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Vol. 23, No. 7, JULY 2006


Distinguished Research Lecturer


Norma Metheny (center) receives the Distinguished
Research Lecturer Award from Karen Giuliano, a
representative of Philips Medical Systems, which
sponsors the award. On hand for the presentation
was Marguerite Rodgers Kinney.


The newly revised ACNP Scope and Standards of Practice of the Acute Care Nurse Practitioner was unveiled at NTI 2006.

The Scope and Standards Task Force began the lengthy revision process in November 2004 and completed it in April 2006. Before tackling the project, the group met to discuss current ACNP practice and future trends. Deborah Becker, RN, MSN, APRN-BC, CRNP, chaired the meeting; Carol J. Bickford, PhD, RN, BC, senior policy fellow of the American Nurses Association (ANA) and Kathryn Werner, MPA, executive director of the National Organization of Nurse Practitioner Faculties (NONPF) participated in the dialogue as invited guests.

At the meeting, task force members received assignments to write standards pertaining to professional practice and professional performance. The first draft was completed, submitted for review in October 2005, and then distributed to current faculty and practicing ACNPs in January 2006 for additional comments. Reviewers were encouraged to engage additional practicing ACNPs and students in the evaluation process. Thanks to the diligence of the group’s participants, the final document was published in time for NTI 2006.

“Having the opportunity to revise the Scope and Standards of Practice for Acute Care Nurse Practitioners was an amazing process,” Becker said. “We took great care in assuring that this iteration of the document, reflected current practice, did not exclude any of the advances in the role that have been accomplished, and did not limit future expansion of the role. Everyone on the Task Force, including my colleagues in acute care, AACN staff and board liaisons and our advisors from NONPF and ANA, had one focus in mind—to create a document that truly reflects what it is to be an acute care nurse practitioner.”

Other members of the ACNP Scope and Standards Task Force were Jill Howie, RN, NP, Mary Holtschneider, RN, BSN, MPA, EMT, (AACN board liaison), Marilyn Hravnak, RN, PhD, CCRN, APRN-BC, Linda Bell, RN, MSN, (AACN National Office staff liaison), Joan King, RN, PhD, ACNP, ANP, Deborah Bingaman, RN, MS, CCNS, CPNP, Sheila Melander, RN, DNS, APRN, ACNP, Denise Buonocore, RN, CCRN, APRN-BC, and Jacqueline Rhoades, RN, PhD, ACNP-BC, ANP-C, CCRN.

To purchase the standards (product #128102), visit AACN’s online bookstore or call (800) 899-2226. The price is $20 for AACN members and $25 for nonmembers.


Grants

Oct. 1 is the deadline to apply for three AACN nursing research grants.

Evidence-based Clinical Practice Grant
This grant funds six awards of up to $1,000 to stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice.

AACN Clinical Practice Grant
This $6,000 grant supports research focused on one or more AACN research priorities. Research conducted in fulfillment of an academic degree is acceptable.

AACN-Sigma Theta Tau Critical Care Grant
AACN and Sigma Theta Tau International cosponsor this $10,000 grant. The grant may be used to fund research for an academic degree. Principal investigators must be members of AACN and/or of Sigma Theta Tau International.

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

Research and Creative Solutions Abstracts Invited for NTI 2007

AACN is inviting abstracts for presentation at the National Teaching Institute & Critical Care Exposition, May 19 through 24 in Atlanta, Ga.

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 also be selected to receive the Research Abstract Award. This award recognizes individuals whose abstracts reflect outstanding original research, replication research or research utilization. Each of 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, 2006, is the deadline to submit research abstracts.

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

The AACN Beacon Award for Critical Care Excellence shines national recognition on units that attain high standards for quality, exceptional care of patients, and healthy, humane and healing work environments.

The Web-based application process asks you to evaluate your critical care unit in six areas:

• Recruitment and retention
• Education, training and mentoring
• Evidence-based practices
• Patient outcomes
• Healing environments
• Leadership and organizational ethics

Applications, which may be submitted at any time, are evaluated on a quarterly basis. Awards are granted twice a year. The application fee is $1,000 per unit.

For more information, visit the AACN Web site.

Q:

Is sterile water preferred over tap water for irrigation of enteral feeding tubes and medication administration by nasogastric or feeding tubes in critically ill adult patients? The literature in support of sterile water is not conclusive, and we are trying to determine the appropriate protocol for our patients.

A:

This is a difficult question because many factors must be considered in making a determination. The literature reports infections occurring in critically ill patients attributed to the same organisms that have been cultured from the sinks or tap water in the unit.1-5 Most of these reports were from the United States; the rest were from other developed countries. Patient populations included those in medical-surgical ICUs, neurosurgery ICUs, a pediatric surgical unit, and endoscopy suites, as well as immunocompromised patients on oncology and hematology units. One university-affiliated, tertiary-care medical center reported contamination of central venous catheters in adult and pediatric bone marrow transplant recipients; incidents were related to use of tap water in bathing patients.6

Outbreaks of antibiotic-resistant P. aeruginosa have been linked to environmental surfaces in healthcare settings such as contaminated sinks and contaminated water. Inadequate hand washing techniques and poor hand hygiene were also implicated in the report.7 Cross-contamination with P. aeruginosa isolated in the ICU tap water has been implicated in cases of ventilator-associated pneumonia after intubation.8

It has been demonstrated that patients in the ICU experience a loss of common flora as a result of severe disease, changes in nutrition, and decreased use of the gut. Such changes in patterns of flora are followed by a significant increase in potentially pathogenic organisms. Increased permeability of the mucosal barrier provides an opportunity for bacterial translocation.9

Based on the above, recommendations can be made. At a minimum, use the same water (filtered) for patient procedures as you use for drinking by the unit staff and patients, rather than using water directly from the tap. Ensure adequate hand washing when dealing with enteral tubes and nutrition as you would for any other process involving compromised-host protective mechanisms such as suctioning and dressing changes. Use universal precautions when handling enteral tube feedings, including connecting the feeding set to the feeding tube, providing water flushes, giving medications, or opening a clogged/blocked feeding tube; these are points where bacteria may be introduced into the feeding, potentially causing an infection for the patient. Using universal precautions also will provide protection to the nurse when there is a potential for contact with body fluids.

When possible, collaborate with your institution’s epidemiology department to determine what organisms are present in the sinks and water taps on your unit as part of environmental monitoring. It would be preferable to use sterile water as a protection for identified immunocompromised patients. Remember, however, that the use of sterile water is not without its own set of problems related to the shelf life of the opened product. Once opened, sterile water bottles should be identified with the date and time and should be discarded in accordance with organizational policies.

References
1. Muscarella LF. Contribution of tap water and environmental surfaces to nosocomial transmission of antibiotic-resistant Pseudomonas aeruginosa. Infect Control Hosp Epidemiol. 2004;25:342-345.
2. Squier C, Yu VL, Stout JE. Waterborne nosocomial infections. Curr Infect Dis Rep. 2000;2:490-496.
3. Trautmann M, Michalsky T, Wiedeck H, Radosavljevic V, Ruhnke M. Tap water colonization with Pseudomonas aeruginosa in a surgical intensive care unit (ICU) and relation to Pseudomonas infections of ICU patients. Infect Control Hosp Epidemiol. 2001;22:49-52.
4. Conger NG, O’Connell RJ, Laurel VL, et al. Mycobacterium simae outbreak associated with a hospital water supply. Infect Control Hosp Epidemiol. 2004;25:1050-1055.
5. Adekambi T, Foucault C, La Scola B, Drancourt M. Report of 2 fatal cases of Mycobacterium mucogenicum central nervous system infection in immunocompetent patients. J Clin Microbiol. 2006;44:837-840.
6. Kline S, Cameron S, Steifel A, et al. An outbreak of bacteremias associated with Mycobacterium mucogenicum in a hospital water supply. Infect Control Hosp Epidemiol. 2005;25:1042-1049.
7. Reuter S, Sigge A, Wiedeck H, Trautmann M. Analysis of transmission of pathways of Pseudomonas aeruginosa between patients and tap water outlets. Crit Care Med. 2002;30:2384-2385.
8. Valles J, Mariscal D, Cortes P, et al. Patterns of colonization by Pseudomonas aeruginosa in intubated patients: a 3-year prospective study of 1,607 isolates using pulsed-field gel electrophoresis with implications for prevention of ventilator-associated pneumonia. Intensive Care Med. 2004;30:1768-1775.
9. Bengmark S. Probiotics, prebiotics, and synbiotics in the intensive care unit. In Nutritional Considerations in the Intensive Care Unit: Science, Rationale, and Practice. Shikora SA, Martindale RG, Schwaitzberg SD (eds). Dubuque, Iowa: Kendall/Hunt; 2002.

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


Public Policy Update

AACN Response to Vision Paper Now Posted Online
In February 2006, the National Council of State Boards of Nursing’s Advanced Practice Advisory Panel released a draft document titled “Vision Paper: The Future Regulation of Advanced Practice Nursing.” The paper generated a rich, often heated dialog among the advanced practice community. The NCSBN Board of Directors requested feedback from boards of nursing, professional associations and other APRN stakeholders. In response, a letter from the AACN and AACN Certification Board of Directors signed by Debbie Brinker, RN, MSN,
CCRN, CCNS, and Mary Fran Tracy, RN, PhD, CCNS, CCRN, FAAN, has been posted on AACN’s Web site.

“We agree with the premise that there is inconsistency in the regulation of APRN practice among the states, and that these inconsistencies may lead to confusion among employers and consumers of APRN services, as well as difficulties in interstate mobility for practitioners,” Brinker and Tracy wrote. “We can also understand that it is frustrating and time consuming for boards of nursing to be confronted with an increasing array of groups seeking recognition for specialty practice.

“However, we believe that the documented value of the nurse practitioner and clinical nurse specialist practice vastly outweighs the need to restructure a process that is working well to protect and meet the needs of patients and families in order to address these emerging regulatory issues.”

To read the complete response document, go to www.certcorp.org/certcorp/certcorp.nsf/certcorp/whatsnew.

Healthcare Professional Group Opposes SOPP and AMA Resolution Approach
AACN has joined other organizations representing more than 3 million healthcare professionals in declaring that the Scope of Practice Partnership (SOPP) formed by various physician organizations, as well as a related American Medical Association resolution, are unnecessary actions that will impede patient access to quality care. The Coalition for Patients’ Rights group, including AACN, has called on the SOPP member organizations to cease their divisive efforts and, instead, work collaboratively to advance the health and well-being of patients.

It is inappropriate for physician organizations to advise consumers, legislators, regulators, policy makers or payers regarding the scope of practice of licensed healthcare professionals whose practice is authorized in statutes other than medical practice acts. The erroneous assumption that physician organizations should determine what is best for other licensed healthcare professionals is an outdated line of thinking that does not serve today’s patients.

The SOPP is a coalition that the AMA formed to assist various physician organizations facing scope of practice “battles.” In a related action, the AMA House of Delegates adopted a resolution in “Limited Licensure Health Care Provider Training and Certification Standards.” The resolution calls for a study of the “qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of the limited licensure health care providers, and limited independent practitioners as identified by the SOPP.

“Our organizations set the highest standards for patient safety, and numerous studies demonstrate that our members provide safe, high quality care,” the organizations said in a news release. “Neither the SOPP nor (AMA) Resolution 814 cite any credible evidence that the scopes of practice of our members are unsafe, problematic, or warrant special scrutiny or study.

“To the contrary, our members are filling a vital need in this country. With shortages in various areas of healthcare, and more than 45 million uninsured Americans, our members are the solution to this country’s healthcare challenges, not the problem. Some physician organizations have characterized our efforts to enhance our scopes of practice as a “threat.” Far from that, with America’s population aging, we are the answer to the challenge of keeping pace with the demand for quality healthcare services. Now is the time to encourage the increased use of all available healthcare professionals to meet the growing demand for affordable, high quality care.”

For more information about this effort, go to www.patientsrightscoalition.org/.

ANSR Urges Nursing Workforce Development Funding
AACN has signed on to an Americans for Nursing Shortage Relief letter asking that at least $175 million be appropriated to fund the Nursing Workforce Development Programs to ensure that sufficient and adequately prepared nurses will be available to provide quality care to Americans.

The ANSR alliance requests the funding under Title VIII of the Public Health Service Act at the Health Resources and Services Administration (HRSA) in FY 2007.
Enacted in 2002, the Nurse Reinvestment Act (NRA) comprised new and expanded initiatives, including loan forgiveness, scholarships, career ladder opportunities and public service announcements to advance nursing as a career. Yet, despite the positive accomplishments posted under the NRA, HRSA fails to have the resources necessary to meet the current and growing demands for our nation’s nursing workforce.

“After years of declining interest in nursing as a profession, we are seeing the opposite occur,” the letter said. “Many Americans have come to find nursing an attractive career. A common theme emerging among prospective nursing students is a concern of facing waiting periods of up to three years before matriculating due to the growing nursing faculty shortage.”

The number of qualified applications turned away during the 2004-05 academic year was estimated to be more than 147,000.

“Without sufficient support for current nurse faculty and adequate incentives to encourage more nurses to become faculty, nursing schools will fail to have the teaching infrastructure necessary to educate and train the next generation of nurses that the nation so desperately needs,” the letter noted.

HRSA Report Warns About Critical Care Workforce Shortage
In response to a recently released Department of Health and Human Services Health Resources and Services Administration (HRSA) report on the widening gap between the size of the nation’s aging baby boomer population and the number of pulmonary and critical care physicians, the nation’s leading critical care societies participated in a news conference in May in San Diego, Calif.

The report warns that the future demand for critical care services in the U.S. might exceed the capabilities of the current delivery system. The report also indicates that as many as two thirds of patients needing critical care services may be receiving suboptimal care because the current demand for critical care services has surpassed the supply of critical care specialists (intensivists) needed to provide optimal care.

Titled “The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians,” the report warns that by 2020, factors such as the growth and aging of the population, lifestyle issues associated with critical care, and the shortage of critical care professionals, could result in an even greater number of patients who will not receive an optimal level of care.

“The American Association of Critical-Care Nurses is gravely concerned about the shortage of intensivists,” past AACN President Kathleen M. McCauley, RN, PhD, FAAN, FAHA, said. “A shortage of critical care specialists puts increasing pressure on critical care nurses who are already feeling the strain of our own workforce shortage and the challenges this presents in our mission to deliver excellent care to patients and their families.”

The HRSA report references findings from previous critical care workforce reports published by the American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine and AACN. The societies, collectively known as the Critical Care Workforce Partnership, previously reported that the demand for critical care services would increase rapidly due to the aging population, while the intensivist supply would not be able to care for a greater proportion of critically ill patients.

The full report is available at www.chestnet.org/downloads/practice/gr/HRSAReportMay06.pdf.

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

PDA Center

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Medicopeia-The Critical Care Nursing Edition is an innovative subscription program selected by nurses for point-of-care use. Medicopeia is an automatically updated and maintained timesaving solution to your informational needs. Never hassle with downloading or registering again; we do it all for you. You choose the Palm device that suits your needs; you'll also receive the following software package:

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• AACN Critical Care Newsline
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For more information or to purchase a PDA, visit www.aacn.org/AACN/conteduc.nsf/vwdoc/PDASpecials; (800) 462-0388.

AACN Medicopeia 2006 Now
Has Epocrates RxPro Drug Information