AACN News—April 2004—Practice

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Vol. 21, No. 4, APRIL 2004


Guidelines Aimed at Improving Practice Around End-of-Life Care. Effort Is Multidisciplinary

By Mary E. Holtschneider, RN, BSN, MPA
AACN Board of Directors

Caring for patients at the end of life poses a variety of challenges for both family members and healthcare providers. More than eight years ago, the cardiac care unit at Duke University Hospital, part of the Duke University Health System in Durham, N.C., undertook an effort to incorporate into daily practice the best measures for helping families cope through the end-of-life process of their loved ones. The results of this initial effort are now woven into the daily practice and culture of the unit.

Data collected on the CCU between 1995 and 1996 indicated an increase in the number of deaths that involved withdrawal of life support. In response, the unit ethics committee examined not only its own practice, but also that of other hospital CCUs. Confronted by a lack of consistency, the committee turned to the literature, but found little written. Recognizing the opportunity to improve practice, Rebecca Johnson, RN, BS, the CCU�s nurse clinician and ethics committee chair, formed a multidisciplinary task force to confront the issues surrounding patients, family members and staff during end-of-life care. Nurses, physicians, pharmacists, respiratory therapists, chaplains and social workers came together to develop unit guidelines to improve this process.

Johnson emphasizes that these guidelines are not protocols, policies or procedures. Instead, they are a framework from which individualized plans of care can be uniquely designed for each patient and family situation. The guidelines focus on several key objectives, including consistent management of pain, dyspnea and anxiety during withdrawal; effective and compassionate ventilator weaning; effective and consistent communication among all team members, including the family; and effective pharmacological management.

�The guidelines were neither a complex nor dictatorial document, but rather served as a catalyst for change in unit culture. Even staff members usually resistant to change and structure have come to embrace this legally and ethically sound format for end-of-life care,� said Wanda Bride, RN, clinical operations director for cardiology at Duke Heart Center.

Ethical Principles
Two ethical principles, adjusted care and double effect, are cited in the unit guidelines and often referred to by all disciplines when discussing withdrawal of support. Adjusted care refers to the approach of providing individualized care for a dying patient where the focus is on alleviating pain, fear and suffering. Double effect refers to the ethical principle of accepting a less than desirable effect in order to achieve an ethically desirable one. For example, morphine causes respirations to diminish as the dose is increased to alleviate pain. This nonintended effect of respiratory depression is necessary to achieve the goal of effective pain relief. Because the intent of using morphine is to alleviate pain and not to diminish respirations, it is ethically permissible.

Because including the family in discussions is integral to providing a peaceful death, family conferences are a key part of the guidelines. Ethical principles are discussed with the family members if appropriate to their individual situations. Topics outlined for discussion include time and sequence that the withdrawal will occur, assurance that families will have liberal access to their loved ones and preparation for the sights and sounds of death.

According to Johnson, �Consistency is the key to trust. An essential component to a smoothly running process is ensuring that each person on the team is fully aware of and supports the proposed plan of care. Only when this occurs, can we remain in harmony with the family and patient. Recognizing that this is not always the case, an algorithm for conflict resolution, which includes all team members, the patient, and the family, is included in the guidelines.�

Multidisciplinary Effort
With respect to pharmacological management, pharmacists helped develop guidelines for morphine and lorazepam, the recommended drugs to decrease pain, anxiety and the sensation of air hunger. The nursing and medical staff did not previously have a consistent approach to managing these drips.

According to CCU pharmacist Van Blalock, RPh, �For too long, we were more focused on the caregiver issues in the end-of-life setting than the patient. Questions involving the legality and ramifications of the medications being used were in the forefront of thought. We were missing the important concept of death with dignity and without pain.

�By involving the families in conversations and informed decision making and properly documenting doses with pain assessments, the use of medications for patient comfort in the end-of-life setting is now viewed as compassionate, responsible care for our patients. It�s really a matter of doing �the right thing.�"

Ongoing education regarding pharmacotherapy is essential. For example, new resident physicians who rotate through the unit often write an order for a �Morphine IV drip, keep respirations above 12.� These residents are quickly educated by the multidisciplinary team that the goal of a morphine drip in end-of-life care is comfort and that respirations are not a limiting factor, as guided by the concept of double effect.

Effective ventilator weaning and airway management are also addressed in the guidelines. Respiratory therapists were vital to the development of the guidelines and the ongoing implementation.

These processes are now an integral part of the unit�s culture. All new staff are educated about these guidelines and ethical principles as part of their orientation.
Cory Miller, RN, BSN, a 17-year CCU staff nurse and preceptor, states, �Teaching these guidelines to new staff is equally important to teaching about CVVHD, Swans, balloon pumps and other technological interventions. It is also important to teach new staff how to talk to the families.

�Before the guidelines, many nurses were uncomfortable with withdrawing support because there was no framework. Nurses would wonder if they were doing things correctly and legally, and would have to walk new residents through the process. With the guidelines, there is a greater sense of confidence in taking these challenging patient assignments.�

Focus on Families
Another aspect of end-of-life care that the CCU staff focuses on is family visitation and participation.

�For those who want to visit and participate, visitation becomes a crucial part of helping the families through the end-of-life process. It provides them with a �reality orientation� that the family member is indeed dying, in spite of all the medical interventions, nursing interventions, and all the prayers. Families are not only encouraged to visit, but to help provide care if they are able,� Johnson explains.

In addition, families have the option of witnessing codes and are supported by a chaplain or other staff member outside the room.

�I have never seen a family member be litigious when they have witnessed a code. In fact, one woman once called her husband�s code, saying that, �It is time to stop.� For those family members who do not witness the code, we invite them back into the room before it is totally cleaned up. This allows them to see �reality� of everything that was done for their loved one.�

Liz Stokes, RN, BSN, a staff nurse who has worked on the unit for a year and has been involved with many patients requiring end-of-life care, echoes Johnson�s remarks.

�The family is truly part of the team. Once they see all we are doing for their loved one, it is very comforting for them,� she says.

Stokes also describes a recent situation in which the husband of a 47-year-old patient refused to withdraw support for his wife.

�He felt that withdrawing support would be �letting go,� and he was not ready to say those words. When the husband witnessed the final code situation and saw that we were doing all we could do, he was finally at peace.�

As far as plans for the future, Johnson states that she would like to better formalize the teaching of ethical principles for new staff members. Although staff is oriented to ethical principles and the guidelines, much of the current ongoing teaching is done informally on patient rounds and whenever there is opportunity. The unit is also dealing with cultural issues as they treat increasing numbers of patients from diverse backgrounds and countries.

�We truly attempt to �rise above� our previous practice by incorporating the entire family into the team by encouraging them to assist with the end-of-life care and the decision-making process, and thus allowing each patient a death with comfort and dignity,� Johnson comments.

CNS and NP: To Blend or Not to Blend
Maintaining Identity


By Kristine Peterson, RN, MS, CCRN, CCNS
Advanced Practice Work Group

How do clinical nurse specialists and nurse practitioners maintain their nursing identity and increase understanding of their roles? What is the best use of these scarce advanced practice resources? Can you blend the skills of an NP and a CNS into one role?

To better understand this emerging issue for advanced practice nursing, let�s listen in on a hypothetical conversation among a group of nurses discussing this issue.

Are These Roles Different?
Janet, an ICU staff nurse, is enjoying lunch with a group of advanced practice nurses. Mary is an experienced critical care CNS. Susan is a CNS who is one of the leaders in the national CNS association. Liz is an acute care nurse practitioner. And, Anne is practicing in a dual NP-CNS role.

As Janet listens to their conversation about work, she observes, �All of you are advanced practice nurses, but you all are doing different things. Is that your choice or are they just assignments?�

Mary explains: �We actually are not all in the same role, so that accounts for some of the differences you see.�

Janet probes further. �I see Anne and Liz doing more what the physicians do, like writing orders, but I don�t see you or Susan doing that. You do more education. Then again, I see Anne doing that as well.�

4 Distinct Roles
Liz tries to end the confusion: �There are four distinct roles that are advanced practice nursing�nurse anesthetists, nurse midwives, clinical nurse specialists and nurse practitioners. Mary, Anne, Susan and I are all CNSs or NPs. In fact, Anne is practicing in a dual NP-CNS role. These two roles are closer in function than the other two APN roles.

�If you look at the official definitions, however, they are quite different. An NP is an advanced practice nurse who assesses and manages both medical and nursing problems and has prescriptive authority.1 A
CNS is a master�s-prepared nurse and an expert in clinical nursing with a specialty focus who advances the practice of nursing through innovative, cost-effective nursing interventions that are based in theory and evidence.�2

Susan interjects: �Although both practice groups are based in the scope of practice as defined by their RN licenses, they diverge at the advanced practice level. An advanced nursing practice role extends nursing practice into the medical domain to some extent. The NP is an independent practitioner functioning chiefly in the medical domain, while the CNS is an independent practitioner functioning chiefly in the nursing domain. The CNS assesses patients from the nursing perspective and uses advanced knowledge to identify problems amenable to nursing care.�2

Mary adds, �The CNS ensures that staff is able to carry forward with the nursing care and works with the system to ensure appropriate staff support is available, such as equipment, education and resources needed to deliver care. NPs concentrate on managing care for individual patients. The CNS may see individual patients, but does so in the nursing domain and through the staff nurse. We serve the nurses so they may better serve the patients.�

Anne explains, �My role came about because the physicians needed an expert nursing clinician to follow some of the patients with more complex needs. It was a bit of a rocky road at first, because there were communication and control issues. As the medical staff became more comfortable with the role, they relaxed and let me do my thing. I think it helped pave the way for other NPs into the system.

�Because I was a CNS first, they were comfortable with me, and got used to the idea of a nurse managing patients. That helped introduce NPs into other areas of the system. I think that is one of the advantages of having a blended role.

Resource Scarce
�There are other reasons this is happening, though. For instance, APRNs are a scarce resource, and hospitals especially have learned the value of their skills, so they will hire in a way that gets them what they need. Care needs are becoming more complex. Nurses, administrators and nurse managers all recognize the value of multiskilled APNs serving as resources. Cutbacks are another reason, I suppose.�

Both roles sound interesting to Janet, who asks for direction.

�Graduate school in nursing is the key to developing entry-level skills,� says Anne. �I was working as a CNS, got comfortable with CNS practice and then added the NP practice elements later. The practice role you choose will determine which skill sets you need to hone.�

But Mary disagrees. �As we were working with the state board of nursing to develop criteria for advanced practice roles, it became clear that the requirements for a CNS and NP are very different. You need a master�s in nursing, but you need the preparation for the specific role as well. The CNS needs content in the competencies for CNS practice. The NP needs content that includes NP competencies, such as clinical assessment, pharmacology and advanced physiology. Because the competencies are different, the education is different. Your state may add certification in your specialty or a second license to practice as a CNS as well.�

�Of course, the NP needs to pass a certification exam for entry into the role,� states Liz.

�You don�t want just anyone to be able to call themselves a CNS,� says Mary. �The person must understand CNS practice, and the competency content is not only critical but also different from other ANP training. It is important for title protection and public protection to have specific requirements to practice as a CNS or in any advanced practice role. If you want to do a dual role, you need both preparations.�3

Filling a Dual Role
�That�s what I like about the dual role,� says Anne. �The APN rounds on each unit with the team, identifies care needs, addresses the needs (through team or by using prescriptive privileges), and serves as a resource to both medical and nursing staff. In this role, you can identify system issues that may affect patients� needs and staff education needs. You provide education as necessary. You then bring this knowledge to the table at administrative meetings and incorporate research findings into practice by sharing them with nursing staff. The APN follows patients as part of the caseload. Of course, the disadvantage is obvious, you can spread the practitioner too thin.�

�Well, I agree it can be overwhelming. But, I think the danger of being overloaded is seen more when you spread the practitioner over more than one position versus over more than one type of practice,� says Anne. �I like my role. A dual role gives you more learning experiences and more variety. You also have more career choices because of the diversity of skills. There is less chance of getting �rusty� because you maintain skills in a variety of realms. Having an APN who has a broad repertoire benefits both patients and staff. It�s kind of like �one stop shopping� rather than have to call a CNS and an NP to manage a patient.�

References
1. What Is a Nurse Practitioner. American College of Nurse Practitioners. Accessed on 3/17/2004.
2. Certification and Regulation of Advanced Practice Nurses. American Association of Colleges of Nursing. Accessed on 3/17/2004.
3. NACNS Statement on Clinical Nurse Specialist Practice and Education. 2nd ed. National Association of Clinical Nurse Specialists. Accessed on 3/17/2004.

Grants

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

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

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

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

Is Your Unit a Beacon of Critical Care Excellence?

Applications are now being accepted for AACN�s new Beacon Award for Critical Care Excellence to recognize exceptional critical care units. For more information, visit our website.

Public Policy Update

Election Politics to Complicate Congress
The election-year session of Congress picks up where the last one left off. Democrats and Republicans appear to agree on little beyond the extent to which partisanship has made lawmaking difficult. Legislators will have to put aside their differences long enough to deal with several inescapable issues during the second session of the 108th Congress.

In the mix are bills to cap medical malpractice lawsuits and to create a fund of more than $100 billion, financed by businesses and insurance companies, to pay asbestos victims. Senate Democratic Leader Tom Daschle said top Democratic priorities this year include raising the minimum wage, passing a mental health parity bill, getting a good higher education bill and rewriting the enacted Medicare bill.

Bush�s Approval Rating Falls on Healthcare Issues
President Bush�s approval rating for his handling of healthcare issues dropped 11 percentage points over the past year, falling to 35% at the beginning of this year from 46% a year ago, according to a Gallup Group survey of 1001 adults. The survey, conducted between Jan. 19 and Feb. 1, found that 57% of adults disapproved of Bush�s work on healthcare, compared with 44% a year ago. The remainder had no opinion. The Bush administration had hoped the Medicare reform law, signed late last year, would cement Bush�s position as a healthcare leader. However, Democrats criticize the law as a giveaway to drug makers and HMOs. A new estimate has raised the law�s 10-year price tag $139 billion from the previous estimate to $534 billion.

ANA Endorses Kerry for President
The American Nurses Association has endorsed Sen. John Kerry (D-Mass.) for president in the 2004 election. Saying that nurses� interests would be better addressed if Kerry was elected president, ANA cited the need for dramatic improvements in the nation�s healthcare system, as well as continued support for RNs and their role in healthcare.

In the Senate, Kerry co-authored the Nurse Reinvestment Act and other nursing workforce development programs. He also co-authored the ANA-backed mandatory overtime bill known as the Safe Nursing and Patient Care Act (S. 373) and opposed the repeal of strong ergonomic protections that were passed during the Clinton administration.

Although AACN bylaws prohibit the organization from endorsing candidates for political office, AACN encourages all members to register to vote and become involved in the political process and will continue to endorse issues of concern to critical care nurses, the profession and the industry. For more information on the elections and candidates and to register to vote visit our website.

RNs Now Top Workforce Demand Projections
For the first time, registered nurses top the U.S. Bureau of Labor Statistics list of occupations with the largest projected 10-year job growth. Nurses have been on the list for some time but never as No. 1. The bureau�s latest projections put the demand for registered nurses at 2.9 million in 2012, up from 2.3 million in 2002. However, the total number of job openings, reflecting job growth and the need to replace nurses who have left the industry, will be more than 1.1 million from 2002 to 2012, the bureau said. President Bush�s fiscal 2005 budget proposal allocates $147 million for nursing education programs, including provisions of the Nurse Reinvestment Act.

Although AACN is pleased with the $5 million increase in this tight budget year, it is also concerned that funding levels are still inadequate to meet the growing demand for nurses. AACN is joining others in the nursing community in requesting an increase of $205 million for FY05 nursing funding and will continue to pursue building on the $15 million funding increase in FY03 and the $30 million increase received in FY04 to ensure that the nation�s growing need for nurses is met.

Senator Frist Introduces Healthcare Disparity Bill
Senate Majority Leader Bill Frist (R-Tenn.) has introduced legislation to close the healthcare gap by improving data collection and analysis on disparities, funding outreach programs, promoting training of minorities in the health professions, and making cultural competency part of the training of healthcare professionals. Closing the Health Care Gap Act of 2004 (S. 2091) also contains measures to standardize measures of quality healthcare. Joining Frist in announcing the legislation was Sen. Mary Landrieu (D-La.), who expressed hope that the measure can be combined with one proposed by Senate Minority Leader Tom Daschle (D-S.D.) to get bipartisan action on the issue.

IOM Recommends Strategies for Diversifying Workforce
A report by an Institute of Medicine panel recommends strategies for achieving greater diversity among health professionals. Titled �In the Nation�s Compelling Interest: Ensuring Diversity in Health Professions,� the report considers the benefits of greater racial and ethnic diversity, and identifies institutional and policy-level mechanisms to garner broad support among health professions leaders, community members and other key stakeholders to implement strategies to increase the proportion of minority students training for careers in healthcare. The report is available online at www.iom.edu > Reports.

More States Bar Forced Overtime
West Virginia and New Jersey have joined the state of Washington in banning mandatory overtime at healthcare facilities, except in emergencies. Covered are workers who provide patient care or clinical services.

AACN believes that mandatory overtime is not an acceptable means of staffing a hospital, because it may place nurses and their patients at increased risk of being involved in medical errors. Instead, nurses should be able to decide whether working overtime will affect their ability to care safely and effectively for patients.

FDA Releases Report on Counterfeit Drugs
Healthcare providers may be better prepared to protect patients from counterfeit drugs, thanks to a report by the Food and Drug Administration.

The report addresses growing concerns about the threat to consumers posed by counterfeit drugs. Though counterfeiting is not now widespread in the U.S. drug market, the FDA is investigating more cases of such activity, often involving well-organized criminal operations working to introduce finished drug products that resemble legitimate drugs but may contain only inactive ingredients, incorrect ingredients, improper doses or be otherwise contaminated. The report outlines a multilevel collaborative approach to the problems, including an emphasis on the use of new technologies to increase security, adoption of secure business practices by all participants in the drug supply chain, education of consumers and healthcare professionals and collaboration with foreign stakeholders.

Drawing on information from a task force�s six-month review of the problem, the FDA also encouraged the drug industry to use tiny radio frequency tags on drug packages to track the medicine from factory to pharmacy.

AACN supports a stepped-up communications effort called the Counterfeit Alert Network. This public-private network will educate and inform key stakeholders, including consumers, of this growing threat to patient safety and serve to protect many from fraud and possible harm as a result of counterfeit drugs. The FDA Counterfeit Drug Task Force final report is available online at www.fda.gov > Hot Topics.

New Survey Benchmarks Healthcare Recruiting
Healthcare recruiters and human resources decision makers have a new national survey with which to benchmark their key recruiting indicators. Bernard Hodes Group, a New York City-based healthcare recruitment and communications company, has released its survey reflecting responses from 151 recruiters and other HR experts and offering insight to recruitment metrics among acute care hospitals (80% of respondents), long-term care, home care and other facility types.

Following are some of the findings:
� Nurses are the third most expensive of the healthcare professions studied at $2,651 cost-per-hire. Direct costs, such as recruiters� salaries, media, collateral materials,and postage, are included. On-boarding or replacement costs are not.
� RNs had the highest turnover rates of all the professionals studied (15.5%). The respondents said the average number of full-time equivalent RNs at their hospital is 416.
� In the hardest-to-fill category, critical care-ER nurses topped the list with a mean of 3.97, followed by operating room/postanesthesia care unit, oncology and then medical-surgical.
� Although most employers (83%) offer employee referral bonuses, only 44% reported offering them in all categories. Fifty-nine percent said they offered employee bonuses for RNs.
� Fifty-nine percent of respondents indicated that they offer sign-on bonuses for new hires. The bulk of those (45%) are for RNs.
� Combining nursing and allied health, the most frequent employer offering to healthcare workers was tuition to attend offsite programs, with 89% offering those; followed by paid time off to attend offsite educational programs (67%), paid time off (65%) and student scholarships (49%).

Study Shows Health Benefits Worth More Than Money Invested
Each additional dollar spent on healthcare services has produced between $2.40 and $3 in tangible gains in healthcare over the past 20 years, according to a study by a coalition of the nation�s leading health organizations. The report, titled �The Value of Investment in Health Care: Better Care, Better Lives,� reveals that without this investment, in the year 2000 alone, there would have been 470,000 more deaths, 2.3 million more people with disabilities, and 206 million more days spent in the hospital. It is hoped that the report, published Jan. 28 by the Value Group, provides sufficient evidence to insert the value of investing in healthcare into discussions as lawmakers address rising healthcare costs.

Public Policy Snapshot
Hospital Capital Projects Include Major IT Plans

About 72% of hospital and health system chief financial officers plan to purchase digital radiology systems in the next five years, with another 64% investing in computerized physician order entry systems, and 61% planning other major IT systems, according to a survey by the Healthcare Financial Management Association.

Nearly three of four hospitals expect their capital spending to increase in the next five years. Overall, hospital capital spending will increase 14% annually during the next five years, compared with 1% annual increases from 1997 to 2001.

Technology projects were the most commonly cited capital projects, with about half of hospital and health systems planning to devote capital to increasing emergency and operating room capacity.

The report, which includes 460 hospital and system CFOs, is based on research by HFMA and PricewaterhouseCoopers. GE Healthcare Financial Services provided funding for the report.

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

Practice Resource Network

Q: Are there specific guidelines for monitoring neuromuscular blocking agents and using the peripheral nerve stimulator and the train-of-four?

A: The goal of administering NMBA is to provide the minimum depth of paralysis that is clinically appropriate for the patient, using the least amount of drug. Monitoring the patient�s neuromuscular response is important to decrease avoidable side effects, such as premature return of spontaneous movement, prolonged paralysis and delay in recovery.

Traditional physical assessment methods to monitor the depth of neuromuscular blockade include observing skeletal muscle movement and respiratory effort. Electronic methods include use of the ventilator software to detect spontaneous ventilatory effort and transcutaneous delivery of current using the peripheral nerve stimulator.

However, the physical assessment and use of the ventilator software are fraught with difficulties, making the train-of-four the easiest and most reliable method available for monitoring the level of NMB.1 Studies have demonstrated that monitoring the depth of NMBA using PNS and train-of-four has resulted in lower doses of NMB drugs and faster recovery of neuromuscular function once the drug has been discontinued.

In 1995, the Society of Critical Care Medicine and the American College of Critical Care Medicine published the first clinical practice guidelines for sedation, analgesia and neuromuscular blockade in the critically ill patient. In 2004, they joined with the American Society of Health-System pharmacists to develop new guidelines on the sustained use of sedatives, analgesics and NMBAs in the critically ill adult.
The �Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Critically Ill Adult Patient� recommends that patients receiving NMBA should be assessed clinically and by using train-of-four monitoring, with a goal of titrating the NMBA to achieve one to two twitches.2

The guidelines are available online at www.sccm.org > Professional Resources > Guidelines.
Adequately assessing the depth of paralysis to avoid complications or adverse effects when administering NMBA is important. The AACN Procedure Manual for Critical Care includes a comprehensive procedure for the use of peripheral nerve stimulators in association with the administration of NMBA.3 This procedure will be useful in developing or reviewing current policies regarding the monitoring of patients on NMBA.

References
1. Rudis MI, Sikora CA, Angus E, et al. A prospective, randomized controlled evaluation of peripheral nerve stimulation versus standard clinical dosing of neuromuscular blocking agents in critically ill patients. Crit Care Med. 1997;25(4):575-583.
2. Murray, MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2002;30(1):142-156.
3. Lynn-McHale DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care (fourth edition). WB Saunders Co; St Louis Mo:2001.