AACN News—August 2003—Practice

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Vol. 20, No. 8, AUGUST 2003

Public Policy Update

Bill Would Provide Grants for Associate Degree Programs
Recently introduced legislation would establish a grant program for associate degree nursing programs to recruit students, provide scholarships and hire faculty. Introduced by Rep. Michael Capuano (D-Mass.), the Nurse Education Promotion Act (HR 2053) would also create a competitive grant program for professional nurses' associations to conduct continuing education programs in cooperation with hospitals and institutions of higher education, which would enable associate degree nurses to take college credit courses toward a bachelor of science degree in nursing. The intent would be to make it possible for students to receive affordable nursing education through the community college system. The bill was referred to the House Energy and Commerce and the Subcommittee on Health.

AACN has endorsed this bill and encourages members to contact their legislators to ask them to sign on as co-sponsors.

California Releases Final Staffing Ratios
The California Department of Health Services has released the final regulations to establish new minimum RN staffing ratios that all California hospitals must meet by Jan. 1, 2004. In the package approved by Gov. Gray Davis and the Department of Health Services, state officials made critical decisions on some hotly contested issues regarding implementation of the California Nurse Association-sponsored law. The law, the first of its kind in the nation, has been a model for RNs and legislators in other states. Following are some of the key decisions in the plan:

� Proposals by the hospital industry to erode the ratios in emergency departments and postsurgical recovery units and for evening, night and weekend shifts were rejected. State officials also rebuffed hospital efforts to further delay implementation.
� Improved nurse-to-patient ratios will be phased into three hospital areas. As of 2008, ratios will be lowered in step-down units, which typically house patients transferred from critical or intensive care units; telemetry units, where patients are connected to monitors; and other specialty care units, such as oncology and rehabilitation.
� Hospital adherence to scope of practice laws that protect patient safety will be ensured. No RN may be assigned or be responsible for more patients than the specified ratios. In addition to clarifying the respective roles of RNs and licensed vocational nurses and the fact that the two are not interchangeable, the regulations require that additional nurses be assigned as needed, according to the severity of patient illness.
� Hospitals are required to document staffing assignments, including the licensure of the direct caregiver for every patient in every unit on every shift, and to keep the records for one year, which will help the state monitor and ensure compliance with the law.

In addition, another bill to help ensure compliance has been introduced. AB 253 authorizes state health officials to conduct unannounced inspections and provides for fines of up to $5,000 a day for hospitals that continue to maintain unsafe RN staffing after final implementation of the ratio law.

AACN addresses its position on staffing in a statement titled "Maintaining Patient-Focused Care in an Environment of Nursing Staff Shortages and Financial Constraints." This statement can be found online.

Massachusetts Considers Minimum Staffing Law
Massachusetts would join California in establishing a minimum nurse-to-patient ratio under a bill introduced in that state's legislature. Backed by the Massachusetts Nurses Association, the bill seeks a ratio of one nurse for every four patients in medical-surgical units and a ratio ranging from between 1 to 1 and 1 to 3 in emergency departments, depending on the severity of patients' conditions. In addition, the measure would require the state health department to create a patient classification system based on acuity to allow staffing flexibility yet account for patients who require more care. The bill was introduced by state Rep. Christine Canavan (D-Brockton).

Congressional Panels OK Funding Bills
U.S. House of Representatives and Senate panels recently cleared two huge bills funding labor, health and education programs next year, despite reservations by both Republicans and Democrats about the tight budgets they had to work with. The labor, health and education bill is the largest of the 13 spending measures Congress must pass each year to fund the government.

The House Appropriations Committee, which oversees federal spending, voted 33-23 along party lines to approve the $138 billion measure, an increase of about 3%. The measure now moves on to the full House. Earlier, a Senate Appropriations subcommittee voted 11-3 to send its smaller, $137.6 billion companion bill to the full committee for consideration.

In other action, the House and Senate each passed the most sweeping Medicare reform legislation since the program's enactment. The House voted 216-215 for a 10-year, $400 billion prescription drug and Medicare modernization bill. The margin in the Senate was wider, with 76 senators voting in favor and 21 voting against.

The bills now head to a House-Senate conference committee to resolve differences. Both bills would provide billions of dollars in payment assistance to rural providers but differ in their treatment of hospitals and physicians. Under the House bill, hospitals would receive a payment update below inflation through 2006; physicians would be spared a rate cut scheduled for next year and see rates rise 1.5% in 2004 and 2005. Neither provision is in the Senate bill, but lobbyists expect the conference committee to retain them in some form. House Speaker Dennis Hastert (R-Ill.) said the House bill would reduce seniors' average individual drug costs by 37%.

Bill Would Expand Access to Nurse Practitioners
U.S. Rep. John W. Olver (D-Mass.) recently introduced the Medicaid Nursing Incentive Act of 2003 (HR 2295) to restore a previous federal mandate to cover the primary care services of pediatric nurse practitioners, family nurse practitioners and certified nurse midwives. The mandate was eliminated by the Balanced Budget Act of 1997, which encouraged states to move Medicaid recipients into managed care but excluded advanced practice RNs as participants. The legislation would expand patient access to quality healthcare by requiring states to offer Medicaid coverage of primary healthcare services provided by APRNs and would eliminate the current option that state Medicaid plans have to deny APRNs as primary care case managers.

Medicaid plans in many states currently recognize only physicians for coverage. The proposed measure would help to control Medicaid spending by offering Medicaid beneficiaries more and often less expensive primary-care provider options. In introducing the legislation, Olver noted that it would particularly benefit rural and other medically underserved areas where nurse practitioners are often more accessible than physicians. The bill also proposes to expand Medicaid fee-for-service coverage to include direct reimbursement for all nurse practitioners and clinical nurse specialists, instead of only the family practitioners, pediatric practitioners and midwives currently covered. In addition, Medicaid-managed care panels would be required to recognize the specialized services of select APRNs, such as the pain management services provided by nurse anesthetists and mental health services provided by clinical nurse specialists-thus clarifying the scope of providers required by managed care plans to specifically include APRNs.

AACN has endorsed this legislation and applauds Olver for introducing this bill supporting the practice of APRNs and helping to ensure that Medicaid patients receive quality care in a timely, cost-efficient manner.

Healthcare Leaders Set Course for Environmental Health Outreach
More than 100 leaders in medicine, nursing and environmental health have set a course for action to achieve a national, interdisciplinary vision for environmental health outreach to healthcare providers. The plan is part of the National Environmental Education & Training Foundation's 10-year National Strategies for Health Care Providers: Pesticides Initiative.

At a recent national forum in Washington, D.C,. participants identified strategies and specific action items to expand the emerging nationwide network of healthcare providers committed to incorporating environmental health into primary care education and practice.

In addition, participants identified opportunities to expand existing provider resources on the topic. In particular, commitments were obtained from several individuals to seek endorsements by national professional associations of the initiative's companion documents "National Pesticide Competency Guidelines for Medical & Nursing Education" and "National Pesticide Practice Skills Guidelines for Medical & Nursing Practice." Additional action items included pursuing consumer-based promotion of environmental health and pesticides messaging in tandem with primary healthcare provider continuing education; initiating discussion and coverage of the issue with leading physician and nursing societies; and creating educational opportunities through credentialing bodies and professional societies that influence providers' continuing education. A conference report is scheduled to be available in fall 2003.

AACN has endorsed the National Strategies for Health Care Providers: Pesticides Initiative implementation plan and supports the call for primary healthcare providers to acquire basic knowledge of the health effects of pesticides and the treatments and preventive public health strategies to address them.

Study Finds Positive Results of Emergency Defibrillation
The immediate use of defibrillators to treat people in a heart crisis does more than save lives, according to a study published in the June 26, 2003, issue of the New England Journal of Medicine. The findings demonstrate that early, effective response to sudden cardiac arrest by defibrillation and cardiopulmonary resuscitation results in an excellent long-term outcome, including normal function and return to work.

Researchers tracked 200 people who had received emergency defibrillation. Of those, 142 survived long enough to be admitted to the emergency department, and 79 were eventually discharged from the hospital. The five-year survival rate for those 79 people was identical to that of the general population. A quality-of-life questionnaire given to 50 of them produced answers typical of healthy people their age, the study said. Some complained of persistent feelings of weariness, but most were back at work. In fact, 65% of the survivors younger than 65 were working, the study found.
Roger D. White, MD, professor of anesthesiology at the Mayo Clinic, Rochester, Minn., was the report's lead author.

In a related finding, a new poll found that only 6% of U.S. workplaces surveyed were equipped with portable defibrillators. Conducted by RoperASW and Philips, the poll also found that 53% of workplaces that currently have portable defibrillators said they'd recommend that other companies have portable defibrillators on site.

AACN supports the recommendations of the American Heart Association on early defibrillation and public access.

Public Policy Snapshot

AACN Advocacy Efforts

AACN has recently submitted comments to federal agencies on several important issues:

Department of Labor
AACN joined other specialty nursing organizations in delivering comments to the Department of Labor on proposed changes to the Fair Labor Standards Act regarding the regulations that determine overtime pay exemptions. AACN is concerned that the proposed changes will eliminate the right to overtime pay for many nurses and has asked for an extension on the deadline for filing comments on the proposals so that the changes can be more thoroughly analyzed by the nursing community.

Department of Health and Human Services
As 2002-03 AACN president, Connie Barden, RN, MSN, CCNS, CCRN, was contacted by Howard Zucker, deputy assistant secretary for health, U.S. Department of Health and Human Services, and asked to comment on the issues surrounding an unexpected sudden increased demand in the need for critical care services across the nation.

Food and Drug Administration
Rebecca Long, RN, MS, CCRN, CNS, a past member of the AACN Board of Directors, prepared comments on behalf of AACN for the FDA regarding the proposed Bar Code Label Rules.

AACN's statements on these issues can be read online.

Public Policy Information Online

The Commonwealth Fund has assembled information highlighting recent research and analytical findings on Medicare, including an overview of prescription drug benefit designs under consideration by Congress.

Medicare's Future: Current Picture, Trends, and Prescription Drug Policy Debate contains more than 50 slides on the following topics:
� Trends in Medicare expenditures
� Medicare performance
� Characteristics of Medicare beneficiaries
� Medicare beneficiary expenses not covered by Medicare
� Medicare's experience with private plans
� Prescription drugs
� Medicare prescription drug legislation

You will also find a bibliography with a selection of further reading on these topics. To access the information, visit http://www.cmwf.org > Medicare.

Track Your State's Legislation Online

Find up-to-date information online regarding relevant nursing and healthcare legislation in your state. Simply visit http://www.aacn.org > Public Policy > State Bill Tracking. Updated information is posted every week.

For more information about these and other issues, visit the AACN Web site at http://www.aacn.org > Public Policy.

Workplace Violence Focus of Stakeholders Meeting

AACN President-elect Kathleen McCauley, RN, PhD, CS, FAAN, recently represented AACN at a healthcare stakeholders meeting on the Workplace Violence Research and Prevention Initiative of the Centers for Disease Control and Prevention-National Institute for Occupational Safety and Health.

The meeting provided stakeholders the opportunity to share information about their organization, identify research gaps and suggest potential collaborative efforts. Other participants represented federal government agencies, academic centers, organized labor, professional associations, industry associations, security personnel, and training and education groups.

Discussion topics included the impact workplace violence has on the nursing shortage and staffing, underreporting of workplace violence, research on intervention strategies, cost-effectiveness of prevention, and linking violence prevention to accreditation by the Joint Commission on Accreditation of Healthcare Organizations. Of particular importance was interest by the National Institute for Occupational and Safety and Health in accessing and partnering with healthcare facilities and services to collect data.

Practice Resource Network

Q: We are in the process of reviewing and revising our patient care standards for critical and progressive care. What is the frequency standard regarding patient assessment and reassessment, including vital signs?

A: AACN does not have a standard for frequency of patient assessment. According to the Standards for Acute and Critical Care Nursing Practice, the priority of data collection is driven by the patient's immediate condition and anticipated needs.1 The 2003 standards of the Joint Commission on the Accreditation of Healthcare Organizations state that patient assessment should be completed within 24 hours of admission, and reassessment should be carried out at regular intervals thereafter.2 The reassessment intervals should be determined by the patient's condition and hospital policy.2 There is no research to definitively state what the minimum frequency interval should be.

When determining the hospital standard regarding patient reassessment, acuity should be the major consideration. You can also survey similar hospitals in your area to determine the community standard. Acuity of patients may vary from unit to unit or even within the same unit. Several different methods of developing hospital patient care standards for critical care and progressive care units can be used to address the differences in acuity. Minimum frequency regarding patient reassessment can be addressed in specific unit-based standards, preprinted physician orders for specific patient populations, disease-based protocols or clinical care pathways.

Remember that the standard you develop represents the minimum level of care that should be delivered. Critical care and progressive care nurses should always increase the level of monitoring based on a change in the patient's condition or in specific treatment interventions that may precipitate a change in condition. However, the level of monitoring should never be less than what has been established as hospital policy. It is the established minimum level to which nurses and the hospital will be held by regulatory agencies and courts of law.

1. Medina J, ed. Standards for Acute and Critical Care Nursing Practice. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2000.
2. Joint Commission on the Accreditation of Healthcare Organizations. 2003 Hospital Accreditation Standards. Oakbrook Terrace, Ill: Joint Commission Resources; 2003:101-103.

AACN, ENA Cosponsored Study Finds Hospitals Still Limit Family Access to Patients During Emergency Procedures

Despite growing support for allowing family members to be present during emergency medical procedures, only 5% of U.S. hospitals have written policies permitting such access during CPR or invasive procedures, according to a new survey of nurses cosponsored by AACN and the Emergency Nurses Association.

In addition, despite guidelines to the contrary, approximately one-fourth of responding nurses say family presence continues to be prohibited during both resuscitation and invasive procedures.

The survey findings were reported in the May 2003 issue of the American Journal of Critical Care and in the June 2003 issue of the Journal of Emergency Nursing.

"When patients are in literally a life-or-death situation, their loved ones should be with them whenever possible," said AACN President Dorrie Fontaine, RN, DNSc, FAAN, one of the study's coauthors and associate dean for academic programs at the University of California at San Francisco School of Nursing. "Having family present during emergency procedures can be a great source of comfort and support for patients."

"A decade of research shows that the presence of family members during invasive emergency procedures can be helpful to families, healthcare providers and the patients themselves," added Kathy Robinson, RN, ENA president and manager of the EMS Program for the Pennsylvania Department of Health. "Yet, despite growing support for family presence during emergency procedures, too many physicians and other healthcare practitioners resist adopting this practice."

Among the findings of the survey, which was sent to members of both AACN and ENA, are:

� Approximately one-fourth of nurses reported that family presence was prohibited during CPR (29%) and invasive procedures (25%), even though their units had no written policies prohibiting such access.
� 5% of the respondents worked in units that had written policies allowing such access.
� Family members ask to be present for such procedures approximately one-third to two-thirds of the time (31% during resuscitation, 61% during invasive procedures).
� Approximately half of the units covered by the survey allow family presence without a written policy (45% during resuscitation and 51% during invasive procedures).
"The option should exist in all hospitals backed up by a written policy," Fontaine said. "There also should be education so staff members can effectively support families in deciding whether to be present during emergency procedures or resuscitation. An ongoing follow-up mechanism should evaluate the effectiveness of the policy and ensure that the rights of patients and their families are always respected."

Robinson agreed, saying, "Many ED managers and hospital administrators may not be aware of the research that has been done on family presence. Also, many may not know how to use the findings to develop guidelines and policies, customize a staff education program, or how to successfully facilitate family presence practices. Families are much more resilient under these circumstances than many healthcare providers think. Anticipated problems during resuscitation in hospitals that adopt this practice have not materialized and, in fact, most times it helps families realize that �everything possible was done' to save their loved ones."

Among the benefits the previous studies have found for allowing families to be present during medical emergencies are:

� Removing doubts about what is happening to the patient
� Reducing anxiety and fear
� Providing feelings of support and help to the patient
� Sustaining patient-family connectedness
� Providing a sense of closure on a life shared together
� Facilitating the grief process
� Engendering feelings of being helpful to the healthcare staff

Fontaine said the nation's critical care nurses, who are the most continually and intimately involved with seriously ill patients and their families, should work closely with physicians and healthcare administrators to adopt more widespread policies supporting family access during emergency procedures.

"It is the responsibility, if not duty, of every hospital to make the option of family presence available to those who will find benefit from the practice," Fontaine said.

Sepsis Education Program Available

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 newly 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 cutting-edge learning program for only the $7.50 shipping and handling fee, call (800) 899-2226 and request Item #004060. Quantities are limited.

Sept. 1 Deadline to Submit NTI Research or Creative Solutions Poster Abstracts for 2004

AACN is inviting research and creative solutions poster abstracts for consideration for AACN's 2004 National Teaching Institute and Critical Care Exposition in Orlando, Fla.

In addition to the posters, 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.

Sept. 1 is the deadline to submit the abstracts.

The application as well as guidelines and resources are now available online.


Evidence-Based Clinical Practice Grant
This program provides awards of $1,000 to stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice. Grant proposals are accepted twice a year and must be received by either March 1 or Oct. 1.

AACN Clinical Practice Grant
This $6,000 grant supports research that is focused on one or more of AACN's clinical research priorities.
Oct. 1 is the annual application deadline for this grant.

AACN-Sigma Theta Tau Critical Care Grant
This $10,000 grant is cosponsored by AACN and Sigma Theta Tau International. The grant may be used to fund research for an academic degree.
Oct. 1 is the annual application deadline for this grant.

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.

AACN Online Quick Poll

If your patient has a triple lumen catheter and you are setting up to monitor CVP, which port is the most appropriate to use?

Proximal 24%
Distal 71%
Medial 5%

Number of Responses: 1155

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 practice and opinions on particular topics. Participate by visiting the AACN Web site.

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