Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
MVC-AACN Newsletter SPRING/SUMMER 2014 AACN has had a busy year so far in 2014! In April we had our New England Horizons conference in Portland, Maine. It was a well-attended event where lots of learning and good times took place! (See article and photos in this newsletter for more details) In May we had NTI in Denver, Colorado. Our new AACN President, Teri Lynn Kiss, introduced her new theme for the upcoming year – Focus the Flame! INSIDE THIS ISSUE 1 Welcome, NTI update 2-9 Sepsis, PAD & ABCDE program review 9 -10 Horizons Conference Review 11-12 June Program – Hope to see you there! 13 Fundraising update, Chapter Board members 14-16 Photos 16 Horizons 2016 information To learn more go to: http://www.ntivoices.com/this-girl-is-on-fire/ Part of her theme included FIRE – Fearlessness, Inquiry, Resilience and Engagement – an element made up of these four qualities, qualities that grow our profession and contribute to our best possible work. Newsletter 1 Bundles, Guidelines & PEARLs: Sepsis, PAD and ABCDE a review by Diane Meagher On October 22, 2013 we held our fall program, Bundles, Guidelines & PEARLs: Sepsis, PAD & ABCDE, at the Westford Regency Inn & Conference Center. The topics, as the title indicates, focused on the latest guidelines for sepsis and PAD (Pain, Agitation and Delirium), as well as the ABCDE Bundle. At last year’s NTI I had attended a session, “Sepsis – The Next Core Measure,” presented by Lisa Soltis, MSN, APRN, PCCN, CCRN-CSC, CCNS, FCCM, Cardiovascular/Critical Care Clinical Nurse Specialist at WakeMed Health and Hospitals, Raleigh, NC. I thought she was a phenomenal speaker so I contacted her to speak for our chapter. She accepted and presented an extended session, “Time is Tissue: Early Recognition and Management of Sepsis.” She began with an overview of the inflammatory changes at the cellular level, including the normal function of the immune system and response to stress and infection. Next she discussed the pathophysiology of shock. Shock is the inability of the circulatory system to deliver enough blood to meet the oxygen and nutrient requirements of body tissues. Hypoperfusion, activation of the inflammatory response, and hypercoagulability are universal conditions with shock, regardless of the clinical condition causing the cellular hypoperfusion. “Timely reversal of the shock state prevents development of multiple organ failure and death, hence the phrase ‘time is tissue.’” The Systemic Inflammatory Response Syndrome (SIRS) is severe inflammation caused by major insults. The SIRS diagnostic criteria include 2 or more of the following: Temperature > 38.0 C or < 36.0 C Tachycardia (HR > 90) Tachypnea (RR > 30 or pCO2 < 32 mmHg) WBCs > 12K or < 4 K/mm3 Sepsis is SIRS caused by infection, severe sepsis is associated with organ dysfunction, and septic shock is associated with hypotension and decreased end-organ perfusion. Lisa shared the epidemiology of sepsis, AMI, stroke and pneumonia to compare the incidence vs mortality, demonstrating sepsis had the highest rate of mortality at 29%. Sepsis is the 6th most common reason for hospitalization, the most costly, and the leading cause of non-cardiac deaths in US. Common causes of sepsis are pneumonia, central venous line associated bacteremia, and urinary tract infections. She posed the question, “why hasn’t sepsis received the same (quality) focus as other disease states?” The Surviving Sepsis Campaign (SSC), an initiative of the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine, was developed to improve the management, diagnosis, and treatment of sepsis. They issued their third edition of "Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. The Surviving Sepsis Campaign Bundles are the core of the sepsis improvement efforts. Using "bundles" simplifies the complex processes of the care of patients with severe sepsis. A bundle is a selected set of elements of care distilled from evidence-based practice guidelines that, when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone. There is a 3-Hour Bundle and a 6-Hour Bundle. To be completed within 3 hours: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics (Cont……) Newsletter 2 3) Administer broad-spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L To be completed within 6 hours: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO2)* 7) Re-measure lactate if initial lactate was elevated* *Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate. We should all be performing routine screening of potentially infected, seriously ill patients to allow for early identification and implementation of therapy. Cultures should be obtained as clinically appropriate before antibiotic therapy as long as it does not delay the initiation of antibiotics. Imaging studies should also be performed promptly to confirm potential source of infection. Administration of effective antimicrobials should begin within the first hour of recognition of septic shock and within 3 hours of severe sepsis without septic shock. Each hour delay in antibiotics increases mortality by 5%. Crystalloids are recommended for initial fluid resuscitation. Hydroxyethyl starches are not recommended, however albumin may be administered for severe sepsis when large amounts of crystalloids have been unsuccessful. Each hour of delay in hemodynamic stability increases mortality by 7%. Vasopressors should be initiated for persistent hypotension despite fluid resuscitation with a target MAP of >65 mmHg. Norepinephrine is the first choice vasopressor. Epinephrine may be added to and potentially substituted for norepinephrine when an additional agent is needed to maintain adequate blood pressure. Vasopressin 0.03 units/minute can be added to norepinephrine with the intent of either raising MAP or decreasing norepinephrine dosage. Low dose vasopressin is not recommended as a single agent. Dopamine may be used as an alternative vasopressor agent to norepinephrine only in highly selected patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia). Phenylephrine is not recommended in the treatment of septic shock except in circumstances where norepinephrine is associated with serious arrhythmias, cardiac output is known to be high and blood pressure persistently low, or as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target. All patients requiring vasopressors should have an arterial catheter placed as soon as practical if resources are available. A trial of dobutamine infusion up to 20 mcg/kg/min may be administered or added to vasopressor (if in use) in the presence of myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP, but not using a strategy to increase cardiac index to predetermined supranormal levels. Corticosteroids are not recommended if able to achieve hemodynamic stability with fluid resuscitation and vasopressor therapy. However, if hemodynamic stability is not achievable, intravenous hydrocortisone is recommended at a dose of 200 mg per day, and then taper when no longer required. ACTH stimulation testing for adrenal insufficiency is not recommended. The guidelines include recommendations for other supportive therapies for severe sepsis. Red blood cell transfusion is only recommended when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin Newsletter 3 concentration of 7.0 –9.0 g/dL in adults, except in extenuating circumstances such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease. Fresh frozen plasma is not recommended to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures. Platelet transfusion is recommended prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding, or when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedure. Blood glucose management should target an upper blood glucose ≤180 mg/dL. Insulin dosing should commence when 2 consecutive blood glucose levels are >180 mg/dL, and blood glucose values should be monitored every 1–2 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter. Glucose levels obtained with pointof-care testing of capillary blood should be interpreted with caution, as such measurements may not accurately estimate arterial blood or plasma glucose values. A combination of pharmacologic therapy and intermittent pneumatic compression devices for deep vein thrombosis prophylaxis are recommended whenever possible unless contraindicated. Stress ulcer prophylaxis using H2 blocker or proton pump inhibitor is recommended for patients who have bleeding risk factors. When stress ulcer prophylaxis is used, proton pump inhibitors are preferred. Administer oral or enteral (if necessary) feedings, as tolerated, rather than waiting 48 hours. Avoid mandatory full caloric feeding in the first week but rather low dose feeding (e.g., up to 500 calories per day), advancing only as tolerated. Use intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) alone or parenteral nutrition in conjunction with enteral feeding in the first 7 days. Goals of care and prognosis should be discussed with patients and families as early as feasible, but no later than within 72 hours of ICU admission, and should be incorporated into treatment and end-of-life care planning, utilizing palliative care principles where appropriate. Next Lisa shared nursing considerations to complement the guidelines. First and foremost she discussed infection prevention through education, accountability, surveillance of nosocomial infections, hand hygiene, and site/device specific considerations. Prevention of respiratory infection includes head of bed elevation greater than 30 degrees, regular oral care including chlorhexidine gluconate, and consideration of endotracheal tube (ETT) with continuous subglottic suctioning, silver coated ETT, and polyurethane ETT cuff. Prevention of central line-associated bloodstream infection (CLABSI) includes central line bundles, maximal sterile barriers during central line insertion, chlorhexidine for skin prep, change IV sets every 96 hours, and consideration of antibiotic impregnated central venous catheters. Prevention of surgical site infection (SSI) includes antibiotic administration within 1 hour of incision, hair removal with clippers, post-op glucose <200 on day 1, and identification and treatment of remote infections before elective surgery. Prevention of catheter-associated urinary tract infection (CAUTI) includes decrease duration of foley catheter use, maintenance of sterile closed drainage system, regular perineal hygiene, and maintenance of unobstructed urine flow. Sepsis screening tools should be utilized in all areas of the hospital for early identification and diagnosis of severe sepsis. Early warning systems, e.g., Code Sepsis Teams, Rapid Response Teams, and protocols should be used to manage patients early. Nurses should be empowered to implement resuscitation bundles. Other supportive care includes nutrition within 24-48 hours, eye care, and pressure ulcer prevention. (Cont…) Newsletter 4 The last portion of Lisa’s presentation focused on hemodynamic monitoring and tissue oxygenation, and she stated, “we manage what we monitor!” She made the case that pressure (e.g., CVP) does not estimate volume because compliance is dynamic and always changing. Causes of decreased compliance include ischemia, inotropes, increased afterload, restrictive Cardiomyopathy, increased PEEP, increased pericardial pressure, and increased intra-abdominal pressure. When metabolic oxygen demand is greater than oxygen delivery, anaerobic metabolism results in lactate production, metabolic acidosis, and dysoxia (impaired tissue oxygenation). The universal goal of critical care is to maintain adequate tissue oxygenation. Mixed venous (pulmonary artery) blood is a good indicator of systemic oxygen delivery and systemic oxygen uptake. Mixed venous oxygen saturation (SvO2) is the percentage of Hgb saturated with O2 in mixed venous blood. Under normal circumstances, only about 25% of oxygen is utilized by the cells (normal SvO2 = 75%). During sepsis, mitochondria can’t utilize available oxygen and SvO2 is elevated >80%. SvO2 <60 indicates impaired O2 delivery, SvO2 <50 indicates global tissue dysoxia. A decrease in SvO2 is one of the earliest signs of problems with tissue oxygenation, i.e., the oxygen demand is exceeding oxygen consumption. ScvO2 is a measurement of central venous oxygenation, drawn from a central line and is an acceptable alternative to SvO2 although can differ from SvO2 by up to 10%. SvO2 may be decreased due to increased O2 consumption (e.g., hyperthermia, shivering, infection, pain), decreased CO/CI (e.g., decreased preload/increased afterload, hypovolemia, sepsis (late), MODS), decreased O2 supply (e.g., respiratory failure, suctioning, increased work of breathing, decreased alveolar/arterial oxygenation), and nursing interventions (e.g., position changes, chest PT, bathing, visitors). Causes of increased SvO2 include decrease in O2 demand (e.g., hypothermia, neuromuscular blocking agents, sedation, sepsis), increased CO/CI (e.g., positive inotropic agents, afterload reduction, fluid administration), and increased O2 supply (increased FiO2, increased SaO2, increased PaO2). When O2 demand increases, the body attempts to increase delivery. If cardiac output increases, SvO2 may remain unchanged. If delivery does not increase in response to the increased demand, the tissues will extract a larger amount of oxygen from the available supply and will result in a decrease in SvO2. To improve tissue oxygenation, maximize the 3 major determinants of oxygen delivery: anemia - consider transfusion if Hgb <7 g/dl (*Hgb in banked blood >14 days old has decreased O2 carrying capacity); cardiac ouput – keep CI >2.4 L/min/m2; hypoxia – keep SaO2 >90%. Cardiac output is equal to HR x SV (stroke volume). Determinants of SV are preload (increased preload = increased SV, decreased preload = decreased SV), afterload (inversely proportional to CO, i.e., high afterload = low CO, low afterload = high CO), and contractility (increased contractility = increased SV, decreased contractility = decreased SV). Up to 50% of patients resuscitated from shock may have continued global tissue hypoxia (i.e., increased lactate and decreased ScvO2 or SvO2) even with the normalization of vital signs and CVP. PAD The next speaker was Leanne Boehm, MSN, RN, ACNS-BC, from the ICU Delirium and Cognitive Impairment Study Group at Vanderbilt University Medical Center, Nashville, Tennessee. Her first presentation was, “Pain, Agitation, and Delirium: New Guidelines for Critically Ill Adults.” The new guidelines were published in 2013 with recommendations as MVC-AACN Newsletter 5 follows. Monitor pain routinely for all adult ICU patients. For patients able to self-report use the Numeric Rating Scale (0-10). For patients unable to self-report use the Behavioral Pain Scale (BPS) or Critical Care Pain Observation Tool (CPOT).i,ii ,iii They do not suggest that vital signs be used alone for pain assessment in adult ICU patients but rather that vital signs may be used as a cue to begin further assessment of pain.iv Assessing pain reduces sedative/ hypnotic use and is associated with improved outcomes.v Other pain management recommendations include: preemptively treating chest tube removal with either analgesics and/or nonpharmacologic therapy; preemptively treating other types of procedural pain with analgesic and/or nonpharmacologic therapy; using opioids as first-line therapy for treatment of non-neuropathic pain; using non-opioid analgesics in conjunction with opioids to reduce opioid requirements and opioid related side effects; using gabapentin or carbamazepine, in addition to intravenous opioids, for treatment of neuropathic pain; using thoracic epidural for postoperative analgesia in patients undergoing abdominal aortic aneurysm surgery, and thoracic epidural analgesia for patients with traumatic rib fractures.vi Recommendations for Agitation/Sedation assessment include: depth and quality of sedation should be routinely assessed in all ICU patients; the RASS and SASS are the most valid and reliable scales; they suggest using objective measures of brain function to adjunctively monitor sedation in patients receiving neuromuscular blocking agents; use EEG monitoring either to monitor non-convulsive seizure activity in ICU patients at risk for seizures, or to titrate electrosuppressive medication to achieve burst suppression in ICU patients with elevated intracranial pressure. Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes (e.g., shorter duration of mechanical ventilation (MV) and a shorter ICU length of stay (LOS)). Maintaining light levels of sedation increases the physiologic stress response, but is not associated with an increased incidence of myocardial ischemia. The association between depth of sedation and psychological stress in these patients remains unclear. They recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation in adult ICU patients, unless clinically contraindicated. They recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients.vii Early deep sedation is associated with longer MV and reduced 6-month survival.viii Research demonstrates a trend towards more PTSD symptoms with deep sedation, and no difference in anxiety or depression scores. Light sedation patients averaged 1 day shorter on MV and 1.5 days shorter LOS.ix Daily sedation interruption decreases duration of MV. The process is to hold sedation infusion until patient awakens and then restart at 50% of the prior dose. “Awake” is defined as any 3 of the following: open eyes in response to voice, use eyes to follow investigator on request, squeeze hand on request, and/or stick out tongue on request. Additional outcomes include fewer diagnostic tests to assess changes in mental status, no increase in rate of agitated-related complications or episodes of patient-initiated device removal, and no increase in PTSD or cardiac ischemia.x,xi They suggest that analgesia-first sedation be used in mechanically ventilated adult ICU patients; that sedation strategies using nonbenzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (either midazolam or lorazepam) to improve clinical MVC-AACN Newsletter 6 outcomes in mechanically ventilated adult ICU patients; that in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidine rather than benzodiazepine infusions be administered for sedation to reduce the duration of delirium in these patients.xii ICU delirium develops in ~2/3 of critically ill patients, hypoactive or mixed forms are most common, and it goes undiagnosed in up to 72% of cases. The following are associated with an increased risk of delirium: benzodiazepines, extended ventilation, immobility, coma and dementia.xiii Sequelae of delirium include increased mortality, longer intubation time, an average of 10 additional days in the hospital, higher costs of care, development of dementia, long-term cognitive impairment, requirement for care in chronic care facility, and decreased functional status at 6 months.xiv,xv ,xvi ,xvii ,xviii Each day of delirium in the ICU increases the hazard of mortality by 10%.xix Duration of delirium was an independent predictor of cognitive impairment - an increase from 1 day of delirium to 5 days was associated with nearly a 5-point decline in cognitive battery scores. A patient’s testimony, “One quite literally loses one’s grip on what is true and what is false because the true and the false are mixed together in a mess of experience.”xx,xxi They recommend routine monitoring of delirium in adult ICU patients - the CAM-ICU and the ICDSC are the most valid and reliable delirium monitoring tools.xxii There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients. Atypical antipsychotics (e.g., quetiapine, ziprasidone) may reduce the duration of delirium in adult ICU patients (must monitor QT interval). They recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium.xxiii ABCDE Next Leanne spoke about the ABCDE Bundle, which provides the first steps in creating a framework or backdrop for implementation of the PAD guidelines. The ABCDE protocol is multiple components, interdependent, and designed to improve collaboration among clinical team members, standardize care processes break the cycle of oversedation and prolonged ventilation. The components of the ABCDE Bundle are: ABC – Awakening and Breathing Coordination D – Delirium Identification and Management E – Early Exercise and Mobility Awakening and breathing coordination provides for synergy of daily awakening and spontaneous breathing trial, and an opportunity for more effective independent breathing. Awakening and breathing safety screens should be performed prior to initiating a Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT). SAT safety screen includes no active seizures, no active alcohol withdrawal, no active agitation, no active paralytic use, no myocardial ischemia (24h), and normal intracranial pressure. SBT safety screen includes no active agitation, oxygen saturation ≥88%, FiO2 ≤50%, PEEP ≤8 cm H2O), no myocardial ischemia (24h), normal intracranial pressure, and no significant vasopressor or inotrope use.xxiv MVC-AACN Newsletter 7 If the patient fails the SAT safety screen, try again the next day; if the patient passes, proceed with SAT - sedation cessation. Turn off/hold all sedatives (off = zero). It is appropriate to continue analgesic drips in postsurgical, trauma, or chronic pain patients. Closely monitor and provide reassurance and repeated explanation of the circumstances. If the patient fails the SAT (anxiety, agitation, pain, respiratory rate (RR)>35/min, SpO2 <88%, respiratory distress, acute cardiac arrhythmia), restart sedation at 50% previous dose, titrate to goal, and try again the next day. If the patient passes SAT, proceed with SBT. If the patient passes the SBT consider extubation; if the patient fails (RR >35/min, RR <8/min, SpO2 <88%, respiratory distress, mental status change, acute cardiac arrhythmias), resume full ventilatory support. “Wake up & Breathe” resulted in less benzodiazepine use, faster extubation, sooner ICU and hospital discharge, and better survival at 1 year.xxv Delirium identification and management begins with identifying risk factors and etiology, and nonpharmacologic prevention and management. “Stop and THINK” - should any medications be stopped or lowered, especially sedatives; use the minimal amount of sedation necessary – light sedation, daily sedation cessation; assess for pain. Use the THINK mnemonic to identify the etiology of delirium: Toxic situations (CHF, shock, dehydration, HTN, new organ failure (liver/kidney)); Hypoxemia, Infection/sepsis (nosocomial); Immobilization; Nonpharmacologic interventions (sleep protocols, noise control, early mobility, hearing aids, glasses reorientation, music); K+ or electrolyte problems. xxvi Assess for delirium with a validated scale, identify and reverse/treat underlying causes of delirium, and optimize non-pharmacologic strategies. Non-pharmacologic interventions include sleep preservation and enhancement, environmental changes (e.g., noise reduction), sensory aids (e.g., glasses), and reorientation and cognitive stimulation. Early mobility is the only non-pharmacologic intervention shown to reduce ICU delirium.xxvii See the PAD guidelines above for recommendations for pharmacologic management of delirium. The final component is Early Exercise and Mobility. The benefits of exercise include functional independence at discharge, decreased duration of delirium, decreased time on ventilator, decreased LOS, decreased costs and improved neurocognitive outcomes.xxviii,xxix ,xxx ,xxxi The Early Exercise and Mobility Protocol begins with passive range of motion (ROM) and progresses to active ROM, sitting/dangling, transferring to chair, marching and walking. The benefits of the ABCDE Bundle include liberation from the ventilator, earlier ICU and hospital discharge, return to normal brain function, independent functional status, and increased survival.xxxii The ABCDE Bundle requires the collaboration of the interdisciplinary patient care team – nursing, respiratory therapy, PT/OT, physicians and pharmacists. For further information and resources, see www.ICUdelirium.org and www.aacn.org. -------------------------------------------------- http://www.survivingsepsis.org/Bundles/Pages/default .aspx. Accessed 5/9/14. http://www.survivingsepsis.org/Guidelines/Documents /Hemodynamic%20Support%20Table.pdf. Accessed 5/9/14. http://www.survivingsepsis.org/Guidelines/Documents /Other%20supportive%20therapy.pdf. Accessed 5/9/14. MVC-AACN Newsletter 8 Endnotes: i Barr J, et al. Crit Care Med. 2013;41:263-306. Payen JF, et al. Crit Care Med. 2001;29(12):2258-2263. iii Gélinas C, et al. Am J Crit Care. 2006;15:420-427. iv Barr J, et al. CritCare Med. 2013;41:263-306. v Payen JF, et al. Anesthesiology. 2009;111:1308-1316. vi Barr J, et al. Crit Care Med. 2013;41:263-306. vii Barr J, et al. Crit Care Med. 2013;41:263-306. viii ShehabiY, et al. Am J Respir Crit Care Med. 2012;186(8):724-731. ix Treggiari MM, et al. Crit Care Med. 2009;37(9):2527-2534. x Kress JP, et al. N Engl J Med. 2000;342:1471-1477. xi Needham DM, et al. Crit Care Med. 2012;40(2):502-509. xii Barr J, et al. CritCare Med. 2013;41:263-306. xiii Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233. xiv Bruno JJ, Warren ML. Crit Care Nurs Clin North Am. 2010;22(2):161-178. xv Shehabi Y, et al. Crit Care Med. 2010;38(12):2311-2318. xvi Rockwood K, et al. Age Ageing. 1999;28(6):551-556. xvii Jackson JC, et al. Neuropsychol Rev. 2004;14:87-98. xviii Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999. xix Pisani MA. Am J Respir Crit Care Med. 2009;180:1092-1097. xx Girard TD, et al. Crit Care Med. 2010;38:1513-1520. xxi Misak CJ. Am J Respir Crit Care Med. 2004;170(4):357-359. xxii Barr J, et al. CritCare Med. 2013;41:263-306. xxiii Barr J, et al. Crit Care Med. 2013;41:263-306. xxiv Girard TD, et al. Lancet. 2008;371(9607):126-134. xxv Girard et al. Lancet 2008; 371:126-134. xxvi Jacobi J, et al. Crit Care Med 2002;30:119-141. xxvii Schweickert WD, et al. Lancet. 2009;373:1874-1882. xxviii Schweickert et al 2009; 373:1874-82. xxix Chiang et al 2006; 86:1271-81. xxx Needham et al 2010; 91:536-42. xxxi Morris et al CCM 2008; 36:2238-43. xxxii Morandi A et al. Curr Opin Crit Care,2011;17:43-9. ii A Review of Horizons by a New Critical Care RN! Submitted by Krista DiPietro Horizons 2014 was especially inspiring for me; it was my first as an RN. I have been a member of AACN since I was a nursing student and attended Horizons twice while in nursing school. I currently work on an IMC unit and feel that I was able to absorb a substantial amount of information from each and every session. From listening to AACN president, Vicki Good, give the keynote address with her inspiring words, to belly laughing while attending a humor session, there wasn’t a moment I didn’t like. There was a large variety of topics this year, ranging from sepsis to heart failure updates to street drugs and many more. Most of the speakers were so engaging that the hour long sessions felt like five minutes. MVC-AACN Newsletter 9 Vicki Good opened the conference with a presentation focused on her motivating AACN theme, “Stepping Forward.” She explained how the first step starts with a decisive moment that leads to transforming knowledge into positive action. This action leaves a “wake” representing our character that changes and grows as we gain experience. The wake we leave can be either choppy or smooth; it’s up to us to decide what kind of wake we will leave. Being new to critical care, this really spoke to me as I begin to envision my new career path. Kathleen Vollman will always represent what I aspire to be….a true mentor. She spoke on several topics including mouth care and ventilator acquired pneumonia and the “power of one” that each of us are in this aspect of patient care. This session really opened my eyes about how only a few minutes can prevent a patient from becoming even sicker than when they were admitted. Kathleen has such a way of presenting the evidence to empower us to act on behalf of the patients entrusted to us. I left Kathleen’s sessions feeling driven to advocate for what our patients need and deserve. The other speaker who left an indelible mark on me was Mary Bylone. Mary spoke about how to use our “bold voice.” Her presentation, Using Your Bold Voice: The Good, The Bad and The Ugly, concentrated on the healthy work environment and how patient outcomes are influenced by it. But, she also spent some time talking about how we have to become aware of our own values, strengths and weaknesses because that’s what the core for our bold voice becomes, and that what I feel is important in my organization. It is from this foundation that we can spread the message that patient safety is our goal as critical care nurses. She really broke down how to prioritize and approach various situations; particularly with skilled communication as the means to hold ourselves and others accountable. For my bold voice to be heard I have to develop strong communication skills to get the message of patient safety out there. Finally, Sue Goran had me in tears with her session on humor, titled “Humor: Not Just a Laughing Matter!” I was laughing uncontrollably. She explained the difference between wit…the thought-oriented experience of humor, mirth…the emotional response (joy), and laughter…the physiological response. She went on, in her own unique comedic style, to point out all of the therapeutic physical and social effects of humor, as well as the benefits to the workplace. Sue ended her session by having the audience members sing the following to the tune of “Row, Row, Row Your Boat:” “Laugh…laugh…laugh out loud, Each and every day; Chuckling…chuckling…chuckling…chuckling, Health is on the way! The Horizons conference is a breath of fresh air, with hundreds of nurses gathering together for a few days of learning, networking and fun. I am already looking forward to Horizons 2016 in Rhode Island. If you have never attended a Horizons conference, whether you are a nursing student or a veteran nurse, you are missing out on something special. Hope to see you in 2016! MVC-AACN Newsletter 10 Don’t forget to mark your calendar for the upcoming MVCAACN program on June 10th being held at the Radisson Hotel & Suites in Chelmsford from 7:30am – 4:30pm! Deborah Tuggle MN, APRN, CCNS, FCCM will present “Critical Care Concepts” PROGRAM DESCRIPTION: This program is designed to provide participants with a comprehensive review of a variety of critical care topics, debunk a multitude of myths, and provide an update on the latest trends in evidencebased practice and critical care guidelines. Attending dynamic nursing conferences can be inspiring and uplifting to professional morale, but the exciting information and new ideas may never make it back to the bedside where it can benefit patients and staff. The final session will discuss methods for keeping up momentum and motivating others towards change. This program is intended for nurses at all levels and in every acute setting. LEARNING OBJECTIVES: At the completion of this seminar the learner will be able to: Discuss the 4 steps of oxygenation. For each step, describe clinical measures, barriers to achieving and therapeutic interventions. Review the fluid compartments and fluid dynamics of the body. Discuss past and current methods for assessing preload and fluid responsiveness. Describe the effects of hypo, iso, and hypertonic fluids on the 3 fluid compartments. Review current recommendations for fluid maintenance and fluid resuscitation. Discuss the risk factors and clinical findings of DVT and PE including as seen in the ventilated patient. Review the pros and cons of various diagnostic tests used in diagnosing DVT & PE. Describe preventives therapy and management of DVT & PE in the critical care setting. Describe common misconceptions about the meaning of arterial blood pressure readings. Discuss how the blood pressure formula can be used to troubleshoot causes of hypotension. Review better measures and better support strategies for perfusion than those conventionally employed. Describe three techniques for turning other nurses on to the information you have obtained. Review 5 ways to raise the bar and cultivate a culture of evidence-based practice in your unit. SCHEDULE: 7:30 – Registration/Continental Breakfast 8:00 – Oxygenation: Debunking Myths & Safeguarding Tissues 9:30 - BREAK 10:00 - The Sea Within: Fluid Replacement Therapy 11:15 – LUNCH (buffet lunch included) MVC-AACN Newsletter 11 12:15 - Pulmonary Emboli: The Silent Killer 1:30 - BREAK 1:45 - Hypotension & Shock: The Truth About Blood Pressure 2:45 - BREAK 3:00 - Take Your Knowledge And Run 4:15 – Evaluation CONTACT HOURS: The American Association of Critical-Care Nurses is approved by the California Board of Registered Nursing, Provider Number 01036. This program has been approved for 7.50 Contact Hours, Synergy CERP Category A, File Number 00018749. ABOUT THE SPEAKER: Deborah Tuggle, MN, APRN, CCNS, FCCM is a Clinical Nurse Specialist with over 35 years of experience in critical care. She is a published author, national speaker and chapter leader in the American Association of Critical Care Nurses (AACN) and an active committee member of the National Association of Clinical Nurse Specialists (NACNS). She is also a committee leader, Paragon Coach, and two-time Presidential Citation winner for the Society of Critical Care Medicine (SCCM). As founder of the continuing education and consultation company, Critical Care Curriculum, Deb has been instrumental in enriching patient care at hospitals around the country. She has a passionate commitment to life-long learning and a reputation for developing quality courses that are both evidence-based and patient-oriented. In addition, to cutting-edge and pragmatic content, her dynamic style and sense of humor keeps audiences engaged, entertained and motivated to improve their care. Deb's courses promote many best practice initiatives including AACN Practice Alerts, Surviving Sepsis Campaign interventions, ihi infection prevention bundles, Joint Commission's National Patient Safety Goals, and many more. She has developed learning opportunities for nurses, physicians, respiratory therapist, and other ancillary staff including ECG and hemodynamic monitoring accuracy, successful rescue responses, optimal ventilator management, collaborative communication skills, and healthy work environments. Her consultation with hospitals on critical care competency has brought them in alignment with AACN expectations and promoted greater confidence and attainment of CCRN and PCCN credentials. Deb is a graduate of the University of Kentucky and the University of Washington Schools of Nursing and employed as a Critical Care CNS at Norton Women's Hospital in Louisville, KY. FOR MORE INFORMATION: Diane Meagher 978-455-4167 or Email: [email protected] MVC-AACN Newsletter 12 Thank you to all who participated in the Chapter Tastefully Simple Fundraiser in support of “Cardiac Quest” - (three 7th grade girls raising money to place AEDs on local playing fields and parks). The girls have placed 3 AEDs in the past year and have plans for 2 more with help from our Chapter! $120 was raised for this worthwhile cause! Thank you! 2014 Chapter Board Members: Chrissy Cebollero will be finishing up her year as President as of June 30, 2014. Michele Woonton will become the new Chapter President as of July 1, 2014. Sue Wheeler is the President-Elect and she will be taking over in July 2015! Sue Sadowski – Scholarship chairperson Linda McGowan and Doris Barreiro - newly appointed to Scholarship committee Diane Meagher – Programs Ellen Stokinger – Membership Chrissy Cebollero – Webmaster Eileen Scondras – past President Sue Ouellette – secretary Dianne Forsyth – treasurer Valerie Fernald - publications If you would like to find out about how to become more involved in the Chapter please reach out to any board member. Go to the www.AACN.org website and at the bottom of the page click on “Chapters”. Next click on Massachusetts, Merrimack Valley, and e-mail a chapter officer”, or simply click here: http://www.aacn.org/dm/Chapters/EmailOfficers.aspx?mid=2874 MVC-AACN Newsletter 13 Photo Gallery Chapter Christmas Dinner at Cobblestones – Dec 2013 One of the 2013 Chapter Scholarship winners, Rebecca Order, with Sue Sadowski RN at the Transitions dinner in June 2013 2014 Scholarship winners are Thomas Coye from Georgetown, going to Salem State College and Devinne Healy from Dracut High, going to Rivier College. MVC-AACN Newsletter 14 Chapter member Maureen McLaughlin presenting at NTI 2014 Horizons 2014 Portland, ME – out on the town MVC-AACN Newsletter 15 Horizons attendees enjoying the city of Portland after classes HORIZONS 2014 in Portland, ME was a fun, well-attended learning event for critical care RN’s from New England and beyond. The Horizons planning committee works on this bi-annual event to make sure it is a worthwhile and fun time for all who attend. Merrimack Valley Chapter member Laura Pruyn won the Nancy Houle Continuing Education Scholarship - a full three-day paid scholarship to attend this Horizons – Congratulations Laura! The next Horizons is in 2016 and will be held in Providence, Rhode Island. Plan ahead to attend in April 2016! If you would like to apply for the Nancy Houle scholarship for Horizons 2016 go to the website: www.Horizons2014.org. MVC-AACN Newsletter 16