AACN News—March 2004—Practice

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Vol. 21, No. 3, MARCH 2004


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.