Wealth of Resources Targets
Advanced Practice Nurses
By Debby Greenlaw, RN, MS,
CCRN, NP-C
Advanced Practice Work
Group
Advanced practice nurses have
met educational and clinical practice
requirements beyond the two to four years of
basic nursing education and have acquired
advanced preparation for expanded clinical
practice by earning a master's or doctoral
degree in nursing.
AACN is committed to
supporting the practice of APNs in providing
healthcare services. The AACN Strategic Plan
outlines methods to meet the needs of its
APN members with strategies focusing on
education, publications and clinical
resources, along with collaborative efforts
that support public policy initiatives and
issues. The
Advanced Practice Work Group,
which is reviewing these resources as part
of its charge for the year, is confident you
will be impressed with the resources AACN
offers to APNs. Check them out.
- Advanced Practice Fact
Sheets provide information on APN roles,
reimbursement and prescriptive authority.
- Advance Practice Links from
the Advanced Practice area of the AACN Web
site (www.aacn.org > Clinical Practice)
connect to a variety of nursing, advanced
practice and medical organizations, graduate
school listings and ethics sites. For
example, there is a link to the Advanced
Practice Nurse Survival Guide Web site,
where more than 600 medical and nursing
resources for APNs are available. Other
links to Medscape and NPLinx provide access
to articles on legal and professional
issues, APN topics and discussions, and
clinical issues and updates.
- ANPACC ListServ is for
Advanced Nursing Practice in Acute and
Critical Care. Its purpose is to enhance
communication among APNs, educators,
researchers and physicians on issues of
concern to advanced practice nurses.
- CCNS Certification is
achieved through an exam for adult, neonatal
or pediatric clinical nurse specialists in
acute and critical care. AACN members
receive a $100 discount on the exam fee.
- AACN News features advanced
practice articles, which can also be
accessed online from the Advanced Practice
area of the AACN Web site. Recent topics
include APN roles, PDA resources, becoming
an entrepreneur, clinical practice
guidelines and protocols, and demonstrating
the value of APNs.
- PDA Center provides a
selection of handhelds and software for use
in daily clinical practice. Tutorials to
assist in making those choices are
available, as well as downloads that are
both free and for purchase.
- Conferences of interest to APNs are featured and can be accessed from
the Advanced Practice area of the AACN Web
site.
- AACN Clinical Issues:
Advance Practice in Acute and Critical Care
article abstracts from each issue can be
accessed from the Advanced Practice area of
the AACN Web site. Selected articles for CE
are available for download.
- Advanced Practice Institute
is planned in conjunction with AACN's
National Teaching Institute and Critical
Care Exposition. Sessions are tailored
specifically to the needs and interests of
APNs, including skills development, role
delineation, patient management and
pharmacology. In addition, API participants
are guests at a special APN reception. The
2003 API is scheduled for May 17 through 22,
in San Antonio, Texas.
- American College of Nurse
Practitioners provides AACN, as a national
affiliate member, two publications- the
American Journal for Nurse Practitioners and
Nurse Practitioner World News-to distribute
to its advanced practice members.
- AACN Resource Catalog and
Online Bookstore offers books and other
supporting products specifically aimed at
APNs.
- Volunteer Opportunities
provide a diversity of opportunities for
networking and professional growth.
In the Circle: Annual
Award Honors Excellent Nurse Practitioners
Editor's Note: The AACN
Excellent Nurse Practitioner Award
recognizes acute and critical care nurses
who function as nurse practitioners and who
demonstrate the key components of advanced
practice nursing, including leadership,
advanced practice clinical skills, research
application, evidence-based practice,
outcome-focused practice, cost containment,
quality assurance, mentoring, problem
solving and communication with patients,
families, staff and systems. Recipients of
this award for 2002 were given complimentary
registration, airfare and hotel
accommodations for NTI 2002 in Atlanta, Ga.,
which also featured the API. Following are
excerpts from exemplars submitted in
connection with this award.
Sophia Chu Rodgers, RN,
MSN, NP-C, ACNP
Albuquerque, N.M.
Lovelace Health Systems
Selina, an 18-year-old
college freshman, was driving from work to
her dorm when a semi-truck struck her car.
Selina sustained a serious closed head
injury, pelvic rim fracture, a left tibial
plateau fracture, C-spine ligamentous injury
and a grade I splenic injury.
After evaluating Selina, who
responded only to pain, I met with her
family. I used all the pertinent films to
explain Selina's injuries. I also discussed
the plan of care and told them that I would
be the liaison who would meet with them
daily.
Selina had some small
setbacks, but overall her neurological
status improved. She had signs of dysphagia,
cognitive impairment and expressive aphasia
along with a left-sided neglect. However,
she did follow some simple commands.
Every morning I met with the
family to review the previous day's progress
and our plan for the day. This became such a
ritual that they joked about adopting me
into their "familia."
Selina's neurological status
continued to improve until she was ready for
transfer to rehabilitation. The day of
discharge was emotional. Selina had been
with us for nearly four weeks.
Eight months had passed since
the accident, and I thought I would never
hear from or see Selina again. Then, I
received a beautiful and moving letter and a
picture her father took of us several months
ago. She stated that she would be returning
to school, and she had no neurological
deficits. This type of reward makes me proud
and glad to be a nurse.
Patricia Long, RN, MSN,
ACNP
Long Beach, Calif.
Long Beach Memorial
Heart Institute
"See if there is anything you
can do for him," the cardiologist requested
on his rounds with the resident. As an acute
care nurse practitioner with expertise in
heart failure, the request was not unusual.
Fred was an overweight
diabetic who had come to the emergency room
complaining of chest pain. Intravenous Lasix
and Nitroglycerin had been started, and he
had been ruled out for myocardial
infarction. Over the past 48 hours, the
diuretic had worked its magic. Fred had lost
15 pounds of fluid; there was no pedal
edema; and the echocardiogram showed his
heart was contracting well. However, he was
still so short of breath he could not stand
to urinate. Was this really heart failure?
I immediately ordered a
B-type natriuretic peptide test. When it
came back at 104 peakograms, a pulmonologist
was called for consultation. Arterial blood
gases, pulmonary function tests and a spiral
CAT scan revealed a pulmonary embolism in
the right lower lobe. Anticoagulation was
started.
After six days, Fred's
breathing had improved, and he could easily
stand to urinate. The respiratory case
manager gave instructions about using the
peak flow meter and his new inhalers. He was
educated about Coumadin and the importance
of keeping green leafy vegetables consistent
in his diet. I reminded him to continue his
daily weighing and maintain his diabetic and
two-gram sodium diet. He was given
medication instructions and advised to call
me if he had any symptoms of shortness of
breath. I arranged a home health nurse and
physical therapist to supervise his home
program.
The best contribution I can
make as a nurse practitioner is to advocate
for my patient, promote collaboration
between all caregivers and provide an
environment where patients like Fred can
receive the expertise and education I have
to offer.
Tamara L. Philpott, RN,
MSN, CCNP-BS, CCRN
Josephine, Texas
Presbyterian Hospital of
Dallas
Equipped with only a name and
diagnosis, I knocked on the door of room 437
on the telemetry unit and entered. An
elderly gentleman wearing only long johns
and a pullover shirt harshly demanded, "Just
who the hell are you?" I took a deep breath,
introduced myself and told him that I was
here to perform a history and physical on
him.
The history revealed several
concerns regarding this 71-year-old rancher,
including a recent diagnosis of severe
aortic stenosis, S/P CABG X 4 in 1996,
stents to his RCA in 1998, hypertension,
hyperlipidemia, depression, tobacco abuse
and degenerative knee disease. John also
revealed a history of several episodes of
syncope and falls, probably from the result
of his aortic valve disease. John reported
that he was slowly deteriorating, limited by
his physical abilities, which led to
increasing dependence on others to manage
the ranch. This loss of control contributed
to excessive drinking, further depression
and financial worries.
John underwent a battery of
tests that ruled out permanent liver damage
and carotid artery stenosis. The most likely
cause for syncope was the aortic stenosis
and alcohol indulgence. John underwent
minimally invasive aortic valve replacement
with a pericardial tissue valve, eliminating
the long-term need for anticoagulation.
John and his family looked to
me for reassurance and guidance. We had
lengthy discussions regarding his future and
social habits. Social work assisted in
arranging for home healthcare, and all the
staff played a vital role in discharge
planning and teaching. He continued to make
progress and was discharged home on
postoperative day four, decked out in
Western boots and jeans. I think of John
often and feel that I got a glimpse of the
Western life.
The Power of One:
Physician-Nurse Collaboration Was Key to
Outcome
By Kate Sullivan Collopy,
RN, PhD, CCNS
Ethics Work Group
At age 57, Mr. R. had
experienced a nagging chest cold for several
weeks. Although he received treatment, his
condition worsened into pneumonia that
resisted treatment with antibiotics. After
six weeks, he was admitted to the medical
unit of a community hospital for
oxygenation, chest physiotherapy, IV
antibiotics and a diagnostic workup.
The first night, he
experienced a progressive decline
culminating in a respiratory arrest. He was
immediately intubated and transferred to the
ICU.
Over the next six weeks, Mr.
R.'s stay in the ICU was characterized by
extremes. Although he was given
comprehensive care led by an experienced
weaning team, several days of improvement
were followed by declines that impeded his
progress. He found the frequent suctioning,
necessitated by copious secretions,
demeaning and agonizing. Sobbing
uncontrollably and complaining that he was
"tired of living this way," he begged the
nurses and respiratory therapists to leave
him alone.
In contrast, his wife and his
longtime primary care physician, Dr. C.,
were indefatigable in their view that each
decline was a temporary setback and that a
permanent improvement was "just around the
corner." When the nurses gently brought up
the possibility that Mr. R. might not
recover, the reply was, "You don't know Jim
like we do." Mrs. R. shared that her husband
had worked full time in the Air Force while
going to school full time and being an
active father. Dr. C. described how Mr. R.
had recovered from a horrific injury to his
knee, working tirelessly in therapy until he
could walk unassisted and without a limp.
The nursing staff became
increasingly frustrated, because they
perceived that Mr. R. was able to view his
situation realistically, but that his wife
and physician were holding on for a
miraculous recovery that was not likely to
occur.
At the same time, Mrs. R. and
Dr. C. were becoming increasingly frustrated
with the nursing staff and most members of
the weaning team. Insisting that, "apart
from his respiratory status," he was a
"relatively young, healthy man," they were
furious that anyone would consider anything
less than aggressive care.
Ms. T., Mr. R.'s primary
nurse, felt torn. On one side, she had a
somewhat resilient, highly vulnerable
patient who, though able to repeatedly draw
on his reserves, was unable to sustain a
rally. He was despondent and irritable with
both his family and his caregivers. On the
other side, she was feeling pressure from
her peers, who expected her to "persuade the
family and Dr. C. to see reason."
Ms. T. scheduled a meeting
with Dr. C. to review the case. However, she
asked him to first spend an hour with her at
Mr. R.'s bedside to get an idea of what it
was like to care for him an extended period
of time. Dr. C. gladly accepted. He had an
opportunity to assist in suctioning,
turning, cleaning and feeding Mr. R. He was
distressed to see how painful performing
basic activities of living were for Mr. R.
and was clearly distressed to see his
patient beg "to be left alone to die." At
the same time, Ms. T. was struck by the
tender care that Dr. C. provided as he
engaged Mr. R. in conversations about his
friends, family and hobbies. It was apparent
that he knew Mr. R. well.
During their meeting, both
Dr. C. and Ms. T. had an opportunity to
discuss their concerns and experiences with
Mr. R. in detail. Ms. T. began to understand
that her physician colleague saw the patient
as an acutely ill man who was in a
reversible condition. She understood his
frustration that anyone would consider
"giving up on him."
Dr. C. began to see that the
nurses were advocating for what the patient
stated that he wanted. They agreed to call a
"timeout" where no weaning would be
attempted for a period of 10 days. In the
interim, psychiatric and pain services
consults were called to ensure that Mr. R.'s
desire to stop treatment was not due to pain
or despair. As a result of the meeting and
the increased understanding that resulted,
communication among the nurses, physicians,
family and patient improved greatly.
During the 10-day period,
several different medications were tried,
which significantly decreased but never
completely alleviated, his pain. Mr. R. had
more uninterrupted sleep and his mood
improved. Although suctioning was still
difficult, he was able to tolerate it
better. As a result of the psychiatric
consult, antidepressants were ordered. Soon
after, weaning was reattempted.
Mr. R. appeared to be
responding well until he experienced a
massive myocardial infarction and
cardiopulmonary arrest. Although he was
resuscitated, it was soon apparent that he
had sustained a significant cerebral insult.
Ms. T. and Dr. C. jointly called for a
patient care conference to discuss his
prognosis with the staff and family. During
the conference, Mrs. R. and her children
agreed to withdraw life support. Mr. R. died
20 minutes after removal of the ventilator.
The family told the staff that they were at
peace, as the last few weeks had given them
an opportunity to work together to try to
give Mr. R. the best possible result.
The key to this outcome was
the collaboration between Ms. T. and Dr. C.
By spending time together in direct patient
care, they each saw a new side of one
another. Dr. C. was moved by how difficult
it was to suction Mr. R. and how hard it was
to hear him beg them to let him die. Ms. T.
was surprised to see the deep, mutual caring
between Dr. C. and Mr. R. that had not been
obvious during brief, daily rounds. Working
together, they were able to share their
clinical judgments, to synthesize
conflicting data to come to consensus and to
present a united front to the family and the
rest of the healthcare team.
Grants
Apply for Medtronic Physio-Control
Small Projects Grant
AACN offers a variety of
small and large research grants. July 1 is
the deadline to apply for the Medtronic
Physio-Control AACN Small Projects Grant.
This grant awards up to $1,500 for a project
that focuses on aspects of acute myocardial
infarction, resuscitation or sudden cardiac
death, such as the use of defibrillation,
synchronized cardioversion, noninvasive
pacing or interpretive 12-lead ECG.
To find out more about AACN's
research priorities and grant opportunities,
visit the AACN Web site. The grants handbook
is also available from AACN Fax on Demand at
(800) 222-6329, Request Document #1013.
Viewpoint: Oh, My
Aching Back! Become Ergonomically Healthy
By Susan Yeager, RN, MS,
CCRN, ACNP, EMT
AACN Board of Directors
When someone mentions healthy
work environment, do you automatically think
of Ben Gay, support hose and orthopedic
shoes? Is a therapeutic back massage more
appealing than jewels as a special gift?
Although the jewel replacement question may
be a bit over the top, supportive ergonomics
to promote a positive work environment
should not be.
Achievement of a positive,
work environment is multifactorial. A
healthy unit is often equated with
communication and conflict management
expertise, such as collaborative
nurse-to-nurse and physician-to-nurse
relationships or supportive management.
However, healthy environments encompass
more, including the actual physical space
and technologic support available to a
caregiver. And, it's not just the aging,
"seasoned" nurse who has to worry about
ergonomic health.
According to 1998 statistics
from the Bureau of Labor, nursing tops the
list of occupations most associated with
work-related, musculoskeletal disorders. In
fact, 12 out of 100 nurses in hospitals
report work-related musculoskeletal
injuries-approximately double the rate for
all other industries combined.
To create an improved
ergonomic reality, our nursing colleagues in
the United Kingdom, Canada and Australia
have adopted a national approach to their
ergonomic health. In these areas,
legislation has even been passed to prohibit
nurses from lifting. Several nurses in the
US are working to collect the necessary data
to promote this best practice in our
nation's hospitals.
As a part of a recently
completed study headed by Audrey Nelson, RN,
PhD, FAAN, director of the VHA Patient
Safety Center, spinal cord and nursing home
units at VA hospitals in Florida and Puerto
Rico participated in a multisite trial.
The study began with an
individual assessment highlighting ergonomic
opportunities in each area. Based on these
recommendations, technology that resulted in
a "no-lift" environment was purchased in
these areas. Although the results of this
study have not yet been published, Nelson
says that the decrease in her endpoints was
positive enough to promote a second phase of
study, with expansion into critical care
units.
Building on Nelson's work, a
spinal cord unit in a VA hospital in San
Diego, Calif., implemented a "no lift"
policy. Headed by Kathleen Dunn, RN, MS,
CRRN, the clinical nurse specialist and
rehabilitation case manager, the policy was
presented to and gained the support of the
unit administrators. Dunn and unit staff
then collaborated with a variety of vendors
to select the product that would provide the
technology necessary to create a more
ergonomic unit.
The technology installed used
ceiling tracks and Hoyer-like devices that
enabled nurses to move patients from the bed
to the toilet or the chair without lifting.
As a result, Dunn says, no injuries have
occurred in the past six months, indirectly
saving $100,000.
The San Diego VA spinal cord
unit staff was able to collectively use
their research utilization voice to create
changes that promote ergonomic health for
nurses. Additional examples of ways nurses
can use their voices in this fashion can be
as informal as a conversation with an
industry partner to provide input into
product development, or as formal as
collecting data. As was the case with the
San Diego VA, vendors want to hear feedback
on prototypes or designs for support devices
from the people who will be using them-the
nurses.
To determine whether your
unit supports ergonomic health, answer
several of the following questions:
- Are the computer terminals
and monitor levels ergonomically correct?
- What is the average patient
weight on a given day/week?
- What is the location, and
weight of commonly used supplies?
- Do the chairs at the
nurse's station have lumbar support?
- Are step stools available?
Going a step further,
collaborate with your Quality Assurance or
Human Resource department to compile answers
to the following questions:
- How many nurses sustain
work-related musculoskeletal injuries
annually?
- Is your area a "high-risk"
area. For example, are spinal cord injured
or large, unconscious individuals cared for
on your unit?
- What is the estimated cost
of workman's compensation and sick leave
pay, and the annual cost of replacement
staff for musculoskeletal-related injuries?
By using data in this
fashion, the economic impact of not having
protective devices can be equated to
eventual cost savings. Support for obtaining
ergonomic technology will be perceived not
as another direct cost to the institution
but as a solution that makes economic sense.
It is a language that decision-makers will
more likely listen to when we exercise our
bold voice.
Public Policy Update
$20 Million Approved for
Nurse Reinvestment Act
AACN commends Congress and
the efforts of Sens. Barbara Mikulski (D-Md.)
and Ted Stevens (R-Ark.) in approving $20
million in new federal funds for nurse
education programs. The funds are included
in the Nurse Reinvestment Act as part of the
omnibus appropriations bill for FY2003.
The Nurse Reinvestment Act
(PL 107-205), which was signed into law in
August 2002, not only expands authority for
existing nursing programs, but also creates
new ones. For example, the new law
authorizes scholarships and loan repayments
for nursing students who agree to work in
areas where there is a shortage of staff
after they graduate. In addition, the act
authorizes public service announcements to
promote nursing as a career, loan
cancellations for nursing faculty, grants
for geriatric nurse education and grants to
encourage nursing best-practices.
Although these funds will
assist in implementing the programs included
IN the act, AACN will continue to
collaborate with other nursing organizations
to obtain additional funding for the
programs in fiscal year 2004.
Bills Would Limit
Unscheduled Overtime
Companion bills introduced by
Sen. Edward Kennedy (D-Mass.) and others in
the Senate and by Rep. Pete Stark (D-Calif.)
and others in the House would restrict the
use of unscheduled overtime for nurses to an
official state of emergency declared by
federal, state or local government. H.R. 745
has been referred to the House committees on
Energy and Commerce and on Ways and Means,
and S. 373, has been referred to the Senate
Committee on Finance.
AACN's Position: AACN
believes that mandatory overtime is not an
acceptable means of staffing a hospital,
because it may place nurses and their
patients at increased risk of being involved
in medical errors. Instead, nurses should be
able to decide whether working overtime will
affect their ability to care safely and
effectively for patients. They should have
the option of refusing overtime assignments
and not be forced into working beyond their
capacity to provide optimal care. AACN
supports this legislation and will continue
to work to educate the public on the
negative impact that mandatory overtime can
have on patient safety.
Nursing Education Bills
Introduced
AACN has endorsed two
recently introduced bills that will increase
education loan opportunities and loan
forgiveness for nursing students. The
Teacher and Nurse Support Act of 2003,
introduced by Sens. Tom Harkin (D-Iowa) and
Ted Stevens (R-Ark.), would amend the Higher
Education Act of 1965 to increase nursing
education loan opportunities within the
Department of Education. H.R. 501, the Nurse
Loan Forgiveness Act of 2003, introduced by
Rep. Tom Tancredo (R-Colo.), would establish
a student loan forgiveness program for
nurses.
AACN encourages members to
contact their legislators to voice support
for these pieces of legislation. Visit
AACN's Legislative Action Center to send your
messages. Full text of the bills can also be
viewed from this area.
Bills Offer Smallpox
Safeguards, Border Funds
In a move that could give
President Bush's lagging smallpox
vaccination campaign a push, Rep. Henry
Waxman (D-Calif.) introduced legislation to
establish "no fault" compensation for those
injured by the vaccine and help states offer
education and testing for risk factors. The
legislation would give states full funding
for the immediate medical care of healthcare
workers or first responders injured by the
vaccine or anyone injured by coming into
contact with someone recently vaccinated. It
would prohibit discrimination against
workers who refuse the vaccine and authorize
up to four days' paid leave following
reactions.
In related news, border-state
hospitals would be reimbursed for treating
illegal immigrants under bills introduced in
the Senate by Sens. Jon Kyl and John McCain,
both Arizona Republicans, and in the House
by a fellow Arizona Republican, Rep. Jim
Kolbe. The lawmakers seek $1.45 billion per
year for four years. And, the House Energy
and Commerce and Ways and Means committees
passed a bill to expedite Medicare
beneficiaries' appeals of claim denials,
establish a beneficiary ombudsman and create
a central, toll-free help center to answer
beneficiaries' questions.
A comprehensive guide to
smallpox vaccination resources for
clinicians is available on the Centers for
Disese Control and Prevention Web site. In
addition, the CDC has established a
Clinician Information Line for Smallpox and
Smallpox Vaccination at (877) 554-4625.
New Patients' Bill of
Rights Introduced
Rep. Charlie Norwood (R-Ga.)
attempted to revive the patients' rights
issue by introducing two bills-one to
establish a Patient Protection Act ensuring
access to certain kinds of care and a
second, the ERISA Clarification Act, to
guarantee that state law on medical
necessity supersedes the federal Employee
Retirement Income Security Act. Although
Norwood acknowledged that such issues may
lack momentum, given the sour economy and a
possible war with Iraq, he said insurers'
and employers' increasing concern about the
cost of healthcare potentially threatens the
quality of care patients receive. The
Patient Protection Act is similar to a bill
passed by the House last year, but allows
states to set more stringent standards than
federal law. The Health Insurance
Association of America said the bills would
impose "hundreds of new, duplicative federal
regulations, throw out the insurers' right
to contract and require insurers to rewrite
millions of existing insurance policies, all
of which will require higher health
insurance premiums."
Register for Terrorism
Updates and Training
The Centers for Disease
Control and Prevention has set up a registry
to provide clinicians with real-time
information to help prepare for or possibly
respond to terrorism events. Participants
receive regular e-mail updates on terrorism
issues and training opportunities relevant
to clinicians.
For more information about
these and other issues, visit the AACN Web
site.
Bush Outlines Funds for
Nursing Education
The president's budget
provides $98 million for nursing programs.
Included is $7 million to implement the
newly authorized scholarship programs
contained in the Nurse Reinvestment Act.
Scholarship recipients must provide nursing
care for a minimum of two years in a
facility with a critical shortage of nurses
to fulfill their service commitment.
In addition, the budget
reflects a redistribution of monies between
basic and advanced nursing education. The
redistribution places the funding priority
on basic education and reflects the
recommendations of an independent expert
panel. The panel's recommendations are
designed to help attract people into the
profession while maintaining support for
advanced practice nurses. For FY2004, the
budget allocates $72 million to support
basic nurse workforce development and $26
million for advanced nursing education. The
budget also includes $10 million for
scholarships focused on increasing diversity
in the health professions through the
Scholarships for Disadvantaged Students
program.
HEALTH AND HUMAN SERVICES
Health Resources &
Services Administration
Advanced Nursing
Education
Nursing Workforce
Diversity
Basic Nurse Education
and Practice |
President's FY2003
Appropriations
Request
$ 6.08B
$ 61.04M
$ 6.17M
$ 16.29M |
President's FY2004
Appropriations
Request
$ 26.00M
$ 72.00M
|
2004
+/- 2003
-$35.04M
-$ 6.17M
$55.71M |
Subtotal: Nursing Workforce
Nursing Education
Loan Repayment
Health Professions
Education |
$ 83.50M
$ 15.00M
$ 11.00M |
$ 98.00M
$ 11.00M |
+$15.00M
-$15.00M |
Total: Health Professions
Scholarships for
Disadvantaged Students
National Health
Service Corps
Bioterrorism Hospital
Preparedness
Bioterrorism Medical
School Curriculum
|
$ 109.50M
$ 10.00M
$191.51M
$ 518.00M
$ 60.00M |
$109.00M
$ 10.00M
$213.00M
$518.00M
$ 60.00M |
-$ 0.5 M
$ 21.49M |
Agency for Healthcare Research &
Quality
National Institutes
of Health
National Institute of
Nursing Research |
$251.00 M
$ 27.30B
$131.00M |
$279.00 M
$ 27.90B
$135.00 Ml
|
+$28.00 M
+$ 0.60B
+$ 4.00M
|
|
