AACN News—May 2005—Practice

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Vol. 22, No. 5, MAY 2005

Practice Alert: Verification of Feeding Tube Placement

The goal of the AACN Practice Alerts is to help nurses and other healthcare practitioners carry their bold voices to the bedside to directly impact patient care. Practice Alerts are directives from AACN that are supported by authoritative evidence to ensure excellence in practice and a safe and humane work environment.

Expected Practice:
• Obtain radiographic confirmation of correct tube placement in critically ill patients who are to receive feedings or medications via blindly inserted gastric or small bowel tubes prior to initial use.
• Mark and document the tube’s exit site from the nose or mouth immediately after radiographic confirmation of correct tube placement; observe the mark to assess for a change in length of the external portion of the tube.
• Use bedside techniques to assess tube location at regular intervals to determine if the tube has remained in its intended position. No one single technique has been shown to be reliable for continually assessing tube placement:
—Review routine chest and abdominal x-rays to determine if they refer to tube location.
—Helpful bedside techniques include measuring the pH and observing the appearance of fluid withdrawn from the tube.
—Do not rely on the auscultatory method to determine tube location.

Supporting Evidence:
• Radiographic confirmation is the only reliable method to date of confirming enteral tube placement. The pH and appearance of an aspirate from the newly inserted tube, though not 100% reliable, are highly suggestive of gastric or small bowel placement and can be used as an initial indicator of placement. However, radiographic confirmation should always be done.
—An aspirate from a gastric tube often has a pH of 5 or less and is usually grassy-green or clear and colorless, with off-white to tan mucus shreds.1-10
—An aspirate from a small bowel tube often has a pH of 6 or greater and is usually bile-stained, ranging in color from light to golden yellow or brownish-green. In addition, the aspirate is usually thicker and more translucent than fluid withdrawn from a gastric tube.1-10
—An aspirate from a tube inadvertently positioned in the tracheobronchial tree or the pleural space typically has a pH of 6 or greater. An aspirate from a tube in the tracheobronchial tree usually has the appearance of fluid obtained during tracheal suctioning. An aspirate from a tube in the pleural space is usually straw-colored and watery, perhaps tinged with bright-red blood caused by perforation of the pleura by the tube.1-10
• There are numerous anecdotal reports of blindly inserted tubes entering the respiratory tract undetected. In most of these cases, the auscultatory method falsely ensured that the tube was correctly positioned in the stomach.11-16 There is also a report of the auscultatory method failing to detect inadvertent placement of a nasogastric tube in the brain.17 The auscultatory method was found to have a sensitivity of only 34% in differentiating between gastric and small bowel tube placement in 85 acutely ill adults.18 In another study, auscultation for insufflated air was found to have a sensitivity of only 45% in determining whether 134 tube insertions resulted in placement above or below the diaphragm.19
• It is not uncommon for a feeding tube to dislocate from its intended site, either after being tugged at by a confused patient or during the delivery of care.20,21 An increase in the external portion of tubing extending from the nose or mouth can signal that the tube’s distal tip has dislocated upward in the gastrointestinal tract, such as from the small bowel into the stomach or esophagus, or from the stomach into the esophagus.22
• Measuring the pH of fluid aspirated from tubes of fasting patients is helpful in differentiating between gastric and respiratory placement, and gastric and small bowel placement.1-7
• Observing the appearance of fluid aspirated from tubes of fasting patients is helpful in differentiating between gastric and respiratory placement, and gastric and small bowel placement.7-10
• Observing the pH and appearance of aspirates from feeding tubes when continuous feedings are in progress is less helpful than when the patient is fasting; nonetheless, these methods are occasionally of benefit in distinguishing between gastric and small bowel tube location.23
• A sudden increase in residual volume from a feeding tube in the small bowel may signal upward displacement of the tube into the stomach. Aspirates from small-bowel feeding tubes are usually less than 10 ml; an increase to 50 ml or higher may signal upward displacement of the tube into the stomach.22
• Injecting 30 ml of air into the tube via a 60 ml syringe immediately before pulling back on the plunger facilitates the withdrawal of fluid from small-diameter tubes.24
• Flushing the tube with 30 ml of water (or normal saline, if indicated for patients with hyponatremia) after residual volume measurements prevents the tube from clogging.25, 26

What You Should Do:
• Obtain an x-ray that visualizes the newly inserted tube to ensure that it is in the desired position (either the stomach or small bowel) before administering formula or medications via the tube for the first time.
• Ensure that your critical care unit has written practice documents such as a policy, procedure or standard of care that include when the initial x-ray should be obtained, a method of marking the feeding tube, where to document the exit site, and the frequency of the documentation.
• If documentation of tube placement is not currently a part of the routine interpretation of chest and/or abdominal x-rays, form a collaborative team including a radiologist, pulmonologist, a staff nurse, and risk manager to develop strategies for implementing this practice.

1. Metheny NA, Williams P, Wiersema L, Wehrle MA, Eisenberg P, McSweeney M. Effectiveness of pH measurements in predicting feeding tube placement. Nurs Res. 1989;38(5):280-285.
2. Metheny NA, Reed L, Wiersema L, McSweeney M, Wehrle MA, Clark J. Effectiveness of pH measurements in predicting feeding tube placement: An update. Nurs Res. 1993;42(6):324-331.
3. Metheny NA, Stewart BJ, Smith L, Yan H, Diebold M, Clouse RE. pH and concentrations of pepsin and trypsin in feeding tube aspirates as predictors of tube placement. J Parenter Enteral Nutr. 1997;21(5):279-285.
4. Metheny NA, Clouse RE, Clark JM, Reed L, Wehrle MA, Wiersema L. Techniques and procedures: pH testing of feeding-tube aspirates to determine placement. Nutr Clin Pract. 1994;9(5):185-190.
5. Metheny NA, Stewart BJ, Smith L, Yan H, Diebold M, Clouse RE. pH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement. Nurs Res. 1999;48(4):189-197.
6. Griffith DP, McNally AT, Battey CH et al. Intravenous erythromycin facilitates bedside placement of postpyloric feeding tubes in critically ill adults: a double-blind, randomized, placebo-controlled study. Crit Care Med. 2003;31(1):39-44.
7. Gharpure V, Meert KL, Sarnaik AP, Metheny NA. Indicators of postpyloric feeding tube placement in children. Crit Care Med. 2000;28(8):2962-2966.
8. Metheny N, Reed L, Berglund B, Wehrle MA. Visual characteristics of aspirates from feeding tubes as a method for predicting tube location. Nurs Res. 1994;43(5):282-287.
9. Harrison AM, Clay B, Grant MJ et al. Nonradiographic assessment of enteral feeding tube position. Crit Care Med. 1997;25(12):2055-2059.
10. Welch SK, Hanlon MD, Waits M, Foulks CJ. Comparison of four bedside indicators
used to predict duodenal feeding tube placement with radiography. J Parenter Enteral Nutr. 1994;18(6):525-530.
11. Metheny NA, Dettenmeier P, Hampton K, Wiersema L, Williams P. Detection of inadvertent respiratory placement of small-bore feeding tubes: a report of 10 cases. Heart Lung. 1990;19(6):631-638.
12. Lipman TO, Kessler T, Arabian A. Nasopulmonary intubation with feeding tubes: case reports and review of the literature. J Parenter Enteral Nutr. 1985;9(5):618-620.
13. Hendry PJ, Akyurekli Y, McIntyre R, Quarrington A, Keon WJ. Bronchopleural complications of nasogastric feeding tubes. Crit Care Med. 1986;14(10):892-894.
14. Metheny NA, Meert K. Invited Review. Monitoring feeding tube placement. Nutr Clin Pract. 2004;19(5):487-496.
15. el Gamel A, Watson DC. Transbronchial intubation of the right pleural space: a rare complication of nasogastric intubation with a polyvinylchloride tube—a case study. Heart Lung. 1993;22(3):224-225.
16. Nakao MA, Killam D, Wilson R. Pneumothorax secondary to inadvertent nasotracheal placement of a nasoenteric tube past a cuffed endotracheal tube. Crit Care Med. 1983;11(3):210-211.
17. Metheny NA. Inadvertent intracranial nasogastric tube placement. Am J Nurs. 2002;102(8):25-27.
18. Metheny NA, McSweeney M, Wehrle MA, Wiersema L. Effectiveness of the auscultatory method in predicting feeding tube location. Nurs Res. 1990;39(5):262-267.
19. Kearns PJ, Donna C. A controlled comparison of traditional feeding tube verification methods to a bedside, electromagnetic technique. J Parenter Enteral Nutr. 2001;25(4):210-215.
20. Metheny NA, Spies M, Eisenberg P. Frequency of nasoenteral tube displacement and associated risk factors. Res Nurs Health. 1986;9(3):241-247.
21. Ellett MLC, Maahs J, Forsee S. Prevalence of feeding tube placement errors & associated risk factors in children. MCN Am J Matern Child Nurs. 1998;23(5):234-239.
22. Metheny NA, Schnelker R, McGinnis J, et al. Indicators of tubesite during feedings.
J Neurosc Nurs. In press.
23. Metheny NA, Stewart BJ. Testing feeding tube placement during continuous tube feedings. Applied Nurs Res. 2002;15(4):254-258.
24. Metheny NA, Reed L, Worseck M, Clark J. How to aspirate fluid from small-bore feeding tubes. Am J Nurs. 1993;93(5):86-88.
25. Metheny NA, Eisenberg P, McSweeney M. Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res. 1988;37(3):165-169.
26. Schallom L, Stewart J, Nuetzel G, Schnelker R, Gardner R, Ludwig J, Metheny N. [Abstract] Testing a protocol for measuring gastrointestinal residual volumes in tube-fed patients. Am J Crit Care. 2004;13:265-266.

By Christine S. Schulman, RN, MS, CNS, CCRN, and Sue Fowler, RN, PhD, CNRN
Research Work Group

The AACN Research Work Group published its first Practice Alert in February 2004. This Practice Alert on ventilator-associated pneumonia was the first in a series of succinct, dynamic directives supported by current literature to direct evidence-based practice at the bedside, promote practice excellence and encourage safe, humane working environments.

The alerts address nursing topics of multidisciplinary importance by reviewing literature and providing steps for implementation, as well as “toolkits” for education and performance improvement evaluation. A total of seven Practice Alerts have now been published in AACN News and on the AACN Web site.. The other topics are Pulmonary Artery Pressure Monitoring, Dysrythmia Monitoring, ST Segment Monitoring, Dye in Enteral Feedings, and Family Presence During CPR and Invasive Procedures. The seventh, Verification of Feeding Tube Placement, appears in this issue of AACN News.

One of the charges for this year’s Research Work Group was to develop a method to evaluate the use of the Practice Alerts. In response, the work group developed the Practice Alert Survey. This survey, which was distributed via AACN’s Critical Care Newsline electronic newsletter, sought feedback about the use and value of the Practice Alerts in clinical practice.

The majority of the 862 survey respondents were staff nurses (48%), followed by clinical nurse specialists (11%), staff development instructors (8%) and managers (7%). Fifty-one percent of the respondents were CCRNs. Most respondents provide care to adults (92%), with 5% caring for pediatric patients. A range of critical care settings was represented, with 23% working in combined ICU/CCUs, 14% working in ICUs, 10% in cardiovascular-surgical ICUs and 6% in CCUs.

Seventy-one percent of those responding used the Practice Alerts in their clinical setting, with 90% saying the alerts influenced or changed their practice. Change occurred equally at the individual and unit levels, with slightly less change occurring at the system level. Some respondents identified change at more than one level.

Asked why Practice Alerts were not being used in their clinical setting, the majority of respondents (73%) did not know they were available. Unfortunately, 13% identified lack of administrative support for implementing Practice Alerts in their clinical settings. Only 4% of respondents said the Practice Alerts were not applicable to their practice, and 2% responded that the alerts were either too difficult or too technical to implement in practice.

Asked to rank the value of the individual Practice Alerts on a scale of 1 to 5 (1 = not valuable at all, 5 = very valuable), all five received fairly high scores indicating value. The Ventilator Associated Pneumonia Practice Alert received the highest score of 4.55, followed by Dysrythmia Monitoring (4.36), Pulmonary Artery Pressure Monitoring (4.35), ST Segment Monitoring (4.12), and Family Presence during CPR and Invasive Procedures (3.91).

In summary, Practice Alerts remain a tool that nurses can use to provide evidence-based and safe practice. Practice Alerts
that are technology driven are implemented more often in practice than those that reflect psychosocial aspects of care, such as Family Presence During CPR and Invasive Procedures. Exactly how the Practice Alerts are used and evaluated in practice is unknown, though the Research Work Group has provided suggestions for the evaluation phase of this process.

Without support from all levels of care providers, staff nurses to administrators, the Practice Alerts cannot be effectively implemented and evaluated for their impact on process and outcomes. It is uncertain from this survey why 13% of those responding felt that their administrators were not supportive of implementing the alerts at the bedside. The work group would like to explore this area further.
Additional Practice Alerts will be generated in an effort to promote evidence-based and safe practice. This initiative reflects efforts to assist nurses to make their optimal contribution to patients, in keeping with AACN’s vision.

The Research Work Group would like more nurses to use the Practice Alerts in their practice. The 862 members who responded to the survey represent only about 1.5% of AACN’s membership, so many more nurses may be actually implementing the alerts in practice. The challenge for the Research Work Group now is to explore multiple avenues for increasing visibility and implementation of the Practice Alerts.
We would like to hear your ideas. Members can contact us at research@aacn.org. Include “Practice Alert” as the subject line.

Christine S. Schulman is a clinical nurse specialist in the ICU at Providence St. Vincent Medical Center, Portland, Ore. Sue Fowler is clinical outcomes manager and advanced practice nurse at Somerset Medical Center, Somerville, N.J.

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

The applications as well as guidelines and resources are available online at www.aacn.org.


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

Clinical Inquiry Grant
This grant provides five awards of up to $500 each 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 one award of up to $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 one award of 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 and small clinical research studies.

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.

ANA Code of Ethics for Nurses: Provision Stresses Advocate Role

Editor’s note: The American Nurses Association’s Code of Ethics for Nurses contains nine provisions that are the foundation of nursing care. The purpose of the code is to provide concise statements of ethical obligations and duties to all nursing professionals.1 It is the profession’s ethical standard and commitment to society, and all acute and critical care nurses should practice in accordance with this code. Following is the third in a series of articles applying the provisions of the ANA Code of Ethics to critical care nursing practice. This article highlights the third provision and its underlying principles.

By Andrea M. Kline, RN, MS, MSN, CCRN, APRN, NP, NP-C, APRN-BC
Advanced Practice Work Group

Provision 3: The Nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.1

Nurses have invaluable impact on the lives of their patients and families each day. Each patient and family brings unique characteristics to the care setting. The AACN Synergy Model for Patient Care defines areas of vulnerability to illness, which include resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making and predictability.2 When caring for patients in the acute care area, nurses continually assess patient and family needs while promoting, advocating and protecting their patients.

Confidentiality is the means by which we provide respect for our patients. Regardless of where patients fall on the health-illness continuum, they have the right to privacy and confidentiality. Nurses safeguard their patients’ rights by practicing beyond the standards of Healthcare Insurance Portability and Accountability Act of 1996 compliance. Nurses advocate for both auditory and physical privacy for their patients and their patients’ families. Included are simple steps to ensure confidentiality, such as providing physical barriers (e.g., closing doors) while making rounds on neighboring patients and limiting case discussions to private areas.

Patient Welfare
Promoting patient welfare includes identifying and reporting potential harm. For example, safeguarding patients includes ensuring protection during research participation. Each individual has the right to decide whether to participate in a research study while receiving equitable quality of care regardless of participation. It is essential that research participants fully understand the risks and benefits of research participation and their right to withdraw from a study protocol at any time. If a patient has misperceptions or misunderstandings regarding the study in which they are enrolled, nurses must inform the principal investigator to clarify any questions or concerns.

Protecting patients also means identifying and reporting potential harm from a colleague, whether it is a nurse, physician or other healthcare professional. For example, harm may result from care by colleagues who are chemically, mentally, or emotionally impaired. The nurse’s responsibilities include ensuring the patient’s care is transferred to a fully capable provider. Our commitment also includes ensuring that the impaired individual receives assistance in regaining optimal function.

Incorporating safeguards in the form of standards of nursing practice into daily practice is another avenue to protect patients. Nursing standards represent best practice efforts to unify nursing care delivery and create minimal standards for acceptable nursing practice. Nurses also have the responsibility to report errors, a crucial element in reducing the likelihood of future errors. Concurrent, no-fault error reporting mechanisms are essential to the respectful and safe healthcare environment. Nurses are accountable for the development of nursing policies and ongoing quality improvement projects to enhance patient safety and decrease errors.

Excellence in nursing practice is driven by the needs of patients and their families.3 Optimum care relies on sufficient numbers of nursing staff being expert practitioners. Ongoing education and validation, including certification of skills and knowledge are essential. It is the accountability of each critical care nurse to achieve individual excellence and to ensure excellence in the profession. AACN Certification Corporation has multiple certification options to validate nursing knowledge.

Advocating and Protecting
Advocating and protecting our patients include questioning goals of care when there is a misalignment between patient-family and medical team goals. Ethics committees and other resources are used when there is unsatisfactory resolution to difficult ethical and moral decision making.

Protecting and advocating for patients encompasses periods during life and continues through the dying process. Adjusting the milieu of the acute care setting from intensive care to palliative care or end-of-life care promotes a dignified death.4 Critical care nurses are challenged to meld the practices of “doing” and “being” for patients at the end of life. Caring practices for the dying patient include nursing activities that create a compassionate and therapeutic environment for patients and their families. Environ-mental adjustments can include investigating cultural practices and attitudes around the time of death, allowing for domestication of the healthcare environment, allowing “alone” time for the patient and family, facilitating spiritual goals (i.e., chaplains, prayers), honoring silence, acknowledging uncertainty, assisting families in memory-making activities, and providing flexibility in family visitation and presence at the patient’s bedside.4 Unnecessary measures in promoting a comfortable death are reassessed, such as frequency of laboratory monitoring, frequency of vital signs and discontinuation of medications that do not have a role in comfort.4

As critical care and healthcare become more complex and advanced, more demands are placed on the nursing profession. Nursing remains one of the noblest of professions. Few others touch the lives of so many during their most vulnerable moments in life. We have the unique and privileged situation to advocate for our patients, while striving to protect their rights to health and safety.

1. ANA Code of Ethics for Nursing With Interpretive Statement. Available at: http://www.nursingworld.org/ethics/code
/ethicscode150.htm. Accessed Jan 22, 2005.
2. The AACN Synergy Model for Patient Care. Available at: http://www.aacn.org/certcorp/certcorp.nsf/vwdoc/SynModel
?opendocument. Accessed March 8, 2005.
3. American Association Critical Care Nurses Standards for Establishing and Maintaining Healthy Work Environments. Available at: http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWEStandards/$file/HWEStandards.pdf. Accessed March 4, 2005.
4. Rushton CH, Williams M, Sabatier KH. The integration of palliative care and critical care: one vision, one voice. Crit Care Nurs Clin N Amer. 2002:133-140.

Evaluating Outcomes Not a New Concept in Nursing
Advanced Practice Nurses Effective in Variety of Settings

By Barbara “Bobbi” Leeper, RN, MN, CCRN
Advanced Practice Work Group

Evaluating outcomes of care is not a new concept to nursing. In fact, Florence Nightingale documented mortality and morbidity rates during the Crimean War.1 Her purpose was to use the data to illustrate the low standard of care to the public.

Through the years, others have assessed outcomes in major areas, including death, disability, discomfort, disease and dis-
satisfaction.1 More recently, regulatory agencies and third party payors are requesting that healthcare providers submit data on selected procedures and diagnoses. In response, healthcare facilities are using multidisciplinary teams that include advanced practice nurses to employ quality improvement processes to improve outcomes for these procedures and diagnoses.

Often, identifying indicators within these processes that are sensitive to nursing is difficult. The American Nurses Credentialing Center requires institutions pursuing Magnet recognition or already recognized as a Magnet facility to submit data on indicators considered indicative of quality nursing care, including incidences of hospital-acquired pressure ulcers and falls.

APNs, including nurse practitioners and clinical nurse specialists, are often challenged to evaluate the impact of their care and services on patient and system outcomes. Because the patient is cared for by a multidisciplinary team, determining the specific outcomes contributed by the APN may be difficult.

Fortunately, the literature provides numerous examples demonstrating the effectiveness of APNs in a variety of settings. Kleinpell2 provided a summary of the research examining the effectiveness of care by acute care nurse practitioners. She suggested that, when selecting outcome measures to use, the APN must determine the purpose of the outcome assessment, the patient population to be studied and the APN activity of interest.2

Specific measures to be studied can be care related, patient related or performance related. Care-related measures include costs, length of stay, readmission rates, morbidity and nosocomial infection rates. Patient-related measures include functional status, patient compliance, health maintenance, stress levels, knowledge, patient falls and blood pressure control. Performance-related measures include quality of care, technical quality and time spent in role components.2 (Table) In addition, Kleinpell provided a list of commonly used outcome measurement tools.2

Similarly, Urden1 categorized types of outcomes to be assessed for the CNS. The categories included clinical outcomes focusing on mortality and morbidity, physiological responses, symptom control, nutritional status and sleep maintenance. Psychosocial outcomes included the topics of return to work, role functioning, anxiety, sexual functioning and knowledge of areas such as medications, diet and treatment regime. Functional outcomes addressed quality of life, self-care, mobility, communication and symptom control. Fiscal outcomes included length of stay, hospital readmission, healthcare services utilization and costs related to care. Lastly, satisfaction outcomes addressed those of the consumer, family, payor and provider.1 Urden also included examples of instruments that can be used to assess these.1

Obviously, there is some overlap between the NP and CNS roles. Regardless of the specific role, the APN is the expert practitioner and has the accountability for promoting and upholding the standards of care.1 Evaluation of these standards must be done continuously, whether looking at a single patient incident or a patient population.

Within the context of a multidisciplinary team, the APN can be a leader in the quality improvement process. Once the process to be studied is determined, the APN can identify key decision makers to participate on a task force. A variety of approaches can be used by the APN for quality improvement. The process of care can be mapped indicating the role of the relevant discipline. Duffy3 provides an Indicator Development Grid to be used for this type of process. Another type of tool that may prove helpful is a form that contains all the key points of the process of care and which team member or department is responsible. This form is helpful in assisting the team to identify and develop strategies to remove possible barriers and improve the process of care. Once gaps or barriers are identified, the multidisciplinary team can develop and implement strategies to address the issues. The APN has been shown to be a key facilitator of the initiative.

Opportunities for APNs to impact patient outcomes and quality improvement are unlimited. Use of standardized tools and processes can maximize the APN’s effectiveness.

Barbara “Bobbi” Leeper is a clinical nurse specialist in cardiovascular services at Baylor University Medical Center, Dallas, Texas.

The author appreciates the contributions to this article by fellow work group member Kelly A. Thompson-Brazill, RN, MSN, AP.

1. Urden L. Outcome evaluation: an essential component for CNS practice. Clin Nurse Specialist. 2001;15(6):260-268.
2. Kleinpell-Nowell R, Weiner TM. Measuring advanced practice outcomes. AACN Clin Issues. 1999;10(3):356-368.
3. Duffy JR. The clinical leadership role of the CNS in the identification of nurse-sensitive and multidisciplinary quality indicator sets. Clin Nurse Specialist. 2002;16(2):70-76.

Public Policy Update

ICN Releases Issue Papers on Global Shortage of Nurses
The International Council of Nurses has published the first series of commissioned issue papers addressing the global shortage of registered nurses. The first papers to be released are titled International Migration of Nurses: Trends and Policy Implications and Nurse Retention and Recruitment: Developing a Motivated Workforce. A summary of ICN’s initial report identifying the policy and practice issues and solutions impacting the supply and utilization of nurses accompanies these first publications. The papers are available at www.icn.ch/global/#3.

Bill Proposes Constitutional Right to Healthcare
Reps. Pete Stark (D-Calif.) and Jesse Jackson Jr. (D-Ill.) have proposed a constitutional amendment to establish healthcare as a basic right. The amendment, stating that “all persons shall enjoy the right to healthcare of equal high quality,” must pass the House and Senate by a two-thirds majority. It would then require ratification by three-fourths of the states, and Congress would have to pass implementing legislation. Stark said a constitutional guarantee to healthcare was necessary because of reductions in company-sponsored health benefits and proposed cuts to the federal Medicaid budget.

JCAHO Plans International Patient-Safety Center
The Joint Commission on Accreditation of Healthcare Organizations plans to establish an international patient-safety center with its consulting and education subsidiary, Joint Commission Resources. Peter Angood, a professor at the University of Massachusetts Medical School who currently is president of the Society of Critical Care Medicine, will be chief patient-safety officer and co-leader of the center. The Joint Commission said the center’s other principals will be Richard Croteau, JCAHO’s executive director for strategic initiatives, and Laura Botwinick, an executive currently on leave for a fellowship at the Institute for Healthcare Improvement.

The commission said the center initially would focus on identifying, analyzing and disseminating patient-safety advances in the U.S. and abroad and on creating organizational “cultures of safety.”

Senate HELP Panel Approves Medical Errors Reporting Bill
The Senate Health, Education, Labor and Pensions Committee has approved legislation aimed at improving patient safety. The bill (S 544) would establish a legal framework for healthcare providers to report medical errors without fear of the data being used in malpractice lawsuits and would set up a database to track such errors to analyze trends and prevent repeating common mistakes.

The Senate unanimously passed a nearly identical medical errors measure last year, and the House passed its own version of the legislation in 2003. The committee approved this year’s bill with the understanding that some concerns about the use of the data raised by ranking Sen. Edward M. Kennedy (D-Mass.) would be resolved before the measure goes to the floor. HELP Chairman Michael B. Enzi, (R-Wyo.), agreed to work with Kennedy and insert a notation into the record clarifying that the intent of the bill is not to bar use of the information in criminal cases.

The momentum for the patient safety legislation followed an Institute of Medicine report that medical errors cause up to 98,000 deaths a year. Reaching a bipartisan agreement on ways to gather and analyze data about medical mistakes without exposing healthcare providers to added liability took the Senate five years. House and Senate leaders disagree about which chamber is to blame for the failure to reach a conference agreement in the 108th Congress. The legislation is expected to pass the Senate again easily. The House Energy and Commerce Committee has not scheduled a markup of its version of a medical errors bill.

The full text of the bill is available at thomas.loc.gov.

Online ANA Survey Provides Snapshot of Nurse Turnover
Five percent of registered nurses said they would leave direct patient care within a year, 2% said they would leave the profession entirely in that time frame and 1% said they would retire, according to the results of a recent online American Nurses Association survey.

Nearly 75,900 registered nurses in hospitals in 44 states responded to the RN Satisfaction Survey, conducted from April 2004 through October 2004. Approximately 79% said they expected to be working in the same hospital and unit for the next year. In addition, 82% reported working overtime, and 26% said they had been given an assignment outside their usual unit within the previous two weeks.

New Visa Process for Foreign Nurses Will Exacerbate Shortage
A change in rules affecting the handling of some visa applications could exacerbate the nursing shortage, according to hospital officials and immigration advocates. Under the new rule, foreign nurses seeking employment in the United States will be required to wait more than three years to receive permanent residency. In the past, nurses sponsored by a U.S. hospital received visa approval and could establish permanent residency in 18 to 24 months.

Public Policy Snapshot

Life Expectancy for Americans Rises

The life expectancy of the average American has increased to a record 77.6 years amid declines in major causes of death, including cancer and heart disease, according to the National Center for Health Statistics annual mortality report. The report also shows that the gap between women’s and men’s longevity continues to narrow, with women living 80.1 years, 5.3 years longer than men and down from a 5.4-year gap in 2002. The difference was as high as 7.8 years in 1979.

The full report is available at www.cdc.gov/nchs.

Is Your Unit a Beacon of Excellence? Apply for Award Online

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.

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. There is no limit on the number of units that may apply from a single facility.

For more information, visit the AACN Web site.
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