Viewpoint
Vasopressin: The VF and Pulseless VT
Underdog?
M. Dave
Hanson, RN, MSN, CCRN, EMT-P, and Janie
Heath, RN, MS, CS, CCRN, ANP, ACNP
AACN Board of
Directors
As a critical
care nurse, you can probably identify a
handful of factors that influence your
practice. Are your clinical decisions
determined by your personal beliefs or past
routines? Do the thoughts or beliefs of your
fellow critical care colleagues influence
your practice? Does having the ability or
control to make certain choices impact your
clinical decision making? Regardless of the
clinical decisions to be made, all critical
care nurses go through a decision-making
process as they consider what will produce
the best patient outcomes.
Certainly, one
of the most important influences on critical
care nursing practice is the fact that
decisions are evidence based. A recent
APNList Serv question (ANPACC@yahoogroups.com)
about the use of vasopressin in septic shock
sparked our curiosity.
Evidence Regarding Vasopressin
We thought about
the evidence to use vasopressin in critical
care for other conditions, such as cardiac
arrest. According to the 2000 American Heart
Association ACLS Guidelines, both
epinephrine (1 mg) and vasopressin (40
units) are the first-line pharmacological
agents if initial defibrillation attempts
fail during ventricular fibrillation or
pulseless ventricular tachycardia.1 We
wanted to know why critical care
practitioners might choose to first
administer vasopressin (Class IIb: fair to
good evidence provides support) as opposed
to epinephrine (Class Indeterminate:
insufficient evidence to support) in a
cardiac arrest situation.
Although
epinephrine has been the mainstay in
treating VF and pulseless VT for many years,
the AHA evidence now suggests that
vasopressin can be substituted as an
alternative Class IIb agent. However, for
many critical care practitioners, the use of
epinephrine as a first-line drug for
treating VF or pulseless VT may be so
entrenched in their routine that it impedes
their ability to change. Regardless of the
reason, the question remains as to what
might influence a critical care clinician to
opt for one drug or another.
What Influences Decision Making?
To help identify
the influences on our decision making in
critical care, we decided to use the Theory
of Reasoned Action2 in a pilot study we
conducted at two large medical centers in
Dallas, Texas, and Washington, D.C.3 This
model provides an excellent framework in
helping to explain the beliefs, attitudes
and norms that influence the decisions of
critical care nurses. Applying the TRA to
critical care nursing decisions means that:
� If you
perceive that the outcome from performing a
behavior is positive, you will have a
positive attitude for performing that
particular behavior. The opposite can be
stated if the behavior is thought to be
negative.
� If your
critical care colleagues see performing the
behavior as positive, and you are influenced
by those particular colleagues, the behavior
is more likely to be expected to occur. The
opposite can also be stated if the behavior
is thought to be negative.
� If you believe
you have more control�more autonomy and
freedom�to facilitate or change a behavior,
the behavior is more likely to be expected
to occur. Conversely, the opposite can be
stated if there is a lower level of
perceived control.
Survey Probes Issue
To explore
decision-making factors among critical care
providers, we used a 20-item questionnaire
that contained both demographic and
practice-related questions reflecting the
TRA framework about the use of vasopressin
in VF and pulseless VT.1
Of the 79
participants, 60% were female and 40% male.
The mean age was 39, with the majority (73%)
identifying themselves as Caucasian. The
participants included registered nurses
(68%), nurse practitioners (7%), clinical
nurse specialists (4%), certified registered
nurse anesthetists (5%), physicians (13%)
and registered pharmacists (3%). The
predominant role of 80% of the respondents
was clinical, with the majority (90%)
working full time in a cardiovascular ICU,
medical ICU, surgical ICU, emergency
department, operating room or transplant
unit. In addition, more than 90% of the
respondents indicated that they held current
ACLS cards; 22% were ACLS instructors; and
52% were board certified in their specialty.
Of interest was
the fact that 61% were aware of the ACLS
guidelines about using vasopressin as a
first-line drug option with VF and pulseless
VT. However, 56% did not see vasopressin
used for VF and pulseless VT, and 67% did
not �use and/or recommend� vasopressin for
VF and pulseless VT.
However, using a
Likert scale of 1 to 5, respondents were
asked how much control they have in using or
recommending the use of vasopressin as a
first-line drug option. According to the
results (1=no control and 5=very much
control), 43% responded in the 1 to 2 range,
41% in the 3 range and only 16% in the 4 to
5 range. Meanwhile, when questioned about
how receptive their critical care colleagues
are to using vasopressin for VF and
pulseless VT (1=not receptive and 5=very
receptive), 14% responded in the 1-to-2
range, 46% in the 3 range and 40% in the
4-to-5 range. Finally, asked whether they
intended to use or recommend vasopressin for
VF and pulseless VT within the next six
months (1=no intentions and 5=very high
intentions), 15% responded in the 1 to 2
range, 44% in the 3 range and 41% in the 4
to 5 range.
Old Habits Hard to Break
Although several
studies have shown that vasopressin may
actually be better than epinephrine as a
first-line drug option in treating VF and
pulseless VT,4-8 in this pilot sample,
vasopressin received lukewarm results. We
wonder if this is an �old habit� that is
simply hard to break. Is this issue one of
our �sacred cows� in critical care?
How serious are
we about evidence-based practice? What can
each of us do to increase our control over
evidence-based practice?
During data
collection for this pilot study, Volker
Wenzel, MD, and colleagues were submitting
important research regarding the science of
resuscitation. According to their findings,
published in the Jan. 8, 2004, issue of the
New England Journal of Medicine, people with
a hard-to-treat type of cardiac arrest are
three times as likely to survive if they are
given vasopressin instead of receiving
epinephrine as the standard emergency
treatment. The data from this latest study
should further remind us of the need to
always base our critical care practice on
the most recent scientific evidence.
We encourage
each of you to assess your professional
ability to effectively influence changes in
nursing practice. In a time when every
intervention counts and improved patient
outcomes are nonnegotiable, our patients are
depending on us to �rise above� and use our
�bold voice� to do the right thing.
References
1. The American
Heart Association in collaboration with the
International Liaison Committee on
Resuscitation. Guidelines 2000 for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care: Part 6: advanced
cardiovascular life support: section 7:
algorithm approach to ACLS emergencies:
section 7A: principles and practice of ACLS.
Circulation. 2000;102(8 Suppl):1136-1139.
2. Ajzen I,
Fishbein M. Understanding Attitudes and
Predicting Social Change. Englewood Cliffs,
NJ: Prentice Hall; 1980.
3. Heath J.
Vasopressin: The VF/Pulseless VT Underdog?
Slide presentation: AACN�s Suffolk County
New York Chapter�s Critical Care Conference;
2003. (To request, e-mail Janie.heath@aacn.org.)
4. Chen P.
Vasopressin: new uses in critical care. Am J
Med Sci. 2002;324(3):146-154.
5. Cain B,
Shannon-Cain J. Vasopressin in advanced
cardiac life support. Crit Care Med.
2001;29(8):1649.
6. Wenzel V, Ewy
GA, Lindner KH. Vasopressin and endothelin
during cardiopulmonary resuscitation. Crit
Care Med. 2000;28(Suppl 11):233-235.
7. Lindner KH,
Dirks B, Strohmenger HU, Prengel AW, Lindner
IM, Lurie KG. Randomised comparison of
epinephrine and vasopressin in patients with
out-of-hospital ventricular fibrillation.
Lancet. 1997;349:535-537.
8. Lindner KH.
Vasopressin administration in refractory
cardiac arrest. Ann Intern Med.
1996;99:1379-1384.
9. Wenzel V,
Krismer AC, Arntz HR, et al. A comparison of
vasopressin and epinephrine for
out-of-hospital cardiopulmonary
resuscitation. N Engl J Med.
2004;350(2):105-113.
Is Your Unit a Beacon of Excellence?
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; and 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.
Is Your Nursing Identity Strong?
ACNPs Have an Opportunity to Educate
By Nancy
Munro, RN, MN, CCRN, ACNP
Advanced
Practice Work Group
You are an acute
care nurse practitioner at a teaching
hospital, but how many times has someone
mistaken you for an intern or resident?
Maybe you are an ACNP in a community
hospital, and a family member calls you
�Doc�?
Ask yourself: Do
you feel that your nursing identity is
strong in your role as an ACNP? The reason I
ask is that I am an ACNP who has been
practicing for almost five years in an ICU
setting. I am in my 28th year of critical
care nursing and was a clinical nurse
specialist for 14 years. Although I believe
my nursing identity is strong, I have
experienced these types of situations. At
first, I considered these mistakes to be
natural. However, as they occurred more
frequently, I began to be concerned.
The ACNP
position is in a rapid evolution. ACNPs
practice in many areas of the secondary and
tertiary care settings, including critical
care, emergency rooms, trauma care and
specialty-based practices. The ACNP role was
established to improve quality care and
promote cost containment. Richmond and
Keane1 described the following
justifications for the role in the tertiary
care setting:
� Changes in
medical residency programs
� Improving
consumer access to healthcare
� Facilitating
physician access
� Bridging the
gap between the nursing and medical world
� Improving
fragmented care.
Although these
are all functions of the ACNP in most work
settings today, the focus of my concern is
on bridging the gap. Richard and Keane
envisioned the ACNP role this way: �The
ability to bridge the gap between the
nursing and the medical world, including the
understanding of quality care and the
factors leading to satisfied patients, is
critical for the future.�1 �Satisfied
patients� is the key concept, because it
helps to articulate the difference between
the nursing and medicine disciplines.
The ACNP can be
a preferred provider of care based on the
important holistic and family-centered focus
the position brings to patient and family
interactions.2 This means that, in addition
to participating in the diagnosis and
treatment of health problems, the ACNP
brings the value-added nursing perspective
that completes the medical care of disease
identification and helps the patient and
family live with that disease.2 This concept
is supported by recent nursing research.
Hoffman and colleagues studied the work
activity difference between an ACNP and
physicians in training, such as
pulmonary-critical care fellows, who were
managing patients� care in a step-down
medical ICU.3 This study concluded that the
ACNP and the physician in training spent a
similar proportion of time performing
required tasks. However, because of training
requirements, the physician spent more time
in nonunit activities. The ACNP spent more
time interacting with patients and patients�
families and collaborating with health team
members.
Van Soeren and
Micevski had similar findings in survey
results in which the ACNP was cited as
promoting greater continuity of care,
focusing attention on issues of patients and
patients� families and participating in a
team approach.4 Consistent presence of an
ACNP focused on coordinating care may
enhance quality care and shorten patients�
stay, though further research is needed to
support this premise.3
This is how I
think I make a difference as an ACNP. I am
not a substitute for a physician. Instead, I
am an APN who is a complementary healthcare
team member, bringing the holistic
perspective that completes the care of the
complicated, high-acuity patient while
diagnosing and treating healthcare problems.
Barbara Daly wrote about �strangers in a
strange land,� comparing the ACNP�s
evolutionary challenge to Heinlein�s
stranger�s struggle from another planet to
integrate into earth�s culture.5 I would
like to alter that concept to describe the
ACNP as becoming the �facilitator in a land
of possibility.�
The ACNP has to
maintain a strong nursing identity while the
role is evolving and be very cautious about
how the role is being developed. The
paradigm of medical education has a strong
presence in the hospital setting and seems
to be looking for a �quick fix� for the loss
of resident hours. The ACNP is a reasonable
answer to that �quick fix,� but it is
imperative to emphasize that ACNPs are not
residents or fellows and to demonstrate how
the ACNP role differs, focusing on the
unique nursing contributions discussed
earlier.
Currently,
healthcare is chaotic. However, from chaos
comes innovation, and the ACNP�s opportunity
is now. As APNs, we have a responsibility to
lead nursing in its quest to demonstrate how
nursing makes a difference every day.
References
1. Richmond T,
Keane A. The nurse practitioner in tertiary
care. J Nurs Adm. 1992;22:11-12.
2. Hanson C,
Hamric A. Reflections of the continuing
evolution of advanced practice nursing. Nurs
Outlook. 2003;51:203-211.
3. Hoffman L,
Tasota F, Scharfenberg C, Zullo T, Donahoe
M. Management of patients in the intensive
care unit: comparison via work sampling
analysis of an acute care nurse practitioner
and physicians in training. Am J Crit Care.
2003;12:436-443.
4. Van Soeren M,
Micevski V. Success indicators and barriers
to acute nurse practitioner role
implementation in four Ontario hospitals.
AACN Clin Issues. 2001;12:424-437.
5. Daly B. Acute
care nurse practitioners: strangers in a
strange land. AACN Clin Issues.
1997;8:93-100.
Apply for AACN Nursing Research Grants
AACN offers a
variety of small and large research grants.
Practice Resource Network
Q:
When using biphasic defibrillators, what are
the required energy levels?
A:
The American Heart Association and its
Emergency Cardiac Care Committee concluded
that biphasic shock energies ≤200 J are safe
and effective and that nonescalating
biphasic energies appear to have success
rates for ventricular fibrillation
termination equivalent to or better than
monophasic shocks.1 According to the
committee and subcommittee, the evidence
supports a statement that low-energy (150),
nonprogressive (150 J, 150 J, 150 J),
impedance-adjusted biphasic waveform shocks
for patients in out-of-hospital VF arrest
are safe, acceptable and clinically
effective.2 They also concluded that
defibrillators may be used for both
out-of-hospital and in-hospital VF arrest,
including persistent or recurrent VF that
does not respond to the initial low-energy
shock.
The objective in
defibrillation is to achieve the highest
efficacy in terminating the arrhythmia with
the lowest energy and current. The AHA had
established a clear evidence-based process
for evaluating technologies in 1997. As a
result, the available biphasic technology
was recognized as consistent with a Class
IIb recommendation: acceptable and useful,
and fair-to-good evidence provides support.
No classification or statement was made
regarding the effectiveness of biphasic
defibrillation using an energy level beyond
200 J, because no data were available at the
time the guidelines were published.
Confusion has
arisen because there are several
manufacturers producing biphasic
defibrillators with both manual and
shock-adviser modes. These devices can
differ in waveform characteristics,
impedance compensation schemes and
recommended energy levels. The clinical
research has yet to determine which biphasic
waveform or energy level is optimal. There
is no standard recommended energy level or
sequence that can be applied to all
defibrillators that use biphasic waveforms.
Based on the
inadequate comparable data, the biphasic
energy levels will vary with different
devices. Therefore, it becomes essential
that healthcare professionals are educated
and trained fully on the equipment available
to them.
If you have a
practice-related question, call AACN�s
Practice Resource Network at (800) 394-5995,
ext. 217.
References
1. American
Heart Association in collaboration with
International Liaison Committee on
Resuscitation. Guidelines 2000 for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Part 6: Advanced
cardiovascular life support. Section 2:
Circulation. 2000;102 (Suppl 8):I-90-I-91.
2. Cummins RO,
Hazinski MF, Kerber RE, et al. Low-Energy
Biphasic Waveform Defibrillation:
Evidence-Based Review Applied to Emergency
Cardiovascular Care Guidelines. Statement
for healthcare professionals from the
American Heart Association Committee on
Emergency Cardiovascular Care and the
subcommittees on basic life support,
advanced cardiac life support and pediatric
resuscitation. Circulation.
1998;97:1654-1667.
3. Walcott GP,
Melnick SB, Chapman FW, Jones JL, Smith WM,
Ideker RE. Relative efficacy of monophasic
and biphasic waveforms for transthoracic
defibrillation after short and long
durations of ventricular fibrillation.
Circulation. 1998;98:2210-2215.
4. Gasch B. With
Public Access Push, AED Space Has Huge
Growth Potential. Cardiovasc Device Update.
July 2002. Available at hhtp://www.findarticles.com/cf_dls/m0KGK/7_8/89578732
/p1/article.jhtml?term=.
Accessed on 1/28/2004.
Public Policy Update
Most Workers Unable to Identify Signs of
Violence
A study
commissioned by the American Association of
Occupational Health Nurses indicates that
most Americans are unable to pinpoint the
most common signs of workplace violence,
though 12% of the study�s participants
showed some level of concern that a violent,
job-related event will occur at their
workplace. The full study is available
online.
JCAHO Rethinks Treatment of ED Overcrowding
The Joint
Commission on Accreditation of Healthcare
Organizations has quietly de-emphasized
emergency room overcrowding as the cause of
treatment delays and inadequate care nine
months after singling out the issue as a
safety problem. Instead, a new accreditation
standard directs hospital leaders to
identify and mitigate barriers to efficient
patient flow throughout their facilities.
A proposed
standard to adopt ED overcrowding as an
initiative in JCAHO�s campaign to influence
public policy affecting quality of care met
criticism that many sources of ED
overcrowding were outside the direct control
of hospitals. After reviewing public
comments, the commission modified the
standard to emphasize the role of leadership
in motivating people throughout the hospital
to expedite the movement of patients in
general, according to the February issue of
JCAHO�s Perspectives publication.
Staffing Ratios Won�t Aid Recruitment and
Retention
More than half
of the 139 hospital and health system
leaders responding to a poll by the
Governance Institute indicated they expect
their state legislatures to consider
mandated nurse-staffing ratios in the next
two years. However, 93% said they do not
believe mandated ratios would help recruit
and retain nurses, and only a quarter of
respondents who expected such an initiative
to be pursued believed it would pass.
Additional information about this survey is
available online at
Healthcare Among Top Voter Concerns for 2004
Healthcare tied
with terrorism and national security to
trail only the economy among voters�
concerns, according to a survey by the
American Hospital Association. Of the more
than 2,000 respondents, 27% said affordable
healthcare should be Congress� highest
priority or was personally the most
important election issue to them. The survey
is available online at
www.hospitalconnect.com > News Sources > AHA
> Press Room > 01/14/04.
Bush Cites Healthcare as a �Critical Issue�
During his
�State of the Union� address, President Bush
called upon members of Congress to improve
access to healthcare and contain health
costs by passing legislation that would
permit the formation of association health
plans, give tax credits to help people
purchase health insurance, cap awards in
medical malpractice lawsuits to help
decrease insurance premiums and encourage
people to purchase health savings accounts.
Bush also
highlighted the Medicare legislation that he
signed last year, saying it provides a
�basic commitment to our seniors� to give
them �the modern medicine they deserve.� He
explained components of the law, including a
drug discount card that, beginning this
year, is expected to save seniors an
estimated 10% to 25% off the retail price of
prescription drugs; coverage for preventive
care screenings to be implemented next year;
and prescription drug coverage beginning in
2006. The text of Bush�s speech is available
online at
www.whitehouse.gov > News > Current News >
January 2004 > January 20, 2004.
Nursing Programs Funding Short of Requested
Amount
The President�s
budget summary for healthcare providers
includes a $40 million increase for the
National Health Service Corps and the
Nursing Education Loan Repayment and
Scholarship Program to broaden access to
healthcare by directing doctors, nurses and
other healthcare professionals into
medically underserved areas. The budget
redirects resources from health professions
grants for advanced nursing to health
professions grants for basic nursing
education to address nursing shortages.
A total of $147
million was allocated for nursing education
programs, including provisions of the Nurse
Reinvestment Act. Although AACN is pleased
with the $5 million increase in this tight
budget year, it is also concerned that
funding levels are still inadequate to meet
the growing demand for nurses. AACN is
joining others in the nursing community in
requesting an increase of $205 million for
FY05 nursing funding and will continue to
pursue building on the $15 million funding
increase in FY03 and the $30 million
increase received in FY04 to ensure that the
nation�s growing need for nurses is met.
IOM Panel Recommends Universal Health System
The Institute of
Medicine has issued a report in which the
agency for the first time formally
recommends that by 2010 the United States
implement a universal health insurance
system to �prevent more unnecessary
suffering, death and economic costs to
society.� A committee of academics, business
leaders, health insurers and healthcare
providers drafted the 205-page report,
titled �Insuring America�s Health:
Principles and Recommendations,� which
concluded that the large number of uninsured
U.S. residents �results in unnecessary
sickness and death, weakens the nation�s
economy and undermines the entire health
care system.�
The report did
not endorse a specific proposal for a
universal health insurance system, but said
that incremental coverage expansions
implemented to date �haven�t put much of a
dent in the problems of the uninsured.� The
report concluded that �small steps are
inadequate� to address the issue.
HHS Regulations Plan Includes Mandatory IRB
Registration
The Department
of Health and Human Services will soon
propose a broad, new requirement for
institutional review board registration, the
department said in the HHS semiannual
agenda, published in the Dec. 22, 2003,
Federal Register (68 Fed. Reg. 72862).
Member contact information, approximate
numbers of active protocols involving
research conducted or supported by HHS,
accreditation status, IRB membership, and
staffing for the IRB would all have to be
reported to HHS, according to the notice.
The notice is to
coincide with an identical proposal from the
Food and Drug Administration slated for this
month. The goal of the dual proposals is to
create a single HHS IRB registration system,
according to the agenda.
�The proposed
registration requirements will make it
easier for the Office for Human Research
Protections to convey information to IRBs,
and will support the current IRB
registration operated by OHRP,� the notice
explained. Similarly, �the proposed rule
would make it easier for the FDA to inspect
IRBs and to convey information to IRBs,�
that agency said in its section of the
agenda.
The White House
Office of Management and Budget already has
cleared the plan as being in compliance with
the Paperwork Reduction Act. OHRP is slated
to propose mandatory research education for
IRB chairpersons and members, IRB staff,
investigators, and other personnel involved
in the conduct of human subjects research.
Study Shows No Link Between Procedure
Volumes and Outcomes
Hospitals that
perform large numbers of certain procedures
may not offer the best care, despite
previous research demonstrating a link
between procedure volume and mortality and
complication rates, according to two studies
recently published in the Journal of the
American Medical Association. One study by
Eric Peterson, an associate professor of
medicine at Duke University, and colleagues
analyzed outcomes for 267,089 coronary
artery bypass graft procedures at 439 U.S.
hospitals between 2000 and 2001. The
researchers found that a hospital�s volume
of that procedure is only �modestly
associated� with successful outcomes and
�may not be an adequate quality indicator,�
For example, hospitals that performed more
than 450 of the procedures annually had a
mortality rate of 2.5%, compared with a 3.2%
mortality rate at hospitals that performed
fewer than 150 procedures per year.
The second study
by Jeannette Rogowski, a senior economist at
RAND in Arlington, Va., and colleagues
studied 94,110 very low-birth weight infants
born at 332 Vermont Oxford Network hospitals
between 1995 and 2000. They found that
babies in hospitals that treated 50 or fewer
premature infants per year had higher
mortality rates for such patients. Overall,
a hospital�s past morality rate was a �far
better predictor of patient outcomes.� The
mortality rate for high-volume hospitals was
13%, compared with 15% for lower-volume
hospitals.
State Report Finds IT Could Alleviate
Nursing Shortage
Hospitals should
adopt technology-based approaches to solve
their nursing shortages, meet the demands of
nurses and improve care quality and patient
safety, according to a report from the
Maryland Statewide Commission on the Crisis
in Nursing�s Technology Workgroup. The
report, titled �Technology�s Role in
Addressing Maryland�s Nursing Shortage:
Innovations & Examples,� includes a list of
overall recommendations and individual
lessons from IT-based strategies in place at
hospitals around the state.
To address
problems associated with the nursing
shortages, such as understaffed units and
unfilled positions, the report recommends an
online back-to-work refresher program to
prepare inactive nurses to re-enter the
workforce. It also recommends several remote
care applications: remote ICU monitoring by
off-site clinicians; robot technology for
nursing homes and home monitoring programs
designed to avoid unnecessary or avoidable
hospital visits.
The use of
applications, such as mobile communication
devices, computerized medication ordering
and electronic patient management systems
can help address the time nurses spend on
nondirect care activities, according to the
report.
Plan Would Increase Use of Technology
U.S. Sen.
Hillary Clinton (D-N.Y.) has announced a
five-point healthcare proposal and
introduced legislation that would establish
a national electronic medical records system
and use other medical technologies to
improve the quality of care in the United
States. Under the Health Information for
Quality Improvement Act (S. 2003), the
federal government would establish standards
for medical records and an electronic system
that would allow providers to access and
share the records. Patients also could
access laboratory results online, record
blood sugar levels in their medical records,
receive electronic messages to remind them
when to take medications and increase e-mail
communication with providers. In addition,
the proposal would establish a national
rating system to allow patients to compare
the quality of physicians, hospitals and
nursing homes. The proposal also would
require increased federal research on
whether hand-held computers and electronic
medical records could improve quality of
care.
In a similar
move in July 2003, Rep. Nancy Johnson (R-Conn.)
introduced the National Health Information
Infrastructure Act of 2003 (H.R. 2915) that
would create a national system for patient
data interchange. The bill, which includes
provisions for voluntary data standards and
patient access to medical records, would
also establish a national IT infrastructure
based on interoperable provider systems to
reduce medical errors, paperwork and costs.
Public Policy Snapshot
Nurses Rate
High in Public Trust
Nearly nine out
of 10 Americans trust their doctors and
nurses, according to a recent Wall Street
Journal Online/Harris Interactive healthcare
poll. Nurses earned the highest level of
trust in administering care to the general
public. But when Americans were asked about
trusting who cares for their own health,
doctors eked out a top finish.
At the same
time, managed care and health insurance
companies are low on the list, with more
than half of those surveyed saying they have
little or no faith in them. Following are
highlights of the poll results:
How much do you
trust each of the following to do the right
thing for the healthcare of those for whom
they have a responsibility?
A Lot Some Not
Not Not
Much at All Sure
Nurses 65% 30 3
1 1
Doctors 61% 32 5
1 1
Pharmacies 49%
40 8 1 2
Hospitals 44% 41
10 3 1
Pharmaceutical
companies 14% 40
26 15 5
Employers 12% 48
28 8 4
Managed care
companies 9% 32
34 17 8
Health insurance
companies 8% 30
36 23 4
And how much do
you trust each of the following to do the
right thing for you and your healthcare?
A Lot Some Not
Not Not
Much at All Sure
NA
Your doctor(s)
63% 26 4 1 2 3
Nurses who
treat you 60% 29
3 1 1 6
Your dentist 58%
29 3 1 3 7
Pharmacies 50%
36 6 2 2 4
The last
hospital
you visited 47%
33 7 4 2 7
Prescription
drugs you take
44% 36 5 2 2 12
Your employer
16% 29 17 8 2 27
Your health
insurance
company 15% 35
25 12 4 9
Your managed
care company 9%
25 19 10 4 33
In the Circle
Award Cites Excellence in Clinical Practice
Editor�s
note: The 3M Health Care-AACN Excellence in
Clinical Practice Award recognizes acute and
critical care nurses who embody, exemplify
and excel at the clinical skills and
principles that are required in their
practice. Sponsored by 3M Health Care, the
award is part of AACN�s Circle of Excellence
recognition program. The recipients were
provided complimentary registration, airfare
and hotel accommodations for the NTI.
Following are exemplars submitted in
connection with the award for 2003.
Elizabeth �Buffy� Schenkel, RN, BSN, CCRN
Wheeling, W. Va.
Ohio Valley Medical Center
Advocacy and
collaboration gave one patient a new lease
on life. R.J. was severely debilitated from
chronic pain. She had an undifferentiated
autoimmune disease, as well as unrepaired
hip and pelvic fractures that left her
feeling miserable.
R.J. was on 2500
mg of meperidine per day by continuous
infusion and prn boluses. As we know now,
the toxic metabolite of meperidine irritates
the brain and causes rebound pain. The more
meperidine that is administered, the more
toxic metabolites that are produced. As this
unending cycle of dependence and toxicity
besieged her brain, R.J. suffered seizures,
hyperthermia, and cardiac arrest�twice.
I was working in
charge on the day shift following R.J.�s
admission after her second arrest. I was
free to make rounds with the doctors, which
I wouldn�t have done if I had a regular
patient assignment. R.J.�s attending
physician was at a loss.
While attending
a conference the previous summer, I learned
of a part-time palliative care specialist in
the area, whose position was funded by the
West Virginia Initiative to Improve
End-of-Life Care. I got permission from the
physician for a consult.
Good things
began to happen. We started R.J. on
methadone, along with adjunct medicines for
pain control. R.J.�s pain went from a �25�
on a 0-to-10 pain scale to a �5� within two
shifts. She could eat, drink, sleep and
participate in daily living activities.
Discharge plans changed from transferring to
an extended care facility to returning home
with follow-up by visiting nurses and the
palliative care specialist.
I am proud to
have been part of the process that led to a
significant renewal for R.J. She had nothing
left to lose, and we gave her back her life.
She has not needed plasmaphoresis in three
years. She is active, can walk again and is
traveling with her husband. R.J. only takes
about one-third of the original dose of
methadone now and has excellent pain
control.
I was in the
right place at the right time to make a
difference in someone�s life. Palliative
care resources were available, the physician
was willing to take the risk, and the
palliative care specialist was able to
follow up. R.J. is living proof that
advocacy and collaboration can bring about
profound and positive change.
Heidi A. Wagner, RN, BSN, CCRN
Saint Paul, Minn.
Fairview University Medical Center
I met M. the day
after her first surgery. She had perforated
her bowel at home and for about one week,
was unaware what was brewing in her abdomen.
Over the next
several weeks, the challenges were many in
caring for M. She was critically ill with
intermittent crisis including sepsis, DIC,
acute tubular necrosis requiring CRRT, skin
breakdown from extensive edema, nutrition,
open abdominal incision with frequent
washouts, acute lung injury, and cholecystic
artery hemorrhage. During her stay on the
surgical ICU, I worked with her family to
incorporate and honor their religious
beliefs. M. and her family are Hindu, and
they had pictures of deity and sacred ashes
that they believed watched over her.
After she bled
heavily and lived, I somehow knew she would
live to go home. It was always difficult to
assess her mental state, because she was on
fentanyl, ativan and cisatracurium drips.
M. was on our
unit for three months. As she progressed,
she often awakened crying inconsolably and
saying, �Where am I?� I provided constant
reassurance and support, and provided her
explanations of her illness. Explaining
procedures and activities before beginning
allowed her to have some sense of control.
Caring for M.
and her family taught me that, through the
talents, support and love of many people,
one can survive incredible odds. Having been
a nurse nine years, I have discovered the
best medicine can be an act of kindness from
one human being to another. I learned
sometimes all I can do is pray or hold a
hand. I had the opportunity to hone my
skills and knowledge of hypovolemic and
septic shock. Through much experience and
general curiosity, a deeper understanding of
CRRT is in my critical care knowledge base.
Have you ever been so curious that you felt
compelled to look up information at home?
That is what I did to understand my patient
and her Hinduism. However, many other pieces
of information I learned caring for M., by
looking at my patient.
Scott A. Woodby, RN, BSN, CCRN
Galveston, Texas
University of Texas Medical Branch
J.C. was
admitted to the medical ICU for chronic
obstructive pulmonary disease exacerbation
that required mechanical ventilation and an
eventual tracheotomy. I had not cared for
J.C. during the first month of his
admission; however, as charge nurse, I had
developed a relationship with him and
assisted in the development of
interdisciplinary goals. Secondary to his
lengthy stay in the MICU, J.C. developed a
poor disposition and was difficult to care
for. Upon completion of my charge nurse
rotation, I volunteered to care for him.
I received
report from the off-going nurse. She stated
that J.C. had required additional
ventilatory support throughout the night.
After some investigation, I discovered that
J.C. had been eating for the previous two
days while on full ventilatory support. I
recalled that J.C. had been off the
ventilator for several days and that the
speech therapist had worked with him. After
reviewing the chart, I found that the speech
therapist had recommended eating only while
off the ventilator.
My assessment
found that J.C. had developed aspiration
pneumonia. I questioned the attending
physician about allowing J.C. to eat on full
ventilatory support. He stated there had
been a miscommunication and that J.C. would
remain NPO until off full ventilatory
support. This was devastating to J.C.,
because eating was one of the few aspects of
his life he had control of. After much
discussion and teaching, J.C. allowed me to
place a dobhoff tube, and enteral feeds were
initiated.
By the end of
the week, J.C. was off the ventilator and
eating. As his condition improved, J.C.�s
real personality began to show. I assisted
J.C. in finding control by allowing him
choices in his daily care. J.C. was
eventually discharged home. Since caring for
J.C., I have been a vocal advocate for
tracheotomies, swallowing and patient
self-control.
|
