Systems of Care

In this month's issue of Critical Care Medicine, there was a fantastic article on systems-based cardiac arrest care. The authors showcase implementation of the "Take Heart America" program in two Minnesota towns. The study objective was to evaluate care before and after implementing the program. The focus of the THA program is to train entire communities from the lay public to providers of emergency services in early recognition and evidence-based intervention of cardiac arrests. Such interventions include:

• AEDs widely available in communities


• Public education to include CPR & AED training


• Early activation of EMS


• Quality pre-hospital care to include: advanced airways, intra-osseous drug delivery, ipedence threshold devices and automated CPR devices


• Hospital care, centers of excellence to include: accessibility to revascularization, ICDs and EP, therapeutic induced hyptothermia


• Data collection and analysis

The goal: to improve survivability after cardiac arrest events by ensuring all stakeholders have the knowledge and resources they need to reach that goal. This is a excellent example of how a system-wide evidence-based and standardized approach to care can greatly impact patient outcomes.

I have provided a link to the abstract below.

Take Heart America: A comprehensive, community-wide, systems-based approach to the treatment of cardiac arrest Lick et al. Critical Care Medicine: January 2011 - Volume 39 - Issue 1 - pp 26-33
doi: 10.1097/CCM.0b013e3181fa7ce4

Making it personal

I read a great a great article in a recent issue of ADVANCE for Nurse regarding nurses and healthcare providers working in areas of clinical practice that they have personal experience with. Often patients and families are discouraged and frustrated as nurses educate them on making healthy lifestyle changes that seem to take something away from them or require strict adherence to medical regimes. The nurses showcased in this article have taken their struggles and victories with various diseases and illnesses to dedicate their professional practice to caring for those with the same issues. It is more than simply practicing what they preach, but relating to patients on a intimate and human level, applying personal experiences to caring practices.

Many of us have stories of illness and struggle. Choosing to use those stories in professional practice is truly inspiring.


Follow this link to the article:

"Being a Good Role Model: Nurses' health histories - good and bad - influence patients." By Sandy Keefe, MSN, RN

APRN Scope of Practice Issues Revisited

There has been much discussion in the media and among professional nursing and medical organizations regarding the impact the Affordable Care Act, the health care law that was passed March 2010 on providers of healthcare. It is an understatement to suggest that this law will impact all levels of providers within the healthcare system and it is important that we as providers and caregivers alike understand the impact the Affordable Care Act will have on our current and future roles as nurses and physicians. I encourage you to read this very positive article from the New England Journal of Medicine: Perspective (see link below). I also encourage you to stay informed and involved with your professional organizations and state licensing boards as we embark on certain changes in the way we deliver health care.

Broadening the Scope of Nursing Practice

See also:

National Association of Clinical Nurse Specialists

American College of Nurse Practitioners

Peds Part I

I read a great blog (510 Medic) about the importance of taking vital signs in pediatric patients. The author cites great research on how often vital signs are not taken, especially blood pressure which puts our patients at risk if we are unable to properly assess and measure vital sign data. This issue cannot be underscored and is applicable to all providers in the emergency services - both pre-hospital and in the hospital. I often get asked about pediatric assessments (including vital signs) from nurses and paramedics alike. My answer is always the same...what does the child look like and do the vital signs match the rest of the clinical picture?

For instance, some years ago I had an ED nurse tell me that an infant had a respiratory rate of 8 - 10 and was in no distress. Apparently I had an alarmed look on my face as she questioned my concern. I asked, "what does the child look like - color, skin temp, capillary refill, respiratory effort, etc.?" She proceeded to tell me the child was comfortably sitting in the mother's lap, skin very warm, flushed cheeks, but taking Pediatlyte from a bottle. Obviously I reassessed the child including vital signs and found that the respiratory rate was in fact almost triple the original rate and the heart rate was quite tachycardic due to fever.

It is important that we synthesize all the patient data and evaluate what we are hearing or seeing. Does it make sense with the clinical picture?

Thanks to 510 Medic for addressing a topic near and dear to my heart! Stay tuned for Part II with a discussing breaking down the numbers and correlating to the pediatric assessment.

Celebrate Clinical Nurse Specialists!

2nd Annual National CNS Week September 1st - 7th

Clinical Nurse Specialist Facts from NACNS:

• Hildegard Peplau, RN, Ed.D. (9/1/1909 – 3/17/1999), is the founding mother of the CNS role. Rutgers University School of Nursing is the birthplace of the CNS role.
• Dr. Peplau was a nursing theorist who published a landmark work in 1952 titled, "Interpersonal Relations in Nursing." She emphasized the nurse-client relationship as the foundation for nursing practice, and the important partnership model that focused on shared experience through observation, description, formulation, interpretation, validation and intervention. This theory was considered "revolutionary", since at that time clients or patients typically were passively receiving treatment and nurses were merely acting out doctor’s orders. In 1956, Dr. Peplau established the first nursing Master’s Degree program with a focus exclusively on clinical practice. Graduates of this program were called "clinical specialists."
• Health systems across the nation are commemorating this recognition week. Plans include community activities and public lectures, receptions honoring Clinical Nurse Specialists, wellness fairs, community outreach, and fundraisers promoting the spirit of nursing, such as organized walks or golf outings which in turn support underserved communities or particular health concerns.
• An estimated 72,521 Clinical Nurse Specialists practice in the U.S. They are licensed registered nurses who hold masters or doctorate degrees in nursing.
• CNSs are expert clinicians in a specialized area of nursing practice. The specialty may be identified in terms of a population (i.e. Pediatrics), a setting (ie. Emergency Dept.), a disease or medical subspecialty (i.e. Diabetes), type of care (ie. Psychiatric), or type of problem (i.e. Pain).
• CNS practice improves the healthcare environment and outcomes by influencing: direct care of patients/clients, nursing standards and personnel, and care delivery systems. In other words, as leaders CNSs drive innovation in their environments from care at the bedside to system-wide improvements.
• Examples of outcomes of CNS practice: reduced medical complications in hospitalized patients, reduced hospital costs and length of stays, improved pain management practices, increased patient satisfaction with nursing care, reduced frequency of emergency room visits.

More proof that STEMI Systems work

A recent news article showcased the coordination of care between EMS and a hospital in Vancouver for patients having an MI: En-route diagnoses save heart attack victims’ lives. It is unfortunate that despite increasing global evidence that pre-hospital diagnosis is an integral piece of improving patient outcomes with STEMI, there are still barriers and turf wars that prevent the same. So how do we change this?

Putting a sacred cow to pasture - cervical and spinal immobilization

The American Emergency Physicians News recently published a piece on the use of spinal immobilization and cervical collars. Despite evidence against the use and very little evidence that using immobilization techniques and equipment protects the patient from further injury this practice continues to put patients at risk for injury. There is increasingly more literature that discusses the harms associated with inappropriate cervical and spinal immobilization, which is defined as either incorrectly applied devices or inappropriately placed on patients without signs/symptoms of injury. This practice has been under scrutiny since the 1980s yet both pre-hospital and emergency departments use this practice routinely despite valid and recent evidence recommending otherwise. Disclaimer: this is not to say that there are not situations that spinal and/or cervical immobilization is not appropriate or necessary; and there is literature that supports this practice.

Further contributing to increased morbidity is prolonged immobilization once in the emergency department. Delays in being evaluated by an emergency department physician or nurse practitioner leave the patient lying immobilized for a prolonged period of time increasing the risk for extension injuries, skin complications, airway complications, elimination issues and emotional distress. Many nurses are not trained or competencied to adequately care for a patient with cervical collars and/or spinal immobilization let alone application and removal; this is often the case in non-trauma centers or in an academic institution with medical residents. Nurses often lose track of how long their patients are immobilized and a substantial delay occurs before being evaluated and removed from such devices. Once in the emergency department, nurses must advocate for their patients and treat immobilization as a priority of care.

Both paramedics and nurses must be familiar with evidence-based practices and know both the risks and benefits of the care they provide. Performing a skill on the basis of “that’s how we’ve always done it” is dangerous business for the patients we care for and it is incumbent upon us to ensure the care we provide is rooted in evidence and not just another scared cow.