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Vol. 23, No. 5, MAY 2006


Personal Digital Assistants—a Welcome Companion

Latest Technology Helps Advanced Practice Nurses Stay Current


By Elisabeth G. Bradley, RN, MS, APRN,BC, CCRN
Advanced Practice Work Group

A common theme for advanced practice nurses in any specialty is the challenge of staying current with the latest best practice recommendations, new drug releases and dosing guidelines, and standards from regulatory agencies.
The sheer volume of new information, coupled with the fact that traditional print references such as textbooks and journal articles are often outdated by the time they go to print, makes personal digital assistants a welcome clinical companion. APNs are confident managing complex patients using advanced clinical judgment and decision making. However, there may not be a corresponding comfort level with the latest information technology available to enhance patient care. To learn how PDAs can help you in your practice, read on.

Immediate Access
Personal digital assistants are small, handheld computers that have evolved from standard personal organizers to user-friendly devices capable of downloading electronic software programs with drug information, medical calculators, diagnostic tools and more. With a wide variety of healthcare software available, PDAs provide immediate access to information formerly available only in print. Stroud, Erkel and Smith (2005) conducted a study to describe the current use of PDAs among nurse practitioner students and faculty. A majority of the 227 participants (96%) indicated that PDA use supported clinical decision making. Use of the PDA for selection of drugs, including dosing and drug interactions, was the most frequently cited example.1

Choosing a PDA
Several factors should be considered when choosing which PDA is right for you:
• Operating System—Just as personal computers have distinct operating systems (Windows and Macintosh), there are two major operating systems for PDAs: the Palm Operating System and Microsoft Windows CE Operating System (Pocket PC). Healthcare software, both free and purchased, can be downloaded to a PDA. If there is a specific application you want to use, be sure to investigate which operating system supports the application. In addition, determine if your information services or technology department only supports one operating system or specific models.
• Screen Color—Color screens are easier to read in low light environments, but decrease battery life and add to the size, weight and cost of the device.
• Memory—Palm OS devices usually come with 8-16 MB of memory and Pocket PC devices 32-64 MB. Most models include expansion slots that allow the user to add additional memory. Memory cards are available in a variety of sizes.2
• Cost—Physical size, memory and color screens have the biggest impact on cost. PDAs typically range from $100 to $1000, with a good selection in the $200-to-$500 range.2

Applications
Downloading appropriate software applications transforms your PDA from a simple organizational tool to a powerful clinical reference. Many applications are available at no cost, referred to as “freeware” while others can be obtained for a minimal cost, often called “shareware.” Your hospital or medical library may have PDA resources collected for their users on local networks or institutional subscriptions.3 Check product evaluations and take advantage of trial subscriptions before making a commitment. Finally, consult with your colleagues. The list of Web sites below is not all inclusive, but rather an introduction to the available resources. Excellent resources and tips for integrating PDAs into practice are available on AACN’s PDA Center. PDA Cortex is a user-friendly site with listserv capabilities.
• Drug databases—A popular drug database among APNs is Epocrates (www.epocrates.com).4 Epocrates Rx is a free drug reference guide with adult and pediatric dosing. An AutoUpdate feature provides users with routine updates.
• Patient tracking—Programs such as HanDBase are available for tracking patient information (e.g., lab data, medical history and prescriptions). Additionally, prescriptions can be written electronically using a PDA, and printed or sent directly to the pharmacy using a program like iScribe (www.iscribe.com)4,5
• Treatment protocols—Evidence-based guidelines such as the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (hin.nhlbi.nih.gov/atpiii/atp3palm.htm) are available for PDAs.6
• Reference suites—Reference suites provide a one-stop shop for drug information, clinical references, diagnostics, medical calculators and more. The Critical Care Nursing Suite at PEPID RN was developed through a partnership between the National Association of Clinical Nurse Specialists and PEPID.7
• AACN Medicopeia—This comprehensive package of clinical nursing software has an auto-install feature, eliminating the need for unlock codes and serial numbers. Includes ample clinical references, drug guide, calculators, hemodynamic and cardiac meds e-references, and the weekly AACN Critical Care Newsline e-newsletter. (www.aacn.org/pdaspecials).
• Professional development—Most PDAs offer an MP3 player, which, along with an additional memory card, allows you to listen to educational sessions from professional meetings, or maybe to your favorite music.

Security
When a PDA is used to track patient information, confidential material could be compromised if the PDA is lost. The Health Insurance Portability and Accountability Act of 1996 regulations apply to all systems that store protected health information. Password protection and data encryption help secure data on PDAs.4 Be sure to check with your organization’s HIPAA security officer regarding institutional policies related to tracking patient information.

The momentum to integrate hand-held devices such as the PDA into clinical practice is growing. A PDA is more than just a convenience; its use can prevent errors and improve patient safety.8 This tool combines the APNs’ clinical expertise with cutting-edge information technology to enhance patient care.

References
1. Stroud SD, Erkel EA, Smith CA. The use of personal digital assistants by nurse practitioner students and faculty. J Am Academy Nurse Pract. 2005;17(2):67-75.
2. PDA Basics, a Tutorial. Available at: www.aacn.org. Accessed January 4, 2006.
3. Tooey MJ, Mayo A. Handheld technologies in a clinical setting. AACN Clin Issues. 2003;14(3):342-349.
4. Lewis JA, Sommers CO. Personal data assistants: Using new technology to enhance nursing practice. Am J Maternal Child Nurs. 2003;28(2),66-73.
5. What can I do with a PDA? Accessed January 4, 2006.
6. Rempher KJ, Lasome CEM, Lasome TJ. Leveraging palm technology in the advanced practice nursing environment. AACN Clin Issues. 2003;14(3):363-370.
7. PEPID RN Critical Care Nursing Suite. Accessed January 5, 2006.
8. Taylor PP. Use of handheld devices in critical care. Crit Care Nurs Clin North Am. 2005;17(1):45-50.


PDA Center


AACN Medicopeia 2006 Now Has Epocrates RxPro Drug Information

Save More than $200 When You Purchase Medicopeia and a PDA Device
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. When you choose the Palm device that suits your needs, you'll also receive the following software package:

• Epocrates RxPro
• ER + ICU Toolbox
• Pocket ICU Management
• Cardiac Meds E-Reference
• Critical Care Assessment E-Reference
• Hemodynamic Management E-Reference
• MedCalc
• MedRules
• Adobe Acrobat Reader for Palm
• AACN Critical Care Newsline
• Lifetime Technical Support

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


National Consensus Project

Guidelines for Quality Palliative Care Set Out Eight Domains


By Debra Lynn-McHale Wiegand, RN, PhD, CCRN, FAAN
Chair, Ethics Work Group

The purpose of the National Consensus Project for Quality Palliative Care was to establish Clinical Practice Guidelines for Quality Palliative Care. The guidelines were developed through consensus of five palliative care organizations (American Academy of Hospice and Palliative Medicine, Center to Advance Palliative Care, Hospice and Palliative Nurses Association, Last Acts Partnership, and National Hospice and Palliative Care Organization). The guidelines have been endorsed by AACN and many other associations and agencies.

The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies (NCP, 2004). The main focus of the framework for the Clinical Practice Guidelines for Quality Palliative Care consists of eight domains of practice. Here are the key points:

Domain 1: Structure and Processes of Care
The first domain stresses the importance of an individualized comprehensive interdisciplinary plan of care. The interdisciplinary team needs to know the patient and family members’ understanding of the patient’s condition and prognosis. Treatment decisions need to be based on goals of care, assessment of risk and benefit, best evidence, and patient and family preferences. Hospital-based policies, procedures and guidelines should exist related to palliative care. Quality improvement programs should evaluate the effectiveness of palliative care provided. Resources should be available to help the interdisciplinary team provide quality palliative care, and palliative care educational programs should be offered to healthcare providers.

Domain 2: Physical Aspects of Care
Nurses, physicians and other members of the palliative care team should be knowledgeable and skilled at efficiently and effectively preventing and managing potentially distressing symptoms. Close observation for pain, dyspnea, anxiety, agitation, and other signs and symptoms of discomfort need to be quickly assessed and managed.

Domain 3: Psychological and Psychiatric Aspects of Care
Assisting patients and families with psychological and psychiatric issues is essential. Patient concerns may include depression, anxiety and delirium, and both patients and family members may experience trouble coping. Bereavement services should be offered to patients and families. Family members at risk for complicated grief and bereavement should be referred to expert psychiatric practitioners.

Domain 4: Social Aspects of Care
Family time together should be encouraged. The healthcare team and the family should meet regularly so that information can be shared, questions can be answered and treatment goals can be discussed and reviewed. Discussions should focus on patient wishes and goals of care. Family meetings offer the perfect opportunity to support the family and to facilitate the family decision-making process.

Domain 5: Spiritual, Religious and Existential Aspects of Care
The patient and family members’ spiritual, religious, and existential concerns should be assessed and addressed. Patients and family members may need help with issues such as guilt, hope, fear, meaning, purpose, beliefs about life and death, life review, and completion of life tasks. Spiritual rituals should be supported. Patients and families should have access to pastoral care and to clergy of their own faith.

Domain 6: Cultural Aspects of Care
Patient and family members’ cultural concerns should also be assessed and addressed. Interpreter services should be used as needed to facilitate communication between the patient, family and the interdisciplinary healthcare team. Communication with the patient and family should be respectful of cultural preferences regarding disclosure, truth telling and decision making. Patient and family cultural rituals should be supported.

Domain 7: Care of the Imminently Dying Patient
Signs and symptoms of impending death need to be assessed and communicated to the patient and family. Care during the active dying phase needs to focus on promotion of comfort and support of the patient and family. Of utmost importance are patient and family preferences. To the greatest extent possible, patients should die in the setting of their choice.

Domain 8: Ethical and Legal Aspects of Care
Adults with decision-making capacity should always direct their course of treatment. Even children with decision-making capacity should be given appropriate weight in decision making. If patients do not have decision making capacity, evidence of previously expressed wishes, values and preferences should guide the decision making process. Consultants such as specialists in ethical and legal issues should be available to help as needed.

Palliative care can be integrated with life-sustaining treatment and is an important component of quality patient care. Palliative care expands the traditional disease-model medical treatments and includes the goals of enhancing quality of life for patients and families, optimizing function, helping with decision making and providing opportunities for personal growth (NCP, 2004).

The information in the guidelines provides helpful advice for integrating palliative care into all aspects of healthcare. An important assumption in the guidelines is that all patients should have access to healthcare practitioners who are skilled and knowledgeable about basic palliative therapies. The guidelines can be accessed from the National Consensus Project’s website at www.nationalconsensusproject.org.

The Ethics Work Group is currently focused on palliative care. The members will be using the Clinical Practice Guidelines for Quality Palliative Care as an important foundation as the work group members address the integration of palliative care in the critical care setting.


Practice Resource Network

Q: The 6th edition of the AACN Core Curriculum for Critical Care Nursing was recently released. We previously purchased the Instructor’s Resource Manual to use with the 5th edition of the Core Curriculum. Can we use this manual with this new edition? I understand content has been added to the new edition, including information about the AACN Synergy Model for Patient Care.

A: Each edition of the Core Curriculum contains information from the previous edition, plus current practice updates. The teaching tools from the Instructor’s Resource Manual will still apply to the new edition. However, page numbers referenced in the teaching outlines will need to be adapted for use with the 6th edition. The slides and transparencies or PowerPoint and transparency materials can still be used for teaching from the Core Curriculum and will have multiple uses for other educational offerings as well. If you are seeking additional information regarding the Synergy Model, we suggest you obtain a copy of Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care.(Item #110149 in the AACN bookstore/catalog).

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.


In the Circle

3M Health Care Excellence in Clinical Practice Award


Editor’s note: Sponsored by 3M Health Care, the Excellence in Clinical Practice Award honors acute and critical care nurses who embody, exemplify and excel at the clinical skills and principles that are required in their practice. Following are excerpts from the exemplars submitted in connection with this award, part of the AACN Circle of Excellence recognition program, for 2005.

Carolee M. Arsenault, RN, BS, CCRN
Holyoke, Mass.
Baystate Medical Center
My 24 years of experience as a critical care nurse told me that 84-year-old John was lying in bed “on thin ice.” I wondered about his chance of survival and if his family had this information. Ken, a novice nurse, reported a relatively stable night but difficulty weaning John from the ventilator and vasopressors.

I reviewed with Ken the function of heart valves and explained why John might need ventilatory and vasopressor support until his valves were replaced. I applauded Ken for a job well done on such a complicated patient.

I read John’s medical record for prognostic indicators, but found none. In rounds, I asked about John’s prognosis, but no one was sure. The question was deferred to the cardiac surgeon who was not present. I stated we needed to get everyone on the same page, including John’s family. If John’s chances for a meaningful recovery were poor, would he or his family want to continue treatment?

John’s wife and daughter Mary arrived at 2 p.m. The cheerful, 82-year-old Mrs. G. was wheelchair bound and anxious to see her husband. She told me how they held hands every night to go to sleep. I took down the side rail and lowered the bed height. She immediately held his hand, smiled and said tenderly, “I’m here, Dear.”

I took Mary aside and asked how she was. She told me she was not sure what was going on with her father. I told her what I knew from reading the chart and from morning rounds. We set up a family meeting for the next day with the cardiac surgeon to clarify prognosis and set goals. John did well over his stay and is now scheduled for valve surgery. I think about him and hope he can soon return home to his bride of 57 years.

Cheryl N. Cook, RN, BSN, CCRN
Shippensburg, Pa.
Chambersburg Hospital
Taking care of a multiple trauma ventilator patient with closed head and neck injuries can be daunting, especially when the prognosis is listed as “grim.” Sometimes, time is the best medicine; however, during those many weeks, the constant care, range of motion, and patient and family emotional support can be exhausting.

For 29 years. I have been labeled as the eternal optimist, and my motto has always been, “Never say never.” Mark was one of those patients who, at first, was considered terminal, then upgraded to “quadriplegic with possible brain damage.” Through the weeks, with loving, caring and sometimes firm compassion, as Mark regained consciousness and showed minimal movement, I encouraged him to maintain his self-esteem and not give up. However, his tracheostomy made communication a challenge.

As he regained greater use of his right arm, I encouraged him to use his right hand to prevent contractures to his left. Depression set in, and Mark was giving up, but he kept hearing me say, “Never say never.” After weeks of hard work on range of motion, I still felt he had lost all hope.

On the day he was transferred to a long-term care facility, Mark tugged on my jacket and used his right hand to straighten his left fingers. He had a twinkle in his eye that said I had connected with my patient’s inner soul.

A follow-up report a year later said that Mark was employed and driving a hand-controlled car. When doctors said that he would never walk again, his response to them was, “Never say never.” To have made a difference, that is the essence of nursing.

Tracy Davis, RN, BSN, CCRN
Kirklin, Ind.
Clarian Health Partners, Inc.
Joshua was a 17-year-old Amish man newly admitted to our pediatric critical care unit. He had been riding in his family’s buggy with his sister and her boyfriend when a semi-truck struck them from behind. The boyfriend was killed at the scene, and his sister had passed away a few hours before in our unit from extreme head and internal injuries. Joshua had many severe injuries, including a concussion, liver laceration, hemothorax, kidney, rib and pelvis fractures, and a spinal cord injury at thoracic nine that had left him with no movement in his lower extremities.

Following my initial assessment, I sought out his family to introduce myself and give them an update. I acknowledged their immense grief for their daughter, and the shock and disbelief they must be feeling. I explained that I would take care of him as if he were my own son. Joshua required many things that day, including ongoing stabilization of his hemodynamic status, a trip to MRI to assess his spinal cord injury, ventilator weaning to extubation and constant reorientation from a severe concussion.

Joshua’s family needed just as much support if not more. We talked about Joshua’s sister, and what a beautiful young woman she was inside and out. We also discussed strategies for telling Joshua about her death, as he had no short-term memory. They asked that I stay with them when they told him. It was a heart-wrenching moment, but afterward I told them how proud I was of them. In return, they told me they thought I had been sent by God to care for their son.

Toward the end of my shift, Joshua’s family asked if they could say a prayer with him, and if I would join them. They are a lovely family, and I felt blessed to be able to help them and their son through such a difficult day.

Capt. Darcy Mortimer, RN, MSN, CCRN
Verona, N.J.
Wilford Hall Medical Center
My experience as an intensive care nurse was invaluable during one of my first flights as a critical care air transport nurse. At the Baghdad field hospital, the patient was a 24-year-old soldier severely injured in a car bomb explosion. His injuries included bilateral below-the-knee amputations, an eye injury, and second/third degree burns to his face and arm. I have never seen a person so severely injured, let alone one of our soldiers. But I couldn’t think about it; he was hypotensive, tachycardic, hypovolemic and anemic.

Air transport was very challenging because inherently it placed the patient at risk for complications. He was ventilated with a stable respiratory status, but he was too unstable to tolerate altitude changes with his severe anemia. He needed blood immediately. The field hospital’s blood supply was depleted, so a call was made for blood donations. While I started the patient on a vasopressor and fentanyl drip, two soldiers donated blood. I considered the need for the patient to be in a hospital versus our mobile environment with his unstable hemodynamic status, anticipated possible in-flight complications and considered my limited medications/supplies. The whole blood, still warm, was handed to me. My internal nursing red flags went up.

I considered whether I could support him in the event of an in-flight blood transfusion reaction. The answer was “yes.” The patient improved during the eight hours we cared for him.
Upon reflection, I am thankful for my nursing experience and knowledge base. It helped me to use the principles behind the practice to be successful in this unique environment. I must be vigilant to be a true patient advocate in uncertain and chaotic situations because others may lose focus of the patient. I am proud to have served this man who serves his country.

Susan Reed, RN, CCRN
Mission Viejo, Calif.
Mission Hospital
Regional Medical Center
Being a critical care nurse with knowledge of CRRT, I was quite enthusiastic when my hospital began its program. As a volunteer on the newly formed CRRT committee, I worked with a team of physicians, nurses, pharmacy personnel and management to develop policies, procedures and protocol. My experience with this therapy proved extremely valuable one night when I was caring for a 19-year-old, multisystem trauma patient.

With a rising BUN, creatinine and a lactic acid level of 14.7, this young man was in severe metabolic acidosis, with a pH of 7.16. He had an equally severe head injury, requiring multiple doses of mannitol, which kept him completely dehydrated. This was the source of his metabolic acidosis and renal failure. The question was how to keep the gentle fluid balance that he needed to maintain homeostasis and not cause his brain to swell. CRRT was the answer, and I set forward advocating for it.

After collaborating with the trauma surgeon and the nephrologist on the case, therapy was initiated. After only a short eight hours, his pH had climbed to 7.31, his lactic acid level declined to 7mmol/L and he was weaned off Levophed. Thanks to the introduction of CRRT, through evidence-based practice, the collaborative efforts of the team who put this program together and the team who cared for this young man, he went on to a remarkable recovery.

Alliance Seeks Federal Funds to Help Relieve Nursing Shortage
The Americans for Nursing Shortage Relief Alliance submitted written testimony to the House Subcommittee on Labor, Health and Human Services, Education and Related Agencies regarding fiscal year 2007 appropriations for Title VIII-Nursing Workforce Development Programs. The testimony advocates for at least $175 million in funding for the programs. This money, it noted, can help leverage HRSA resources to fund a higher rate of Nurse Education Loan Repayment and Nursing Scholarship applications, as well as implement other essential endeavors to sustain and boost the nation’s nursing workforce.

The ANSR Alliance is comprised of 51 national nursing organizations, including AACN, that united in 2001 to identify and promote creative strategies for addressing the nursing and nurse faculty shortages.

ANSR seeks to work with policymakers to advance programs and policies that will sustain and strengthen the nation’s nursing workforce. Nurses represent the largest occupation of all healthcare workers and provide patient care in virtually all locations in which healthcare is delivered, the ANSR testimony noted. It cited several facts as contributing to the nursing shortage:

• The nursing workforce is aging. With only approximately 8% of RNs under the age of 30, the average nurse is 46.8 years of age. Approximately half of the RN workforce is expected to reach retirement age within the next 10 to 15 years.
• In December 2005, the Bureau of Labor Statistics projected that registered nursing would create the second largest number of new jobs among all occupations within nine years. In addition, employment of registered nurses is expected to grow much faster than average for all occupations through 2014. It is anticipated that approximately 703,000 additional jobs, for a total of 3,096,000, will be available for RNs by this date.
• Nearly 1,800 faculty members leave their positions every year, with fewer than 400 faculty candidates receiving their doctoral degrees each year. The number of full-time nurse faculty required to “fill the nursing gap” is approximately 40,000. Currently, the National League for Nursing estimates that fewer than 10,000 full-time faculty members are in the system.

The testimony also pointed out that nurses play a critical role as frontline, first-responders to disasters. Unless steps are taken now, the nation’s ability to respond to disasters will be further hindered by the growing nursing shortage. An investment in the nursing workforce is a step in the right direction to rebuild the public health infrastructure and increase the nation’s healthcare readiness and emergency response capabilities.

Nurses Convene in Washington for Internship Program
More than 115 nurses participated in the 4th annual Nurse in Washington Internship event to learn how to influence healthcare through legislative and regulatory processes. Participants learned from health policy experts and government officials, networked with other nurses and visited members of Congress.
AACN is a supporter of the program.

Donation After Cardiac Death
A consensus document on Donation After Cardiac Death was published in the February 2006 issue of the American Journal of Transplantation.

AACN participated in the national conference of transplant professionals and ethicists who met to garner consensus on the medical and ethical propriety of organ donation after cardiac death. Justine Medina, RN, MS, director of Professional Practice & Programs at AACN, was one of the facilitators at the conference.

The participants agreed that the practice of DCD would be supported in an effort to generate additional organ donors, not to replace donors resulting from brain death.
Free access to the article is available at www.blackwell-synergy.com/toc/ajt/6/2.

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

Grants


July 1 is the deadline to apply for the following AACN nursing research grants:

Clinical Inquiry Grant
This grant provides awards up to $500 to qualified individuals carrying out clinical research projects that directly benefit patients and/or families. Interdisciplinary projects are especially invited. Ten awards are available each year.

End-of-Life/Palliative Care Small Projects Grant
This grant provides awards of $500 each to qualified individuals carrying out a project focusing on end-of-life and/or palliative care outcomes in critical care. Examples of topics are bereavement, communication issues, caregiver needs, symptom management, advance directives and life support withdrawal. Two awards are available each year.

Medtronic Physio-Control/AACN Small Projects Grant
Cosponsored by Medtronic Physio-Control, this grant funds an award up to $1,500 to a qualified individual carrying out a project focusing on aspects of acute myocardial infarction, resuscitation or sudden cardiac death, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing, or interpretive 12-lead electrocardiogram. Examples of eligible projects are patient education programs, staff development programs, competency-based educational programs, CQI projects, outcomes evaluation projects, or small clinical research studies.

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


Is Your Unit a Beacon of Excellence?


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.