Vol. 4, No.

10 | October 2012

High Acuity & Critical Care Nurses Make Their Optimal Contribution

PAGE
ACNP Scope Medicaid Patients:
5 and Standards
New Edition
Most ED Visits
Legitimate
PAGE

PAGE

7 Apply for
Research
15
Grants
by Nov. 1 PAGE

PAGE
Hospital 17
10 at Home
Programs
Children Swallow
or Insert Batteries
PAGE
ABCDE Bundle Scholarships:
13 Improves Ventilated
Patient Outcomes
AACN Health
Policy Internship
PAGE

20
GO MOBILE
GET INFORMATION QUICKLY
ON YOUR MOBILE DEVICE
www.aacn.org/godigital
Go with digital on one, two or all three member publica-
tions (AACN Bold Voices, American Journal of Critical Care
and Critical Care Nurse) and eliminate duplicate copies!
Going digital lets you access information when you
need it. And on your mobile device!

Digital instead of print benefits members through:

Earlier arrival than print delivered by mail
Reduced clutter from piles of paper
Quick and easy mobile access of content
Features to download, save, search, bookmark and
print current and past issues

Say yes to digital and no to paper. Go to www.aacn.org/

godigital, check Yes, Id like to go with digital! and click
SUBMIT NOW!

iPad, iPhone and Droid shown here. Other mobile interfaces vary.
 Nursing News Direct toYou

AACN RSS feeds automatically

deliver critical care nursing updates.

Stay up-to-dateAACN RSS feeds keep Quickly understand RSSLearn about

you automatically informed about the latest Really Simple Syndication, what it means
acute and critical care news, evidence- and how to your receive your automatic
based practices, clinical resources and updates with AACNs RSS educational tools
peer-reviewed articles. and information.

Save time and effortRSS feeds conveniently Information you can trustBrought to you
gather large amounts of pertinent information by AACN, partner to critical care nurses for
in one place, linking you directly to online more than 40 years.
content you care about.

Follow us online
Subscribe now or learn more at #AACN
www.aacn.org/rss #nursing

info@aacn.org | 800/899-2226

A Community of Exceptional Nurses

 Dare to
Compete
Were you caught up in the excite-
ment of the Olympic Games? More
than 10,000 athletes enthusiasti-
cally participated knowing they
W e received a 21-year-old female
patient from the intensive care unit (ICU)
werent likely to go home with
even one of nearly 1,000 individual
following a car accident. She had been medals awarded. Their daring has
delivering newspapers to make extra much to teach us about honing our
money for the family. Her husband usually own skills and abilities so we can
watched their 2-year-old daughter, but dare to compete as individuals
that morning he had a job interview. So, and teams in healthcare today.
the woman put her daughter in the car seat, and off to work they went.
Not long after, an accident occurred. The mother sustained multiple inju- Read more in my note on page 22.
ries and her daughter was killed. Her husband took the loss very hard
Kathryn Roberts
and blamed himself for the daughters death.
AACN President
[In] the Step Down unit, [the mother] told the nurse she would love
to see her baby one more time. The nurse talked to her husband, her
Another Angle

parents, the hospital chaplain, and the funeral director. All felt that The important thing in life is not
attending a funeral service would be important in helping the mother to triumph but to compete.
to achieve closure. I dont know if this had ever been done before,
Olympic Creed
but we held a funeral service in her room. The funeral director
and hospital chaplain arrived, carrying a small white casket with gold
handles and angels. The beautiful little girl looked as if she were
sleeping. Her grandma put a Precious Moments angel necklace on her.
Because the little girl loved butteries, pink ones were placed inside
the casket and her aunt put gold butteries on the outside.

The funeral director put the casket next to the mothers bed. Her
cervical collar and pulse oximeter were removed, so she could turn her
head to see the baby and hold her daughters hand one last time.

When [the service] was over, everyone except the parents left the
room. The family thanked me for the help and encouragement I
provided. The nurses truly made a difference by making sure the
patient got her wish. Im so proud of all of these nurses who made this
experience possible for a mother who had such a tremendous loss.
Source: Monica Dancu in Hudacek, Sharon. Making a Difference: Stories from the Point of Care,Vol. II.
Indianapolis: Sigma Theta Tau International; 2004; 258-259.

AACN BOLD VOICES OCTOBER 2012 3


The American Association of Critical-Care
Nurses is the worlds largest specialty nursing
organization. AACN is committed to a healthcare
system driven by the needs of patients and
families where acute and critical care nurses make
their optimal contribution.
Board of Directors
President
Kathryn E. Roberts, RN, MSN, CNS, CCRN, CCNS
Clinical Nurse Specialist
Pediatric Intensive Care Unit
The Childrens Hospital of Philadelphia, Pa.
President-elect
Vicki Good, RN, MSN, CENP
Administrative Director of Patient Safety
CoxHealth
Springeld, Mo.
Secretary
Melissa Hutchinson, RN, MN, CCNS, CCRN, CWCN
Clinical Nurse Specialist, MICU/CCU
VA Puget Sound Health Care System
Seattle, Wash.
Treasurer
Mary Bylone, RN, MSM, CNML
Vice President, Patient Care Services and
Chief Nursing Ofcer
The William W. Backus Hospital
Norwich, Conn.
Directors
Linda M. Bay, RN, MSN, ACNS-BC, CCRN, PCCN
Clinical Nurse Specialist
Clement J. Zablocki VA Medical Center
Milwaukee, Wis.
Sheryl Leary, RN, PhD(c), CCRN, CCNS, PCCN
Clinical Nurse Specialist
VA San Diego Healthcare System
San Diego, Calif.
Karen McQuillan,
RN, MS, CNS-BC, CCRN, CNRN, FAAN
Clinical Nurse Specialist
R Adams Cowley Shock Trauma Center
University of Maryland Medical Center
Baltimore, Md.
Riza V. Mauricio, RN, MS, CCRN, CPNP
Pediatric ICU Nurse Practitioner
The Childrens Hospital of the University of Texas
MD Anderson Cancer Center
Houston, Texas
Kathleen K. Peavy, RN, MS, CCRN, CNS-BC
Critical Care Clinical Nurse Specialist
Southern Regional Medical Center
Riverdale, Ga.
Pamela Popplewell, RN, DNP, ANP-BC
Director of Nursing, Surgery
VA Puget Sound Health Care System
Seattle, Wash.
Maureen Seckel,
RN, MSN, APN, ACNS-BC, CCNS, CCRN
Clinical Nurse Specialist,
Medical Pulmonary Critical Care
Christiana Care Health System
Newark, Del.
Clareen Wiencek, RN, PhD, ACHPN, ACNP
Nurse Manager/Clinician
Thomas Palliative Care Unit Massey Cancer Center
Virginia Commonwealth University
Health System
Richmond, Va.
Mary Zellinger, RN, MN, ANP, CCRN-CSC, CCNS
Clinical Nurse Specialist,
Cardiovascular Critical Care
Emory University Hospital
Atlanta, Ga.
Chief Executive Ofcer
Wanda L. Johanson, RN, MN
4 www.aacnboldvoicesonline.org OCTOBER 2012
AACN Certication Corporation, the credentialing
arm of the American Association of Critical-Care
Nurses, maintains professional practice excellence
through certication and certication renewal of
nurses who care for acutely and critically ill
patients and their families. AACN Certication
Corporation develops and administers the CCRN,
PCCN, CCRN-E, CCNS and ACNPC specialty
exams in acute, progressive and critical care; CMC
and CSC subspecialty exams in cardiac medicine
and surgery; and, in partnership with the
American Organization of Nurse Executives, the
CNML exam for nurse managers and leaders.
Board of Directors
Chair
Pamela Bolton,
RN, MS, CCRN, CCNS, PCCN, ACNPC
Critical Care Nurse Practitioner/Clinical Specialist
Good Samaritan Hospital, Cincinnati, Ohio
Chair-elect
Linda Harrington,
RN-BC, PhD, CNS, CPHQ, CPHIMS, FHIMSS
Vice President and Regional Chief Nursing
Informatics Ofcer
Catholic Health Initiatives, Englewood, Colo.
Secretary/Treasurer
Diane Byrum, RN, MSN, CCRN, CCNS, FCCM
Clinical Nurse Specialist
Presbyterian Hospital Huntersville
Huntersville, N.C.
Directors
Sonia Astle, RN, MS, CCRN, CNRN, CCNS
Clinical Nurse Specialist
Inova Fairfax Hospital
Falls Church, Va.
Karen S. Kesten, RN, DNP, APRN, CCRN, PCCN, CCNS
Assistant Professor and Program Director
Georgetown University
School of Nursing and Health Studies
Washington, D.C.
Sheryl Leary, RN, PhD(c), CCRN, CCNS, PCCN
Clinical Nurse Specialist
VA San Diego Healthcare System
San Diego, Calif.
Karen McQuillan,
RN, MS, CNS-BC, CCRN, CNRN, FAAN
Clinical Nurse Specialist
R Adams Cowley Shock Trauma Center
University of Maryland Medical Center
Baltimore, Md.
Mary Frances Pate, RN, DSN, CNS
Associate Professor
University of Portland School of Nursing
Portland, Ore.
Consumer Representative
Myra Christopher
Kathleen M. Foley Chair for Pain and
Palliative Care
Center for Practical Bioethics
Kansas City, Mo.
Editorial Ofce
AACN Communications
101 Columbia, Aliso Viejo, CA 92656
(800) 394-5995 ext. 512
(949) 448-7335
aacnboldvoices@aacn.org
www.aacn.org
Editor: Ramn Lavandero; Managing
Editor: Marty Trujillo; Clinical
Advisor: Julie Miller, RN, BSN, CCRN ;
Assistant Editor: Judy Wilkin;
Writers: Stacy Goldman, Jim Kerr, Neal
Lorenzi, Dennis Nishi, Jason Winston;
Art and Production Director: LeRoy
Hinton; Design: Brian Burton Design,
Inc., Matthew Edens; Web Editor: Paul
Taylor; Publishing Manager: Michael
Muscat; Communications Director:
Richard Howell; Senior Director of
Communications and Strategic
Alliances: Ramn Lavandero
Advertising Sales Ofce
SLACK Incorporated
6900 Grove Road, Thorofare, NJ 08086
(800) 257-8290
Sales Manager, Recruitment/
Classieds: Monique McLaughlin,
mmclaughlin@gomindworks.com;
Director, Association Services: Kathy
Huntley, khuntley@gomindworks.com;
Administrator: Michele Lewandowski;
Vice President, Sales: Michael
Graziani; Chief Operating Ofcer:
John Carter
AACN BOLD VOICES (print ISSN 1948-7088,
online ISSN 1948-7096) is published monthly
by the American Association of Critical-Care
Nurses (AACN), 101 Columbia, Aliso Viejo,
CA 92656. Telephone: (949) 362-2000. Fax:
(949) 362-2049. Copyright 2012 by AACN.
All rights reserved. AACN BOLD VOICES is
an ofcial publication of AACN. No part of
this publication or its digital edition may be
reproduced or transmitted in any form or by
any means, electronic or mechanical, including
photocopying, recording or by any information
storage retrieval system, without permission
of AACN. For all permission requests, please
contact Sam Marsella, AACN, 101 Columbia,
Aliso Viejo, CA 92656. Telephone: (800)
899-1712. Email: sam.marsella@aacn.org.
Prices on bulk reprints of articles available on
request from AACN at (800) 899-1712. Printed
on acid-free paper. AACN BOLD VOICES is
indexed in the Cumulative Index to Nursing &
Allied Health Literature (CINAHL).
The statements and opinions contained in
AACN BOLD VOICES do not necessarily
represent the views or policies of the American
Association of Critical-Care Nurses, except
where explicitly stated. Advertisements in
this publication or its digital edition are not
a warranty, endorsement, or approval of the
products or services by AACN or the editors and
content contributors of AACN BOLD VOICES,
who disclaim all responsibility for any injury
to persons or property resulting from any
ideas or products referred to in the articles or
advertisements.
Individual subscriptions by request.
Institutional subscriptions: $200.
Printed in the USA.
 AACN

AACN Releases ACNP

Scope and Standards
A new edition of AACN Scope and Standards for Acute Care Nurse Practitioner
Practice will be available this month in AACNs Online Bookstore in print, download-
able PDF and Kindle versions.
The scope and standards describe and measure the expected level of practice and
professional performance for acute care nurse practitioners (ACNPs). The new edition
aligns with the Consensus Model for
APRN Regulation also called the New edition of scope
LACE Model developed to create and standards addresses
national congruence for licensure,
accreditation, certication and education advanced practice in adult
of advanced practice nurses. and pediatric acute care.
An expert work group updated the
2006 edition to reect the specialtys evolving role and an ever-changing critical care
landscape. New material includes comment from practicing nurse practitioners and
faculty and students in nurse practitioner programs, making this edition a valuable
resource for those developing educational programs, job descriptions and credentialing for advanced practice nurses.
The role of acute care nurse practitioners continues to expand as more hospitals and healthcare organizations
discover the value of having ACNPs on staff, says Linda Bell, AACN clinical practice specialist. Their work envi-
ronment often extends beyond traditional acute and critical care settings. The new edition addresses the full scope
of ACNP practice, including those whose education and training prepares them to care for children with acute and
critical illnesses.
A well-timed release for the start of the academic year, AACN Scope and Standards for Acute Care Nurse
Practitioner Practice incorporates advances in scientic knowledge, clinical practice and technology, and other
changes in the dynamic healthcare environment. It offers a practical tool for students, educators and advanced
practice nurses caring for high acuity or critically ill patients and their families in every setting.

National Awards Recognize Reductions

in Healthcare-Associated Infections
The U.S. Department of Health
and Human Services and the Critical
Care Societies Collaborative a
partnership of major professional
and scientic societies whose
members care for Americas criti-
cally ill and injured and includes
AACN; the American College of
Chest Physicians, Northbrook,
Ill.; American Thoracic Society,
New York; and Society of Critical
Care Medicine, Mount Prospect,
Ill. announce the third in the
three-year national awards program
to recognize teams of critical care
professionals and healthcare institu-
tions for outstanding leadership to
reduce or eliminate healthcare-asso-
ciated infections (HAIs).
The awards which recognize
benchmark systems of excellence
that reduce targeted HAIs for 25
This years awards
also address catheter-
associated urinary
tract infections.
months or longer strive to moti-
vate the healthcare community to
reduce or eliminate HAIs on a large
scale and encourage nurses, other
clinicians and hospital executives
to use evidence-based guidelines to
improve clinical practice.
They will recognize success in
reducing or eliminating central line-
associated bloodstream infections
(CLABSIs), ventilator-associated
pneumonia (VAP) and the addi-
tion this year of catheter-associated
urinary tract infections (CAUTIs).
Hospitals, units and teams that
successfully reduce or eliminate
HAIs may apply for the awards,
which will be presented during
the 2013 AACN National Teaching
Institute & Critical Care Exposition
in Boston.
Visit www.aacn.org/hhs-ccsc-
award for details on eligibility,
selection criteria, application
requirements and deadlines,
or email questions to awards@
aacn.org.

AACN BOLD VOICES OCTOBER 2012 5

 AACN
NTI 2013 Its
Not Too Early to
Start Planning
Boston, a modern city steeped in
American history, hosts the American
Association of Critical-Care Nurses
40th annual National Teaching
Institute & Critical Care Exposition
(NTI), May 18-23, 2013. To start
planning your NTI experience:
Use the NTI ROI toolkit to build a compelling
case for your organizations return on investment
when it supports your attendance at NTI. A strong
way to connect value is to connect your organiza-
tions goals to NTIs educational opportunities.
Download the ROI toolkit at www.aacn.org/nti.
Make hotel reservations now. The AACN
Housing Bureau will accept hotel reservations
beginning Oct. 10. Book early for the best selection
and discounted rates since reservations are assigned
on a rst-come, rst-served basis. After April 2,
2013, reservations are subject to availability. Visit
www.aacn.org/nti > Hotel and Travel for a list of
Tactical Care Teams
Help Save Lives on the
Battleeld
The U.S. military has launched tactical care teams to save
soldiers lives on the battleeld, according to New Tactical
Care Teams Aim to Save More Lives, posted in Air Force
Times. For nearly a year, a three-member team of Air Force
health professionals has successfully evacuated and treated
299 severely wounded troops by taking the emergency depart-
ment to the injured, the article says.
Tactical critical care evacuation team (TCCET) members
include an emergency medicine or critical care physician,
a certied registered nurse anesthetist and an emergency
department or critical care nurse. TCCETs specialize in
moving and treating patients who may die if immediate emer-
gency treatment is not administered.
Bart Iddins, Air Mobility Command surgeon, says in the
article that the rst teams skills are being put to good use with
troops in Afghanistan, where improvised explosive devices
remain a primary weapon. Many casualties suffer blast-related
injuries such as burns, lung and blunt force trauma, head injury
and amputation.
Iddins indicates uncontrolled bleeding, loss of airway and
tension pneumothorax are the most common causes of prevent-
able death on the battleeld. TCCETs are trained specically
to deal with such emergency scenarios, unlike those trained in
rst-responder or combat care.
This kind of aggressive treatment saves lives, Iddins says in
the article, but is beyond the scope of traditional pre-hospital
tactical casualty evacuation capabilities. TCCET is designed
to bring a higher level of medical care directly to the casualty,
specically at the point of injury, in order to initiate emergency
department/trauma department-level-control resuscitation
earlier and more aggressively than has traditionally occurred,
he explains.
Transitions
Events in the lives of members and friends in the AACN
community
hotels and rates, and to book your hotel reservation. Geraldine BourneCERTIlCATIONsJennifer Brugos,
Call (800) 340-1840 with questions. AWARDsBarbara ChamberlainBOARDsBernice
ColemanFELLOWsJo Ellen Craghead, certica-
Purchase an AACN gift certicate so a nurse TIONsDorrie FontaineEXECUTIVEPROGRAMsMarge
colleague can experience NTIs essential knowl- FunkBOARDsCaryl Goodyear-BruchNEWPOSITIONs
edge, resources and networking opportunities. Pamela MitchellEXECUTIVEPROGRAMsMaria Shirey,
Order by Oct. 19, to qualify for NTI 2012 rates. award

Start exploring all the unique experiences Visit www.aacn.org/transitions for more informa-
Boston has to offer. Visit http://events. tion about each transition. Please send new entries to
bostonusa.com/nti. aacnboldvoices@aacn.org. Honor or remember your
colleagues with a gift to AACN at www.aacn.org/gifts.

6 www.aacnboldvoicesonline.org OCTOBER 2012

 AT THE BEDSIDE

Research-based COPE Program Provides Better

Outcomes for Premature Infants, Parents

A
new program, Creating Opportunities for Parent
Empowerment (COPE), helps parents of prema-
ture infants provide better care, leading to better
outcomes and reduced healthcare costs, according to a new
study published online by the National Institute of Nursing
Research, Bethesda, Md.
Because of Nursing Research: Helping Families COPE
With Premature Births reviewed the effects of COPE, which
provides parents knowledge, skills and condence needed
to improve their caregiving abilities, as a way to alleviate
stress.
Nurse scientist Bernadette Melnyk, The Ohio State
University, Columbus who designed the program with
her associates found parents are often overwhelmed, and
feel lost and helpless in the NICU and do not know how to
touch, comfort, or soothe their infant.
In a clinical trial of more than 200 families of prema-
ture infants, Melnyk found that use of COPE improved the
knowledge and beliefs parents had about their premature
infants, and parents interacted with their child in a more
positive way, appropriate to the infants developmental level.
The study also showed that fathers in the COPE program
tended to be more involved in the infants care in the NICU
than fathers not in the program; while mothers in the COPE
program had lower stress in the NICU and lower anxiety
and depressive symptoms after the infant came home than
mothers who did not receive COPE.
In addition, COPE intervention reduced NICU stays
by about four days and reduced costs between $4,800
and $10,000 for infants younger than 32 weeks gestation
compared with standard care.
CCRN Neonatal: Caring for the
Most Vulnerable
Nurses who have the
required experience
caring for acutely and
critically ill newborns
may qualify for AACN Certication Corporations CCRN
Neonatal exam. The 150-item exam awards the CCRN
credential and validates nurses knowledge of caring for
the most vulnerable patients.
Accredited by the National Commission for Certifying
Agencies, the CCRN Neonatal exam is developed by
neonatal nursing experts. It covers the most signicant
problems seen with high acuity newborn patients across
the United States, and other essential aspects of neonatal
nursing such as caring practices, facilitation of learning
and advocacy for babies, parents and families.
To learn more about the CCRN Neonatal certication
exam, visit www.aacn.org > Certication > CCRN >
Documents and Handbooks > CCRN/PCCN Certication
Exam Handbook.
Fathers tended to be more
involved in NICU care, and mothers
had lower stress.

Nov. 1 AACN Research Grant Application

Deadline Fast Approaching
Applicants for AACN research grants which support our community to seek evidence that supports bedside nurses
to ensure safe and excellent outcomes for high acuity and critical care patients and their families have until Nov. 1 at
5 p.m. Pacic Time to submit an application online.
Principal investigators must be current AACN members and,
AACN will award nearly depending on the grant, research projects must be completed within
$200,000 to support two years. Proposals may include technology to achieve optimal patient
assessment, management and/or outcomes; healing and humane envi-
evidence-based research. ronments; processes and systems for the optimal contribution of high
acuity and critical care nurses; symptom management; and managing outcomes and preventing complications.
For detailed information including application criteria and supporting documents, visit www.aacn.org/grants or
email research@aacn.org.

AACN BOLD VOICES OCTOBER 2012 7

 AT THE BEDSIDE

Stimulants as Student Study Aid

Might Be on the Rise
Pressure over grades and college admissions prompts more
U.S. high school students to abuse prescription stimulants such
as Adderall and Ritalin, The New York Times reports, but the
connection is being disputed.
Physicians and teenagers from more than 15 high schools
with high academic standards estimate that 15 to 40 percent of
students use stimulants as a study aid, the Times article states.

The New York Times and TIME magazine

publish conicting reports about
student use of prescription stimulants.
While the medicines tend to calm those with attention decit
hyperactivity disorder (ADHD), in people without ADHD, just
one pill can jolt them with energy and focus to push through all-
night homework binges, the article says.
Pills that have been a staple in some college and graduate school circles are going from rare to routine in many
academically competitive high schools, the Times reports, adding that abuse can lead to depression, mood swings
and heart irregularities.
TIME magazine responds that national statistics dont really support the idea that misuse of these drugs among
high school students is growing, The Advisory Board Co. notes in a Daily Brieng article. In fact, National Institute of
Drug Abuse data reveal that prescription stimulant misuse among high school seniors has dropped from a high of 32
percent in 1981 to 12 percent in 2011.
TIME concludes stimulant misuse in elite high schools could be surging, but data in The New York Times dont
prove it, and publishing the data could worsen whatever trend does exist by leading students to think everyones
doing it.

Azithromycin Increases Risk of

Death for Cardiac Patients

A
study in The
New England
Journal of
Medicine nds the
widely prescribed anti-
biotic azithromycin
may increase the risk of cardiovas-
cular death in some patients.
According to Azithromycin and
the Risk of Cardiovascular Death,
individuals at highest risk include
those with heart failure, diabetes
or a previous heart attack, and
those who have undergone bypass
surgery or had stents implanted. The
antibiotic is thought to trigger an
arrhythmia that can
lead to death.
Researchers at
Vanderbilt University,
Nashville, Tenn.,
analyzed health
records and data from
millions of prescriptions for the anti-
biotics azithromycin, amoxicillin,
ciprooxacin and levooxacin.
The medications were issued to
about 540,000 Medicaid patients in
Tennessee over a span of 14 years.
During ve days of therapy,
researchers found that patients
taking azithromycin had a
2.5-times higher chance of dying
from a cardiovascular cause when
compared to patients on amoxicillin
or no antibiotics. Although more
study is required, the researchers
feel strongly enough about the
results to recommend that physi-
cians prescribe a different antibiotic,
such as amoxicillin, to patients in
the highest risk group.
Azithromycin may
trigger a lethal
arrhythmia.

8 www.aacnboldvoicesonline.org OCTOBER 2012

 AT THE BEDSIDE

Supporting Frontline Hospital Staff

Leads to Safer and Happier Patients
Frontline hospital staff important to patients, hospi-
who receive support from Meaningful Recognition, tals and care providers. She
management are more Authentic Leadership: adds, How we treat hospital
likely to give a higher level workers whether we
of patient care, according
Not Optional support them, give them a
to a study in Health Services AACNs Healthy Work Environment Standards state that say in decisions about their
Research. meaningful recognition and authentic leadership are work, and treat them not as
The Importance of a required to ensure staff satisfaction and optimal patient interchangeable or dispens-
High-Performance Work outcomes. And along with skilled communication, true able cogs in a wheel but as
Environment in Hospitals collaboration, effective decision making and appropriate a valued resource affects
looked at 45 adult, medical- stafng, each individual and organization are responsible their ability to work together
surgical units, including for leadership and recognition. Download the standards to provide care that patients
1,527 unit-based hospital and access a free healthy work environment assessment want and need.
providers, to examine the tool at www.aacn.org/hwe. A related article in
benets of a high-perfor- AMN Healthcare notes,
mance work environment High-performing work
(HPWE) for employees, How we treat hospital workers ... environments reward
patients, and hospitals. affects their ability to work together. and recognize employees,
The cross-sectional offer opportunities to
study found an HPWE, as perceived by multiple occu- grow, and give people more ability to work independently.
pational groups on a unit, is signicantly associated with Hospitals can have a great impact on performance by demon-
desirable work processes, retention indicators, and care strating that they value their staff, support and professional
quality. employees.
In a Health Behavior News Service article, the studys lead What makes you feel valued in your workplace and keeps
author Dana Beth Weinberg, associate professor, Queens you at your job? Tell us at aacnboldvoices@aacn.org, click on
College, Flushing, N.Y., states, The key nding was the the blue auto-reply button in the digital edition or post a wall
strong relationship between the way hospitals value and comment at facebook.com/aacnface.
support their workforce and a range of outcomes that are

Drug Manufacturers to Provide

Opioid Education for Prescribers
In an effort to reduce opioid misuse, abuse and addic- s !VINZA
tion, the U.S. Food and Drug Administration (FDA), Silver s "UTRANSBUPRENORPHINETRANSDERMAL
Spring, Md., approved a Risk Evaluation and Mitigation s $OLOPHINEMETHADONE
Strategy requiring manufacturers to provide continuing s $URAGESICFENTANYLTRANSDERMAL
education to prescribers. s %MBEDANOTCURRENTLYAVAILABLE
In addition to funding grants for continuing medical s %XALGOHYDROMORPHONE
education, drug manufacturers will need to produce s +ADIAN
educational materials for patients on safe use, storage and s -3#ONTIN
disposal of extended-release and long-acting opioids, s /PANA%2OXYMORPHONE
according to a related Medscape article. The FDAs strat- s /XY#ONTINOXYCODONE
egy includes these pain relievers: Prescriber education is currently voluntary, but federal
ofcials say they will work to make it a prerequisite. The
FDA goal: Reduce abuse balance sought by all parties, the article notes, involves
potential of opioids without reducing the potential for abuse without overly restricting
access to needed medications.
overly restricting access.

AACN BOLD VOICES OCTOBER 2012 9

 AT THE BEDSIDE

H ouston, Texas

Photo: Albuquerque Journal online edition.

Make a big splash
at Memorial Hermann. Hospital at Home
Memorial Hermann is a world-class health system with Programs Offer a
locations throughout Houston and the surrounding
areas. With benefits eligibility that begins the first day Potential Alternative
of employment, this is a great time to become part of

E
our award-winning organization. Our team of more arly studies of hospital at home programs for
than 20,000 consistently votes us among Houstons chronically and acutely ill patients show the potential
Best Places to Work. Find out whyand take your for improved outcomes, higher satisfaction and lower
career to a higher level. costs, but obstacles to wider implementation remain, notes a
recent article in Kaiser Health News.
The model, which delivers hospital-level services to
patients at their home and has been tested in several U.S.
Choose locations and adopted globally, generally includes visits daily
Challenging from locations by physicians and three times daily by nurses. Most programs
throughout
Critical Care Houston:
treat patients with chronic obstructive pulmonary disease,
congestive heart failure, cellulitis or pneumonia; some
Careers Childrens Memorial patients have added conditions such as dehydration, nausea,
Hermann Hospital urinary tract infections, blood clots and blocked pulmonary
Katy arteries, the article adds.
Patients and families tell Kaiser Health News, in Some
Memorial City
Patients Can Choose to Be Hospitalized at Home, that the
Northeast comfort of home outweighs the more immediate availability
CONTACT US Northwest (Inner Loop) of help. Its better in my house because if I need to eat, I
Toll-free Southeast dont have to push a button. I can go to the kitchen, one
1-866-441-4567
Southwest patient says. And here I sleep better because you dont have
email all the people coming and going and I dont feel as nervous.
hotcareers@memorialhermann.org Sugar Land
The downsides include large up-front investment by
or online Texas Medical Center hospitals, pressure to keep beds full and difculty of
jobs.MemorialHermann.org The Woodlands obtaining physician buy-in. Also, traditional fee-for-service
Medicare does not cover it, but private Medicare Advantage
plans can, the article adds.
Hospitals such as Presbyterian Healthcare, Albuquerque,
N.M., appreciate the alternative approach to care for a
growing aging population. We are never going to build
enough bricks and mortar (institutions) to provide care for all
the baby boomers and the elderly who will need it by 2030,
EOE, M/F/D/V. No agencies, please.
executive director Lesley Cryer tells Kaiser Health News.

10 www.aacnboldvoicesonline.org OCTOBER 2012

 AT THE BEDSIDE

From ICU Intervention

to End-of-Life Care
Nurses are key to helping patients and families transition The study illustrates the role of nurses as catalysts that
from intervention to end-of-life (EOL) care in the ICU, accord- can encourage these discussions and facilitate the move from
ing to a study conducted at University Hospital Southampton, a diagnosis of death to the consensus that will best assist
5NITED+INGDOM families and ensure that they are provided with consistent
Challenges in Transition From Intervention to End of Life information, researchers report. Another key nding is the
Care in Intensive Care: A Qualitative Study, in International ability of nurses to factor in variables other than medical
Journal of Nursing Studies, examines EOL care in an ICU from concerns and to look at quality of life for both the patient and
the perspective of the nurses and physicians involved in the family.
patient care management. This study should encourage nurses in these situations to
The study step forward and recognize that their input in this process is
Nurses are more likely used data from critical.
studies in two
to understand the
of the hospitals
inevitable link between ICUs from 2008 AACN Resources for
to 2009 involving
futile care and dying. Palliative and EOL Care
interviews with
26 healthcare providers (13 nurses and 13 physicians) caring The following AACN resources support bedside clinicians
for 17 patients at the end of life. when addressing one of the most frequent sources of
Researcher Maureen A. Coombs, University Hospital moral distress: dealing effectively with patients and family
Southampton, and colleagues identied three stages in the members at the end of a patients life:
EOL trajectory in the ICU: care with hope of recovery, tran-
sition from intervention to EOL care and controlled death. U *>>i>` `vvi
>i]iVi
They identied three common themes that challenge the U *} ViiVi*>>i>` `vvi
>i]
middle-stage transition from intervention to EOL care, namely, e-learning course
establish a diagnosis of dying, manage EOL consensus and
facilitate family grieving. U


*>>i>` `vvi,iVi
The study also identied nurses role in each stage of tran-
sition. Nurses are more likely to understand the inevitable link
between futile care and dying, it notes.

Discrepancies in Identifying
Children With Sepsis
A new study conducted by Northwestern University Feinberg School of Medicine, Chicago, seeks to quantify the
similarities and differences between the measures to diagnose pediatric patients for severe sepsis and septic shock.
Dening Pediatric Sepsis by Different Criteria: Discrepancies in Populations and Implications for Clinical Practice
in Pediatric Critical Care Medicine, nds the research,
administrative and clinical criteria used to diagnose One in three patients clinically
pediatric severe sepsis and septic shock yielded a diagnosed with sepsis wouldnt
similar instance of 5 to 6 percent. But there was only
a moderate level of agreement in patients identied by have been included in studies based
different criteria. on ICD-9 or consensus guidelines.
One-third of patients who had been diagnosed
clinically with sepsis would not have been included in studies based on consensus guidelines or the International
Classication of Diseases (ICD), 9th edition. Researchers note that differences in selection of patients need to be consid-
ered when extrapolating data.
The observational cohort study included 1,729 pediatric patients in a 42-bed pediatric ICU at an academic medical
center. Patients were 18 or younger and screened for sepsis or septic shock with consensus guidelines, diagnosed by
healthcare professionals and matched to the clinical modication codes in the ICD.

AACN BOLD VOICES OCTOBER 2012 11

 AT THE BEDSIDE

Study Suggests Modications in

ABAs Burn-specic Sepsis Criteria

A
study of the American
Burn Associations (ABAs),
Chicago, criteria for the
onset of sepsis that would trigger
consideration of infection treatments
for severely burned patients failed to
nd strong correlations.
The ABAs burn-specic sepsis
criteria, which were developed
because most trauma patients exhibit
symptoms of systemic inammatory
response syndrome even without
infections, suggest that a patient
meeting three of the six variables
should trigger clinicians to try to iden-
tify sepsis and begin administering
antibiotics. Correlation of American
Burn Association Sepsis Criteria With
the Presence of Bacteremia in Burned
Patients Admitted to the Intensive
Patients who meet
Perhaps, the ABA sepsis criteria need
three of six variables
should trigger the
identication and
treatment of sepsis.
were drawn within 1 day of admis-
Care Unit, in Journal of Burn Care &
Research, reviewed electronic records
from burn patients at the U.S. Army
Research Institute from 2006-2007
to look for correlations between the
ABAs trigger and the presence of
bacteremia.
The study says that of the ABA vari-
ables, only temperature and heart rate
had statistically signicant correlation.
Nonetheless, maximum insulin drip
rate, abdominal distension, and stool
volume were found to be signicant.
to be modied slightly.
Researchers reviewed 282 blood
cultures from 196 patients, and they
expressed concern that a signicantly
greater number of negative cultures
sion compared with positive cultures,
which were drawn at a median time of
4 days.
The studys other potential liabili-
ties include a small sample size, lack
of clear guidance on ventilator modes,
the role of antibiotics, the possi-
bility of false positive cultures due
to catheter contamination, a limited
focus on bacteremia and difculty in
distinguishing true infection from colo-
nization in cultures besides blood.

Make your move.

LOVE YOUR
CAREER
Excellent Critical Care Opportunities
Clinical challenge, compassionate care and a heightened spirit of teamwork are the essence of being a critical care
nurse at HCA North Texas. Work shoulder to shoulder with people who know that excellence takes a partnership
among all members of the team. And with a wide array of adult and pediatric critical care settings, your growth
potential is unlimited.
For information on current Critical Care opportunities with HCA North Texas, please visit our website below, and enter
job number: 231040.

www.joinhcanorthtexas.jobs
EOE

12 www.aacnboldvoicesonline.org OCTOBER 2012

 AT THE BEDSIDE

ABCDE Bundle: Collaboration to Improve

Outcomes for Ventilated Patients
We implemented the ABCDE bundle May 1, 2011, and
our rst set of outcomes reect 6 months of bundle data, she
explains. The 2011 case-mix index was the same as it was
[for] 2010. Improved outcomes included a 32% drop in venti-
lator days, the death rate decreased 10%, and the average
length of stay for the ICU went from 2.55 days to 2.31 days.
There were no ventilator-associated pneumonias.

Coordinated effort
reduces oversedation,
immobility and
development of delirium.

ABCDE Bundle Tools

From AACN
Access AACN resources that support excellence at the
bedside:

T he ABCDE bundle, an innovative protocol initiated

nationwide last year, has improved the health of patients
who are ventilated, it was reported during a presentation
U


*
,i
U
V>
>i i,iii}i


Bundle Into Practice, CE article in Critical Care Nurse,
at AACNs 2012 National Teaching Institute & Critical Care
April 2012
Exposition in Orlando, Fla.
The bundle is a coordinated interdisciplinary effort to U i
ii>`>>}ii]



manage the care of critically ill patients by reducing overse- Practice Alert
dation, immobility and the development of delirium. The
protocols ve steps:
s !WAKENINGTRIALSFORVENTILATEDPATIENTS
s 3PONTANEOUSBREATHINGTRIALS
s 2. RESPIRATORYTHERAPISTCOORDINATIONTOPERFORMTHE
spontaneous breathing trial by reducing or stopping
sedation to awaken the patient
s !STANDARDIZEDDELIRIUMASSESSMENTPROGRAMINCLUDING
treatment and prevention options
s %ARLYMOBILIZATIONANDAMBULATIONOFCRITICALLYILL
patients
This dened and coordinated intervention bundle
helps RNs, physicians, respiratory therapists and physical
therapists to collaborate toward improving outcomes by
reducing ICU-related complications, Chandra Alexander, a
charge nurse and assistant manager of the ICU at McKenzie
Willamette Medical Center in Springeld, Ore., tells
medscape.com in ABCDE Bundle: Improving Outcomes for
Ventilated Patients.

AACN BOLD VOICES OCTOBER 2012 13

 AT THE BEDSIDE

Preventable, Treatable Infections

Cause One in Six Cancers
Low-cost vaccinations for preventable or treatable infections such as human papilloma virus (HPV) and hepatitis
could dramatically reduce cancer rates, particularly in the developing world, according to an international study.
Global Burden of Cancers Attributable to Infections in 2008: A Review and Synthetic Analysis, published online
May 9 in The Lancet Oncology, says one in six cancers worldwide about 2 million per year, with 80 percent of those
in the developing world can be attributed to preventable or treatable infections. Most (1.9 million) involved HPV,
hepatitis B and C, and Helicobacter pylori.
The percentage attributable to infections was
HPV, hepatitis B and C, and Helicobacter 22.9 in less-developed countries, compared to
pylori accounted for most of the infections. 7.4 percent in more-developed countries, with
rates of 32.7 percent in sub-Saharan Africa but
just 4 percent in North America. Uterine cervical cancer was the most common type among women, with about half of
the infection-related cancers, and liver and gastric cancers accounted for more than 80 percent of those in men.
The study says application of existing public health methods for infection prevention, such as vaccination, safer
injection practice, or antimicrobial treatments, could have a substantial effect on the future burden of cancer world-
wide. A related editorial emphasizes the potential for preventive and therapeutic programmes in less developed
countries to signicantly reduce the global burden of cancer and the vast disparities across regions and countries.
Lyon, Frances International Agency for Research on Cancer studied 27 cancers from 184 countries in 2008 and
found that deaths from infection-related cancers climbed by 500,000 between 1990 and 2008. Of 7.5 million global
cancer deaths in 2008, the agency traced 1.5 million to these potentially preventable or treatable infections, according
to a related article in The Daily Brieng.

1 RUWKHUQ$UL]RQD+HDOWKFDUHVWZRPDLQFDPSXVHV)ODJVWDII0HGLFDO
&HQWHUDQG9HUGH9DOOH\0HGLFDO&HQWHUZHUHUHFHQWO\UDQNHGDV%HVW
5HJLRQDO+RVSLWDOVE\861HZVDQG:RUOG5HSRUW2XU+HDUWDQG9DVFXODU
&HQWHUVWURNHDQGFDUGLDFDUUHVWFHQWHUVDQGDYDULHW\RILQDQGRXWSDWLHQW
VHUYLFHVSURYLGHRXUQXUVLQJVWDIIZLWKFKDOOHQJLQJDQGVWLPXODWLQJOHDUQLQJ
RSSRUWXQLWLHV

: HDUHFXUUHQWO\VHHNLQJ51VIRU
 &ULWLFDO&DUHa)ODJVWDII0HGLFDO&HQWHU
 &9,&8a)ODJVWDII0HGLFDO&HQWHU
 7HOHPHWU\,&8a9HUGH9DOOH\0HGLFDO&HQWHU

, QDGGLWLRQWRZRUOGFODVVFDUHZHVWULYHWRSURPRWHDVWURQJZRUNOLIHEDODQFH
IRURXUHPSOR\HHV&ROOHDJXHVKDYHDFFHVVWRDYDULHW\RIFRQWLQXLQJHGXFDWLRQ
RSSRUWXQLWLHVDQH[WHQVLYHZHOOQHVVSURJUDPDQGDQ(PSOR\HH$VVLVWDQFH
3URJUDP$ZD\IURPZRUNWKH\HQMR\WKHIRXUVHDVRQFOLPDWHEUHDWKWDNLQJ
VFHQHU\ZDUPIULHQGO\FRPPXQLWLHVDQGUHFUHDWLRQDOSOHDVXUHVWKDWPDNH
1RUWKHUQ$UL]RQDDZRQGHUIXOSODFHWROLYHZRUNDQGSOD\

) RULQIRUPDWLRQDERXWRXUIDQWDVWLFFDUHHURSSRUWXQLWLHVJHQHURXVEHQHW
SDFNDJHVIDFLOLWLHVVHUYLFHVDQGWRDSSO\YLVLWZZZQDKHDOWKFRPFDUHHUV

)LQGXVRQ

14 www.aacnboldvoicesonline.org OCTOBER 2012


ICU Diaries May
Reduce PTSD
Effect for
Families, Patients
A pilot study indicates that family members of
intensive-care patients who use an ICU diary might
experience a reduction in post-traumatic stress symp-
toms, as might the patients.
Intensive Care Diaries and Relatives Symptoms of
Posttraumatic Stress Disorder After Critical Illness: A
Pilot Study, in American Journal of Critical Care, focuses
on the link between the experiences of patients and
families, and seeks ways to reduce post-traumatic stress
symptoms for all parties. Providing patients with
diaries is a simple and practical intervention, the study
concludes.
Use of ICU diaries may be
better than therapy focused
only on patients.
For the study, researchers in the United Kingdom
and Sweden recruited 36 close relatives of patients who
spent at least 72 hours in the ICU with a minimum
of 24 hours of mechanical ventilation. Five family
members and the spouse of a patient who died with-
drew before the three-month follow-up. The nal
group of 30 family members (17 spouses, eight chil-
dren, three parents and two siblings) was split into 15
for control (no diary) and 15 for intervention (diary).
Researchers used the Post-Traumatic Stress
Syndrome-14 tool one month after discharge and again
after three months. The median score for the control
group increased from 26 to 28, while the intervention
groups median dropped from 24 to 19.
Explanations for the effect, the study indicates,
could include reducing the need for patients to rely
on family to ll in memory gaps from hospitaliza-
tion, providing a structure or narrative of the ICU
stay or giving all parties an opportunity to express
their feelings. The shared diary may be better than a
therapy that is focused only on the patient, the study
concludes.
AT THE BEDSIDE
Most Medicaid
Patients Visit ED for
Legitimate Acute
Problems
M
edicaid abuse is often cited as a major cause for
hospital overcrowding and budget shortfalls, but
a new study by the Center for Studying Health
System Change, Washington, D.C., nds that the majority of
Medicaid patients visit the emergency department (ED) for
legitimately acute medical problems.
Study highlights
barriers to
care among
adult Medicaid
recipients.
Dispelling Myths About Emergency Department Use:
Majority of Medicaid Visits Are for Urgent or More Serious
Symptoms, a research brief published by the center, nds
nonelderly Medicaid patients had nearly twice as much
ED use at 45.8 visits per 100 enrollees vs. 24 visits per 100
enrollees for the privately insured. But most of the visits were
for urgent and semi-urgent symptoms that required imme-
diate care.
The ndings highlight the disparity in general health
between the privately insured and Medicaid recipients,
who often face barriers to primary and specialty care that
likely contribute to higher ED use, the study notes. Medicaid
adults have higher ED use across all medical conditions and
age groups, greater severity of illness, higher rates of severe
disability and a greater likelihood of a secondary diagnosis of
mental disorder.
The study used gures from the National Hospital
Ambulatory Medical Care Survey, a federal database that
records visits to the ED at general and short-stay hospitals in
the United States excluding federal, military and Veterans
Administration hospitals. Researchers analyzed 34,134 cases
from 2008 the most recent gures available repre-
senting approximately 123.7 million total ED visits.
AACN BOLD VOICES OCTOBER 2012 15
 AT THE BEDSIDE

In Our Acquired long QT syndrome is

a reversible condition that can lead
and lower respiratory infections such as pneu-
monia (see page 8 of this issue). (Kozik et al,

Journals to torsades de pointes and sudden cardiac

Hot topics from
this months
AACN journal
How is the persisting drug
shortage affecting critical
care nurses? Critical Care Nurse
readers in 34 states report 92 percent
experienced shortages from Aug. 1, 2011
through Jan. 31, 2012. Of 58 different drugs
mentioned, they included narcotic anal-
gesics, benzodiazepines, diuretics and
antiemetics. Reported effects on patients
included suboptimal to unsatisfactory
responses to substituted drugs, delays in
treatment or care and additional clinical
problems. (Editorial, CCN, Oct 2012)
death. A retrospective
CCN, Oct 2012)
Critical care providers have
review of ICU patient frequent access to conden-
charts determined tial information in the course of
the frequency of the clinical practice. A dilemma can arise
syndrome, onset, when a patients family members or friends
frequency of medica- request condential information. Because
tions, and risk factors of confusion and misinformation about
for the syndrome, HIPAA, the Health Insurance Portability and
which occurred Accountability Act, nurses often wonder
in more than half how to respond to questions regarding a
(52 percent) of the patients condition, explaining diagnoses
patients. Among the and procedures to patients in areas where
patients, 59 percent conversations may be overheard, and
received a known QTc-prolonging medica- disposing of medications and intravenous infu-
tion. The antiemetic ondansetron (Zofran) was sion bags in an appropriate, condential manner.
the most frequently prescribed medication. A The Privacy Rule allows some latitude in profes-
signicant association was identied between sional judgment, but reasonable safeguards must
acquired long QT syndrome and azithromycin be employed for personal health information.
(Zithromax), frequently used to treat upper (McGowan, CCN, Oct 2012)

facebook.com/ccnface twitter.com/ccnme www.ccnonline.org

Seizure Risk for Patients Treated With Cefepime

Patients with kidney impairment require adjusted dosage of the antibacterial drug cefepime because of the risk of
seizures, warns the U.S. Food and Drug Administration (FDA), Silver Spring, Md., in a Drug Safety Communication.
Cefepime, used to treat a variety of infections and pneumonia, will carry a revised set of warnings because of
the 59 cases of nonconvulsive status epilepticus whose symptoms can include altered mental status, confusion
and decreased responsiveness since its approval in 1996 through February 2012. To minimize the risk, the FDA
suggests clinicians adjust the
All but one case of nonconvulsive status epilepticus dose of cefepime in patients with
involved patients with kidney impairment. creatinine clearance of 60 mL/
min or less.
Of those 59 patients, 58 had renal dysfunction, and 56 did not receive appropriate adjustment of cefepime
dosage as recommended. The seizures were reversible for 43 patients after discontinuing cefepime and/or receiving
hemodialysis.
The FDA notes that patients were at least 65 years old in 56 percent of the cases, and 69 percent were women.
There were 16 fatalities, with 13 of them attributed to an intercurrent illness.

I Am a Critical Care Nurse

Amazing. Thats how Stacey Little`iVLiii>>iU
i`V>

1>vvi>>i
Vi`V>
ii] }]>]i>Lii>
>>i`L>ii>`V>}iiiiV`vi]>Li
V>L>ii>>iiL`>}}i`iUi
tries to put herself in a family members shoes and helps them be at the bedside as
V>LiU"i"VLiCritical Care Nurse from the back to read about
how her desire to become a physician led to nursing as a way to care for patients in
a much more preferable way.

16 www.aacnboldvoicesonline.org OCTOBER 2012

 AT THE BEDSIDE

More Children Swallowing

or Inserting Batteries
Emergency department (ED) visits resulting from children swallowing batteries doubled between 1990 and
2009, according to research conducted at Nationwide Childrens Hospital, Columbus, Ohio.
Pediatric Battery-Related Emergency Department Visits in the United States, 1990-2009, published in
Pediatrics, notes an estimated 5,525 such ED visits occurred in 2009, with most visits by children younger than 5.
Most were caused by small, disc-like button batteries.
Gary A. Smith, director of the hospi-
Button batteries caused the most ED visits for tals Center for Injury Research and
ear insertion by older kids and adolescents; Policy, and colleagues studied data
from the U.S. Consumer Product Safety
nose insertion by younger ones. Commission. They identied battery-
related ED visits among children younger than 18 and reported that the annual number of visits increased from
2,591 in 1990 to 5,525 in 2009.
The team found that 84% of all swallowed batteries were button-type with 29% coming from toys, 16%
from hearing aids, 14% from watches and 12% from calculators. Among children who suffered chemical burns to
the mouth, in contrast, cylindrical batteries were responsible for more than 90% of cases, notes a related article in
the May 14 Los Angeles Times.
The bulk of insertions into the nose and the ear involved button batteries; most insertions into
the ear involved adolescents and children who were more than 5 years old, while
insertions into the nose were most likely for children younger than 5, the article adds.
The researchers recommend keeping loose batteries safely hidden from children
and securely taping the battery compartment of toys and other devices. They also
suggest manufacturers use childproof battery covers or keep covers in place with screws.

Hypertonic Saline Inhalation Shortens

ED Stays, Lowers Admission Rates for Kids
Using hypertonic saline inhala-
tions to treat acute wheezing in
preschool children signicantly
shortens emergency department
(ED) stays and lowers hospital
admission rates, nds a study in
Pediatrics.
In Hypertonic Saline and Acute
Wheezing in Preschool Children, 41
children, ages 1 to 6, were random-
ized after one albuterol inhalation
to receive either 4 mL of hypertonic
saline or 4 mL of normal saline twice
mixed with their albuterol treatment
every 20 minutes in the ED and four
times a day if hospitalized. Children
in the hypertonic saline group had
a signicantly shorter length of stay
(median two days vs. three days)
and lower admission rate (62 percent
vs. 92 percent) compared to those in
the normal saline group, the study
shows.
Researchers from Tel Aviv
Universitys Sackler School of
Medicine in Israel, point out most
acute wheezing episodes in
preschool children are associated
with rhinovirus, causing airway
surface dehydration, inammation
and failure to clear mucus. Because
these children dont respond well to
available treatments, including oral
steroids, pro-mucus clearance and
prohydration treatments are called
for, they add.
Hypertonic saline inhalation, a
pro-airway surface liquid hydration
therapy, signicantly decreases
both length of stay by 33% (1 day)
and the absolute risk of hospitaliza-
tion by 30% in preschool children
presenting with acute wheezing
episode to the emergency depart-
ment, researchers note in a July
3 MedConnect summary. These
results could have an important
clinical impact on the way we
treat many wheezing preschool
children.

AACN BOLD VOICES OCTOBER 2012 17

 AT THE BEDSIDE

Mount Everest Studies Expand Clinical

Knowledge About Hypoxia

A
trip to the summit of Mount Everest has helped
experts understand the effects of low oxygen Testing for low blood oxygen
levels on the body at altitude and how to on Everest.
improve care of patients in the ICU who have difculty
breathing.
An article in the Camden New Journal, London, notes
more than 250 experts were tested as they made the

Findings may improve treatment

for hypoxic conditions such as cystic
brosis, ARDS and emphysema.
18,000-foot trek called the Caudwell Xtreme Everest
expedition in May 2007, to see how they would cope
with hypoxia. Eight of them reached the summit.
Some people can walk to the summit without Photo: Reuters/Handout/Caudwell Xtreme Everest Expedition.
needing to adapt. For others it takes much longer. If we
can understand our rate of adaptation we can establish the best way to treat them [patients] in intensive care,
Monty Mythen, professor, University College London Hospitals, says in the article.
Since the trek and subsequent data analysis, the ndings have been presented around the world and in many
journals. Among the ndings, it was discovered that the summit of Everest is the limit of human tolerance for
hypoxia.
Mike Grocott, professor, University of Southampton, and leader of the 2007 study, says in the article, We are
very excited to be starting studies in patients to evaluate some of the treatments and tests that have been developed
out of the 2007 expedition. The article notes that it is hoped the research will lead to improved treatments for
conditions such as cystic brosis, acute respiratory distress syndrome, emphysema, septic shock and blue babies.

New Jersey Hospitals Adapt

to Handle Large Patients
Obesity causes hospitals to invest millions of dollars in equipment to accommodate large patients and training to
prevent lifting and moving injuries among nurses, a New Jersey newspaper reports.
In New Jersey, where one in four adults is obese, hospitals are adding rooms with wider doors, special beds and ceil-
ing lifts that hold more than 1,000 pounds, states N.J. Hospitals Adapting to Larger Patients, in The Record, Hackensack,
N.J. In a national survey, hospitals indicated they spent up to $1.5 million
last year on equipment and other needs of obese patients, according
Hospitals invest millions in
to Novation, a national healthcare supply company in Irving, Texas, the equipment and training to
article adds.
Not only here, but across the country, youre always looking to
care for large patients.
accommodate larger, bigger and heavier because its what were seeing, Madelyn Pearson, senior vice president for
patient-care services at Englewood Hospital and Medical Center, N.J., says in the article.
At Englewood, large patients can be transported from bed to chair or bathroom with a ceiling lift. A staff training
program has helped reduce lifting and moving injuries 40 percent, Pearson adds.
Crystal Disant, a nine-year ICU nurse at Englewood, says nurses no longer fear injury when moving heavier patients.
We used to just rely on each other to help turn them, she says in the article, adding, Its a huge fear you have of getting
hurt.
How does your hospital move large patients and help prevent team member injuries? Tell us at aacnboldvoices@aacn.
org, click on the blue auto-reply button in the digital edition or post a wall comment at facebook.com/aacnface.

18 www.aacnboldvoicesonline.org OCTOBER 2012

 CERTIFICATION

Certication Capsules

Three New Certication Testing Sites Available

Applied Measurement Professionals, Inc. (AMP), AACNs testing vendor, has opened three new computer-based testing loca-
p>>]
]>]"]>` i`]"i]V>i>>>Livi>V>``>iU>ii>
*
open sites in Tampa Bay, Fla., Brewer, Maine, and Lake Success, N.Y.

Self-Assessment Exams for CCRN-Adult and PCCN Now Available

1i>iv>iii>`vViwV>]Viiii>i`]>`ViwV>ii>U-Vi>i>
iVi>`>vv
>i}

,*px
,*v

, -
>`v*

U-
ii>iL>i`
Vii>>`ii>ii>iViL>i`i>U >Viip

, i>`{xv*

pV`ii>>i>`>ViV>iU/`i>-
]>>V}
iwV>*i>i/>i9
Exam > Self-Assessment Exams.

New CMC and CSC Print Practice Exams Now Available

*>VVi

>+i]
``Vxx>`*>VVi
-
>+i]
`x>i>>>Li
v


i iU/iLi>i`i>iviV>`>Vi`Vi

>`V>`>V}i

-
LiV>i>U/ifniLiVifv>iV`iii>]x>VVii]ViV>i
>`>`LL}>U+iiiiiv>>`ivii`i>Vi>Uii]iV>
be used to accurately predict or guarantee exam performance, because they are not psychometrically valid.

(LETTERS from page 21)
outcomes with the best possible trip which may not
always be a pleasant one.
Terry Cahill
Union, Ky.
I am impressed with Theresa Browns insight about the
requirement for patient satisfaction ratings. I believe
consumers need to be educated about the things the
healthcare team should be doing that make a dramatic
impact on someones life, because saying the right phrases
each time one enters a room doesnt translate into
competency and good outcomes. Has anyone developed
an evaluation tool that asks about actions that impact
outcomes? Possible questions could include: Did everyone
who cared for you wash their hands every time they came
into your room? Were you offered help when you couldnt
do your own hygiene? Were you encouraged to walk
every shift? Did you wear special devices to prevent blood
clots? Were you turned frequently if you were unable
to talk? Not only would this help patients and families
evaluate care, it would give them insight about expected
standards of care.
Bonnie J. Carlin
Gainesville, Fla.
I totally agree with Theresa Brown. I believe in quality
care that can be conrmed by data from NDNQI and
other sources, not by opinions. Surveys dont ask how
a patient is feeling or their perspective about how the
procedure, surgery or reason for admission went. Instead,
surveys ask about the room and the food, and dont nd
out anything thats not already known or can be found
in other hospital data. Those who determine healthcare
reimbursement promote the expectation that hospitals
should be hotels and staff should treat patients as if they
were on vacation. Hospitals arent a vacation destination.
Gerri Ann Danilowicz
Bloomsburg, Pa.
Theresa Brown nails it about the ridiculous requirement
of hospitals being graded for patient satisfaction. Hospitals
are not pleasure palaces. They are where illnesses are
treated, which often goes hand-in-hand with pain and
unpleasant memories. I agree with Brown that outcomes
should drive the grading system. Outcomes count, not
perceptions. A person may have received excellent care,
recuperated well, yet their perception is one of dislike
for the hospital. And it is the perception that determines
Medicare reimbursement. Who devised this clever idea?
Susan M. Dirkes
Newport, Mich., Naples, Fla.

AACN Bold Voices encourages your letters for possible print and/or online publication. Please be concise. Letters may be edited before
publication. Include your name, credentials city, state and email address (for verication). Write to aacnboldvoices@aacn.org.

AACN BOLD VOICES OCTOBER 2012 19

 AACN

AACN to Award Nurse in Washington

Internship Scholarships for Fourth Year
The Nurse in Washington
Internship (NIWI) program spon-
sored by the Nursing Organizations
Alliance, a coalition to create a strong
voice for nurses teaches nurses
how to inuence health policy at the
local and national levels.
AACN will award scholarships
for the fourth consecutive year to
support members attending the 2013
program, March 24-26 in Washington,
D.C.
Participants visit members of
Congress and acquire the skills to
work with legislators to advance
policies and agendas. Additional
objectives include learning key steps
to bring about change in the legisla-
tive process and how to schedule
meetings on Capitol Hill. Attendees
health policy locally
also network with nurses from across
the country who share their interest in
health policy advocacy.
To apply for an AACN scholar-
ship, assess gaps in your health
policy knowledge and skills, identify
what you want to learn and explain
how you will evaluate your learn-
ing. Your application must indicate
how attending NIWI will further your
professional development.
The deadline to apply for an
AACN scholarship is Monday, Oct.
15. Please note that you must register
separately for NIWI at www.nursing-
alliance.org but are not required to
do so before applying to AACN.
AACN Continuing Professional
Development Scholarships support
NIWI and other programs that help
How to inuence members enrich their career and
acquire knowledge and skills beyond
traditional academic nursing. Visit
and nationally. www.aacn.org/niwi for more informa-
tion, or email scholarships@aacn.org
with questions.

Keep It Simple: Nursing News Direct to You

RSS (Really Simple Syndication) feeds conveniently enable you to track large amounts of online
information by gathering pertinent news and updates in one place. RSS feeds save time and effort.
They eliminate the need for manual Web searches to nd content you care about.
Many websites offer RSS feeds, and the required RSS readers are free and simple to use on both
desktop computers and mobile devices.
AACN offers several RSS feeds to automatically deliver important critical care and high-acuity nursing
information directly to you. The feeds keep you up-to-date with news about AACN, the healthcare industry,
evidence-based practices and clinical resources. Our feeds include an overall AACN RSS feed, plus multiple feeds
for two of our peer-reviewed journals, American Journal of Critical Care and Critical Care Nurse.
If youre unfamiliar with RSS feeds and the associated technology, AACNs website provides educational
information including a short video, a
print article and tools to get you up and Q: How do high acuity and critical care nurses some
running quickly. of the busiest clinicians in an extremely demanding
To learn more and subscribe, visit profession keep up with their preferred professional
AACNs RSS feeds landing page at www. organization and the latest nursing knowledge and
aacn.org/rss and watch for additional RSS
practices that ensure optimal patient outcomes?
content enhancements in the coming
months.
A: Subscribe to AACN RSS feeds.

20 www.aacnboldvoicesonline.org OCTOBER 2012


STANDING UP FOR NURSES
WHO TAKE A STAND
ND
Our professional
organizations
need to stand up
for bedside nurses
who take a stand
to protect their
patients and exercise
their legal right to
refuse unsafe nursingg
assignments. To paraphrase the theories of Martha
Rogers, each of us is an exaggerated sum of our parts, and
each time we react to our environment we contribute
to creating ourselves as unique individuals. Reaction
is what separates us from one another and exagger-
ates us into unique individuals. Does this not require
nurses to empower patients so they recognize that their
outcomes greatly depend on how they react to their lives
and their health? In turn, does this not require hospitals
to staff appropriately so nursing practice becomes less
fragmented and more focused? Patient and family educa-
tion rarely gets addressed because nurses cant get beyond
maintenance of essential care, often leaving our shift
thankful that we didnt kill anyone. Maintenance will
never shorten length of stay or improve outcomes. Bare-
bones stafng levels sacrice outcomes and create moral
distress. They shrink prot margins and create an envi-
ronment where mistakes are more likely.
Debra Ball-Mills
Indianapolis
NURSE OBESITY
Re: Page 12 in August AACN Bold Voices
Nearly 45 percent of nurses work the night shift, cut off
from sleep, healthy food, interaction with many health
team members and a general sense of community. There
always seems to be plenty of candy, soda, pizza and left-
over doughnuts at night, but no salad, vegetables and
fruit. When sugary, caffeinated, salty food is all thats
available, thats what our staff eats. There are usually
vending machines with non-healthy choices, but the
healthy choice cafeteria if there is one is closed.
What about opportunities for exercise? Treadmills near
the units would allow exercise and reduce stress. Several
medical centers have tried to address these needs, but
they are few. I appreciate that AACN Bold Voices has
brought up this issue.
S.J. Sparling
Philadelphia
Nurses, like other people, can choose to lead a healthier
lifestyle. Look around. Many patients require our care,
LETTERS
because they did not take care of their own health. Do we
want to be like them? I know I dont, so I choose to exer-
cise and pack food for my day because my hospital offers
very unhealthy food to both staff and patients. (Its also a
highly regarded cardiac hospital that still allows smoking
on hospital grounds.) I choose a 12-hour shift because it
allows me to work three days a week, and working in the
operating room keeps me physically active. Those who
work at night should be offered a time to nap and healthy
food options. If only vending machines are available, why
not stock them with fruits, nuts, low-fat cheese and water?
Wellness programs need to provide information about
change that truly helps nurses see that well soon become
patients if we dont take care of our health.
Amy Fiebke
QUALITY OF SLEEP IN ICU
Re: Page 14 in August AACN Bold Voices
I have seen several things improve quality of sleep for ICU
patients who are not mechanically ventilated or chemi-
cally sedated. Our unit stocks eye masks and earplugs.
The volume of all our pumps, monitors and other noise-
making devices can be lowered. We darken the room and
close the door when a patients condition allows, leaving
a glass window open to view their status. To avoid awak-
ening patients during the night, we cluster care when
possible. Finally, we try to avoid conversation outside
patients rooms. Together, these create an environment
for healthy, normal sleep patterns. But our system isnt
foolproof. So I look forward to reading more research and
suggestions to promote full sleep cycles for ICU patients.
Nicole Brynes
Rochester, Minn.
Loved the article on hospital noise. When did this culture
shift occur? And how? Its going to be hard to change.
Bonnie McCarty
Metairie, La.
PATIENT SATISFACTION
Re: Page 8 in August AACN Bold Voices
I am tired of hospitals being run by business people who
try to turn them into hotels. Therefore, Medicare jumping
in also with patient satisfaction goals affecting reimburse-
ment really angers me. Hospitals are not intended to be
fun. If they were there would be no room at the inn. Being
nice to someone and making the experience as pleasant as
possible is one thing. But satisfaction cannot be a goal for
reimbursement when patients are much sicker, because
criteria for inpatient care have become stiffer. My goal is
for a patient to make it to the front door. That means good
(Letters continued on page 19)
AACN BOLD VOICES OCTOBER 2012 21
 FROM THE PRESIDENT

Kathryn Roberts

W ere you caught up in the excitement of this years Olympic Games?

Perhaps you were among the millions who watched on TV, at your desk or
on a mobile device. Maybe you were lucky enough to be in London and see
them in person. Heres what captured my attention.
More than 10,000 athletes enthusiastically participated knowing they
werent likely to go home with even one of nearly 1,000 individual medals
awarded. Yet each of them dared to compete.
For most, it wasnt to win a medal, but to be embody the motto of the
games Citius, Altius, Fortius swifter, higher, stronger. Each one had the
courage to strive for excellence. Not necessarily against others, but against
their personal best. Because, as the
Dare to Compete Olympic Creed says, the most impor-
tant thing in the Olympic Games is not
to win but to take part the most important thing in life is not the triumph but the struggle.
The important General Colin Powells explanation of why we all must compete rings true. He says its not
just to show were better than another person or group. It is to test ourselves, prove ourselves
thing in life is not ... to show that we have trained and raised our skills as high as we can. ... This is how we
to triumph but to perfect our skills and capabilities.
We have much to learn from these daring Olympians about honing our own skills and abil-
compete. ities. They set clear goals for themselves. They develop a plan to achieve those goals. And they
Olympic Creed know how theyll measure success.
Many athletes competing in the Olympics face seemingly insurmountable challenges on
their journey. Challenges magnied a hundredfold in the Paralympics which immediately
followed and, sadly, received much less fanfare in the United States.
Somehow, Olympic athletes nd strength within to continue competition. They may hope
to beat another individual or team, but for many thats secondary. The primary goal: to achieve
a personal best.
Like it or not, healthcare today requires as individuals and teams the daring to
compete and challenge ourselves to be swifter, higher and stronger. Sometimes priorities
become misaligned to focus on rankings and being better than the other guys that could be
a unit, a hospital or health system, or even another profession instead of honing our own
knowledge, skills and abilities. But thats what our patients and their families need from us.
Daring to compete puts us in a perfect position to realign those priorities. It focuses our
individual and team goals by requiring us to answer questions such as: What is our end goal?
What will reaching it require? Where are we falling short of our personal (or team) best? How
will we know we reached our goal?
Sometimes I struggle to answer these questions. Thats a signal to step back, get input from
mentors and colleagues just like athletes do from their coaches and fellow players in
order to gain the clarity I need to develop a practical plan with measurable outcomes. What
about you?
Where have you dared to compete? Where have you yet to? Your stories inspire our
colleagues across the country. And they inspire me personally. Would you share them on my
Facebook page facebook.com/aacnkathrynroberts or by email at dareto@aacn.org?

22 www.aacnboldvoicesonline.org OCTOBER 2012

Become a Certied Nurse
Manager and Leader
Be among the rst nurse managers in the nation to earn the new CNML
credentialthe only certication developed specically for nurse managers.
Developed by the certifying organizations of two associations who have For additional information,
been at the forefront of nurse manager leadership development the a candidate handbook, and to
American Organization of Nurse Executives (AONE) and the American apply online, visit the AONE
Association of Critical-Care Nurses (AACN). Based on a comprehensive Credentialing Center website
study of national practice, the Nurse Manager Learning Domain at www.aone.org/CNML

Framework and the Nurse Manager Skills Inventory , the CNML or call 312-422-2807.
examination includes four major content areas:

 Financial management
 Human resources management
 Performance improvement
 Strategic management and technology

AACN BOLD VOICES OCTOBER 2012 23

 Las Vegas 1EVQDGT

2TGEQPHGTGPEGU1EVQDGT
+HPRG\QDPLF0RQLWRULQJ
3URJUHVVLYH&DUH3KDUPDFRORJ\
/CKP%QPHGTGPEG1EVQDGT
$$&13URJUHVVLYH&DUH3DWKZD\V

Earn up to 25.25 hours

Register Today!
YYY%QPVGORQTCT[(QTWOUEQO

,QFROODERUDWLRQZLWK