AACN News—February 2004—Practice

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Vol. 21, No. 2, FEBRUARY 2004

Watch for AACN Practice Alerts
New Communication to Advise on Clinical Practice Standards

By Cheryl Ann McKay, RN, MSN, CCNS,
and Murray Speers, RN, BSN, CCRN
Research Work Group

Although the scientific basis of critical care nursing has advanced tremendously in the last 20 years, this evidence has still not been translated into practice in many critical care units. For example, in your own unit, you may see intubated patients with the HOB less than 30 degrees or clinicians routinely using normal saline instillation prior to suctioning, despite the fact that research has shown these practices to increase nosocomial pneumonia rates or cause oxygen desaturation.

Why is our practice so out of date in some areas? The reasons are many. Lack of time, no easy way to access literature and lack of communication within our units are just a few. In an effort to assist critical care nurses to ensure that patient care routines are based on the current evidence, AACN is launching AACN Practice Alerts as a new communication tool to boldly state clinical practice standards of care.
AACN�s Practice Alerts will be succinct, dynamic directives supported by authoritative evidence that will be easy to use. Clinicians will be able to access tools to assist them to identify variations in their practice from the standard of care and for implementing an action plan for changing practice.

The goal of the AACN Practice Alerts is to reduce variation in care with respect to the key elements of practice prioritized by the AACN Research Work Group. The following sections will be included in the content:

� Expected Practice: Statement of what clinical practice should be for selected areas of practice
� Supporting Evidence: The research, expert opinion or support from other organizations for the expected practice statement
� What You Should Do: A brief description of how to make practice changes, if necessary
� Key references: Evidence that supports the alert

Practice alerts will be issued to address a variety of clinical practice situations that require changes. AACN�s Practice Alerts will direct clinicians to change their practice when actual practice is lagging behind current research or expert opinion. These alerts will also be issued to increase awareness of new trends or information that could impact patient care quality or outcomes.

AACN will disseminate the information in a variety of ways, including AACN News, the Critical Care Newsline electronic newsletter, news releases and Web site postings. The Web site will also house information to assist clinicians to compare their unit�s current practice routines with the recommended practices, as well as educational materials and suggestions for updating clinical practice.

As we embark on our mission to provide you with the AACN Practice Alerts, let�s remember to use our collective voices and strive to continually evaluate and improve our current level of practice to ensure optimal care for all critical care patients.


Expected Practice:
� All patients receiving mechanical ventilation, as well as those at high risk for aspiration (e.g., decreased level of consciousness, with enteral tube in place), should have the head of the bed (HOB) elevated at an angle of 30 to 45 degrees unless medically contraindicated.
� Use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage by continuous suctioning of tracheal secretions that accumulate in the subglottic area.
� Do not routinely change, on the basis of duration of use, the patient�s ventilator circuit.

Supporting Evidence:
� Critically ill patients who are intubated for >24 hours are at 6 to 21 times the risk of developing ventilator-associated pneumonia (VAP)1-3 and those intubated for <24 hours are at 3 times the risk of VAP.4 Other risk factors for VAP include decreased level of consciousness, gastric distention, presence of gastric or small intestine tubes, and a trauma or chronic obstructive pulmonary disease diagnosis. VAP is reported to occur at rates of 10 to 35 cases/1000 ventilator days, depending on the clinical situation.3
� Aspiration of oral and/or gastric fluids are presumed to be an essential step in the development of VAP. Pulmonary aspiration is increased by supine positioning and pooling of secretions above the ET tube cuff.1,5,6
� Morbidity and mortality associated with the development of VAP is high, with mortality rates ranging from 20 to 41%.4,7-8 Development of VAP increases ventilator days, critical care and hospital lengths of stay (LOS) by 4, 4 and 9 days, respectively,2,7 and results in >$40,000 additional costs/VAP case.2,6
� Compared to supine positioning, studies have shown that simple positioning of the HOB to 30 degrees or higher significantly reduces gastric reflux and VAP (8% versus 34%, respectively),4,9-12 yet national surveys and reports in the literature describe poor compliance rates with HOB elevation in critical care units.4,13-15
� Studies on the use of special ET tubes that remove secretions pooled above the cuff with continuous suction decrease VAP by 45% to 50%.16-19
� Studies on the frequency of ventilator circuit changes have found no increase in VAP with prolonged use.20-22
� National regulatory and expert consensus groups include these interventions as critical to decrease VAP.1,23-25

What You Should Do:
� Always keep the HOB elevated to 30 degrees or higher for patients receiving mechanical ventilation, unless medically contraindicated; use an ET tube with continuous suction above the cuff; do not routinely change ventilator circuits.
� Ensure that your critical care unit has written practice documents, such as a policy, procedure or standard of care, that includes these practice alerts.
� Determine your unit�s rate of compliance with the HOB elevation directive and use an ET tube with continuous suction above the cuff (VAP Toolbox at www.aacn.org).
� If compliance is <90%, develop a plan to improve compliance:13
�Consider forming a multidisciplinary task force (nurses, physicians, respiratory therapist, clinical pharmacist) or a unit core group of staff to address VAP practice changes.
�Educate staff about the significance of nosocomial pneumonias in critically ill patients and how these interventions can reduce VAP (VAP Toolbox at www.aacn.org).
�Incorporate content into orientation programs, initial and annual competency verifications.
�Develop a variety of communication strategies to alert and remind staff of the importance of these VAP interventions (VAP Toolbox at www.aacn.org).
�Develop documentation standards for HOB elevation that include rationale for when the HOB is not elevated.
�Incorporate HOB elevation to at least 30� in any unit standing orders; include monitoring into your critical care scorecard/QI plan/PI activities to ensure that practice changes continue.
� Include your unit�s success story on the AACN Web site and be included in a national listing of Practice Excellence for VAP (www.aacn.org).

Other VAP Articles of Interest
� Hixon S, Sole M, King T. Nursing strategies to prevent ventilator-associated pneumonia. AACN Clin Issues. 1998;9:76-90.
� Pfeifer L, Orsen L, Gefen C, et al. Preventing ventilator-associated pneumonia. Am J Nursing. 2001;101:24AA-24GG.

Need More Information or Help?
� VAP Toolbox at www.aacn.org
� Audit tool for measuring compliance with HOB elevation in critically ill patients
� Methods for estimating HOB elevation
� Power Point slide program for VAP education sessions
� Communication strategies for important practice information
� How to make and sustain system changes
� Talk with a clinical practice specialist for additional information/assistance (www.aacn.org)

1. Weinstein R, Chinn R, Larson E, et al. Guidelines for prevention of healthcare-associated pneumonia. Morbidity and Mortality Weekly Report. In press.
2. Rello J, Ollendorf D, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122:2115-2121.
3. Craven D. Epidemiology of ventilator-associated pneumonia. Chest. 2000;117:186S-187S.
4. Kollef M. Ventilator-associated pneumonia: a multivariate analysis. JAMA. 1993;270:1965-1970.
5. Torres A, Serra-Batiles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992;116:540-542.
6. Craven D, Rosa F, Thornton D, et al. Nosocomial pneumonia: emerging concepts in diagnosis, management and
prophylaxis. Curr Opinions in Crit Care. 2002;8:421-429.
7. Bercault N, Boulain T. Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case-control study. Crit Care Med. 2001;29:2303-2309.
8. Heyland D, Cook D, Griffith L, et al. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Resp Crit Care Med. 1999;159:1249-1256.
9. Ibanez J, Penafiel A, Raurich J, et al. Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect of supine and semi recumbent positions. J Parenter Enteral Nutrit. 1992;16:419-422.
10. Orozco-Levi M, Torres A, Ferrer M, et al. Semi-recumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med. 1995;152:1387-1390.
11. Drakulovic M, Torres A, Bauer T, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet. 1999;354:1851-1854.
12. Dotson R, Robinson R, Pingleton S. Gastroesophageal reflux with nasogastric tubes: Effect of nasogastric tube size. Am J Respir Crit Care Med. 1994;149:1659-1662.
13. Zack J, Garrison T, Trouillion E, et al. Effect of an educational program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30:2407-2412.
14. Berenholtz S, Pronovost P. Barriers to translating evidence into practice. Curr Opinions in Crit Care. 2003;9:321-325.
15. Grap M, Cantly M, Munro C, et al. Use of backrest elevation in critical care: pilot study. Am J Crit Care. 1999;8:475-480.
16. Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Int Care Med. 1995;122:179-186.
17. Mahul P, Auboyer C, Jospe R, et al. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretion drainage and stress ulcer
prophylaxis. Int Care Med. 1992;18:20-25.
18. Kollef M, Skubas N, Sundt T. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest. 1999;116:1339-1346.
19. Cook D, KeJonge B, Brochard L, Brun-Buisson C. Influence of airway management on ventilator-associated pneumonia: evidence from randomized trials. JAMA. 1998;279:761-787.
20. Dreyfuss D, Djedaini K, Weber P, et al. Prospective study of nosocomial pneumonia and of patient circuit colonization during mechanical ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis. 1991;143:738-743.
21. Kotilainen H, Keroack M. Cost analysis and clinical impact of weekly ventilator circuit changes in patients in intensive care unit. Am J Infect Control. 1997;25:117-120.
22. Kollef M, Shapiro S, Fraser V, et al. Mechanical ventilation with or without 7-day circuit changes: a randomized controlled trial. Ann Intern Med. 1995;123:168-174.
23. Joint Commission on Accreditation of Healthcare Organizations. ICU Core Measures � draft statement. www.jcaho.org/pms/core+measures/candidate+core+measure+set.htm. Accessed September 26, 2003.
24. Parrish C, Krenitsky J, McCray C. Nutritional support for the mechanically ventilated patient. In: AACN�s Protocols for Practice, Care of the Mechanically Ventilated Patient Series. Aliso Viejo, Calif: AACN; 1998.
25. Collard H, Saint S. Prevention of ventilator-associated pneumonia. Agency for Health Care Policy and Research Web site: www.ahcpr.gov/clinic/ptsafety/chap17a.htm.

Members of the Research Work Group are (from left, seated)
Justine Medina (AACN practice and research director), Caryl
Goodyear-Bruch (AACN board liaison) and Marianne Chulay
(chair) and (from left, standing) Jessica Palmer, Cheryl McKay,
Deborah Barnes (AACN clinical practice specialist), Sister
Maurita Soukup and Murray Speers.

What�s New for the Advanced Practice Institute?

By Riza V. Mauricio, RN, MSN, CCRN, CPNP
Advanced Practice Work Group

We have raised the bar! Based on your feedback, the Advanced Practice Work Group has crafted sessions for the 2004 Advanced Practice Institute, scheduled in conjunction with AACN�s National Teaching Institute and Critical Care Exposition in May in Orlando, Fla.

The topics were carefully selected to meet the needs of APNs. Before deciding on the topics, we defined what we believe are the essential ingredients of a meaningful API. Several topics were identified, including an in-depth discussion of pathophysiology, down to the cellular level. The management of each disease entity will include evidence-based practice. Speakers will also discuss current and future research projects.

Who Is Speaking?
The presenters are chosen from the numerous abstracts submitted and from a pool of nationally known experts in their fields. Presenters are not limited to nurses but a combination of health professionals in their respective specialties.

What Topics Are Discussed?
The conference sessions involve a series of topics that are dissected from a range of submitted abstracts and chosen by the Advanced Practice Workgroup as essential for APNs in their areas of practice. Among the preconference offerings are two pharmacology sessions, one on coding and billing, and a session on chest x-ray interpretation. In addition, a skills workshop on central line insertion will again be offered. Registration to the skills lab session is limited to 20 attendees to provide maximum opportunity for �hands on experience�. A review class for the CCNS certification exam will also be part of the preconference weekend.

The presentations during the conference proper encompass a wide variety of topics that are relevant to daily practice. Topics range from clinical management of patients, practice outcome evaluation, research/publication, and professional development. Here�s a sampling of the titles included in the conference curriculum: Drug Complications in Critical Care, Neurohormonal Influence in Heart Failure, Mysteries of Microcirculation, Hypertensive Emergencies, Critical Thinking�What Is It? Matrix of Abdominal Pain, Nutritional Support in Critically Injured Patients, Glycemic Control in Critically Ill, Writing for Publication and Assessing Outcomes in APN Practice. For those who care for pediatric patients, education on ventilator management in acute lung injury is planned.

Will API Sessions be Fun?
The API speakers were encouraged to employ a variety of teaching methods to enhance the learning of participants. Some of them are unique and entertaining. Case studies, grand rounds and pro and con debate sessions are planned.

Save the Date!
You can be a part of this outstanding learning experience. Save the dates and register for API 2004, May 15 through 20 in Orlando. April 6 is the early-bird deadline to save on registration.
Public Policy Update

California Nurses Association Begins Campaign to Monitor Nurse-to-Patient Ratios
The California Nurses Association recently announced a campaign to identify hospitals that fail to comply with the new state nurse-to-patient ratio rules that took effect on Jan. 1. CNA representatives said that the union will recruit nurses �in every hospital unit in California� to monitor whether the hospitals are complying with the rules. Under the rules, nurses will not have to care for more than eight patients at a time. The rules also call for one nurse per five patients in medical-surgical units by 2005, as well as one nurse per four patients in specialty care and telemetry units and one nurse per three patients in step-down units by 2008. In addition, the regulations state that licensed vocational nurses can comprise no more than 50% of the licensed nurses assigned to patient care and that only registered nurses can care for critical trauma patients. The rules also require at least one registered nurse to serve as a triage nurse in emergency departments.

Report Says Medical Errors Underreported
A report by the National Academy for State Health Policy found that, though 21 states have mandatory medical error reporting systems, releasing information about adverse events and errors to the public remains �sporadic and inconsistent.� Titled �How States Report Medical Errors to the Public: Issues and Barriers� and produced with support from the Robert Wood Johnson Foundation, the report notes that underreporting of medical errors and adverse events is a problem. The reasons for underreporting include a lack of internal systems at medical facilities to identify events, uncertainty about reporting requirements, a culture of nonreporting, a lack of state enforcement, bureaucratic burden, competition and market share, fear of publicity, and fear of liability.
�Nursing�s Agenda for the Future� Progress Report Available Online
In the fall of 2001, leaders from more than 60 national nursing organizations met in an unprecedented Nursing�s Agenda for the Future summit to forge the future vision of the nursing profession. That historic meeting led to the publication of a report titled �Nursing�s Agenda for the Future: A Call to the Nation,� a blueprint for what nursing should look like in the year 2010.

The progress report is an update of the activities that are moving NAF�s programmatic and fund-raising goals forward. The report is available online at www.nursingworld.org.

2003 Nursing School Enrollment Increase Larger Than Projected
The annual survey by the American Association of Colleges of Nursing shows that fall enrollments in entry-level baccalaureate programs in nursing increased by 16.6% over last year. Despite this gain, more than 11,000 qualified students were turned away from baccalaureate nursing programs because the number of faculty, clinical sites and classroom space is limited. Without increased federal support, the potential for future growth in nursing education programs may be limited at a time when the demand for well-educated nurses is rising.

The association�s findings are based on responses from a total of 564 (82.7%) of the nation�s nursing schools with baccalaureate- and graduate-degree programs. The survey found that total enrollment in all nursing programs leading to the baccalaureate degree was 126,954, up from 116,099 in 2002. This marks the third year of enrollment increases in baccalaureate programs, which had declined steadily from 1995 to 2000, when enrollments in baccalaureate programs dropped by almost 19%, from 127,683 to 103,999 students.

HIPAA Privacy Regulations
Now that the privacy regulations of the Health Insurance Portability and Accountability Act of 1996 have the force of law, much of the past confusion has subsided, and a majority of physician executives agree that HIPAA is an adequate safeguard of patient privacy, according to the 2003 Modern Physician/Price-waterhouseCoopers technology survey. Of the 432 people who submitted valid responses, 69.2% said the regulations authorized by HIPAA will protect the privacy of personal healthcare information. Only 10.6% said they will not. A year ago, a 42.2% plurality of survey participants were unsure whether HIPAA would protect patient privacy.

End-of-Life Care Inadequate
A new study shows that end-of-life medical care is best with hospice service versus hospital or nursing home care. The research, published in the Jan. 7, 2004, issue of the Journal of the American Medical Association, shows that many patients dying in hospitals and nursing homes get inadequate physical and emotional care from doctors and nurses who treat them. However, it is rare when they receive hospice services during their final days, according to the largest study to date measuring the quality of end-of-life medical care.

After reviewing the deaths of nearly 1,600 patients in 22 states and conducting 120 interviews with those patients� relatives, the researchers say that nearly three in four family members report �excellent� care from hospice services, where end-of-life care is either provided at a special facility or at home, largely by family members assisted by visiting specially trained medical personnel. However, fewer than half of those whose loved ones spent their final days in other institutions were satisfied.
Specifically, the researchers reported:
� According to respondents, nearly 25% of dying patients did not get enough pain medication, and sometimes got none at all. This was more likely to occur in nursing homes as compared with hospice care.
� One in three family members say that hospital and nursing home staff didn�t provide enough emotional support.
� Families reported more concerns with the patient being treated with respect when dying, when patients were at a nursing home, hospital, or home with home health services, compared with persons who died at home with hospice services. In addition, 25% felt the doctor�s communication was poor.
� Only 15% of respondents said they thought institutional healthcare providers had enough knowledge of the patient to provide the best care possible.

Public Policy Snapshot

What�s the Status of Congressional Issues?

Nurse advocates saw Congress finalize some issues of concern to them while not completing work on other important issues.

Legislation passed:
� Medicare reform legislation that will add a prescription drug benefit, introduce competition and include rural provider benefits
� Funding for Nurse Reinvestment Act programs as part of the Department of Health and Human Services appropriations process
� Appropriations of $20 million in new federal funds for nurse education programs in FY2003 (in the midst of funding such programs for FY2004 when adjourned)

Issues addressed but not finalized:
� Caps for medical malpractice awards
� Ban on mandatory overtime
� Medical error reporting bill
� Providing affordable and adequate healthcare for all Americans
Capitol Hill sources report top priorities in 2004 will include reducing the number of uninsured Americans, overhauling Medicare and tackling medical malpractice damage limits.


AACN offers a variety of small and large research grants. Following is information about one of grants for which the application deadline is approaching

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.

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