AACN News—September 2004—Practice

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Vol. 21, No. 9, SEPTEMBER 2004


Practice Alert: ST-Segment Monitoring

Expected Practice:
—Use the lead that best defines the patient’s “ST fingerprint” when monitoring for acute coronary occlusion and reocclusion of the vessel following therapeutic intervention.
—Use leads III and V3 for ST-segment monitoring for patients with acute coronary artery syndrome. Use ST-segment analysis to monitor patients:
• In the early phase of acute coronary syndromes (ST-elevation or non–ST-elevation MI; unstable angina/“rule out” MI).
• Who present to the emergency department with chest pain or anginal-equivalent symptoms.
• Who have undergone nonurgent percutaneous coronary intervention that has sub-optimal angiographic results.
• With possible variant angina due to coronary vasospasm
—Mark electrode placement with indelible ink.
—Establish ST level with the patient in the supine position, set the ST alarm parameter 1-2 mm above and below the patient’s baseline ST level and measure ST-segment changes 60 ms beyond the J point of the ECG complex.
—Properly prepare the patient’s skin before attaching the ECG electrodes.

Supporting Evidence:
• Research demonstrates that monitoring for ST-segment changes in 12 leads provides the most accurate data for identification of ischemic events. If 12-lead bedside monitoring is not available, multiple studies have shown that determining patients’ ST fingerprint, defined as the pattern of ST-segment elevations and depressions that is unique to a particular patient based on the anatomic site of coronary occlusion, can be used to diagnose reocclusion of the affected vessel.1-9
• Multiple studies show that if only two leads are available for ST-segment monitoring, leads III and V3 are recommended for patients with acute coronary syndromes, unless available information from a previous 12-lead ECG obtained during an ischemic event indicates that another lead is more sensitive.1,2,4-14
• Researchers have reported that 80% to 90% of ECG-detected ischemia events were clinically silent. In-hospital ischemic events are associated with poor patient outcomes, including in-hospital MI or death. The groups of patients that benefit the most from continuous ST-segment monitoring are patients with acute coronary syndromes presenting to the ED, patients undergoing a catheter-based procedure, patients with a cardiac history undergoing a surgical procedure and patients in the ICU following cardiac surgery as well as other procedures. Research is also beginning to show evidence that medical patients who are receiving mechanical ventilation and are to undergo ventilator weaning may benefit as well.1,15-21
• Some studies show that variability of electrode placement occurs during routine ECG monitoring. Expert consensus recommends marking the locations of the electrodes with indelible ink to ensure that if electrodes are removed for any reason (leads V2 and V3 are typically removed during recording of echocardiograms), they can be replaced in their original locations. ECG information obtained from electrodes located close to the heart (precordial leads) is especially prone to waveform changes when the electrodes are relocated as little as 1 cm away from the original locations.1,22
• Studies show that patients must be in a supine position with the head of the bed no more than 30 to 45 degrees when ST-segment analysis is performed. When an ST alarm sounds and patients are found in a side-lying position, patients should be returned to the supine position. If the ST-segment deviation persists in the supine state, it should be considered indicative of myocardial ischemia.1,2,15
• Failure to properly prep the skin before placing the electrodes may cause the monitoring alarms to sound erroneously. Preparation may include shaving areas where electrodes are to be placed and/or cleaning the skin with alcohol to remove skin oils.1,2,16,23

What You Should Do:
• When replacing current ECG monitoring equipment, consider equipment that has ST-segment monitoring capabilities.
• Review organization policies and procedures related to cardiac monitoring to ensure the standard of care is the same across settings.
• Develop proficiency standards for staff involved in the monitoring process to ensure patient safety and effective monitoring.
• Provide appropriate ECG education for staff.
--Include didactic content and hands-on practice with return demonstration of lead placement.
• Conduct an audit on determining appropriate leads to use for ST-segment monitoring and appropriately setting ST alarm parameters.
• If compliance for either is < 90%, develop a plan to improve compliance. Consider forming a multidisciplinary task force (nurses, physicians, respiratory therapists, monitor technicians) or a unit core group of staff to address ECG monitoring practice changes.
--Educate staff about the significance of correct placement of electrodes and skin preparation.
--Incorporate content into orientation programs, and initial and annual competency verifications.
--Develop a variety of communication strategies to alert and remind staff of the importance of ECG monitoring.
--Ensure that practice changes continue.

Need More Information or Help?
• For additional information or assistance, call the AACN Practice Resource Network at (800) 394-5995, ext. 217. Practice Alerts are online at www.aacn.org > Clinical Practice.

References
1. Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings. Circulation. In press.
2. Drew BJ, Krucoff MW. Multilead ST-segment monitoring in patients with acute coronary syndromes: a consensus statement for healthcare professionals. ST-segment Monitoring Practice International Guideline Working Group. Am J Crit Care. 1999;8:372-388.
3. Krucoff MW, Parente AR, Bottner RK, et al. Stability of multilead ST-segment “fingerprints” over time after percutaneous transluminal coronary angioplasty and its usefulness in detecting reocclusion. Am J Cardiol. 1988;61:1232-1237.
4. Klootwijk P, Cobbaert C, Fioretti P, Kint PP, Simoons ML. Noninvasive assessment of reperfusion and reocclusion after thrombolysis in acute myocardial infarction. Am J Cardiol. 1993;72:75G-84G.
5. Kwon K, Freedman SB, Wilcox I, et al. The unstable ST-segment early after thrombolysis for acute infarction and its usefulness as a marker of recurrent coronary occlusion. Am J Cardiol. 1991;67:109-115.
6. Krucoff MW, Croll MA, Pope JE, et al. Continuously updated 12-lead ST-segment recovery analysis for myocardial infarct artery patency assessment and its correlation with multiple simultaneous early angiographic observations. Am J Cardiol. 1993;71:145-151.
7. Krucoff MW, Wagner NB, Pope JE, et al. The portable programmable microprocessor-driven real-time 12-lead electrocardiographic monitor: a preliminary report of a new device for the noninvasive detection of successful reperfusion or silent coronary reocclusion. Am J Cardiol. 1990;65:143-148.
8. Krucoff MW, Green CE, Satler LF, et al. Noninvasive detection of coronary artery patency using continuous ST-segment monitoring. Am J Cardiol. 1986;57:916-922.
9. Krucoff MW, Pope JE, Bottner RK, Renzi RH, Wagner GS, Kent KM. Computer-assisted ST-segment monitoring: experience during and after brief coronary occlusion. J Electrocardiol. 1987;20(suppl):15-21.
10. Drew BJ, Pelter MM, Adams MG, Wung SF, Chou TM, Wolfe CL. 12-Lead ST-segment monitoring vs single-lead maximum ST-segment monitoring for detecting ongoing ischemia in patients with unstable coronary syndromes. Am J Crit Care. 1998;7:355-363.
11. Aldrich HR, Hindman NB, Hinohara T, et al. Identification of the optimal electrocardiographic leads for detecting acute epicardial injury in acute myocardial infarction. Am J Cardiol. 1987;59:20-23.
12. Bush HS, Ferguson JJ, Angelini P, Willerson JT. Twelve-lead electrocardiographic evaluation of ischemia during percutaneous transluminal coronary angioplasty and its correlation with acute reocclusion. Am Heart J. 1991;121:1591-1599.
13. Drew BJ, Tisdale LA. ST-segment monitoring for coronary artery reocclusion following thrombolytic therapy and coronary angioplasty: identification of optimal bedside monitoring leads. Am J Crit Care. 1993;2:280-292.
14. Tisdale LA, Drew BJ. ST-segment monitoring for myocardial ischemia. AACN Clin Issues Crit Care Nurs. 1993;4:34-43.
15. Pelter MM, Adams MG, Drew BJ. Transient myocardial ischemia is an independent predictor of adverse in-hospital outcomes in patients with acute coronary syndromes treated in the telemetry unit. Heart Lung. 2003;32:71-78.
16. Leeper B. Continuous ST-segment monitoring. AACN Clin Issues. 2003;14:145-154.
17. Adams MG, Pelter MM, Wung SF, Taylor CA, Drew BJ. Frequency of silent myocardial ischemia with 12-lead ST-segment monitoring in the coronary care unit: are there sex-related differences? Heart Lung. 1999;28:81-86.
18. Estrada CA, Rosman HS, Prasad NK, et al. Evaluation of guidelines for the use of telemetry in the non–intensive-care setting. J Gen Intern Med. 2000;15:51-55.
19. Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gersternblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med. 1986;314:1214-1218.
20. Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits DE, Gerstenblith G. Silent ischemia predicts infarction and death during 2-year follow-up of unstable angina. J Am Coll Cardiol. 1987;10:756-760.
21. Larsson H, Jonasson T, Ringqvist I, Fellenius C, Wallentin L. Diagnostic and prognostic importance of ST recording after an episode of unstable angina or non–Q-wave myocardial infarction. Eur Heart J. 1992;13:207-212.
22. Wenger W, Kligfield P. Variability of percordial electrode placement during routine electrocardiography. J Electrocardiol. 1996;29:179-184.
23. Clochesy JM, Cifani L, Howe K. Electrode site preparation techniques: a follow-up study. Heart Lung. 1991;20:27-30.

Other Articles of Interest
Daleiden AM, Schell H. Setting a new gold standard: ST-segment monitoring provides early detection of myocardial ischemia. Am J Nurs. May 2001;101(suppl):4-8.
Drew BJ. Celebrating the 100th birthday of the electrocardiogram: lessons learned from research in cardiac monitoring. Am J Crit Care. 2002;11:378-388.


Public Policy Update


Report Links Medical Errors With Overtime Hours
Nurses who work shifts longer than 12 hours or who work unplanned overtime at the end of a shift are as much as three times more likely to make errors, such as giving patients incorrect medications or dosages, according to a study published in the July/August issue of Health Affairs.

In the study, researchers from the University of Pennsylvania School of Nursing surveyed 393 registered nurses in hospitals nationwide. During one month in 2002, the nurses kept a daily log of their shift lengths, overtime, break schedules, coffee intake, weariness driving home and number of errors or near-errors they committed.
Nurses who worked at least 12.5 hours committed errors on 103 of 2,057 shifts, or 5%, and reported near-errors (defined as mistakes nurses caught before they affected patients) on 97 shifts, the study found. Nurses working an average shift of between eight and 12 hours made errors on 12 of 771 shifts, or 1.6%, and committed near-errors on 20 shifts. The study found that 14% of nurses worked at least 16 continuous hours one or more times during the month, with the longest shift lasting 23 hours, 40 minutes. About half of the nurses’ errors involved medication. Other errors included procedural mistakes.

Researchers were “puzzled” to find that nurses who planned to work longer shifts and overtime reported fewer errors than those who worked unexpected overtime and those who worked an average length shift. Ann Rogers, the study’s lead author, suggested that nurses who planned to work longer shifts purposely could get more sleep and go about their tasks in a calmer manner.

There is a “growing concern” that the national shortage of nurses is leading to an overstressed workload that can jeopardize patient care. As the “epidemic of medical errors” becomes more apparent, some hospitals are “bending to nurses’ demands” on limiting longer shifts. For example, some states are considering rules that would limit working hours for nurses. However, some hospital administrators have said facilities should establish their own standards. Researchers plan to release additional reports from the study, including papers on nurses’ caffeine consumption and whether nurses fall asleep while driving home from work. An abstract of the study is available at www.healthaffairs.org.

HHS Awards $15.5 Million to Expand, Strengthen Nursing Workforce
Health and Human Services Secretary Tommy G. Thompson has announced almost $15.5 million in grants to 62 universities, colleges, nursing schools, medical centers and other healthcare institutions to expand the nation’s supply of qualified nurses and promote diversity in the nursing profession.

A 2002 HHS report titled “Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020,” predicted that the nursing shortage is expected to grow to 29% by 2020, compared to a 6% shortage in 2000. During Thompson’s tenure, funding for nursing programs has increased dramatically, and six new nursing programs were implemented as part of the Nurse Reinvestment Act of 2002.

Most of the funds announced, $10.1 million, will support 38 grants under the Nurse Education, Practice and Retention Program. That program is designed to:
• Increase enrollment in baccalaureate nursing programs.
• Develop internship and residency programs.
• Promote cultural competency among nurses.
• Improve access to healthcare for medically underserved populations.
• Boost nurses’ retention rates.

The remaining $5.4 million will support 24 grants under the Nursing Workforce Diversity Program. That program supports student scholarships, stipends and pre-entry preparation, as well as nursing retention activities for individuals from disadvantaged backgrounds.

Healthcare Changes Increase Musculoskeletal Disorders in RNs
According to results of a survey of 1,163 registered nurses, organizational changes in healthcare have led to an increase in musculoskeletal disorders among registered nurses, independent of the effects of physical job demands associated with nursing. The nurses had been on the job for at least 12 months and had not been injured or in an accident off the job for up to three months before the onset of symptoms.

The survey included questions about neck, shoulder and back problems; physical and psychological demands; and healthcare changes. Nurses were asked to report whether 12 healthcare system changes that addressed staff levels, patient severity of illness and the delivery of nursing care had increased, decreased or stayed the same during the previous year.

In the August 2004 issue of the American Journal of Public Health, Dr. Jane Lipscomb and colleagues from the University of Maryland in Baltimore report that 20%, 17% and 29% of nurses reported neck, shoulder and back pain, respectively. When analyzed individually, three of 12 “negative” healthcare system changes were significantly associated with musculoskeletal disorders at all three body sites. They were having full-time RNs replaced by part-time or temporary RNs, having a facility or unit shut down and having unlicensed personnel provide direct patient care.

Compared with none or one change, the risk of neck problems when more than six changes were present was almost five times greater. The corresponding risk of shoulder and back problems was increased by three-fold. The authors concluded that the adverse impact on health caused by the changing healthcare system must be addressed to prevent further injuries among nurses.

Senate Passes Patient Safety and Quality Improvement Act
There’s been bipartisan agreement since a landmark 1999 Institute of Medicine landmark report that medical errors can and should be reduced through new legislation. With unexpected Senate action to pass the Patient Safety and Quality Improvement Act, that agreement may finally translate into law. The remaining hurdle before a White House signing ceremony is ironing out differences between versions of the legislation in a House-Senate conference. Although there are relatively few days left in the current session of Congress, key leaders are optimistic that they can get a bill done this year.

Cosponsored by Senate Majority Leader Bill Frist, MD (R-Tenn.), Judd Gregg (R-N.H.), Sen. Jim Jeffords (I-Vt.), John Breaux (D-La.) and others, the Senate-passed bill (S. 720) would establish a system in which providers would voluntarily report medical errors to patient safety organizations. These errors could be reported on a confidential basis. The organizations would analyze the data to identify patterns of errors and recommend systems of care to prevent recurrences.

House language differs in that it includes spending authorization provisions and provisions governing the interoperability of patient safety computer systems.

Nurse Recruiters Turning to Mexico to Ease U.S. Shortage
A growing number of nursing recruiters in the United States are looking to Mexico to counter a staffing shortage affecting many U.S. hospitals.

Some companies are beginning to offer incentives, such as reimbursement for specialized English classes, visa applications and tests for certification in the United States. Recruiters typically have focused on finding nurses in the Philippines, India, South Korea and Nigeria. Nurses educated in foreign countries and recruited to work in the U.S. must pass a national licensing exam, an English proficiency test and comply with state nursing board standards.

The trend has raised concerns among some World Health Organization and American Nurses Association officials in the United States and some healthcare experts, who say that Mexico cannot afford to lose highly trained nurses. Nevertheless, some Mexican government employment offices have offered classrooms and administrative assistance to at least one nurse recruiting company.

Immigration Law Could Lead Nurses to Leave U.S. Jobs
The Department of Homeland Security has given a reprieve to foreign healthcare workers, good news for hospitals that rely on nurses from Canada. Tighter immigration laws due to take effect in July would have required foreign workers to comply with new certification requirements. However, that requirement has been put off for a year.

Thousands of Canadian nurses who work in U.S. healthcare institutions could leave their jobs when the final provisions of an eight-year-old immigration law take effect. The law will require that Canadian nurses, attracted to the United States by the higher wages offered by U.S. providers, receive licenses through testing of proficiency and English competency.

The National Council of State Boards of Nursing estimates that up to 15,000 Canadian nurses will leave their jobs as a result of the new law, and the council says that healthcare institutions across the United States will be affected. Hospitals near the Canadian border could be particularly hard hit because Canadians account for up to 40% of nurses at those facilities. Currently, there are more than 100,000 vacant nursing jobs across the United States, and the Joint Commission on Accreditation of Healthcare Organizations estimates that number will grow to 275,000 by the time the oldest baby boomers reach retirement age.

New Health Information Technology Framework
Health and Human Services Secretary Tommy G. Thompson has announced a 10-year plan to transform the delivery of healthcare by building a new health information infrastructure, including electronic health records and a new network to link health records nationwide.

Thompson also announced a number of new action steps to help advance health information technology. The framework builds in part on a $60 million health information technology program at the Agency for Healthcare Research and Quality, including $50 million in FY 2004 for grants and contracts to support the development, adoption and evaluation of HIT in a variety of healthcare settings, especially rural and underserved communities. These awards will be announced in late September or early October. An additional $10 million will be invested by AHRQ in partnership with HHS’s Office of the Assistant Secretary for Planning and Evaluation for the development and adoption of HIT standards.

HRSA Awards Support Education in Health Professions
The Health Resources and Services Administration has announced $46 million in scholarship funds to support health professions education for disadvantaged students. The scholarships range from $700 to $650,000 and will go to 444 colleges and universities in 45 states, the District of Columbia, Puerto Rico and the Virgin Islands.

Last year, scholarships helped more than 3,000 students, many of whom practice in medically underserved areas when they graduate. The program provides scholarships to financially needy students who are enrolled full-time in health professions and nursing programs. Scholarship funds go to accredited schools, which determine students’ financial need and select scholarship recipients.


Public Policy Snapshot

Sentinel Event Statistics: As of June 29, 2004

Sentinel event-related data, reported to the Joint Commission from accredited organizations, address serious adverse events. This data can provide critical information in the prevention of errors and adverse events. The commission has reviewed 2,552 Sentinel Events since January 1995.

Type of Sentinel Event # %

Patient suicide 382 15%
Op/post-op complication 330 12.9%
Wrong-site surgery 310 12.1%
Medication error 291 11.4%
Delay in treatment 172 6.7%
Patient death/injury in restraints 113 4.4%
Patient fall 114 4.5%
Assault/rape/homicide 89 3.5%
Transfusion error 73 2.9%
Perinatal death/loss of function 71 2.8%
Patient elopement 49 1.9%
Fire 45 1.8%
Ventilator death/injury 39 1.5%
Anesthesia-related event 38 1.5%
Infection-related event 38 1.5%
Medical equipment-related 33 1.3%
Maternal death 31 1.2%
Infant abduction/wrong family 19 0.7%
Transfer-related event 18 0.7%
Other less frequent types 297 11.6%

Settings of Sentinel Events # %

General hospital 1649 64.6%
Psychiatric hospital 329 12.9%
Behavioral health facility 135 5.3%
Psych unit in general hospital 129 5.1%
Emergency department 109 4.3%
Long term care facility 87 3.4%
Home care 52 2.0%
Ambulatory care 53 2.1%
Clinical laboratory 6 0.2%
Health care network 2 0.1%
Office-based surgery 1 <0.0%

Additional Sentinel Event statistics are available online at www.jcaho.org > Latest From JCAHO.

For more information about these and other issues, visit the AACN Web site at www.aacn.org.

Grants

Evidence-Based Clinical Practice Grant
This grant funds awards up to $1,000 to stimulate the use of patient-focused data and/or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice. Grant proposals are accepted twice a year and must be received by either March 1 or Oct. 1.

AACN Clinical Practice Grant
This $6,000 grant supports research focused on AACN research priorities. Research conducted in fulfillment of an academic degree is acceptable. Oct. 1 is the annual application deadline for this grant.

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

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


Practice Resouce Network

Q: I am attempting to gather current information regarding the practice of infusing vasopressors via central line access. Are there any documents that support this as best practice? In our progressive care unit, we frequently infuse vasopressors peripherally. Is this placing the patient at risk?

A: There are two major considerations that support infusing vasopressors by central line if possible.

First, many of these high-risk agents can cause tissue injury or necrosis if they pass into the tissues. The manufacturer’s recommendations for infusion should be considered the “gold standard.” If the recommendation is that the drug be infused through a central line, that should be the practice if possible. Any line infusing a vasopressor needs close observation to prevent incidents. In addition, patients requiring titration of vasopressors will need frequent assessments to evaluate stability and outcomes of management. Of course, in an emergency, pressors can be started in a peripheral line and switched to a central line when available. This is supported by the AACN Protocol for Practice “Intravenous Drug Delivery.” (Product #180163)

Second, vasopressors are usually administered because the patient is hypotensive or needs increased renal perfusion. In these patients, peripheral perfusion is diminished already. One cannot ensure that anything infused peripherally is reaching the central circulation. To achieve the desired therapeutic effect, these drugs must be infused into the largest circulating pool possible. In an emergency, you would start these drugs in any accessible line, knowing that you will switch them to a central line as soon as possible.

If you have a practice-related question, call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or e-mail your question to practice@aacn.org.


In the Circle
Award Recognizes Nurses for Caring Practices

Editor’s note: Part of AACN’s Circle of Excellence recognition program, the Excellence in Caring Practices Award is presented in honor of J. Wilson Rodgers to honor nurses whose caring practices embody AACN’s vision of a healthcare system driven by the needs of patients and families. Following are excerpts from the exemplars submitted in connection with this award for 2004.

Captain Jacqueline M. Cole
RN, BS, BSN, CCRN
Flasher, N.D.
David Grant Medical Center
Travis AFB, Calif.
J. came to us in respiratory distress. I learned he was a World War II veteran, who received a Purple Heart for being a survivor on the beaches of Normandy. As a critical care nurse in the Air Force, this story hit home.

Soon after admission, J. was intubated. Over a couple of days, he became septic and developed acute respiratory distress syndrome. He was completely supported hemodynamically.

I focused on giving holistic nursing care to the family members, explaining what was going on physically and physiologically. Stories were told to let them embrace this event mentally and emotionally. I offered them chaplain services, and unit rules were bent, allowing them to see him at any time.

Soon, I sensed an internal war going on about end-of-life choices. His wife said she and her husband had talked about end-of-life issues, but she was facing difficulty following through. He did not want to be on life support, but another son far away was at odds over withdrawing care.

On my third night, the family was at the bedside. This gathering turned into an emotional argument between the brothers. I removed them from the unit and gave support to the wife. I reminded her of her husband’s wishes and told her to follow her heart. When I came to check on them the next day, the room was empty. The family was in the waiting area. No words were spoken; only hugs were shared. I felt honored to have been a part of this family’s loss and to have helped them through a difficult time.

Dahlia Lopez, RN, CCRN, TNCC
Albuquerque, N.M.
University Hospital
My 10 years of critical care nursing have left lasting impressions. One such experience strengthened my conclusion that patient and family are one.

At 32, L.V. was brought to our unit with complications following the delivery of twin boys by cesarean section. She was in respiratory distress, in pain, fearful and unable to communicate. As Mexican nationals, L.V. and her husband were without the support of the family. Adding to the stress and compounding her anxiety was the fact that they did not have insurance coverage.

I am bilingual and, in Spanish, I explained the procedures and the equipment being used. I held L.V.’s hand and assured her that all measures to make her comfortable would be taken. Even with this knowledge and me by her side, her eyes held the same plea, “ayuda me” (“help me”).

L.V. was diagnosed with lupus. Her hospital course was lengthy. Her desire to control what she could was manifested in a lack of sleep. Intubated and on a ventilator, she had developed pneumonia and renal failure, and required chest tubes. Her closure of the cesarean section wound required special cleaning. Strong medication at high doses would not change her fear of sleeping.

With collaboration, which I orchestrated, the medical ICU team of doctors, physical therapists, social workers and, finally, L.V.’s family from Mexico, a plan was devised to alleviate her fear, instill trust and begin activities to improve her strength. The final recovery period took more than two months. L.V. had not seen her twin boys since she was admitted, so I made arrangements for all of the family to come visit. The family was finally together.

Brunella Before, RN, AD
Suffield, Conn.
Baystate Medical Center, Springfield, Mass.
The 81-year-old woman was admitted to the ICU for a grade IV liver laceration after a fall. At the same time, she had respiratory problems and was ruled in for an MI. She was admitted and transferred in and out of the ICU three times over two months.

Her husband and three daughters came in every day to visit. Her daughters did not want to leave her side, stressing she would not leave any of them under the same circumstances. I was reminded of my own mother and how she wouldn’t leave one of her children if we needed her. I thought of my three daughters, and how upset they would be if I was the one who was in that bed.

I struck up a supportive and communicative relationship with her family. After one visit, the daughters returned home to find their father had died. They had to tell their mother the sad news. She was transferred out of the ICU only to be readmitted two more times. Each time, she seemed to lose her will to get better.

I spoke with them about what their mother’s wishes would be if she needed to be on a ventilator in a nursing home. They said that was not something she would want. They came to a decision to withdraw support, and asked me if I was working the next day. I had worked four 12-hour shifts and had the next day off, but I told them that, if they needed me, I would come in. When they called the next day, I went in and discussed again what their mother would want. They withdrew support and thanked me for coming in to stay with them. I didn’t feel that I had done anything special. I just treated them like I would like to be treated.

Tara Fliegelman Wesoloskie
RN, BA, BSN
Manchester, Conn.
Connecticut Children’s Medical Center
Baby C.A. was born in September 2002, after being diagnosed in-utero with hypoplastic left heart syndrome. Although she had known the diagnosis for 16 weeks, nothing could have prepared his mother for the critical condition the infant would be in.

Tara began caring for the baby eight hours after birth. As sick as he was, Tara was able to provide emotional and spiritual support for his family. His mother did not want to leave his side. However, after meeting Tara, she felt an immediate connection and knew she was leaving him in the best hands possible.

Tara cared for C.A. every day she worked during C.A.’s lengthy stay. Two months later, after he was transferred to the neonatal ICU, C.A. began to show signs of failure. It became obvious that he would not make it home without having his second-stage surgery. Postoperatively, he was returned to the pediatric ICU and had a stable course. After Christmas, he was discharged home.

His mother kept in close contact with Tara. Initially thriving, C.A. unexpectedly arrested at home and was flown to our facility. His mother immediately notified Tara and learned she would not be working for several days. However, when Tara heard of C.A.’s condition, she immediately came to the hospital to offer support.

C.A. spent another month in the PICU. We didn’t know whether he would live or die. During this time, his mother told me she would never have made it through his first couple of days had she not met Tara. Coming in from home during this last admission just proved what we already knew: how dedicated Tara truly is.

Rhode Island Hospital Trauma Intensive Care Unit
Providence, R.I.
Rhode Island Hospital
Every day, the staff cares for patients with injuries resulting from a variety of causes, including motor vehicle accidents, gunshot wounds and burns. Every member provides the highest quality care in an environment of true compassion.

For example, an African female, who was in this country on a work visa, was admitted to the trauma ICU after sustaining critical injuries from a motor vehicle accident. Her husband was vigilant at her bedside. Through an interpreter, we learned that he was destitute. Asked what we could do for him, he responded, “Bring our daughter here from Africa.” The staff raised funds for airfare and lodging for both husband and daughter.

Our abilities were recently tested when Rhode Island experienced a tragic nightclub fire during which 68 critical burn patients were admitted. The care provided to these patients on the trauma ICU was highly acute and emotionally draining. Asked later how the staff coped with the magnitude of this event, one nurse said, “We never took a breath; we just kept going.”

Many patients return months later to visit and thank their caregivers. Family members we have supported through the end-of-life process keep in touch and visit often. Patients and their families have communicated their feelings of gratitude in cards and letters: Your professionalism, sincerity, dedication and caring were continuous, unrelenting and yet so seemingly effortless. Do not underestimate the power of a positive attitude. It was your smiles and positive outlook that kept me going.”


Review Panels Important to Selection Process for Grants and Research and Creative Solutions Abstracts

Appointments have been announced for volunteers who will work closely with AACN on research grants applications and Research and Creative Solutions abstract submissions.

The appointees were selected from the pool of volunteers registering in AACN’s just-in-time Volunteer Profile Database online.

Following are the volunteers who have participated or will participate as members of these groups in the coming year:

Research Grants Review Panel
This group will help review, evaluate and select AACN grant recipients.
Janet D. Pierce, RN, CNS, DSN, CCRN,
APRN, ARNP
Diane J. Mick, RN, CNS, DNS, PhD, CCNS,
CS, APRN, NP, APRN-BC
Kathryn G. Sapnas, RN, MSN, PhD, CCRN,
CNOR
Sue E. Sendelbach, RN, ND, PhD, CCNS,
FAHA
Elizabeth Manias, RN, MS, PhD
Renee Twibell, RN, DNS, PhD
Freda DeKeyser, RN, ND, PhD
Deanna L. Reising, RN, DNS, PhD, APRN

Research and Creative Solutions Abstract Review Panel
This group will help review, evaluate and select Research and Creative Solutions abstracts for NTI 2005, May 7 through 12 in New Orleans, La.
Roberta A. Fruth, RN, MSN, PhD
Kathleen Ellstrom, RN, CNS, PhD
Barbara J. Mayer, RN, MS
Catherine J. Ryan, RN, CNS, MSN, PhD,
CCRN, APRN
Linda C. McIntosh, RN, MNEd, PhD, CCRN
Sheila R. Boegli, RN, MS, MSN, CCRN,
CCNS, APRN
Claudia P. Barone, RN, EdD, LNC, CPC
Brenda K. Hardin-Wike, RN, MNSc, CCRN,
CCNS
Leslie A. Swadener-Culpepper, RN, MSN,
CCRN, CCNS
Elizabeth J. Bridges, RN, MN, PhD, CCNS
Mary A. Stahl, RN, MS, MSN, CCRN,
CCNS, CS
Jessie M. Casida, RN, CNS, MS, MSN,
CCRN
Wanda G. Sandlin, RN, MSN, CCRN, CNAA
Julia Read, RN, MS, MSN
Mary F. Tierney, RN, BS, MSN, CCRN,
APRN, NP, NP-C, APRN-BC
Lori A. Jentz, RN, BS, BSN, CCRN
Cynthia H. Elmido, RN, MS, MSN, CCRN
Susan M. Mitchell, RN, MSN, MBA, CCRN
William M. Donnelly, RN, BSN, MBA, CCRN
Leonard Leos, RN, MSN
Henry B. Geiter Jr., RN, ADN, CCRN
Hilaire J. Thompson, RN, CNS, MSN, PhD,
APRN, CNRN
Richard A. Dingwall, RN, CCRN
Tricia K. Matson, RN, ADN, BS
Martha Schmidt, RN, BS, BSN
Jason S. Edwards, RN, BSN
Jennifer L. Kane, RN, BS, BSN
Ronda Hatchett, RN, BS, BSN
Michelle A. Speicher, RN, BSN, MBA