AACN News—May 2004—Practice

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Vol. 21, No. 5, MAY 2004

Critical Care Societies Promote �The Power of You� Letter-Writing Campaign

Join your colleagues May 17 through 19, during National Critical Care Awareness and Recognition Month, to educate Congress on the growing critical care workforce shortage and its implications for the future. AACN and three other critical care professional societies�American College of Chest Physicians, American Thoracic Society and Society of Critical Care Medicine�are partnering on a letter-writing campaign that outlines the crisis and calls for federal action. Through this effort, our collective concerns can be heard as one voice.

May 17 through 19, you can contact your congressional representatives through AACN�s Legislative Action Center advocacy website and ask them to work with us. Letters will be available for you to sign and send electronically, or you can draft your own letter to express your concerns. Through this collective effort, critical care professionals can prompt health policy discussions to ensure the best critical care medicine for the future.


Expected Practice:
� Verify the accuracy of the transducer-patient interface by performing a square waveform test at the beginning of each shift.
� Position the patient supine prior to PAP/RAP (CVP) measurements. Head of the bed (HOB) elevation can be at any angle from 0� (flat) to 60�.
� Level the transducer air-fluid interface to the phlebostatic axis (4th ICS 1⁄2 AP diameter of the chest) with the patient in a supine position prior to PAP/RAP measurements.
� Obtain PAP/RAP measurements from a graphic (analog) tracing at end-expiration.
� Use a simultaneous ECG tracing to assist with proper PAP/RAP waveform identification.
� PA catheters can be safely withdrawn and removed by competent registered nurses.

Supporting Evidence:
� The square waveform test, or dynamic response test, determines the ability of the transducer system to correctly reflect pressures in the pulmonary artery.1-5 This test can identify system problems, such as air bubbles in the tubing, excessive tubing length, loose-fitting equipment and patient problems, such as catheter patency. Any of these problems may affect accuracy of PAP/RAP measurements and should be corrected prior to pressure measurement. Experts recommend the following situations as appropriate to perform the square waveform test: on the initial system setup, at least once each shift, after opening the catheter system (eg, for rezeroing, drawing blood, or changing tubing), and whenever the PAP waveform appears to be damped or distorted.1-4,6
� Consider the following changes in PA pressures as clinically significant (ie, not reflective of the normal variability in PA pressures): ∆PAS > 4-7 mm Hg; ∆PAEDP > 4-7 mm Hg; ∆PAWP > 4 mm HG.7,8
� Studies in a variety of patient populations have found that PAP/RAP measurements are accurate when the head of the bed is elevated to any angle between 0� and 60�, as long as the patient is in the supine position.9-11 Two studies have also shown that PAP/RAP readings are accurate with the patient in a lateral position, if the angle of rotation is exactly 30� or 90� with the head of the bed flat and the location of the transducer air-fluid interface changed to the appropriate external landmarks for lateral positioning (30� lateral: distance from surface of bed to the left sternal border; 90� right lateral: 4th ICS/midsternum; 90� left parasternal border).1,12-14 When utilizing a 30� side-lying angle, a method of ensuring an accurate angle is needed and should be readily available to the bedside practitioner.13
� Leveling the transducer air-fluid interface to the left atrium corrects for changes in hydrostatic pressure in vessels above and below the heart.1,3 In the supine position, the external landmark for the left atrium is the phlebostatic axis (4th ICS1⁄2AP diameter of the chest).15,16 Studies have found that improper positioning of the air-fluid interface can lead to significantly different PAP/RAP readings.17,18 Once the correct location for the phlebostatic axis is identified, a mark should be placed on the chest wall and a laser pointer level or a carpenter�s level should be used to properly level the transducer air-fluid interface anytime the patient is repositioned.1,2,18
� Changes in patient position, even slight HOB ≠ or �, require releveling of the transducer air-fluid interface before obtaining PAP/RAP measurements.
� Changes in intrathoracic pressure during respiration significantly alter hemodynamic pressures. Obtaining accurate PAP/RAP measurements requires reading pressure waveforms during end expiration only.1-4,9,19 Digital readouts on pressure monitors reflect pressures obtained throughout respiration and are significantly different from end-expiratory pressures, requiring pressure to be read from graphic waveform tracings.6,20,21
� Levels of evidence supporting validation of PAP/RAP waveform measurement with simultaneous ECG tracings include clinical literature, expert opinion and sound theoretical principles of hemodynamic measurement.1-4
� Studies and surveys show that after education and clinical monitoring to assess competency, registered nurses can safely withdraw or remove PA catheters.22-24 Before incorporating withdrawing or removing PA catheters into nursing practice, verify that it is within your state�s scope of practice for registered nurses.

What You Should Do:
� Always identify and mark the phlebostatic axis, obtain PAP/RAP with the patient in the supine position and the head of the bed elevated between 0� and 60�, read pressures from a graphic (analog) recording at end expiration, and periodically perform a square waveform test.
� Ensure that your critical care unit has written practice documents, such as a policy, procedure or standard of care, that include these expected Practice Alert standards.
� Determine your unit�s rate of compliance with these Practice Alert standards.
� If compliance is < 90%, develop a plan to improve compliance:13
� Consider forming a unit task force to address the need for changes in PAP/RAP measurement practices.
� Educate staff about the inaccuracies that can occur in PAP/RAP measurements with improper techniques (Education Toolbox at www.aacn.org).
� Incorporate content into orientation programs, initial and annual competency verifications.
� Develop a variety of communication strategies to alert and remind staff of the importance of these PAP/RAP practices.

Need More Information or Help?
� A Web-based educational program on pulmonary artery pressure measurement is available at www.pacep.org.
� PAP/RAP Practice Alert information is available at www.aacn.org
� Square waveform test information
� Identifying correct PAP/RAP waveforms from simultaneous pressure and ECG tracings
� Identifying correct phlebostatic axis location for leveling transducers in the supine position
� Audit tool for measuring compliance with PAP/RAP expected practice standards
� Power Point slide program for PAP/RAP measurement education sessions
� Talk with a clinical practice specialist for additional information or assistance (www.aacn.org).

1. Keckeisen M, Chulay M, Gawlinski A, eds. Pulmonary and artery pressure monitoring. In AACN�s Protocols for Practice: Hemodynamic Monitoring Series. Aliso Viejo, Calif: AACN; 1998.
2. Quaal S. Quality assurance in hemodynamic monitoring. AACN Clin Issues. 1993;4:197-206.
3. Daily E, Schroeder J. Techniques in Bedside Hemodynamic Monitoring. St Louis, Mo: Mosby-Year Book; 1994.
4. Quaal S. Ask the experts. Crit Care Nurse. 1995;10:92-93.
5. Gardner R. Direct blood pressure measurement: Dynamic response requirements. Anesthesiology. 1981;54:227-236.
6. Ahrens T, Penick J, Tucker M. Frequency requirements for zeroing transducers in hemodynamic monitoring. Am J Crit Care. 1995;4:466-471.
7. Moser D, Woo M. Normal fluctuation in pulmonary artery pressure and cardiac output in patients with severe left ventricular dysfunction abstract. Am J Crit Care. 1996;5:236.
8. Nemens EJ, Woods SL. Normal fluctuations in pulmonary artery and pulmonary capillary wedge pressure in acutely ill patients. Heart Lung. 1982;11:393-398.
9. Dobbin K, Wallace S, Ahlberg J, et al. Pulmonary artery pressure measurement in patients with elevated pressures: effect of backrest elevation and method of measurement. Am J Crit Care. 1992;1:61-69.
10. Wilson A, Bermingham-Mitchell K, Wells N, et al. Effect of back position on hemodynamic and right ventricular measurements in critically ill adults. Am J Crit Care. 1996;5:264-270.
11. Woods S, Mansfield L. Effect of body position upon pulmonary artery and pulmonary capillary wedge pressures in noncritically ill patients. Heart Lung. 1976;5:83-90.
12. VanEtta D, Gibbons E, Woods S. Estimation of left atrial location in supine and 30� lateral position abstract. Am J Crit Care. 1993;2:264.
13. Bridges EJ, Woods SL, Brengelmann GL, et al. Effect of the 30 degree lateral recumbent position on pulmonary artery and pulmonary artery wedge pressures in critically ill adult cardiac surgery patients. Am J Crit Care. 2000;9:262-275.
14. Kennedy GT, Bryant A, Crawford MK. The effects of lateral body positioning on measurements of pulmonary artery and pulmonary wedge pressures. Heart Lung. 1984;13:155-158.
15. Paolella L, Dortman G, Cronan J, et al. Topographic location of the left atrium by computed tomography: reducing pulmonary artery catheter calibration errors. Crit Care Med. 1988;16:1154-1156.
16. Courtois M, Fattal P, Kovacs S, Tiefenbrunn A, Ludbrook P. Anatomically and physiologically based reference level for measurement of intracardiac pressures. Circulation. 1995;92:1994-2000.
17. Kee L, Simonson J, Stotts N, Skov P, Schiller N. Echocardiographic determination of valid zero reference levels in supine and lateral positions. Am J Crit Care. 1993;2:72-80.
18. Bartz B, Maroun C, Underhill S. Differences in midanteroposterior level and midaxillary level of patients with a range of chest configurations. Heart Lung. 1988;17:309.
19. Ahrens T. The effects of mechanical ventilation on hemodynamic waveforms. Crit Care Clin North Am. 1991;3:629-639.
20. Ahrens T, Schallom L. Comparison of pulmonary atery and central venous pressure waveform measurements via digital and graphic measurement methods. Heart Lung. 2001;30:26-38.
21. Lipp-Ziff E, Kawanishi D. A technique for improving the accuracy of the pulmonary artery diastolic pressure as an estimate of left ventricular end-diastolic pressure. Heart Lung. 1991;20:107-115.
22. Wadas TM. Pulmonary artery catheter removal. Crit Care Nurse. 1994;14;62-72.
23. Roundtree WD. Removal of pulmonary artery catheters by registered nurses: a study in safety and complications. Focus Crit Care. 1999;18:313-318.
24. Zevola, DR, Maier B. Improving the care of cardiothoracic surgery patients through advanced nursing skills. Crit Care Nurse. 1999;19:34-44.

Other Articles of Interest
1. Gawlinski A. Facts and fallacies of patient positioning and hemodynamic measurement. J Cardiovasc Nurs. 1997;12: 1-15.
2. Bridges E. Monitoring pulmonary artery pressures: just the facts. Crit Care Nurse. 2000;20:59-78.
3. Leeper B. Monitoring right ventricular volumes: a paradigm shift. AACN Clin Issues. 2003;14:208-219.
4. Quall SJ. Improving the accuracy of pulmonary artery catheter measurements. J Cardiovasc Nurs. 2001;15:71-82.

Practice Resource Network

Q: I�m starting to work on the AACN Beacon Award for Critical Care Excellence application and am not sure what is needed in the comment section of the question. Can you help?

A: The comment section for each question, which is limited to 300 words, is designed to provide you the opportunity to explain or describe what makes your unit unique or excellent. It allows you to illustrate the processes in place for you to meet or exceed the listed standard. If your unit does not meet the listed standard, you have the opportunity to explain what actions are being taken so your unit can meet the standard. Areas to expand on may include methods of monitoring and evaluating people, processes or outcomes and methods of communicating information, findings or changes. These comments will have a primary influence on the reviewers� decision with respect to the total application presentation.

Q: How frequently are the applications reviewed and how soon after I submit the application can I expect a response?

A: The reviewers have 90 days from the time the application is received to review and provide written comments. Evaluation feedback will be provided to units that do not succeed in obtaining the award with their first application submission. The units will have a chance to use the feedback to provide additional detail to their original responses and resubmit their application for further consideration at no additional cost.

For more information on the Beacon Award for Critical Care Excellence, go to our website.


July 1 is the deadline to submit applications for funding by the AACN Small Grant Program. Following is information about the grants that are available:

AACN Clinical Inquiry Grant
Five $500 awards are available to qualified individuals carrying out clinical research projects that directly benefit patients or families. Interdisciplinary projects are especially invited.

End-of-Life/Palliative Care Small Projects Grant
One award of $500 is available. Eligible projects may focus on any age group, patient education, staff development, CQI projects, outcomes evaluation projects or small clinical research studies. A broad range of topics may be addressed, including bereavement, communication issues, caregiver needs, symptom management, advance directives and life support withdrawal.

Medtronic-Physio-Control Small Projects Grant
One award of $1,500 is available. Funds will be awarded for projects involving patient education, competency-based education, staff development, CQI, outcomes evaluation or small clinical research studies. Topics should focus on aspects of acute myocardial infarction, cardiac resuscitation, sudden cardiac death, use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretive 12-lead electrocardiogram. Collaborative projects involving interdisciplinary teams, multiple nursing units, home health, subacute and transitional care or other institutions and community agencies are encouraged.

To find out about AACN�s research priorities and grant opportunities, visit our website.

Public Policy Update

Study: 20% of Terminal Patients Die in Hospital ICUs
More than 20% of terminally ill patients in the U.S. die in expensive ICUs, though nine of 10 Americans say they would prefer a low-tech approach to death, according to researchers at the University of Pittsburgh School of Medicine. Analyzing 552,157 deaths in six states using 1999 hospital discharge data, researchers found that 38% of the deaths occurred in the hospital and 22% in the ICU. Extrapolated nationally, more than half a million Americans die annually in ICUs. End-of-life ICU use was highest among infants, at 43% of ICU deaths, and lowest for people older than 85, at 14%. Terminally ill ICU patients had an average stay of 12.9 days at a cost of $24,541, compared with 8.9 days at a cost of $8,548 for terminally ill patients not in the ICU. The study was published in the March issue of Critical Care Medicine.

Senators Support More Funds to Develop Nursing Workforce
Forty-one senators have signed a letter urging the Labor and Health and Human Services Appropriations subcommittee to increase funding for nurse education and development programs by $63 million in fiscal year 2005. The letter, circulated by Sens. Barbara Mikulski (D-Md.) and Susan Collins (R-Maine), says adequate funding for the programs is needed to fulfill the promise of the Nurse Reinvestment Act. The senators note that nursing programs turned away more than 11,000 qualified students last fall, partly because of a shortage of faculty, and that the Health Resources and Services Administration could fund only a fraction of the applications it received for nursing student loan repayment and scholarships in FY2003. To read the letter and send a message to your senator, go to www.aacn.org > Public Policy.
Voters Cite Healthcare Reform as Major Campaign Issue

According to a nationally representative survey conducted for the Commonwealth Fund between Sept. 3, 2003, and Jan. 4, 2004, nearly six in 10 Americans say presidential and congressional candidates� views on healthcare reform will be a �very important� factor in determining whom they vote for this November. More than three in five adults said they favor repealing the recent federal tax cut to guarantee health insurance security for everyone. About 26% of adults reported being uninsured for some time during the previous 12 months, of which three out of five reported problems getting the care they need because of cost. Roughly 41% of Americans aged 19 to 64 said they had problems paying their medical bills or were paying off medical debt. A majority of Americans (59%) said the cost of health insurance should continue to be shared by individuals, employers and the government. The survey report, titled �The Affordability Crisis in U.S. Health Care: Findings From The Commonwealth Fund Biennial Health Insurance Survey,� is available online at www.cmwf.org.

Secretary of Labor Announces $24.4 Million Healthcare Initiative
U.S. Secretary of Labor Elaine L. Chao has announced a new national healthcare initiative worth $24.4 million to address critical worker shortages in the industry. The High Growth Job Training Initiative is a strategic effort to better prepare workers to take advantage of new job opportunities in high-growth sectors of the American economy. Through executive forums with leaders of expanding industries, critical workforce gaps and issues are identified. Solutions, such as grants, are then created in cooperation with employers, educational institutions and the public workforce system. Part of the President�s High Growth Job Training Initiative, the first two announced were $3 million to The Johns Hopkins Health System and $1.5 million to the State of Maryland. The Johns Hopkins Health System grant will fund training for current workers, provide GED and diploma preparation and upgrade training for positions experiencing critical worker shortages. Between 450 and 500 employees will benefit from the project. Operated by the Governor�s Workforce Investment Board, the second grant will address the lack of faculty for healthcare professions by funding scholarships for nurses who pursue credentials to teach at the college and university level. Additional funding will train current workers for future healthcare jobs and support scholarships for LPNs and other incumbent workers seeking credentials as registered nurses.
Additional information is available online at www.dol.gov.

Budget Debate Targets NIH Funding
The FY2005 �budget crunch� is forcing lawmakers to make �some difficult choices� on healthcare spending. Recent reports of growth in entitlement spending�specifically Social Security and Medicare�combined with growing tension over four decades of growth in healthcare spending, is pressuring lawmakers to reduce discretionary spending. The National Institutes of Health, whose funding has increased 107% since 1998, is �a tempting target for cutbacks,� as illustrated by the resurgence of criticism over some NIH studies that some lawmakers say are not the best use of federal funds. Already, the Bush administration has requested only a 2.7% increase in NIH spending over the previous year. The decrease is significant after annual increases of 15%.

Schwarzenegger Doesn�t Plan to Change California Nurse-to-Patient Ratio Requirements
California Gov. Arnold Schwarzenegger has indicated he does not plan to become involved in the controversy over the state�s nurse-to-patient ratio requirements this year.

Under the rules, which took effect Jan. 1, nurses do not have to care for more than eight patients at a time. The rules also call for one nurse per five patients in medical-surgical units by 2005, as well as one nurse per four patients in specialty care and telemetry units and one nurse per three patients in step-down units by 2008. In addition, the regulations state that only registered nurses can care for critical trauma patients and that at least one registered nurse must serve as a triage nurse in emergency departments.

According to an anonymous weekly survey launched in January by the California Healthcare Association, nine of 10 California hospitals are not complying with the rules.

House Approves Organ Donor Reimbursements
The House has voted 414-2 to approve a bill (HR 3926) that would reimburse organ donors for travel and other nonmedical expenses involved in transplant surgery. Beginning Oct. 1, the bill would allow the Department of Health and Human Services to spend $5 million a year to reimburse qualified donors and provide another $15 million for grants to states, public awareness campaigns and studies on improving recovery and donation rates. The bill also would fund new programs to coordinate organ donations at hospitals and procurement agencies. The bill now goes to the Senate, which passed a similar measure (S 573) in November.

Medical Errors Legislation Stalled
The CongressDaily news service recently examined how legislation that would address medical errors has stalled in Congress. The House voted 418-6 about a year ago to approve a bipartisan patient safety bill (HR 663). Although members of Congress say that medical error legislation could lead to better care and fewer medical malpractice lawsuits, they remain divided over two different bills. The House bill would create Patient Safety Organizations that would collect and analyze confidential reports of medical mistakes and suggest ways to avert future errors. Any information reported to PSOs would remain confidential. The House bill would give the Health and Human Services secretary the authority to �demand access to regional patient safety groups� data.�

The Senate bill was drafted by Senate Health, Education, Labor and Pensions Chair Judd Gregg (R-N.H.) and other leading senators. The proposal would also set up a patient safety database, but would not require regional groups to report patient safety lapses. The proposal would not protect the identities of those reporting errors. th bills are stalled by lawsuits.

Public Policy Snapshot

1 in 10 ED Patients Admitted to ICU

Findings from the National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary revealed that 12% of emergency department visits resulted in hospital admission. Included were direct admission to the ICU, critical care unit or coronary care unit, which occurred in about 1 of 10 admissions.

Number and percent of ED visits with corresponding standard errors, by visit disposition: United States, 2002

Disposition # of visits in thousands Standard error in thousands % of visits Standard error of %
All visits 110,155 4,416
Admit to Hospital1 13,471 721 12.2 0.5
Admit to ICU/CCU2 1,405 162 1.3 0.1

1 Includes those admitted to ICU/CCU.
2 ICU/CCU is intensive care unit/critical care unit or coronary care unit and is a subset of those admitted to hospital.

The full report can be viewed online at http://www.cdc.gov/nchs/.

Check Out These Health Policy Reports

� A recent Sigma Theta Tau report on the state of nursing globally laid out a number of similarities in the profession, but also showed dramatic differences in such areas as education. The third and final outing of the Arista Think Tank series was made up of five sessions in different regions of the world aimed at discovering the role of nurses and challenges facing the profession. A copy of the executive summary is available online.

� A report released by the Immigration Policy Center says that foreign-born professionals play a crucial role in filling severe shortages within the two largest healthcare occupations: physicians and nurses. However, recent changes in immigration policy have made it tougher to meet this need. According to the report, U.S. immigration policies are restricting the ability of healthcare providers to recruit needed nurses, physicians and other health professionals. The report is available online at www.ailf.org.

� A study published in the March/April 2004 issue of the journal Health Affairs examines factors such as professionalism, regulation and market forces that are driving hospital patient safety initiatives. The study, conducted between September 2002 and May 2003 by the Center for Studying Health System Change, is based on interviews with the largest hospitals in 12 U.S. communities. An abstract of the study is available online at www.healthaffairs.org.

� Two reports in the April 8, 2004, edition of the New England Journal of Medicine respond to an Agency for Healthcare Research and Quality report on racial health disparities that some had complained was edited to downplay differences in health outcomes among whites and minorities. The report, requested by Congress to track healthcare quality and differences in use of services, found in part that African-American and low-income U.S. residents have a higher mortality rate for cancer than the general population because they are less likely to receive tests for certain forms of the disease and other preventive services. The report also cited a number of other healthcare disparities. In a January letter to Health and Human Services Secretary Tommy Thompson, eight Democrat lawmakers said that HHS �watered down� the report, alleging that the final version included revisions that �alter the report�s meaning, undermine efforts to address disparities and fit a pattern of the manipulation of science by the Bush administration.�

� The Agency for Healthcare Research and Quality has issued four new briefs on bioterrorism and health system preparedness: Addressing the Smallpox Threat: Issues, Strategies, and Tools; Disaster Planning Drills and Readiness Assessment; Optimizing Surge Capacity: Hospital Assessment and Planning and Optimizing Surge Capacity: and Regional Efforts in Bioterrorism Readiness. The briefs are available on the AHRQ Web site at www.ahrq.gov.

� The U. S. General Accounting Office has released a report on the Occupational Safety and Health Administration�s voluntary workplace safety and health strategies that says the results are promising but should be fully evaluated before they are expanded. The GAO assessed the types of strategies used, the extent of their use and their effectiveness. GAO also obtained suggestions from specialists for additional voluntary compliance strategies. The report, titled �Workplace Safety and Health: OSHA�s Voluntary Compliance Strategies,� is available online at www.gao.gov.

� The Center on an Aging Society�s brief, the fifth in a series on chronic conditions, states that health providers and systems are increasing their commitment to cultural competence, or providers� ability to deliver health services that meet patients� social, cultural and linguistic needs. The brief adds that greater attention to that issue could help improve access to and quality of care, as well as health outcomes for certain populations. The brief, titled �Cultural Competence in Health Care: Is It Important for People With Chronic Conditions?� is available online at ihcrp.Georgetown.edu > Center on an Aging Society.

For more information about these and other issues, visit our website.

AACN Online Quick Poll

A recent report by the National Academy of Sciences suggests that to reduce �error-producing fatigue� that endangers patients, nurses should be prohibited from working more than 12 hours in any 24-hour period or more than 60 hours a week. Do you agree?

Yes 64%
No 28%
Not sure 7%
Don�t care 2%

Number of Responses: 1,502

This poll is a voluntary survey for our users and is not scientifically projectable to any other population. AACN presents these surveys to give our users an opportunity to share their practice and opinions on particular topics. Participate by visiting our website.
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