your hospital�s policies and procedures as they relate to practice issues. This will ease your frustration when confronted by future occurrences. Being able to divide the work to accommodate all of the patients� needs is crucial in answering the question about whether you are comfortable with the situation and consider it to be safe practice.

If you are concerned about your state�s practice acts or want a more defined explanation of the roles of others, contact your state board of nursing. Contact information for all state boards are listed online at www.ncsbn.org. You can also volunteer to attend hospital committee meetings where scopes of practice are discussed. By being the best possible advocate for the patients� safety and well-being, you can influence the changes necessary to create the proper skill mix for the patient acuity level.

References
1. Westfall P. Nurse attorney organization makes UAP recommendation. Insight. 1998; 7(2).
2.http:// www.aacn.org.
3. www.nursingworld.org/ethics/chcode.htm
4. Kinsella L. Truth telling in patient care, resolving ethical issues. Nursing. 2001;31:52-55.


Critical Care Across the Continuum: Progressive Care Nurses Are Part of Critical Care

By LeAnn Ash, RN, BSN, CCRN
Cochair, Progressive Care Task Force

What is a progressive care or intermediate care or step-down RN? What skills do they need to provide care for patients in their units? What technology is needed to monitor patients on these units? What educational tools do they need to train new nurses and continue their educational growth? Does AACN have resources to assist these nurses in their practice?

These are just a few of the questions probed by members of AACN�s Progressive Care Task Force when we met in San Antonio, Texas, in January 2002.

Prior to our face-to-face meeting in San Antonio, we began brainstorming via a conference call in October 2001 to identify issues relevant to progressive care nurses and specific to their environment of care. At our meeting, we further explored these issues and ways to address them.

Using AACN�s vision as a guide, the task force members agreed that patients in progressive care units are critically ill, even though they are not being cared for in the traditional ICU setting. Thus, the task force concluded that progressive care nurses are critical care nurses who practice beyond the walls of the ICU. We are committed to providing them the affiliation, resources and tools that all AACN members enjoy.

Because progressive care nurses require the same competencies, educational resources and support as other critical care nurses, the task force believes that AACN can play a critical role in ensuring that they are able to make their optimal contribution to the care of their patients and families. The task force examined in depth the concept of �critical care along the continuum� to encompass patients in progressive care as well as in ICUs.

The task force is now in the process of assessing AACN�s vast educational resources with respect to their usefulness to progressive care nurses and will make recommendations to the AACN Board of Directors regarding existing resources as well as what is needed. In addition, articles written by task force members to highlight key issues in the progressive care arena will appear in upcoming issues of AACN News.

Members of the Progressive Care Task Force are:
� LeAnn Ash, RN, BSN, CCRN (cochair), Keller, Texas, pediatric staff nurse
� Melissa Fitzpatrick, RN, MSN, FAAN (cochair), Chapel Hill, N.C., editor and principal healthcare strategist
� Diane Salipante, RN, MSN, MS, CCRN, Pittsford, N.Y., nurse practitioner, progressive care unit
� Terri �Mary� Palazzo, RN, MS, CCRN, Falls Church, Va., director of cardiac services for a progressive care unit
� Susan Helms, RN, MSN, CCRN, Archdale, N.C., clinical nurse specialist
� Ray Quintero, RN, MSN, CCRN, Yorktown, Va., manager and educator
� Randeen Cordier, RN, MSN, Salsbury, Md., clinical nurse manager
� Madeleine Burke, RN, BSN, CCRN, Miami, Fla., nurse clinician and care coordinator
� M. Dave Hanson, RN, BSN, CCRN EMT-P (board liaison), Dallas, Texas, nurse educator
Katie Schatz, RN, MSN, NP, clinical practice specialist at the AACN National Office, is the staff liaison to this group.


Looking for Guidance? Apply to be a Wyeth Nursing Fellow

Acute and critical care nurses can further develop their professional leadership skills and be published through the AACN Wyeth Nursing Fellows Program, now celebrating its 10th anniversary.

This nine-month fellowship, which pairs mentors and fellows, is sponsored by Wyeth Pharmaceuticals in collaboration with AACN and the American Journal of Nursing.

Under the program, the mentors will guide their fellows in preparing personal plans that include completing individualized projects, attending AACN�s National Teaching Institute and Critical Care Exposition and developing manuscripts on a current cardiopulmonary topic for publication in a supplement to the May 2003 issue of AJN.

The mentors and fellows will be honored at the 2003 NTI, May 17 through 22 in San Antonio, Texas. The fellows receive complimentary NTI registration, travel and lodging. The mentors receive complimentary NTI registration and a $500 educational grant.

Applications for the 2002-03 class of mentors and fellows must be received by June 21, 2002. To obtain an application, call (800) 899-2226 and request Item #2005 or AACN Fax on Demand at (800) 222-6329 and request Document #2005. Applications are also available online at http://www.aacn.org.

For further information, call (800) 394-5995 for AACN Clinical Practice Specialist Kathleen Schrader, RN, DNSc, CEN, at ext. 372 or Research Associate Dolores Curry at ext. 377.


Practice Resource Network


Q: We are developing sedation guidelines for our ICU patients. Do you know of protocols or articles that would assist us in this task?

A: According to the �Standards and Intents for Sedation and Anesthesia Care� in the Revisions of Anesthesia Care Standards Comprehensive Accreditation Manual for Hospitals, the following definitions should be used when referring to sedation:

�The standards for sedation and anesthesia care apply when patients receive, in any setting, for any purpose, by any route, moderate or deep sedation as well as general, spinal, or other major regional anesthesia. Definitions of four levels of sedation and anesthesia include the following:
� Minimal sedation (anxiolysis)�a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
� Moderate sedation/analgesia (conscious sedation)�a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either without or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
� Deep sedation/analgesia�a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
� Anesthesia�consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.� (Visit http://www.jcaho.org/search_form.html)


AACN Position
AACN approved the joint position statement titled �Role of the Registered Nurse (RN) in the Management of Patients Receiving Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures,� which was authored by AWHONN.

IV Conscious Sedation
Intravenous conscious sedation is produced by the administration of pharmacological agents. A patient under conscious sedation has a depressed level of consciousness but retains the ability to independently and continuously maintain a patent airway and respond appropriately to physical stimulation and/or verbal command. It is within the scope of practice of a registered nurse to manage the care of patients receiving IV conscious sedation during therapeutic, diagnostic, or surgical procedures provided the following criteria are met:

� Administration of IV conscious sedation medications by non-anesthetist RNs is allowed by state law and institutional policy, procedure, and protocol.
� A qualified anesthesia provider or attending physician selects and orders the medications to achieve IV conscious sedation.
� Guidelines for patient monitoring, drug administration and protocols for dealing with potential complications or emergency situations are available and have been developed in accordance with accepted standards of anesthesia practice.
� The RN managing the care of the patient receiving IV conscious sedation shall have no other responsibilities that would leave the patient unattended or compromise continuous monitoring.
� This nurse is able to:

1. Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia recognition and complications related to IV conscious sedation and medications.
2. Assess total patient care requirements during IV conscious sedation and recovery. Physiologic measurements should include, but not be limited to, respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm and patient�s level of consciousness.
3. Understand the principles of oxygen delivery, respiratory physiology, transport and uptake, and demonstrate the ability to use oxygen delivery devices.
4. Anticipate and recognize potential complications of IV conscious sedation in relation to the type of medication being administered.
5. Possess the requisite knowledge and skills to assess, diagnose and intervene in the event of complications or undesired outcomes and to institute nursing interventions in compliance with orders (including standing orders) or institutional protocols or guidelines.
6. Demonstrate skill in airway management resuscitation.
7. Demonstrate knowledge of the legal ramifications or administering IV conscious sedation and/or monitoring patients receiving IV conscious sedation, including the RN�s responsibility and liability in the event of an untoward reaction or life-threatening complication.

� The institution or practice setting has in place an educational/competency validation mechanism that includes a process for evaluating and documenting the individuals' demonstration of the knowledge, skills and abilities related to the management of patients receiving IV conscious sedation.
� Evaluation and documentation of competence occurs on a periodic basis according to institutional policy.

Additional Guidelines
Following are some additional guidelines:

� Intravenous access must be continuously maintained in the patient receiving IV conscious sedation.
� All patients receiving IV conscious sedation will be continuously monitored throughout the procedure as well as the recovery phase by physiologic measurements, including, but not limited to, respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and patients� level of consciousness.
� Supplemental oxygen will be immediately available to all patients receiving IV conscious sedation and administered per order (including standing orders).
� An emergency cart with a defibrillator must be immediately accessible to every location where IV conscious sedation is administered. Suction and a positive pressure breathing device, oxygen, and appropriate airways must be in each room where IV conscious sedation is administered.
� Provisions must be in place for back-up personnel who are experts in airway management, emergency intubation, and advanced cardiopulmonary resuscitation if complications arise.

AACN Protocol for Practice
The AACN Protocol for Practice titled �Sedation and Neuromuscular Blockade in Patients with Acute Respiratory Failure,� which incorporates detailed nursing practice implications and an annotated bibliography, can be purchased by calling (800) 899-2226 (Request Item #170725) or online at http://www.aacn.org> Bookstore. The price is $11 ($14 for nonmembers).

For additional information and a list of suggested reading, visit the AACN Web site.
Grants

End-of-Life/Palliative Care Grants Are New

Two new small project grants of $500 each are now available to fund studies related to end-of-life or palliative care outcomes in critical care. Applications are due July 1, 2002. The application can be downloaded from the AACN Web site at www.aacn.org > NEW! AACN End-of-Life Grant.

Eligible projects may address a range of topics, including bereavement, communication issues, caregiver needs, symptom management, advanced directives and life support withdrawal. The research may focus on any age group and may include patient education programs, staff development programs, competency-based educational programs, CQI projects, outcomes evaluation projects or small clinical research studies. Collaborative projects are encouraged.

July 1 is also the deadline for two other small project grants:

Clinical Inquiry Grant
Up to $500 will be awarded for projects that directly benefit patients or families. Interdisciplinary projects are especially invited. The principal investigator must be currently employed in a clinical setting and directly involved in patient care.


Medtronics Physio-Control AACN Small Projects Grant
Funding of up to $1,500 will be awarded for projects focusing on aspects of acute myocardial infarction, cardiac resuscitation, sudden cardiac death, use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretive 12-lead ECG. Collaborative projects are encouraged. This grant is funded by Medtronics Physio-Control.

The grants application book can be downloaded from the AACN Web site at http://www.aacn.org. or is available from Fax on Demand at (800) 2226-329 (Document #1013).

Research and Creative Solutions Abstracts Invited for NTI 2003

Sept. 1 is the deadline to submit research and creative solutions abstracts for AACN�s 2003 National Teaching Institute and Critical Care Exposition, scheduled for May 17 through 22 in San Antonio, Texas.
Abstracts must be relevant to the care of the acute and critically ill or critical care nursing and must be noncommercial in nature. The first author must be a nurse holding current AACN membership. Only completed research and finished projects are eligible, and abstracts must not have been previously published or presented nationally.

The designated presenters of accepted 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.

In addition, four awards will be presented for oral research abstracts reflecting outstanding original research, replication research or research utilization. Each of these awards provides an additional $1,000 toward NTI expenses.

Following is information about the abstracts:

Research
Abstracts can focus on any aspect of critical care nursing research, including reports of research studies or reports of research utilization. Only abstracts of completed projects will be accepted. Abstracts reporting research studies must address the purpose; background and significance; methods; results; and conclusions.

Creative Solutions
Abstracts should focus on specific strategies and practice innovations that are used by nurses to solve difficult, unique or interesting problems in patient care, nursing practice, nursing management or nursing education. The creative solution must have been implemented, with outcomes evaluated. Abstracts must address the purpose of the project and include a description of the creative solution, as well as evaluation and outcomes.

To obtain abstract forms, call (800) 899-AACN (2226) and request Item #6007, or visit the AACN Web site.

In the Circle: Award Spotlights Multidisciplinary Team Collaboration


Editor�s note: The following are excerpts from exemplars submitted in connection with the 2001 Multidisciplinary Team Award, a part of AACN�s Circle of Excellence recognition program. This award recognizes multidisciplinary teams that clearly practice key principles of collaboration and multidisciplinary practice. Team recipients are eligible for $2,500 to fund projects. In addition, individual recipients are given public recognition and a personalized plaque.


Cath PCI Quality Support Team
Charlottesville, Va.
University of Virginia Health System
The high-risk nature of diagnostic and treatment options for cardiovascular patients demands ongoing review. Thus, in November 1994, a collaborative practice team was charged with developing an outcomes management model for patients undergoing cardiac catheterizations or coronary interventions.

The team consisted of representatives from relevant areas, including physicians, nursing, pharmacy, utilization review, social work, nutrition, respiratory care, chaplain, clinical laboratory, finance and administration. Multiple task forces worked simultaneously to analyze processes and achieve a working model.

After reviewing comparative regional and national data and analyzing the scientific literature, our team concluded that we had opportunities for improvement of both financial and clinical outcomes. Because practice variations existed among the disciplines in five different geographic regions of our hospital that cared for this patient population, several practice changes were necessary as part of the improvement process.

Data from the three-month pilot period showed that the highest variances were those surrounding the new practice changes. Investigation revealed that clinicians were fearful of the changes in practice and were more comfortable with the known protocols of care. Through education about how the outcome model was grounded on research supporting the efficacy for the practice changes without an increase in complications, the staff became more comfortable following the clinical pathway and orders.

The impact of this initiative has been multifaceted. The synergy that emerged when dedicated and knowledgeable disciplines came together to improve one aspect of a process of care transcended into numerous improvements that encompass the entire continuum of care.

Prevention First-Special Kids
Charleston, W. Va.
Charleston Area Medical Center
The Prevention First Program at Women and Children�s Hospital is an idea that has grown. We started the program with the idea of providing more consistent care for children with special needs. These children often had multiple disciplines involved in their daily lives, and the only people who knew all these aspects of care were the parents. The problem was that, in an emergent situation, the family members could not supply this information, or at least not enough of it to satisfy the needs of the hospital/facility. In addition, these children were frequently readmitted, which further complicated their care and was a detriment to normal growth and development. Another problem was that this increased the financial burden on the family and the admitting facilities. For this reason, our initial plan was to:
� Identify the children with special needs.
� Make a notebook that would list all medications and past medical history, as well as special identified needs that would be specific for each patient, including parent interviews. We would also obtain consent from the family to be a part of this project.
� Obtain a list of disciplines that would need access to the information, including the areas in the hospital that would be caring for the child.

Our research has shown a marked decrease in our readmissions, as well as a significant cost decrease since the inception of the program. However, because the level of work involved in updating the books has been astronomical, we have made plans for the future to include:
� Having one notebook available to the parents at each hospital or office visit. This notebook would be updated, and the information kept in one place. This would also make the parents more involved and responsible in their child�s care.
� Adding another case coordinator to the program, especially for follow-up and home visits.
� Updating our list of patients who meet our program criteria.

We hope to research our progress, both in cost and inpatient time within the next year. We also want to do long-term follow-up regarding the future development of these children and the impact they have on society.

Heart Failure Intervention Team
University of Texas Medical Branch
Galveston, Texas
The Heart Failure Intervention Team focuses on the complex needs of congestive heart failure patients and their families, applying principles of multidisciplinary collaboration. The team was formed in response to institutional data that revealed CHF as a primary cause of hospital readmissions, emergency department visits and economic burdens for both the hospital and the patients. Our data indicated that 51% of CHF patients had inadequate financial resources to afford discharge medications and 53% were admitted because their treatment was not optimized.

The HFIT team was established to address the needs and optimize the care of these patients. The team consists of cardiologists, advanced practice nurses, a cardiac rehabilitation nurse, a dietitian, a social worker, pharmacy clinical specialists, the chaplain, a respiratory therapist and a physical therapist. Each member evaluates the patient and provides individualized education and counseling based on the needs identified. Barriers to learning are identified, and education is provided on disease process, compliance with medication, diet, daily weights and clinical follow-up. Resources, activity level and self-care skills are assessed. Funding issues are reviewed and resources activated to assist non- and underfunded patients. Scales, pillboxes and a CHF medication diary are provided. A clinical pathway was developed as a guideline for patient care.

The APN serves as the team leader at weekly meetings to discuss recommendations for changes in patient management. Regular telephone follow-up is carried out to check on compliance with medication, diet and daily weights. Follow-up also is done through clinic visits, communication with home care agencies, primary care physician contact and cardiac rehabilitation. A home health CHF clinical pathway is used.

The results are improved patient satisfaction, improved quality of life, reduced CHF readmissions and emergency department visits and improved survival rate. These outcomes are especially evident in underprivileged and nonsponsored patients.