AACN News—November 2003—Practice

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Vol. 20, No. 11, NOVEMBER 2003

Public Policy Update

AACN Commends Vote to Reject Overtime Changes
AACN applauds the vote by the U.S. House of Representatives in support of a nonbinding motion instructing House-Senate conferees to block a proposed Department of Labor change to the Fair Labor Standards Act that would have revised overtime protections. The 221-to-203 vote reflected a switch in position for seven Republicans who previously had supported the revisions. The House decision followed a similar, favorable vote in the U.S. Senate.

Although nonbinding, the House vote does provide instruction to the conference committee that will finalize the bill. Despite the consensus by the House and Senate on this issue, President Bush has announced he will veto the Labor-Health and Human Services appropriations bill if it includes an amendment to bar implementation of the proposed FLSA revisions.

An overview of the proposed changes can be found at http://www.dol.gov > Employee Standards Administration Wage and Hour Division.

AACN opposes the proposed changes and, along with other nursing organizations, submitted comments to the Department of Labor outlining concerns. These comments are available online.

Education Levels Tied to Quality of Care
Hospitals with low percentages of nurses who have bachelor's degrees have nearly twice as many surgery patient deaths as those with high percentages of nurses with bachelor's degrees, according to a study published in the Journal of the American Medical Association. Researchers from the University of Pennsylvania examined the outcomes for 232,342 surgery patients discharged from 168 hospitals in Pennsylvania between April 1, 1998 and Nov. 30, 1999, along with administrative and survey data about nurses at each hospital.

Patient outcomes were studied for common operations, including knee replacements, appendectomies and gallbladder removals. At the hospitals studied, the percentage of nurses with bachelor's degrees ranged from none to 77%. Researchers adjusted for hospitals' size, teaching status, level of technology and nurse staffing, as well as for nurse experience and board certifications of patients' surgeons.

The study found that hospitals with fewer than 10% of nurses with bachelor's degrees had patient death rates of about 3%, while hospitals where more than 70% of nurses had bachelor's degrees had patient death rates of about 1.5%. For every 10% increase in the proportion of nurses with bachelor's degrees, there was a 5% decrease in the likelihood of patient death within 30 days of admission. According to national 2001 data, 61% of new registered nurses came from associate degree programs, 36% came from bachelor's degree programs, and 3% came from hospital diploma programs.

NQF Releases Nursing Care Standards Draft
The National Quality Forum has released a draft of a set of consensus standards for measuring nursing care in hospitals. According to a draft of the standards, the 13 measures are based on a growing body of evidence that demonstrates the influence of nursing personnel and the stability of nursing personnel on patient outcomes, hospital costs and the professional atmosphere in which care is provided.

The measures of nursing care were sufficiently supported by scientific data to gain the endorsement of various committees representing consumers, purchasers, researchers, providers and health plans. They include prevalence of conditions or events suffered as a result of a hospital stay, such as pneumonia, pressure ulcers and falls. The standards also include total work hours by nurses per 1,000 patient days.

The NQF, established as a public-private partnership in 1999, published consensus standards for overall hospital performance earlier this year. The Leapfrog Group, the CMS and the Joint Commission on Accreditation of Healthcare Organizations have said they plan to incorporate NQF standards in their quality-measurement efforts. Additional information and a draft of the standards are available online at www.qualityforum.org.

Study Shows That Healthcare Quality Varies Widely
A study, conducted by HealthGrades, Lakewood, Colo., on medical outcomes at the nation's hospitals found that healthcare quality varies widely state by state, with better-performing facilities generally concentrated in northern or less populous states and worse-performing facilities generally in southern states. The study compiled information on 26 procedures and diagnoses at nearly 5,000 U.S. hospitals using Medicare data adjusted for severity of illnesses. The data cover the years 2000 through 2002.

New York ranked the highest for quality of hospitals, followed by Florida, Ohio, Michigan and Maryland. The rankings were based on results of five procedures and diagnoses in the areas of angioplasty, heart attack care, heart bypass surgery, heart failure and pneumonia. In other findings, quality-improvement efforts at the state level were tied with higher quality for coronary bypass surgery. Among the best performers were New Jersey, New York, Pennsylvania, Michigan, Massachusetts and Virginia, which have well-established efforts by Medicare quality improvement organizations or support profiling physician outcomes. The report is available online at http://www.healthgrades.com > Media.

California Nurse Staffing Enforcement Law Defeated
Legislation authorizing tougher enforcement measures of California's nurse-staffing law was defeated in the final hours of the legislative session in September. Nurses' lobbyists said they would "be back next year" to push for heavier sanctions against hospitals that don't meet the state's mandatory minimum nurse-to-patient staffing ratios, which take effect Jan. 1.

The proposals in the state legislature called for unannounced hospital inspections and fines of up to $5,000 per day for violations of the staffing law that put patients in "immediate jeopardy." Currently, state health officials can fine a hospital $50 per patient per violation if the hospital fails to comply with its own plan for correcting unsafe conditions.

California labor organizations said they have formed a watchdog group to track hospital compliance with the new state law that mandates minimum nurse-to-patient staffing ratios. Hospital Watch, made up of 11 labor groups, including the Service Employees International Union, will ask hospital employees for reports on their hospitals' staffing levels and will educate the public about the law, a spokeswoman said.

ANA and UAN File Amicus Brief on Definition of �Supervisor'
The American Nurses Association and its affiliate, United American Nurses, AFL-CIO, collaborated to file an amicus brief with the National Labor Relations Board regarding its review of the statutory definition of "supervisor." The board asked for briefs to address how and whether employees use "independent judgment" and "assign and direct" work so as to be viewed as supervisors that must be excluded from bargaining units. Two of the three cases that the board is focusing on involved nurses.

ANA and UAN addressed from a policy perspective the impact of the potential exclusion of RNs who work as charge nurses or who delegate work to unlicensed assistive personnel. The amicus brief cited the literature highlighting that positive working conditions are an important piece of addressing the nursing shortage. In addition, many workplace gains have been acquired through collective bargaining. Given the historical support for the ability of professional nurses to organize, the ANA and UAN urged the board to adopt an interpretation of the law that recognized the professional norms of nursing, which through state laws and the Code of Ethics for Nurses, authorize and require delegation to others on the nursing team, without the employer giving nurses true managerial prerogatives associated with supervisory status.

For more information, read the brief online at http://www.nursingworld.org.

AHRQ Releases New Study on Medical Errors
According to a new study by the Agency for Healthcare Research and Quality, medical injuries in hospitals claim more than 32,500 lives in the United States each year, and that such complications lead to at least 2.4 million extra days on the wards and up to $9.3 billion in added costs. A 1999 report from the Institute of Medicine claimed that medical errors lead to between 44,000 and 98,000 deaths a year in the United States, at an annual cost of $17 billion.

The new study, which looked at 18 categories of hospital complications and not the entire gamut, doesn't challenge those estimates. But it does refine the numbers in a way that the previous report could not.

In the last two years, AHRQ, a division of the U.S. Department of Health and Human Services, has used a system for identifying medical injuries in hospital patients that relies on hospital billing records. The method is less taxing and more cost-effective than sifting through medical records, which has been the gold standard of patient safety studies.

For the latest study, researchers looked at nearly 7.5 million billing records from 2000. The cases covered 994 hospitals in 28 states, representing about 20 percent of all the nation's hospitals. The researchers limited their study to 18 categories of complications, called patient safety indicators. These included serious blood infections, bad reactions to transfusions, botched surgeries and trouble during delivery. They tallied the extra days of hospital care attributable to the problems and what they cost to control.

Serious blood infection, or sepsis, following surgery was the most draining complication, leading to an average of nearly 11 extra days in the hospital at a cost of more than $57,000 per patient. Almost 22% of patients who suffered postsurgery sepsis died of the infection.

The second most serious medical injury was a rupture, or "dehiscence," of a wound after surgery. Patients with this complication spent an average of about nine more days in the hospital, and racked up $40,000 in extra costs, while nearly 10% died of the injury. Infections caused by medical care rounded out the top three, adding more than nine days to a hospital stay at a cost of nearly $39,000 per patient, with a risk of death just over 4%.

Overall, the researchers say that the 18 types of patient injuries could account for 2.4 million extra hospital days, between $4.6 and $9.3 billion in added costs and roughly 32,500 deaths each year. Future studies may be able to flesh out how many of these truly are preventable, Zhan says. The researchers estimate the share of preventable injuries at between 50 percent and 75 percent of the total. The problem, however, is figuring out what the total truly is. One way to do that is to implement a confidential, nonpunitive reporting system for medical errors modeled on that covering the airline industry. Legislation establishing such a program is now making its way through Congress. The study, "Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization," was published in the Oct. 8, 2003, issue of the Journal of the American Medical Association.

Bill Introduced to Reduce Medication Errors
Rep. Amo Houghton (R-N.Y.) has introduced a bill (H.R. 3035) to reduce medication errors by improving the computer systems of hospitals and healthcare providers who deliver inpatient and skilled nursing care. Nurses and other healthcare providers could improve patient safety by avoiding medication errors under the bill, which would set up a competitive grant program for hospitals and skilled nursing facilities. Funds from this $1 billion, 10-year program could be used to purchase or improve computer software and hardware or provide education and training to staff on patient safety programs. The bill specifically sets aside 20% of the grant money for rural providers, who often have the greatest need and the smallest budgets for obtaining the latest technology.

For more information, contact Houghton's office at (202) 225-3161.

Public Policy Snapshot

AHRQ Evidence Report on Working Conditions and Patient Safety

As part of its Evidence-based Practice Program, the Agency for Healthcare Research and Quality is developing scientific information for other agencies and organizations to base clinical guidelines, performance measures and other quality improvement tools. Contractor institutions review the relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.

The systematic literature review on the Effect of Health Care Working Conditions on Patient Safety provided sufficient evidence to make specific recommendations about strategies for improving patient safety. Following is a summary of these recommendations:

� Strategies to increase staffing levels of licensed and unlicensed nurses in both acute care hospitals and nursing homes will likely lead to improved patient outcomes.
� Preventable complications are lower when complex technical procedures are performed by physicians who conduct them frequently.
� Duration of experience of the health professional is associated with better patient outcomes for some types of clinical care.
� Systems to reduce interruptions and distractions will likely reduce the incidence of medical errors.
� Systems to improve information exchange, transfer of responsibility, and continuity of care between hospital and nonhospital settings decrease medication errors and, in some settings, hospital re-admissions.
� Levels of ambient noise in healthcare settings do not adversely affect patient safety.

Dec. 1 Is Deadline to Apply for 2005 Distinguished Research Lecturer Award

Dec. 1 is the deadline to submit nominations for the Distinguished Research Lecturer Award for 2005. The recipient will present the Distinguished Research Lecture at the 2005 NTI in New Orleans, La. The lecture is sponsored by a grant by Philips Medical Systems.

The ideal candidates for this award should:

� Be nationally recognized for publications, presentations, and/or mentorship in research relevant to acute and/or critical care clinical practice
� Be viewed as a consultant in their area of expertise
� Have made significant contributions to acute and critical care nursing practice through research
� Be a dynamic and interesting speaker (nominators should cite an example of nominee's expertise in public speaking)

The Distinguished Research Lecturer Panel will select the recipient for 2005 in January. The awardee receives a $1,000 honorarium and $1,000 toward NTI expenses, as well as a plaque.

The 2005 Distinguished Research Lecturer nomination form is available online. For more information, call (800) 394-5995, ext. 321; e-mail, dolores.curry@aacn.org.

2003-04 AACN Grants Support Clinical Projects and Research

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, which are accepted twice a year, must be received by either Jan. 15 or July 1.

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, which are accepted twice a year, must be received by either Jan. 15 or July 1.

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.

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.

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