AACN News—July 2005—Practice

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Vol. 22, No. 6, JUNE 2005

Public Policy Update

JCAHO Releases 2006 Patient Safety Goals
JCAHO has released the 2006 National Patient Safety Goals and related requirements for each of its accreditation programs. The goals and requirements apply to the more than 15,000 JCAHO-accredited and certified healthcare organizations and programs.

Major additions include a requirement that “hand-offs” of patients between caregivers be standardized, with particular attention to ensuring the opportunity for asking and responding to questions. In addition, a new requirement for accredited organizations providing surgical or other invasive services specifies that all medications, medication containers and other solutions used in perioperative settings be labeled.

Access the goals and requirements for hospitals at www.jcaho.org .

Funds Set Aside to Reimburse for Healthcare Services for Undocumented Aliens
The Centers for Medicare & Medicaid Services has issued its final guidance on the implementation of a section of the Medicare Modernization Act regarding federal reimbursement of emergency health services furnished to undocumented aliens.

Congress has set aside $1 billion through 2008 to help hospitals and other emergency providers recoup some of the expenses of providing this critical care.
The notice and related information are available at www.cms.hhs.gov .

Report Recommends Steps for Mass Casualty Preparedness
Steps that are needed to help states, communities, health systems and providers be prepared to respond to a mass casualty event are outlined in a report released by the Agency for Healthcare Research and Quality and the U.S. Department of Health and Human Services.

Titled “Bioterrorism and Other Public Health Emergencies: Altered Standards of Care in Mass Casualty Events,” the report was prepared by an expert panel that examined current care standards and how they might need to be altered to save as many lives as possible. The panel recommended:

• General and event-specific guidance for allocating scarce health and medical care resources
• A process to address nonmedical issues related to the delivery of health and medical care
• A comprehensive strategy for risk communication with the public
• Modifications of federal, state and local laws and regulations that affect the delivery of health and medical care
• Practical tools, such as searchable databases, for verifying credentials of medical and other health personnel
• Strategies to ensure health and medical leadership and coordination for the health and medical aspects of system responses
• Continued and expanded training of providers and others to respond effectively
• A research agenda specific to health and medical care standards
• A Community-Based Planning Guide for Mass Casualty Care to assist preparedness planners
• Identification and support of states, health systems, communities and regions to develop mass casualty health and medical care response plans based on the Planning Guide

The report is available at www.ahrq.gov > Research Findings > Public Health Preparedness > Bioterrorism Planning and Response > Tools and Resources .

Medicaid Bill Would Improve Access to APNs
A bill that would amend the Social Security Act to improve access to advanced practice nurses and physician assistants under the Medicare program has been introduced in Congress. The Medicaid Advanced Practice Nurses and Physician Assistants Access Act (H.R. 2716), which was introduced with bipartisan support, was referred to the House Committee on Energy and Commerce. The current rule gives state Medicaid plans the option to recognize APNs and PAs as primary case managers, thus denying Medicaid patients in underserved areas access to these healthcare providers.

Cosponsors of the bill include Reps. Sherwood Boehlert (R-N.Y.), Lois Capps (D-Calif.), Phil English (R-Pa.), Stephanie Herseth (D-S.D.), Nancy Johnson (R-Conn.), Sue Kelly (R-N.Y.), Steve LaTourette (R-Ohio), Edward Markey (D-Mass.), Todd Russell Platts (R-Pa.), Edolphus Towns (D-N.Y.) and Henry Waxman (D-Calif.).
The full text of the bill is available at thomas.loc.gov .

Panel Wants to Review FDA Drug Recall and Safety Issues Handling
Members of a U.S. advisory panel want to review how the FDA handles drug recalls and serious safety issues. The panel voted unanimously in favor of the agency providing it with details on its actions leading up to drug withdrawal so that the advisers could help identify areas for improvement.

The panel will serve in an advisory capacity regarding drug safety and management of risks from medications. Some of the panel members indicated that they favor giving the FDA more power to compel drug companies to complete studies after approval so regulators can learn about potential problems sooner.

For more information about these and other issues, visit the AACN Web site .

In the Circle
New Award Cites Excellence in Patient Safety

Editor’s Note: Sponsored by Baxter Healthcare, the Excellence in Patient Safety Award was new in 2005. Part of AACN’s Circle of Excellence recognition program, this award cites patient-care teams that have made significant contributions toward patient and caregiver safety in acute and critical care. Following are excerpts from exemplars submitted in connection with this award for 2005.

Heparin Error Reduction Workgroup
Minneapolis, Minn.
Abbott Northwestern Hospital
The human cost of medication errors is well documented in medical literature, and administration of heparin has become more complex over the years as dosing now incorporates patient age, gender, height and weight.

In spite of previous standardization of heparin therapy by computerized protocols at Abbott Northwestern Hospital, errors still occurred. In response, a Heparin Error Reduction Workgroup composed of nurses, pharmacists and physicians was formed.

Human Factors analysis to investigate human characteristics and the relationships they have with the systems and devices they use was initiated to further reduce heparin-related medication errors. Human Factors consultants observed the heparin administration workflow in nursing stations and conducted interviews with nurses, physicians and pharmacists. They analyzed the information gathered to determine the various pathways followed to order, dispense and administer heparin. Pathways were then compared to identify anomalies and confusing or ambiguous steps in the process.

Based upon the recommendations of the analysis, the existing computer program was revised and tested for ease of use by staff nurses and pharmacists. Heparin-related errors that resulted in increased monitoring or harm to patients were tracked following implementation of the recommendations. In the first quarter postimplementation, there was an 11.4% reduction in heparin errors from pre-implementation baseline in 2002, with a further reduction to 37.8% observed in the subsequent quarter in 2003. The most dramatic impact was on errors that caused harm to patients, which decreased from nine in 2002 to three in 2003.

Key reasons that this project succeeded were the Human Factors analysis and the decision-making authority granted to the HERW to change and improve the computerized heparin dosing system. The recommended system changes enhanced care delivered to patients by decreasing heparin-associated errors and improved the work environment of the healthcare practitioners.

Cincinnati Collaborative for Patient Safety
Cincinnati, Ohio
The Cincinnati Collaborative for Patient Safety initiative brought 10 hospitals together to improve patient safety by implementing evidence-based practices in ICUs. Through the Greater Cincinnati Health Council and the support of the hospital CEOs, team members collaborated to reduce central line infections by using a modified Institute for Healthcare Improvement method. The changes included using chlorhexidine as the exclusive skin prep, a full-body sterile drape, and a sterile gown and gloves with a mask and cap (maximum sterile barriers).

Hospitals present monthly updates on their progress toward changing practices. During these discussions, project leaders share their achievements. They problem solve to overcome barriers such as data collection strategies, contents and organization of central line carts, and physician cooperation. Once one ICU began to improve, friendly competition pulled the other ICUs into the project.

Project leaders created specifications for a central line kit and an accessory pack for manufacturers that matched evidence-based practices. As compliance with the practices increased to 90%, catheter-related blood stream infections fell significantly, with eradication of all line infections in 50% of the ICUs. The ICU nurses ensure that MSB and chlorhexidine are used during all line insertions, having a direct impact on increasing patient safety that is visible to nurses, physicians and administrators through feedback of process measures and outcomes.

The role of the critical care nurse in protecting the patient has set the standard for future patient safety practices. The project created a system where ICUs can create a community standard of patient safety and implement evidence-based practices even after project completion.

Froedtert Hospital Insulin Patient Safety Team
Milwaukee, Wis.
Froedtert Hospital
Insulin, which is recognized by the Institute of Safe Medical Practice as a high-alert problematic medication, has been the subject of several JCAHO sentinel event publications. Recent research has tied normalized glycemic control to significantly improved mortality, complications and infection rates.

A multidisciplinary team, including physicians, RNs, RN-CDEs, pharmacists, a dietician and a consumer representative, was formed. The project scope was to improve inpatient safety related to insulin therapy, specifically decreasing the frequency and severity of hypoglycemia while improving overall glycemic control.

Glucometer data, pharmacy insulin administration records and individual patient medical record reviews were used to establish baseline glycemic control and hypoglycemic rates. Baseline data showed nearly 25% of inpatients received insulin for treatment of hyperglycemia during their hospitalization. Although initially alarming, this rate was consistent with the literature.

A process map, FMEA (Failure Modes and Effects Analysis), descriptive statistics, process capability, baseline sigma level and ANOVA were utilized to establish baseline data. Interventions, including a hypoglycemic treatment protocol, standardized sliding scales, a continuous insulin infusion protocol and the addition of several universal patient safety features, were developed. Improvements were piloted in the surgical ICU. Pilot results were analyzed, utilizing descriptive statistics, two sample t tests and power and sample size.

Results showed improved standardization of hypoglycemia treatment and earlier comprehensive documentation of recovered glucose level following hypoglycemia (p-value 0.0008), reduced frequency and severity of hypoglycemia in patients receiving regular insulin (p-value 0.007) and improved glycemic control (p-value 0.000) with use of the continuous insulin infusion protocol. All protocols and guidelines were approved by the hospital PNT (pharmacy, nutrition and therapeutics) and then formally implemented throughout the hospital in December 2003. An inpatient diabetes management team provides daily surveillance of hospitalwide hypoglycemia and hyperglycemia, followed by interactions with primary services to improve overall diabetes management.

Norma Metheny to Present 2006 Distinguished Research Lecture

Norma Metheny, RN, PhD, FAAN, has been selected to receive the 2006 Distinguished Research Lecturer Award. She will present the Distinguished Research Lecture at AACN’s National Teaching Institute and Critical Care Exposition in May in Anaheim, Calif.

Metheny’s research is focused on increasing the safety of critically ill patients receiving tube feedings. Her work has directly impacted and changed the methods nurses use to determine proper placement of enteral tubes.

Metheny’s studies since 1999 have been directed toward determining methods to detect aspiration in patients receiving mechanical ventilation. She has shown the relationship between gastric residual volume, feeding site and aspiration, and body position and aspiration, and the impact nurses can have on modifying the frequency of aspiration. Her current research involves testing for pepsin in suctioned tracheal secretions, a marker for aspiration, and developing a test that is more user-friendly for use in the clinical setting.
Metheny lectures nationally and internationally and has numerous publications related to her research.

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

Nominations for 2007 Lecture
Dec. 1 is the deadline to apply for the 2007 AACN Distinguished Research Lecturer Award. The recipient will present the Distinguished Research Lecture at the NTI 2007 in Atlanta, Ga.

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

To view a list of past recipients, go to www.aacn.org > Research > Awards & Recognition .

Research and Creative Solutions Abstracts Invited for NTI 2006

AACN is inviting abstracts for presentation at its 33rd National Teaching Institute and Critical Care Exposition, May 20 through 25 in Anaheim, Calif.

Selected abstracts will be exhibited as either a poster or oral presentation. Individuals whose abstracts are accepted will receive a $75 reduction in NTI registration fees.
Four research abstracts will be selected to receive the Research Abstract Award. This award recognizes individuals whose abstracts reflect outstanding original research, replication research or research utilization. The award recipients will present their findings at one of the research oral presentation sessions at NTI and will also receive an additional $1,000 toward NTI expenses.

Sept. 1, 2005, is the deadline to submit the abstracts.

The applications as well as guidelines and resources are available online at www.aacn.org > Research > NTI Abstracts .

Distinguished Research Awardee

Sandra Dunbar (second from right) is congratulated
by (from left) past AACN President Marguerite Rodgers
Kinney, her mentor who introduced her, and AACN
President-elect Mary Fran Tracy after Philips
representative Karen Giuliano presented Dunbar the
Distinguished Research Lecturer Award prior to the
Distinguished Research Lecture at NTI 2005 in New
Orleans, La. Philips sponsors the lecture.

Applications Open for ICU Design Award

Applications are now being accepted for the ICU Design Citation Award to recognize a critical care unit that demonstrates attention to functional and humanitarian issues in a complementary manner.

Cosponsored by AACN, the Society of Critical Care Medicine and the American Institute of Architects, this award focuses on planning and design. Aug. 15 is the deadline to apply. For more information, e-mail cprendergast@sccm.org or call (847) 827-6826.
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