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Reflections of Nurse Educator

Chinazo Echezona-Johnson, Ed.D, LL.B, MSN, RNC-MNN Assistant Director of Maternal-Child Educator, Health and Hospital Corporation, Metropolitan Hospital Center

CHINAZO.ECHEZONA-JOHNSON@NYCHHC.ORG

Teaching is an art. Some people are born teachers while others acquire the skill. To be a great teacher, one has to have a sense of humor and be very flexible. Teachers will never teach to gain monetary reward. However, they will teach to achieve the best reward - satisfaction that they have an impact on the education of the leaders of the world, the training of CEOs, and the success of new breed of professionals. Teaching is a noble profession. Cont'd

Prescriptive Authority for Nurse Practitioners

Lacy Kusy

lazer31285@aol.com

The physician shortage in primary care, plus the growth of nurse practitioners and increasing need for access to health care, creates a necessity for more autonomous nurse practitioners. However, current restrictions on nurse practitioners, particularly prescription regulations for controlled substances, limit what practitioners can do for patients. These restrictions also increase wait times for patients and have the potential to increase liability claims as physicians prescribe medications for patients they have not adequately evaluated. Nurse practitioners have proven to be a safe, quality, and cost saving approach to primary care. To meet the growing needs for patients, nurse practitioners must have the ability to prescribe controlled substances in all 50 states. Cont'd

Family Presence during a Code Blue

Lacy Kusy

lazer31285@aol.com

I have been a nurse in the Cardiac Intensive Care Unit for over five years now, and have participated in many code blues. Some of these situations are appropriate for family to attend and some are not. Each situation is assessed individually to determine the appropriateness of family presence. I had been caring for a young lady, Ms. R.V., who was an 18 year old that had received a heart transplant for a congenital heart defect when she was 13 years old. She was admitted to TGH to be placed on the heart transplant list again, as her transplanted heart had been failing for months. Due to the failing heart, other organs began to also fail. R.V. had gone into heart and kidney failure and required continuous renal replacement therapy (CRRT) for continuous dialysis treatment since her blood pressure was continuously low. I had cared for R.V. for three days so far and had gotten to know her and her mother very well. R.V. and her mother were extremely close. Her mother brought her in dinner as often as she could and visited on her days off. Because her daughter had been in the hospital for so long, the patient’s mother had to return to work. She would work during the day and visit in the evening. This particular day, R.V. was stating how excited she was to see her mom that evening, and her mom was going to bring her a salad from Panera Bread. I could sense her excitement in her voice and facial expressions, although she had very little energy to spare. Around shift change, my patient began to feel “different”, and state that “something isn’t right”. I immediately took her vital signs, laid her back down in bed, and called her doctors. I also called her mother to see how close she was to the hospital. Not long after R.V. stated she felt “different”, her oxygen saturations plummeted, she turned blue, stopped breathing, and a code blue was called. With many doctors and nurses at the bedside, CPR was performed for at least 15 minutes before R.V.’s mom arrived. She was very distressed and anxious to see her daughter. One of the doctors felt that she should not be around to witness the CPR on her daughter. I, on the other hand, stated that R.V. and her mom are very close and that she should be allowed to stand in the back to be with her daughter, an 18 year old child. This particular doctor was one that strictly attends code blue situations and had no previous relationship with this patient or her mother. I calmly expressed that in this situation, the mother of R.V. should be at the bedside of her daughter if she wants to because her daughter looked as though she would not survive the code situation. R.V.’s mother was not in the way, and she stood at the head of her daughter and whispered into her ear. Once R.V.’s primary doctors arrived, they agreed that the mother should stay in the room if she wanted to be with her daughter. R.V. did not survive the code. Her mom, however, was able to be with her daughter as she passed and held her hand as she took her last breath. As heartbreaking as this scenario was, the patient’s mother thanked me for allowing her the privilege of being with her daughter as she finally got peace and can “rest now”. Although not all code blue situations are deemed appropriate for family presence, the nurse and care providers should assess each family and patient separately to determine what is best for the patient and the family. Cont'd

"Phase 1; Exploration of paramedic protocol for field IV insertion" and "Field IVs: To Replace or Not"

Caitlin Wright, En-Dien Liao, and Dr. Deborah Behan

en-dien.liao@mavs.uta.edu

This is a two-phase study. We are willing to have either two different phases for you to publish, or combine our two studies into one manuscript for publication. HURCA Abstract Caitlin Wright, Senior II Nursing Faculty Advisor: Dr. Deborah Behan, PhD, RN-BC Phase 1; Exploration of paramedic protocol for field IV insertion Current protocol at a south central hospital in the U.S. requires nurses to change field IVs within 24-48 hours. Changing IVs in-hospital result in patient duress and nurse time loss. This article reports data from the IV Insertion Protocol Survey and the Paramedic Educator Survey. These surveys attempt to identify paramedic protocol and practice related to IV insertion and aseptic technique. Further, the surveys explore paramedic education regarding IV insertion. Surveys were hand-delivered, participants were invited to participate in the anonymous survey, and data were then analyzed using RemarkOffice. The results suggest paramedics are educated on the use of aseptic technique and that paramedics clean the IV site unless circumstances such as limited space or patient acuity prevent proper cleansing. Eighty-eight percent of participants report following a protocol, 64% almost never/never use hand sanitizer, and 83% of educators said that paramedics are not instructed to use hand sanitizer. In summary, paramedics use aseptic technique, which suggests that field IVs should not need to be replaced within 24-48 hours after a patient’s hospital admission. PURPOSE STATEMENT The purpose of this study is to determine whether or not the paramedic providers to this South Central region of the United States follow a protocol for IV insertions that is equivalent to hospital protocol. PHASE 1; EXPLORATION OF PARAMEDIC PROTOCOL FOR FIELD IV INSERTION OUTLINE Introduction • Background o Some studies indicate that IV insertions are periodically performed without maintenance of aseptic technique. • Problem and Purpose o Current protocol at a South Central hospital in the United States requires nurses to change all field IVs within 24-48 hours after a patient’s admission. o If paramedics are complying with a protocol requiring site cleansing before IV insertion, changing the IV in-hospital may not be necessary. o The purpose of this study is to determine whether or not the paramedic providers to this South Central region of the United States follow a protocol for IV insertions that is equivalent to hospital protocol. Materials and Methods • IV Insertion Protocol Survey and the Paramedic Educator Survey were created for the study. • The survey is a 10 item survey using a likert scale to determine paramedic practice and adherence to IV insertion protocol. • A pre-written script was read before each survey. • The survey was given to each paramedic, paramedic educator, and paramedic supervisor who chose to participate. Results • Eighty-eight percent said they follow a protocol for IV insertion. • Eighty-nine percent of participants reported to always use aseptic technique and the remaining 11% reported almost always. • Nine percent of participants always use hand sanitizer before inserting IVs in the field, and 64% almost never/never use hand sanitizer. • Certain circumstances in the field may not allow for aseptic technique to be used. • The Paramedic Educator Survey results showed that 100% of the educators teach cleaning of the skin before IV insertion. Discussion • The EMS providers that we surveyed do not have a protocol that is equivalent to hospital IV insertion protocols; they follow algorhythms. • The results from the Paramedic Educator Survey suggest that paramedics are taught to use aseptic technique when inserting a peripheral IV • The group felt that it was impractical to use hand sanitizer before applying gloves. • Educators did not express the desire to begin teaching about the use of hand sanitizer. • There is no form or official process of communicating whether or not the IV was placed with proper aseptic technique • Future study recommendations: hand-off report between paramedic and receiving personnel, follow IVs in-hospital to see if there is a need for replacement Conclusion • EMS providers in this South Central region of the United States have been well educated on aseptic technique and IV insertion. • Change of protocol could better manage nurse time, as well as provide substantial health benefits for the patient. ABSTRACT FIELD IVS: TO REPLACE OR NOT En-Dien Liao, B.S. in Nursing The University of Texas at Arlington, 2014 Faculty Mentor: Deborah Behan, Ph.D., RN-BC Patients admitted to the emergency room via Emergency Medical Services with a field-established peripheral intravenous catheter (IV) were observed for 96 hours while in the hospital. Currently, many nurses restart the IV upon admission because they feel an IV started by a paramedic while in the field needs to be changed within 48 hours of hospital admission. The purpose of the study was to determine if field IVs started by paramedics could be utilized after patient admission to the hospital. Each day, observations of the IV site were recorded for signs of redness, swelling, and pain or tenderness, which would indicate the IV needed to be restarted. Results suggest that IVs started in the field by a paramedic in the ambulance may last up to 96 hours before they need to be changed. PURPOSE STATEMENT The purpose of this study was to determine if the field EMS IVs can last up to 96 hours without being changed by the nurse in the acute care setting. This study is aimed at identifying the aftereffects of IVs inserted in the field and determining whether or not pre-hospital IVs need to be replaced in the acute hospital setting within 24-48 hours of patient arrival. OUTLINE Introduction Purpose • The purpose of this study was to determine if the Emergency Medical Service (EMS) peripheral intravenous catheters (IVs) can last up to 96 hours. Background/Literature Review • Lawrence and Lauro (1988)- field-started IVs are 2.88 times more likely than hospital-started IVs to develop complications within 24 hours of insertion. • Lee et al. (2009)- In the hospital setting, IV catheter replacement time can be extended from 48 up to 96 hours. • Wright (2011)- evaluation of aseptic technique used by EMS personnel. • 88% of EMS follows a protocol for IV insertion • 100% always or almost always use aseptic technique when inserting field IVs • All paramedic educators were found to teach cleaning of the skin with alcohol prior to IV insertion Method • On random days, the researcher went to the emergency room (ER) and identified patients who arrived by EMS with an EMS established IV. • After admission orders, the patient was followed to room. • Verbal consent obtained, and patients were followed for the next four days • Data were collected each day on the following criteria: Site, redness, swelling, and pain/tenderness. Result • Total participants: 62 (134 measurements across 4 days) • One participant withdrew, and another participant passed away IV Location: Within the 134 measurements, 37 of the measurements were for an IV located in the right arm (33.9%). Seventy-two of the measurements were for an IV located in the left arm (66.1%). IV Redness: Out of 134 measurements, 12 measurements had redness (9%) and 110 measurements did not have redness (82.1%). IV Pain: Out of the 134 measurements, seven measurements were reported as pain or tenderness (5.2%) and 114 reported no pain or tenderness (85.1%). IV Swelling: Out of the 134 measurements, seven had signs of swelling (5.2%) and 110 measurements did not (85.8%). Discontinued Reasons ranked from highest to lowest: 36 due to discharge (64.3%), 6 to leaking (10.7%), 5 to policy removal (8.9%), 5 to pulled-out (8.9%), 2 to infiltration (3.6%), 1 to bruising (1.8%), and 1 to poor location (1.8%). Conclusion • EMS IVs may remain longer than 24 hours and up to 96 hours before they need to be changed. • Potential benefits : • Better quality of care for patients • More time saved for nurses from restarting IVs • Decreased cost to hospitals from reduced length of stays in hospitals. • Majority of patients were left handed • Inconsistency between system policy and actual bedside practice. Further education from nurse educators may be needed on the hospital’s IV policies. • Future Research: correlation between IV needle size and IV leakiness. • Wright (2011) found 82% of paramedics to use 18 gauge needles • Leaking was found to be the 2nd highest cause for IV discontinued Cont'd

Clinical Considerations for Patients with Active Clostridium difficile Infection

Donna Boyer,RN,WCC James McShane,BA,RN

donna.boyer@genesishcc.com and James.McShane@genesishcc.com

This article addresses the probable significant environmental Clostridium difficile (c. difficile) spore contamination that occurs when patients with active C. difficile infection are utilizing low air loss mattress therapy. We site published works that have proven environmental contamination exists in the absence of low air loss therapy. We assert that by virtue of the mechanism of action of low air loss surfaces, significantly increased environmental soiling is inevitable. Therefore, the risk of spreading infection is significantly increased. We are calling for additional research to determine the extent of increased contamination that occurs when low air low therapy is used on patients with active C difficile infection. Cont'd

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