AACN News—December 2003—Practice

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Vol. 20, No. 12, DECEMBER 2003

Viewpoint: Collaboration With Respiratory Therapists Is Best for Patients

By Suzanne M. Burns,
AACN Board of Directors

Don�t touch the knobs" is a common �request" in critical care units. The understanding of this statement is so integrated into the practice arena that little explanation is required. When I jokingly refer to this statement in my talks on mechanical ventilation and weaning, everyone laughs and shakes their heads in knowing assent. They understand that the statement is a reference to a boundary delineated by our colleagues in respiratory care.

Mechanical ventilators are complex machines, and the respiratory therapists are specialists in managing them. I believe that the reason respiratory care practitioners promote the �don�t touch the knobs"perspective is because, like nurses, they want ventilated patients to be cared for safely and effectively, and they want to ensure that no untrained individuals adjust a ventilator. Unfortunately, this thinking can be carried to the extreme. For example, a nurse attending one of my talks shared this example:

In my hospital, the nurses are forbidden to �touch the ventilator.� When my patient had a sudden and profound drop in oxygen saturation, I began bagging the patient on 100% oxygen. The respiratory therapist and doctor were called, but the therapist was busy and the doctor took the better part of an hour to arrive. Because I was not allowed to turn the Fio2 on the ventilator to 100%, I had to bag the patient the whole time.

This nurse related her frustration with the �don�t touch the knobs" directive, because her ability to further assess the patient was severely impeded by being tethered to the side of the bed as she manually ventilated the patient and because she knew that the repercussions of not following this directive would result in being �written up"if she turned up the Fio2. Her frustration was heightened because the appropriateness of the intervention, the competency of the individual and the patient needs are not addressed by this directive.

Another example comes from South Carolina, where an advanced practice nurse with educational and skill-based expertise in ventilator management was caring for a ventilated patient who began to decompensate. The patient was bagged. The respiratory therapist who was called was unavailable. After a prolonged period of bagging the patient, the nurse adjusted the ventilator settings, put the patient back on the ventilator and continued his assessment. When the therapist arrived, the nurse informed her of his interventions. Because the �rules"dictated that only a therapist should manage the ventilator, this nurse was �written up.�

These are only two examples of a practice that is prevalent in this country. Although the intent of the �don�t touch the knobs"statement is to protect the patient, these extreme interpretations instead put the patient at extremely high risk, do not reflect the competency and education of all professionals who may care for that patient, and do not reflect collaborative relationships of trust and respect.

Standards of practice and the evidence of research validate that knowledge of mechanical ventilation is an essential part of critical care nursing practice, and the interventions required to care for the critically ill are within the scope of practice of critical care nursing. Care of the mechanically ventilated patient is a responsibility of the critical care nurse; therefore, being knowledgeable and responsible for that care includes understanding the therapy. These patients are critically ill and their well-being, their lives, depend on how quickly and correctly the nurses respond to their needs. Therefore, critical care nurses must fully understand the ventilators they use and be able to respond appropriately if the need arises. This does not mean we should do what respiratory therapists do, unless we are trained and are competent to do so.

In the medical ICU where I work, weaning trials are common and a major focus of the care we provide. In fact, we are proud of the outcomes of our multidisciplinary, collaborative, long-term mechanical ventilation program. We have learned that systematic reduction of variation and care delays is essential to the successful attainment of positive program outcomes. Our team is staffed with respiratory therapists who are extremely knowledgeable and collaborative.

We arrived at a truly collaborative unit many years ago when, to facilitate timely and appropriate weaning of our ventilated patients, we decided to train some of our nurses to make selected ventilator changes, such as Fio2, PSV and CPAP. These cross-trained nurses change settings when needed �now"and intervene when no therapist is available. This allows nurses to make changes and to continue to assess the patient and respond with other interventions as appropriate. As with any intervention nurses initiate in our institution, appropriate documentation is accomplished by critical care nursing and respiratory care flow sheets. The therapist and physician are notified of the intervention as soon as possible. This approach precludes lengthy, nonproductive delays or a nurse spending vital time on the phone trying to locate a therapist or physician.

Because they are knowledgeable, capable and essential clinicians, we rely heavily on respiratory therapists in practice. However, they cannot be continuously at the bedside. In many hospitals, true collaboration between therapists and nurses exists; in others, it is simply a standoff.

Collaboration is clearly the kind of practice we need to ensure good patient outcomes. In fact, abundant evidence exists that links collaborative practice to positive outcomes. In the case of care of the ventilated patient, the more nurses and therapists know, the better the care. To know what the nurse can do or what may be harmful, we must fully understand what �turning the knobs"does to the patient. Nurses would not give a drug to a patient without knowing the potential affects, nor would a knowledgeable nurse make a ventilator change without understanding the potential responses.

The development of a truly collaborative practice ensures that the contributions of all healthcare professionals are recognized and used to the benefit of the patient. Let�s collaborate with our respiratory therapy colleagues and do the right thing for our ventilated patients. Use your bold voices to identify practices that prevent your ability to provide safe passage for your patient and work hard to ensure that trusting and respectful collaborative practice exists. As AACN President Dorrie Fontaine encourages, this is truly �rising above"artificial boundaries and makes our work environment one in which the best clinicians want to work. The development of such a practice setting is simply the right thing to do for our patients.

Tell us about your successful collaborative practice models with respiratory care practitioners. E-mail or call (800) 394-5995, ext. 502.

Apply Online for AACN Beacon of Excellence Award

Applications are now being accepted for AACN�s new Beacon Award for Critical Care Excellence to recognize exceptional critical care units. This program will give national recognition to units that attain high standards for quality, exceptional care of patients, and healthy, humane and healing work environments.

The Web-based application process will ask you to evaluate your critical care unit in six criteria areas:

� Recruitment and retention
� Education, training and mentoring
� Evidence-based practices
� Patient outcomes
� Healing environments
� Leadership and organizational ethics

Applications may be submitted at any time and will be evaluated on a quarterly basis. Awards are granted twice a year. The application fee is $1,000 per unit. There is no limit on the number of units that may apply from a single facility.

For more information, visit the AACN Web site.

Grants Support Clinical Projects and Research

AACN offers a variety of small and large research grants. Following is information about grants for which application deadlines are approaching:

Clinical Inquiry Grant
This program provides awards of $500 each to fund projects that directly benefit patients and families. Interdisciplinary projects are of special interest. Grant applications must be received by Jan. 15.

End-of-Life Palliative Care Small Projects Grant
This program provides $500 each for projects that address a range of topics, including bereavement, communication, caregiver needs, symptom management, advance directives and life-support withdrawal. Grant applications must be received by Jan. 15.

AACN Critical Care Grant
This grant awards up to $15,000 to support research focused on one or more of AACN�s research priorities. The proposed research may not be used to meet the requirements of an academic degree. Grant applications must be received by Feb. 1.

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. Grant applications must be received by Feb. 1.

Hospice in Critical Care
This one-time, $4,700 grant will be awarded to a qualified individual carrying out a project that focuses on end-of-life or palliative care outcomes in the critical care area. A broad range of topics may be addressed. However, special consideration will be given to projects that focus on implementation of palliative care or hospice in the critical care unit. Proposals are due Feb. 15.

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. Grant applications must be received by March 1.

To find out more about AACN�s research priorities and grant opportunities, visit the AACN Web site or e-mail .

Practice Resource Network

Q: Is there a policy or guideline regarding when it is helpful or advisable to use the continuous cardiac output Svo2 pulmonary artery catheter? Specifically, for which patient population and which clinical scenario?

A. AACN�s evidence-based Protocol for Practice on Svo2 Monitoring provides the rationale for use, as well as the recommendations for practice based on the available research. The module is available online at www.aacn.org > Bookstore > AACN Product Catalog. (Item #170703; $11 for AACN members and $14 for others). In addition, the American Society of Anesthesiology has a publication titled Guidelines for Use of Pulmonary Artery Catheters, which specifically references use PA catheters with surgical patients. This document references the continuous Svo2 monitoring catheter, which you might find helpful. It is available online at www.asahq.org > Publications and Services > General Publications.

If you have a practice-related question, call AACN�s Practice Resource Network at (800) 394-5995, ext. 217, or e-mail your question to .

Public Policy Update

Workplace Changes Needed to Keep Patients Safe
Nurses� work environments need substantial changes to better protect patients from healthcare errors, according to a report released by the Institute of Medicine. Titled �Keeping Patients Safe: Transforming the Work Environment for Nurses,"the report calls for changes in how nurse staffing levels are established and mandatory limits on nurses� work hours. The recommendations are part of a comprehensive plan to reduce problems that threaten patient safety by strengthening the work environment in the areas of management, work-force deployment, work design and organizational culture.

Following are some of the findings and recommendations in the report:

� As the health professionals who interact most frequently with patients in all settings, nurses� actions are directly related to better patient outcomes. Nurses also defend against medical errors. For example, a study in two hospitals found that nurses intercepted 86% of medication errors before they reached patients.
� ICUs should increase internal oversight when staffing falls below one nurse for every two ICU patients.
� Measures of staffing levels should be developed for hospital report cards and, whenever possible, healthcare facilities should avoid using nurses from temporary agencies to fill staffing shortages.
� Long work hours pose one of the most serious threats to patient safety, because fatigue slows reaction time, decreases energy, diminishes attention to detail, and otherwise contributes to errors. State regulatory bodies should prohibit nursing staff from working longer than 12 hours a day and more than 60 hours per week.
� To improve nurses� work environments and restore trust, organizations should involve nurse leaders in all levels of management and solicit input from nursing staff on decisions about work design and implementation. Nurses are in prime positions to help pinpoint inefficient work processes that could contribute to errors, identify causes of nursing staff turnover, and determine appropriate staff levels for each unit.
� Healthcare organizations should dedicate financial resources to support nursing staff in the ongoing acquisition and maintenance of knowledge and skills, the report says.

Implementation of the recommended changes in nurses� work environments would likely help healthcare organizations recruit and retain nurses, the report says.

The study was sponsored by the U.S. Department of Health and Human Services� Agency for Healthcare Research and Quality. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. Copies of the report are available online at .

Are Patients Happy if You Are Happy?
There�s a 60% likelihood that, if employees are happy, patients are happy and vice versa, but it�s impossible to say which group�s increase drives the other, according to a study by Press Ganey Associates. The firm based its findings on a comparison of approximately 19,500 inpatient satisfaction surveys with 50,500 employee satisfaction surveys at 33 hospitals in 19 states. Additional information is available online.

Commission on Collegiate Nursing Education Amends Accreditation Standards
The Commission on Collegiate Nursing Education has amended the standards used to ensure quality in baccalaureate and graduate level nursing programs. The revised Standards for Accreditation of Baccalaureate and Graduate Nursing Programs, which will be effective Jan. 1, 2005, reflects improved consistency in the use of terminology, clarification of intent, and the elimination of redundancy. In addition, the revised standards identify specific sets of professional nursing guidelines that programs must use as the foundation for curricula. The document may be accessed online.

Dean Calls For New Nursing Incentives
Warning of a looming nurse shortage in America, Vermont Gov. and Democrat presidential hopeful Howard Dean has called for a ban on mandatory overtime for nurses and new tuition assistance for those in school.

�I was taught a lot of good medicine by nurses,"said Dean, who is a medical doctor.

He also called for better staffing ratios and higher pay, telling healthcare professionals that his background as a physician makes him a candidate who can be trusted on healthcare issues.

Dean put no price tag on his proposal and conceded that much of it would have to be accomplished through local bargaining. However, he said the president could set the tone leading to those changes. He said steps must be taken to encourage more people to enter the nursing profession. Dean said there�s an urgency to the effort because nursing shortages are already popping up and will only get worse.

Dean�s proposal includes:

� Banning mandatory overtime so that nurses are not forced to work double shifts when staffing is short
� Setting federal minimum staffing requirements and bolstering Medicare reimbursements to pay for additional nurses
� Boosting recruitment for nursing school among men and minorities.
� Boosting pay for nurses and putting in place programs to assist nursing students with tuition
� Allowing nurses to establish a practice independently from physicians, a measure that could drastically increase the availability of basic health care in rural areas

Information about the healthcare platforms of the other candidates is available online.

California Nurse-Patient Ratios Will Cost Hospitals At Least $900 Million
Hospitals throughout California are spending more money to comply with a state law on nurse-patient ratios.

The law, signed by outgoing Gov. Gray Davis two years ago, mandates a certain number of nurses on the hospital floor for every patient in a bed, depending on the department. The new ratios take effect in January. Legislation that would penalize hospitals that do not meet the new ratios stalled last month in the state Legislature.

Hospitals may absorb some of these costs by cutting budgets in other areas, healthcare officials say. However, most of the increased costs will likely be passed to insurance companies, which, in turn, will pass them on to businesses, and eventually trickle down to employees.

There also are concerns about the mandated ratios not allowing much flexibility in delivering care. For example, ratios are based on the type of licensed beds at a hospital. When a hospital gets busy and runs out of general beds, it could not put some patients in available ICU beds, because ICU-licensed beds would have to maintain the same nurse-patient ratio.

Hospitals say they simply can�t fill all the job vacancies. It�s even a challenge tapping into local schools: Nursing programs at area colleges and universities have been capped because of state budget cuts. Recruitment had gone beyond U.S. borders, with hospitals recruiting nurses from countries such as Canada, England and the Philippines.

U.S. Urged to Suspend Smallpox Program
The federal government should suspend phase two of its smallpox vaccination program until it can better evaluate the need and risks, according to an Oct. 22, 2003, Web site article of Health Affairs, the policy journal of the Health Sphere. The potential development of weapons of mass destruction by Iraq shaped initial debate over the program, but there is no way to know if the absence of such weapons indicates a lower risk for the U.S., according to the authors. Relatively few people�38,000�were vaccinated in phase one of the program, compared with the government�s initial goal of approximately 500,000 hospital and health workers.

The article is available online at .

10th State Removes Physician Supervision of Nurse Anesthetists
Alaska became the 10th state in less than two years to opt out of a federal physician supervision requirement for nurse anesthetists. The opt-out is effective immediately.

Taking advantage of an anesthesia care rule that allows states to become exempt from the supervision requirement, Alaska Gov. Frank Murkowski wrote to the Centers for Medicare & Medicaid Services that his state was opting out because �the exemption from this federal Medicare regulation will provide significant long-term benefits to all Alaskans.�

Iowa, Nebraska, North Dakota, Idaho, Minnesota, New Hampshire, New Mexico, Kansas and Washington already had opted out of the requirement.

Grants Awarded for Bioterrorism Training and Curriculum
Health and Human Services Secretary Tommy G. Thompson has announced $26.6 million in new grants to strengthen bioterrorism training and education for the nation�s health professions workforce. These first grants in HHS� Bioterrorism Training and Curriculum Development Program will fund continuing education for healthcare practitioners and curriculum development in health profession schools. Additional information is available online at www.hrsa.gov.

Nurses Urge Renaming of TB Respirator Rule
Two health professional organizations are urging the Occupational Safety and Health Administration to create a separate respiratory protection regulation by renaming the tuberculosis respirator protection standard. The groups assert this would allow OSHA to incorporate all airborne infectious diseases into the standard. But labor officials disagree.

Labor officials say such a move would leave healthcare workers inadequately protected from infectious diseases, such as severe acute respiratory syndrome, which they say require worker protection measures much more stringent than called for under the TB rule. However, the health professional organizations are signaling they would entertain revisions to the current standard.

For example, the groups are urging OSHA to �determine respiratory protection requirements for healthcare workers based on the size of the infectious microbe."The groups argue that �the need for a new, separate respirator standard to protect against airborne infections is underscored by the trend toward the emergence of newer, more virulent strains of infectious diseases that will continue to have worldwide impact.�

In comments submitted jointly by the American Association of Occupational Health Nurses and the Association of Occupational Health Professionals on the agency�s rulemaking for assigned protection factors, the groups recommend changing the title of its respirator protection standard from �Respiratory Protection for M. Tuberculosis,"to �Respiratory Protection for Airborne Infectious Diseases."

OSHA extended the public comment period on assigned protection factors and had no comment on the recommendation. The respirator TB standard calls for personal protective equipment and fit testing saying, �Frequent random inspections shall be conducted by a qualified individual to assure that respirators are properly selected, used, cleaned, and maintained."Regarding fit testing, the standard states, �Every respirator wearer shall receive fitting instructions, including demonstrations and practice in how the respirator should be worn."Additional information is available online at www.osha.gov. Search in the index for Respiratory Protection.

Public Policy Snapshot

Factors Found to Influence Withdrawal of Ventilatory Support

Mechanical ventilation is the most common form of advanced life support in the ICU, yet the factors associated with physicians� decisions to withdraw ventilation from critically ill patients in anticipation of death are often unclear. In an observational study, investigators in ICUs, mostly in North America, tried to determine what influenced the outcomes of these discussions about end-of-life care. They focused on the factors that led physicians to withdraw ventilatory support in anticipation of death.

According to the study:*

� One of the four factors influencing the decision to withdraw ventilatory support was the patient�s reliance on medications to maintain blood pressure.
� The other three factors involved more subjective judgments by the ICU physicians, including their predictions of survival and cognitive function beyond the ICU, and their perceptions of the patient�s preferences.
� Physicians influence the decision-making process by virtue of how they forecast the patient�s future, and the family influences these decisions by helping physicians to understand the patient�s desires.

The researchers note that their results call into question the traditional biomedical model of withdrawal of life support that focuses on the patient�s age and physiological determinants such as worsening organ function. Although they are encouraged that their findings suggest that the process of withdrawal of life support is attentive to patients� wishes, they are also concerned that when patients� are unable to communicate their preference, neither family members nor physicians may accurately represent their wishes.

* Source: Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. New England Journal of Medicine, Sept. 18, 2003.

For more information about these and other issues, visit the AACN Web site.

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