AACN News—July 2004—Practice

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Vol. 21, No. 6, JUNE 2004

First Beacon Awards Announced at NTI
Four Critical Care Units Earn Recognition for Excellence

Four award winners were announced during the NTI as the inaugural recipients of AACN’s new Beacon Award for Critical Care Excellence, a program designed to recognize the nation’s top hospital critical care units.

Receiving the award are the adult medical-surgical ICU at Baystate Medical Center, Springfield, Mass.; the medical ICU at Georgetown University Hospital, Washington, D.C.; the coronary care unit at Methodist Hospital, Houston, Texas; and the surgical ICU II at the University of California-Davis Medical Center, Sacramento.

Units that receive the Beacon Award exhibit the highest quality standards in nurse recruitment and retention, staff training, patient outcomes, healthy work environments, leadership and evidence-based practice and research.

“These critical care units have set an example that should be emulated, and we are proud to recognize their excellence with the Beacon Award,” said 2003-04 AACN President Dorrie Fontaine, RN, DNSc, FAAN. “These are important standards for a critical care unit to meet.”

“It is exciting to be nationally recognized for what we do every day as critical care nurses in our ICU: maintain high standards for quality, provide exceptional care of patients and provide for a healthy and healing work environment,” said Sheila Elliott, ICU nurse manager at Baystate Medical Center.

“Receiving the award gives us the inspiration to set higher standards for ourselves and the team, and fulfilling them,” said Jennifer Sweeney, a clinical nurse at University of California-Davis.

“We have the best team in the world,” said Bernie Gallagher of Methodist Hospital. “We work hard and have fun at work.”

“ICU nursing is not about IV pumps, monitors and drips,” said Gina Corbett, a nurse at Georgetown University Hospital. “The greatest impact I have made is in treating the patient in a holistic manner, including the care of patients’ families.”

Applications for the Beacon Award are accepted year-round and must be submitted online. Applicants are evaluated according to the following factors:
• Recognized excellence in the intensive care environments in which nurses work and critically ill patients live.
• Recognized excellence of the highest quality measures, processes, structures and outcomes based on evidence.
• Recognized excellence in collaboration, communication and partnerships that support the value of healing and humane environments.
• Development of a program that contributes to actualization of AACN’s mission, vision and values.

Congratulations to Research Grant Recipients

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.
The recipient of this award for 2003 was:

Arlene Keeling, RN, PhD
Crozet, Va.
Implementation of a Long-Term Mechanical Ventilation Outcomes Manager Program Data Management Project Using a Personal Data Assistant Platform

The recipients of this award for 2004 are:

Kristine Peterson, RN, MS, MSN, CCRN, CCNS
Plymouth, Minn.
Perineal Skin Health in Critically Ill Adults With Fecal Incontinence

Maureen Silvernale, RN, BS, MSN, CCRN, APRN, NP
Yadkinville, N.C.
Family Involvement With Personal Care in Long-Term Cardiothoracic Surgical Patients

Kelly Thompson-Brazill, RN, MSN, APRN, NP, APRN-BC
Raleigh, N.C.
Impact of a Clinical Management Guideline in Preventing Ventilator-Associated Pneumonia

Grant proposals are accepted twice a year and must be received by either March 1 or Oct. 1.

AACN Mentorship Grant

This $10,000 grant provides research support for a novice researcher with limited or no research experience to work under the direction of a mentor with expertise in the area of proposed investigation.

The recipient of this grant for 2004 is:

Penelope Villars
Houston, Texas
The Effects of Body Position, Body Mass Index, and Body Fat Distribution on Pulmonary Function

The annual application deadline for this grant is Feb. 1.

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 recipient of this award for 2003 was:

Chris Winkleman, RN, PhD, CCRN
University Heights, Ohio
Selected Cytokines and Mobilization of ICU Patients: Is There a Relationship?

The recipients of this award for 2004 are:

Joan Liaschenko, RN, MN, PhD
Minneapolis, Minn.
An Investigation of the Factors Influencing Critical Care Nurses’ Inclusion of Families in End-of-Life Care

Rhonda M. Board, RN, PhD, CCRN
Londonderry, N.H.
Psychoneuroendocrine Response in Critically Ill Children

The annual application deadline for this grant is Feb. 1.

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.

The recipient of this award for 2004 is:

Carol Taylor, RN, MSN, PhD
Washington, D.C.
Optimizing Care of Persons Seriously Ill and/or Dying: Assessment of Educational Needs and Self-Efficacy of Health Professionals and Evaluation of Current Practice

Oct. 1 is the annual application deadline for this grant.

End of Life/Palliative Care Small Projects Grant

This grant awards $500 to carry out a project focusing on end-of-life or palliative care outcomes in critical care.

The recipients of this award for 2004 are:

Christine Convard, RN
Newport, Vt.
North Country Hospital Bereavement

Kathrina Edoo, RN, CCRN
Cherry Hill, N.J.
SOLACE Project (Sentiments of loss amid consolation and encouragement)

Faith Giersdorf, RN, BSN, MBA, CCRN
Port St. Lucie, Fla.
End of Life/Palliative Care in the ICU Setting—A Nurse’s Perspective

Geneva Llewellyn, RN, AA, CNS, MSN, CCRN
Athens, Ala.
End-of-Life Care

Sarah Moscatel, RN, MS, CCRN, CCNS
Lakewood, Colo.
Nurses' Transitions During End-of-Life Decisions in Critical Care

Applications for this grant are accepted twice a year and must be received by Jan. 15 or July 1.

AACN Clinical Practice Grant

This $6,000 grant supports research that is focused on one or more of AACN’s clinical research priorities.

The recipient of this award for 2003 was:

Karen K. Giuliano, RN, MS, MSN, APRN, FAAN
Atkinson, N.H.
Physiologic Monitoring for Critically Ill Patients With Sepsis

Oct. 1 is the annual application deadline for this grant.

Initiating Hospice Care in Critical Care Grant

This one-time, $4,700 grant supports research that focuses on end-of-life or palliative care outcomes in critical care.

The recipients of this award are:

Christine Westphal, RN, MS, MSN, CCRN
Allen Park, Mich.
Effect of an Interactive Workbook and Family Support Service on Emotional Distress, Need Satisfaction and Resuscitation Decisions

Debra Delk, RN, BS, BSN
Longmont, Colo.
Impact of Introducing a Palliative Care Standard on the Knowledge, Attitude, and Beliefs of Critical Care Nurses Providing End-of-Life Care

Debra Lynn-McHale Wiegand, RN, MSN, PhD, CCRN, FAAN
New Wales, Pa.
Life-Sustaining Therapy: Family Experiences

Frances Simpson, RN, BSN, CCRN
Pflugervill, Texas
Evaluation of Early Palliative Care Intervention on Outcomes Among Ventilated Patients in Critical Care

Jean Pruitt, RN, MN, MS, CCRN
Canton, Ga.
Improving Communication Skills of Neuroscience Intensive Care Professionals on End-of-Life/Palliative Care

Joseph White
Bessemer, Ala.
End of Life in the ICU: Family Perspectives and Outcomes

Linda Dalessio, RN, BS, MSN, CCRN
Wolcott, Conn.
Initiating Palliative Care in the ICU

AACN Research Priorities

AACN identifies five broad priority areas to guide research activities and initiatives. The priorities reflect areas of interest and relevance to AACN and its members and provide a framework for identifying potential gaps in the development or use of nursing knowledge. These priorities are:

• Effective and appropriate use of technology to achieve optimal patient assessment, management or outcomes
• Creating a healing, humane environment
• Processes and systems that foster the optimal contribution of critical care nurses
• Effective approaches to symptom management
• Prevention and management of complications

Dunbar to Deliver Distinguished Research Lecture at NTI 2005

Sandra Dunbar, RN, DSN, FAAN, is the recipient of the 2005 Distinguished Research Lecturer Award, sponsored for the fourth year by Philips Medical Systems. The Distinguished Research Lecture is scheduled during AACN’s 2005 National Teaching Institute and Critical Care Exposition in May in New Orleans, La.

The primary focus of Dunbar’s research has been understanding the experience of living with a life-threatening illness and the improvement of outcomes for patients and their families. Published widely, her work has been funded continuously since 1998 by grants from a variety of sources, including the National Institutes of Health and National Institute for Nursing Research, American Heart Association, Veterans Administration, Department of Defense, and industry and foundations.

Dunbar’s expertise has been recognized in a variety of ways, including appointment to the AHA/ACC Working Group on Quality of Care and Outcomes Research in CVD and Stroke, appointment to a named professorship at Emory University, selection for the Katharine A. Lembright Award for Excellence in Cardiovascular Nursing Research, selection for the Nursing Research Award by the Heart Failure Society of America, and appointment to study sections at NIH, the VA, AHA/Georgia Affiliate and the American Institute of Biological Sciences. Dunbar is a past president of AACN.

Part of AACN’s Circle of Excellence recognition program, the Distinguished Research Lecturer Award honors a nationally known researcher who has made significant contributions to acute and critical care research; is known for publications, presentations and mentorship relevant to acute and critical care; and is viewed as a consultant in his or her area of expertise.

Nominations for 2006 Lecture
Dec. 1 is the deadline to apply for the 2006 AACN Distinguished Research Lecturer Award. The recipient will present the Distinguished Research Lecture at the NTI 2006 in Anaheim, Calif.

The lecturer receives an honorarium of $1,000, an additional $1,000 toward NTI expenses and a crystal replica of the AACN vision icon. The award is funded by a grant from Philips Medical Systems.

For more information, call (800) 394-5995, ext. 377; e-mail, research@aacn.org.

With Distinction

2004 Distinguished Research Lecturer Cathie Guzzetta (center) is congratulated by 2003-04 AACN President Dorrie Fontaine (left) and Philips Medical Systems representative Karen Giuliano prior to the Distinguished Research Lecture delivered during the NTI in Orlando, Fla. Philips Medical Systems provides funding for the lecture. The Dallas County Chapter, of which Guzzetta is a past president, also funded a one-time $1,500 scholarship to honor her.

Submit Research, Creative Solutions Abstracts for NTI 2005 in New Orleans, La.

AACN is inviting research and creative solutions poster abstracts for consideration for AACN’s 2005 National Teaching Institute and Critical Care Exposition May 7 through 12 in New Orleans, La.

In addition to the posters, 16 research abstracts and 16 creative solution abstracts will be selected for oral presentation. Four of the research applicants will be selected as award recipients. The awards for research poster abstracts reflect outstanding original research, replication research or research utilization. Each of the awards recipients is presented a plaque and $1,000 to use toward NTI expenses.

Sept. 1 is the deadline to submit the abstracts.

The application, guidelines and resources are now available online.


Evidence-Based Clinical Practice Grant
This grant funds awards up to $1,000 to stimulate the use of patient-focused data and/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 focused on one or more AACN research priorities. Research conducted in fulfillment of an academic degree is acceptable. Oct. 1 is the annual application deadline for this grant.

AACN-Sigma Theta Tau Critical Care Grant
AACN and Sigma Theta Tau International cosponsor this $10,000 grant, which may be used to fund research for an academic degree. Principal investigators must be members of AACN or of Sigma Theta Tau International. The principal investigator must have at least a master’s degree. Oct. 1 is the annual application deadline for this grant.

To find out about AACN’s research priorities and grant opportunities, visit the AACN Web site or e-mail research@aacn.org.

Practice Resource Network

Q: Is the use of anticoagulants necessary in maintaining the patency of indwelling central venous catheters?

A: A limited number of studies examine the incidence of thrombotic occlusion in CVCs comparing nonheparinized saline with heparinized saline. One study shows equal rates of thrombotic occlusion in CVC patency comparing nonheparinized saline with saline.1 Few other studies have been published on the impact of flush solutions, with or without heparin in maintaining patency of CVC. Caution should be used in changing practice standards because there is currently little research-based evidence to support this.

The Centers for Disease Control and Prevention 2002 Guidelines for the Prevention of Intravascular Catheter-Related Infections discuss that thrombi and fibrin deposits on catheters might serve as a medium for microbial colonization of intravascular catheters, and that the use of anticoagulants might have a role in the prevention of catheter-related blood stream infections. Research evaluating the benefit of heparin prophylaxis in patients with short-term CVC, suggests that the risk of catheter-related central venous thrombosis was reduced with the use of prophylactic heparin. However, no substantial difference in the rate of catheter-related bloodstream infections was observed. Because the majority of heparin solutions contain preservatives with antimicrobial activity, whether a decrease in the rate of these infections is a result of the reduced thrombus formation, the preservative or both is unclear.2

Complications, including drug interaction and heparin-induced thrombocytopenia and thrombosis syndrome, have been reported in association with heparin flushing.3 Therefore, there are underlying patient conditions that will contraindicate adding heparin.

Positive displacement devices that prevent retrograde blood flow and consequently reduce the risk of thrombus formation in the catheter lumen are available. These devices effectively reduce the number of occlusions and result in significant cost savings when compared to thrombolytic therapy.4

Many of the guidelines for the use of CVC guidelines are ambiguous and do not offer clear direction for practitioners. It is important to review the recommendations the manufacturer included with the catheters being used and to follow institution policy and procedure regarding the use of anticoagulant in maintaining CVC catheters.

1. Stephens LC, Haire WD, Tarantolo S, et al. Normal saline versus heparin flush for maintaining central venous catheter patency during apheresis collection of peripheral blood stem cells (PBSC). Transfus Sci. June 1997;18:187-193
3. Kadidal VV, Mayo DJ, Horne MK. Heparin-induced thrombocytopenia (HIT) due to heparin flushes: a report of three cases. J Intern Med. 1999;246(3):325-329.
4. Rummel MA, Donnelly PJ, Fortenbaugh CC. Clinical evaluation of a positive pressure device to prevent central venous catheter occlusion: results of a pilot study. Clin J Oncol Nurs. 2001;5(6):261-265.

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 practice@aacn.org.

Public Policy Update

House Bill Requires Disclosure of Nurse Staffing Information
Patients would have greater assurances of receiving safe, quality nursing care, and nurses would have whistleblower and staffing-related workload protections, under legislation (Patient Safety Act, HR4374) introduced in the U.S. House of Representatives by Rep. Maurice Hinchey (D-N.Y.).

The legislation would require healthcare institutions, under conditions of participating in the Medicare program, to make public information regarding nurse staffing levels, mix and patient outcomes. If enacted, the Patient Safety Act would require disclosure of the number of RNs and unlicensed personnel providing direct care, the average number of patients per RN providing care, patient mortality rates, the incidence of adverse outcomes, and methods used for adjusting staffing levels and patient care needs. In addition, language would be added to Medicare law to protect nurses who report or voice concerns about unsafe patient conditions from retribution.

Study Links Nurses and Errors
A study published in the June issue of the American Journal of Nursing shows that nurses are held accountable for most medical errors, despite the fact that physicians rarely consider nurses part of the decision-making team. Two members of the University of Montana team that conducted the study said the disparity could help explain the high turnover among nurses.

The study surveyed nurses, physicians, pharmacists and administrators at 29 small, rural hospitals in nine Western states during a three-year period. All were asked what kinds of errors are reported in their hospitals, along with monthly case studies asking respondents to identify errors and describe better ways to handle them. According to the study, 90% of physicians, administrators and pharmacists and 96% of nurses place primary responsibility for patient safety on nurses, even though only 8% of physicians identify nurses as part of the decision-making team.

Ann Freeman Cook and Helena Hoas, psychology professors at the University of Montana and members of the study research team, said they would like to see physicians, pharmacists, administrators and nurses equally share the responsibility for patient safety. Mistakes typically thought of as related to nursing, such as giving the patient too much medication, are likely to be reported as “errors,’’ the study said. However, a doctor’s misdiagnosis is more likely to be considered a difference in “clinical judgment’’ than an error.

Expert Group Creates First Quality Palliative Care Guidelines
The National Consensus Project for Quality Palliative Care, a national group of palliative care experts, has released the first national set of clinical practice guidelines for palliative care. The group is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, Last Acts Partnership, and the National Hospice and Palliative Care Organization. AACN has endorsed the guidelines.

The guidelines are posted at www.nationalconsensusproject.org

Survey Shows Workplace Intimidation Adversely Affects Patient Safety
Intimidating behavior by physician-prescribers and other healthcare providers is a common element of many healthcare practice settings that may cause medication errors, according to survey data released by the Institute for Safe Medication Practices. More than 2,000 healthcare professionals, including nurses, pharmacists and other providers, responded to ISMP’s November 2003 survey.

Of those, 7% said they were involved in a medication error during the past year in which intimidation clearly played a role. Almost half of the respondents (49%) indicated that past experiences with intimidation altered the way they handle questions about medication orders. About 40% of all respondents who had concerns about the safety of a medication at least once in the past year assumed that it was correct rather than interact with an intimidating prescriber.

Even when the prescriber was questioned about safety, almost half (49%) of respondents felt pressured into dispensing a product or administering a medication despite their concerns. Although respondents made it clear that intimidating behavior was not limited to physician-prescribers, the survey showed that physician-prescribers used condescending language or were impatient with questions twice as often as other healthcare providers. Sixty-nine percent said a prescriber had at least once in the last year responded, “Just give what I ordered,” when faced with a question. Intimidation ranges from subtle questioning of judgment to more explicit threatening behavior. Nearly a quarter of respondents often encountered condescending language or tone of voice (21%) or impatience with questions (19%). Almost half of respondents reported being the recipients of strong verbal abuse (48%) or threatening body language (43%) at least once during the last year.

To reduce workplace intimidation and improve patient safety, ISMP recommends that healthcare organizations create a code of conduct and values to encourage behaviors that safeguard team cohesion and staff morale, sense of self-worth, and safety. ISMP also suggests establishing a conflict resolution process that ensures effective communication, protects patients and strictly enforces a zero tolerance policy for intimidation, regardless of the offender’s standing in the organization.

The survey is available online at www.ismp.org > Medication Safety Alerts > Survey Results.

OSHA Targets Suture Needles and Other Sharps
The Occupational Safety and Health Administration has announced it will inspect hundreds of healthcare institutions this year for needlestick safety violations. Setting the tone for this effort was a landmark OSHA decision to cite and fine two healthcare facilities not in compliance with the requirement to use safety-engineered sharp devices facility wide.

Among the violations were failure to use personal protective equipment, failure to minimize exposure during collection of arterial blood gas and failure to use needle-free adhesive anchors to secure catheters. Since the bloodborne pathogens standard was revised in 2001 to clarify and emphasize the requirement to use safety devices to reduce the risk of exposure, the number of citations issued by OSHA for BPS violations has increased dramatically.

House Rejects Reporting Undocumented Immigrants
The House of Representatives voted 331-88 on May 18 to reject HR3722, a bill sponsored by Rep. Dana Rohrabacher (R-Calif.) to require hospitals to identify and report undocumented immigrants to federal agencies to qualify for special funding under the Medicare Modernization Act. The American Hospital Association and other opponents said that, in addition to imposing new paperwork burdens on hospitals, the measure would have forced hospital workers to act as de facto Border Patrol agents and deterred immigrants from getting the healthcare they need, posing a significant public health risk.

California’s Nurse-Staffing Law Upheld
A California judge has upheld the state’s landmark nurse-staffing law, which requires hospitals to maintain specific nurse-to-patient ratios at all times. The California Healthcare Association, which represents 450 of the state’s hospitals, challenged the “at all times” requirement in a lawsuit filed against the state Department of Health Services in December. The suit contended that the language would require ratios to be met even when a nurse takes a brief lunch, bathroom or coffee break and, if taken literally, would “result in virtually all nursing units in the state failing to comply.” The judge ruled that the regulations clearly state that a nurse who is away from his or her assigned floor would not be counted for purposes of compliance.

The California Nurses Association called the ruling “a huge victory” that would “boost the efforts of RNs in several dozen other states who are pursuing similar ratio laws.” The hospital association said its members may have to delay patient admissions, discharge patients sooner or cancel elective surgeries to comply with the ratios.

California is the first and so far only state to pass such a specific nurse-staffing law. Under regulations that took effect Jan. 1, each nurse is limited to six patients in general medical-surgical units, four patients in emergency departments, two in intensive care and labor units, and one in operating rooms. The nurse staffing law was signed by then-Gov. Gray Davis in 1999, and the state Department of Health Services held numerous rounds of public comment to set the ratios before the law went into effect four years later.

Articles Examine Workforce and Work Environment Issues
“The Endangered Health System: a Program Report on Workforce and Work Environ-ment Issues” is the topic addressed in the May 31, 2004 Online Journal of Issues in Nursing. The issue features four articles that examine recent strategic planning efforts to resolve workforce issues, such as nurse supply and demand. Included are three articles that summarize national reports related to nursing workforce issues. The final article reviews the nursing profession’s response to the issues cited in these and other national reports on the nursing shortage and calls for a tiered, comprehensive approach to increase supply, respond to current demand, and enhance the working environment to benefit recruitment and retention. The articles are available online at www.nursingworld.org > Publications.

Public Policy Snapshot

Tracking Mandatory Overtime Issues

As an active supporter of the Safe Nursing and Patient Care Act (HR745 and S373), AACN believes that mandatory overtime places nurses and their patients at increased risk and is an unacceptable means of staffing a hospital. Following is a summary of some of the measures related to this difficult issue for RNs and healthcare facilities.

2004—West Virginia enacted legislation prohibiting hospitals from mandating that nurses accept overtime assignments. The commissioner of labor is charged with the enforcement of the law and shall administer a penalty for any violations. Connecticut enacted legislation prohibiting hospitals from requiring nurses to work more than a predetermined, scheduled work shift, except in certain circumstances, such as participating in a surgical procedure until completed and public health emergency. The law requires the Commissioner of Public Health to adopt regulations establishing minimum nurse-to-patient ratios. Legislation was also introduced in Florida, Georgia, Hawaii, Iowa, Illinois, Massachusetts, Michigan, Missouri, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Vermont and Washington.

2003—Louisiana, Nevada and West Virginia enacted legislation requiring that study committees be established to explore the issue. Twenty-two other states introduced legislation or regulations prohibiting mandatory overtime by setting maximum hours of work per day or week, with protected right of refusal for work time requested in excess of predetermined maximums.

2002—Maryland enacted a law stating that an employer may not require a nurse to work more than the regularly scheduled hours, according to a predetermined schedule. Exceptions include emergencies and when a nurse’s critical skills and expertise are needed. Minnesota adopted legislation to prohibit action against a nurse who refuses mandatory overtime because it would jeopardize patient safety. New Jersey enacted legislation preventing a healthcare facility from requiring an employee to work in excess of an agreed to, predetermined and regularly scheduled daily work shift, not to exceed 40 hours per week. Texas enacted regulations requiring hospitals to develop policy and procedures for mandatory overtime. Washington added language stating that acceptance of mandatory overtime by a nurse is strictly voluntary and that refusal is not grounds for adverse actions against the nurse.

2001—Maine passed legislation to prevent a nurse from being disciplined for refusing to work more than 12 consecutive hours, except in certain circumstances. In addition, nurses must be given 10 consecutive hours off following overtime. Oregon enacted legislation preventing a nurse from being required to work more than two hours beyond a regularly scheduled shift or 16 hours in a 24-hour time period. Regulations adopted in California prior to 2001 prevent an employee scheduled to work a 12-hour shift from working more than 12 hours in a 24-hour period, except in a healthcare emergency.
Source: American Nurses Association

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