The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists. The purpose of this publication is to keep our members updated on the NACNS headquarters news; connect our members with fast-breaking clinical news; and update clinical nurse specialists on state and federal legislative actions. If you have any questions or wish to advertise in this publication – please contact Jason Harbonic at firstname.lastname@example.org.
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Federal and State Policy News
Held at the Loews Coronado Island, San Diego, CA over 600 individuals attended the recent NACNS Annual Meeting. This meeting was a commemoration of our founding as well as a celebration of the what the future holds for the CNS role. In addition to honoring our past presidents, we heard from NACNS’ first president – Pat Bielecki’s daughters, who graciously brought greetings on their mother’s behalf. Pat Bielecki was posthumously given one of two 2015 President’s Awards. The American Association of Critical-Care Nurses (AACN) was the other recipient of the 2015 President’s Award. AACN provided technical support to NACNS during their early years to assist in the formation of an association.
Key announcements at the meeting included the 2015-2020 NACNS Mission and Goals, the new NACNS logo, and an infographic that represents highpoints of the First Annual CNS Census which was completed on December 31, 2014. The 2016 Call for Abstracts was made available to all participants as well as a list of the 2015 NACNS Webinars. All of these items can be found on the NACNS Web site at www.NACNS.org.
At the November 4, 2014 board meeting, the NACNS Board of Directors approved a proposal by the 2014 Bylaws Committee to bring a set of proposed bylaws changes to the NACNS membership for consideration and vote. According to the NACNS Bylaws, the membership must be made aware of the intention of the Board to have a bylaws related vote 30 days prior to the Annual Business meeting. The bylaws changes were announced in the CNS Communique, on the NACNS Web site, and presented via 2 webinars in early 2015 and at the 2015 Annual Membership Business meeting that was held on March 6, 2015 at the 2015 NACNS Annual Meeting in San Diego, CA. The membership will be able to vote on the bylaws changes through March 31, 2015. You will have received a ballot via email. If you would like a hard copy ballot please request this from Jason Harbonic at email@example.com.
The bylaws changes seek to update the NACNS bylaws and streamline language throughout the document. Generally, the proposed changes in the bylaws recommend:
NACNS’ Nominating Committee worked diligently to identify NACNS volunteers in order to comprise the 2015 – 2016 Slate of Candidates of Officers and other elected positions. Voting closed just before the 2015 NACNS Annual Meeting.
The following individuals won the election:
Seeing your Name in Print: Writing for Publication
NACNS Journal Editor, Jan Fulton, PhD, RN, ACNS-BC, ANEF, FAAN will provide a discussion of the key issues a CNS should consider when contemplating writing for publication. She will address selecting a good match in publication, the importance of publishing for both the educator and clinician and the technical process most journals use in selecting a manuscript for publication.
Humpty Dumpty Syndrome: Putting the Septic Patient Back Together Again
Severe sepsis is the #1 cause of death in the ICU. For decades, researchers have struggled to develop therapies that could improve the devastating mortality rate associated with the shock, inflammation, coagulation and multiple organ failures characteristic of this syndrome. Deborah Tuggle, MN, APRN, CCNS, FCCM will present this session and will review the Surviving Sepsis Campaign and the care bundles currently advocated as best practice in sepsis therapy. She will include a discussion of current pharmacologic interventions.
Breaking the Pain Cycle - Pain Management Update
CNSs have a very important role in planning interventions to decrease pain and increase patient participation in their pain management plan. In addition, a growing number of CNSs live in states that are gaining prescriptive authority. Pain management, due to the addictive nature of the medication, continues to be a concern for state and federal regulators as well as prescribers. Les Rodriguez, MSN, MPH, RN, ACNS-BC will help learners assess and utilize pain medication to break the pain cycle. At the end of the session the learner will be able to discuss the need for setting goals for pain management and discuss considerations of utilizing different medications and modalities.
Looking Beyond the First Impression – Malnutrition Identification and Assessment
Identification, assessment, and treatment of malnutrition of the hospitalized adult is a serious and often unaddressed issue with serious consequences. NACNS’ Malnutrition and the Hospitalized Patient Task Force, led by Susan Smith DNP, RN, ACNS-BC will present this webinar series. The first webinar is designed to provide the CNS with information on best practices for assessment, prevention, treatment and management of the malnourished patient. The second session will incorporate additional disease specific management strategies and team approaches. The second session will be presented in November, 2015.
Moving toward a Violence Free Workplace
Health care facilities continue to experience violence related to the stress of hospitalization and the open access provided patients and other visitors. Enhance the knowledge of the CNS in dealing with violence including implementation of programs to assist in decreasing violence in the healthcare workplace. Nationally known speaker, Jean Proehl, MN, RN, CEN, CPEN, FAEN will be faculty for this important webinar.
Malnutrition and the Hospitalized Adult – Essential Considerations in Identification and Management
Essential disease specific considerations in the management of the malnourished adult patient will be the focus of this second NACNS Malnutrition and the Hospitalized Patient Task Force webinar led by Susan Smith DNP, RN, ACNS-BC. Best practices and the importance of collaborative interdisciplinary teams will be addressed. The CNS role in policy development, staff education and patient care are also explored. Resources to support the CNS in practice will be discussed. The first webinar in this series Malnutrition Identification and Assessment will be presented in September 2015.
All Webinars will be available as enduring continuing education until 2019 on the NACNS website – www.NACNS.org
Registration for each session will remain at 2014 prices!
Please watch the NACNS homepage – www.nacns.org and the CNS Communique for information on the 2015 NACNS Webinar Series.
At the March 2015 Board of Directors meeting, it was decided that NACNS would continue work on CNS population-based competencies. The APRN Consensus Model, currently being considered for adoption by a number of states, calls for licensure of APRNs based on population. NACNS collaborated with other organizations on the development of the adult/gero and women’s health/gender specific competencies. A task force met and developed a draft of competencies for family across the lifespan.
Announcements for volunteers for each of these Task Forces will be sent via blast email at the end of March and beginning of April. Each task force will be comprised of between 7 and 10 NACNS members.
The approximately 3,700 respondents to the 2014 CNS Census answered a question about their span of work. According to our Census, of those responding to the survey, 44.05 % across the whole healthcare system, 39.89% work with two or more units and the remainder approximately 21.8% work with one unit.
ANCC hosted the Friday breakfast for the NACNS Annual Meeting. Part of the breakfast was a presentation designed to discuss the changes ANCC is making to their certification exams. An ANCC staff person noted that ANCC has extended the application dates for a number of their NP and CNS certifications. This is good news for the CNS who may currently meet the requirements of the original certification exams, but do not meet the criteria for certification under the new – APRN Consensus Model-oriented certification exams. Generally speaking, these national certification exams will accept applications until December 31, 2016 and individuals will be eligible to take the exam until October 31, 2017. After that date, ANCC will only accept renewal by professional development and practice hour requirements for these older exams. No individual will be able to test for certification with these exams, but you will be able to renew.
You must review the specific information related to the CNS certifying exam you are interested in on the ANCC website. Please note, as this is a recent change, not all areas of the ANCC website indicate this change. The change in date information is found on each web page that describes the specific exam.
This impacts the following CNS exams offered by ANCC:
NACNS would love to hear from faculty, students and program directors on this issue. Will this change allow your CNS candidates to complete their program and be eligible to take a certification exam for licensure? Please send your comments to firstname.lastname@example.org – with ANCC in the subject line.
The third edition of the ANA Nursing: Scope and Standards of Practice, 3rd Ed. is currently available in draft for public comment on the ANA Web site. Comments are due on this document by April 6, 2015. It is critical that nurses review and weigh in on aspects of this document as it forms the foundation of our practice.
Kathy Apple, MS, RN, FAAN the CEO of the National Council of State Boards of Nursing (NCSBN) has announced her retirement effective Sept. 30, 2015.
Her retirement comes after 14 years of service as the CEO of the NCSBN. Throughout her tenure, Kathy has worked diligently to support the important work of U.S. boards of nursing (BONs), steadfastly promoting the mandate to protect the public through the regulation of nursing practice at the state, national and international levels.
During her tenure Apple has ensured that the NCLEX Examinations have met the highest levels of psychometric soundness and legal defensibility when assessing the competence of entry-level nursing practice. She oversaw the expansion of Nursys, NCSBN’s national licensure and discipline database, to a fully functional data exchange system utilized by BONs in their daily public protection activities. This system has grown from a database with 10 participating BONs in 2001 to its current level of 55 participating boards.
In support of evidence-based regulation, Apple initiated the NCSBN Center for Regulatory Excellence, a grant program for research related to nursing regulation that has awarded more than $11 million in grants since its inception in 2007. She brought forth the viability of a professional, peer-reviewed journal for the purpose of publishing nursing regulation research with the launch of the Journal of Nursing Regulation in 2010.
Under Apple’s collaborative direction, NCSBN’s national presence was increased through the building of effective working relationships with major national nursing and other health care organizations. Apple established the Tri-Regulator Leadership Collaborative composed of the Federation of State Medical Boards and the National Association of Boards of Pharmacy to address issues of mutual concern and to model interprofessional leadership.
Apple established NCSBN’s leadership presence internationally with the International Council of Nurses, expanded the associate membership of NCSBN to 21 nurse regulatory bodies from other countries and launched the International Nurse Regulator Collaborative, a seven country diplomatic collaborative for respective nurse regulatory bodies to work on issues of common interest.
Apple will be honored at the NCSBN annual meeting, Aug. 19-21, 2015, in Chicago.
The NCSBN BOD, led by President Brekken, has begun the search process of identifying the next NCSBN CEO. Korn Ferry, a leading executive search company, has been retained to assist the BOD.
CDC and other healthcare agencies have been highlighting the danger of antibiotic resistant bacteria for a number of years. There has been a steady increase in the presence of carbapenem-resistant Enterobacteriaceae (CRE) infections in patients receiving inpatient medical care, such as in hospitals, long-term acute care facilities, and nursing homes.
In their usual forms, bacteria from the Enterobacteriaceae family (e.g. E. coli) are a normal part of the human digestive system. However, some of these bacteria have developed defenses to fight off all or almost all antibiotics we have today. When these bacteria get into the blood, bladder or other areas where germs don't belong, patients suffer from infections that are difficult, and sometimes impossible, to treat.
While CDC has warned about CRE for more than a decade, new information shows that these bacteria are now becoming more common. One type of CRE has been detected in medical facilities in 42 states. Even more concerning, this report documents a seven-fold increase in the spread of the most common type of CRE during the past 10 years.
Facilities that have been successful at stopping CRE have implemented rapid, coordinated and aggressive action including prevention and antibiotic prescription changes. CDC released a CRE prevention toolkit reiterating practical CRE prevention and control steps. Leadership and medical staff in hospitals, long-term acute care hospitals, nursing homes, health departments, and even outpatient practices must work together to implement these recommendations to protect patients from CRE.
Outbreaks highlight the importance of CDC and state health departments working collaboratively to identify and stop the spread of antibiotic resistant pathogens. In the FY 16 budget, CDC has requested funding to support State Antibiotic Resistance Prevention Programs in all 50 states and 10 large cities and a regional lab network to help identify and respond faster to outbreaks. This funding would provide critical national infrastructure to prevent the growing threat of CRE and other drug-resistant pathogens.
Prevent Diabetes STAT: Screen Test Act Today
The American Medical Association (AMA) and the Centers for Disease Control and Prevention (CDC) have joined forces to take action against diabetes type 2. This disease impacts more than 86 million Americans who are living with prediabetes and nearly 90 percent of them unaware of it.
Prevent Diabetes STAT:Screen, Test, Act - Today™, is a multi-year initiative that expands on the robust work each organization has already begun to reach more Americans with prediabetes and stop the progression to type 2 diabetes, one of the nation’s most debilitating chronic diseases. Through this initiative, healthcare providers should begin to see prediabetes as a critical and serious medical condition.
People with prediabetes have higher-than-normal blood glucose levels but not high enough yet to be considered type 2 diabetes. Research shows that 15 to 30 percent of overweight people with prediabetes will develop type 2 diabetes within five years unless they lose weight through healthy eating and increased physical activity.
As an immediate result of this partnership, the AMA and CDC have co-developed a toolkit to serve as a guide for physicians and other health care providers on the best methods to screen and refer high-risk patients to diabetes prevention programs in their communities. The toolkit along with additional information on how key stakeholders can Prevent Diabetes STAT is available online. There is also an online screening tool for patients at www.preventdiabetesstat.org to help them determine their risk for type 2 diabetes.
OIn February 2014, the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force (RPTF) released A Prioritized Research Agenda for Suicide Prevention: An ActionPlan to Save Lives, which outlines the research areas that show the most promise in helping to reduce the rates of suicide attempts and deaths in the next 5-10 years.
The Prioritized Research Agenda is organized around six key questions, each of which will be addressed in a series of webinars sponsored by the National Council for Behavioral Health in collaboration with the Action Alliance and the National Institute of Mental Health. Four webinars remain in the series:
For more information, and to register for upcoming webinars or access webinar archives, visit the National Council’s website.
HIV has proven stubbornly resistant to potential vaccines. Most vaccines work by triggering the immune system to produce antibodies that help beat back infections. But proteins on HIV’s surface mutate rapidly and change shape continuously. These quick transformations keep most antibodies from latching onto and neutralizing the virus. In January of 2015, NIH-funded scientist report the identification of a compound that appears to protect against many HIV strains. It is thought this new molecule may result in a method of HIV prevention and treatment.
Research has shown that antibodies can neutralize many different strains of HIV. These broadly neutralizing antibodies bind to small unchanging regions of the HIV envelope protein. But strategies to make vaccines that prompt the body to produce antibodies against these regions have had limited success.
A team of researchers led by Dr. Michael Farzan of the Scripps Research Institute took a novel approach to try to protect against a wide variety of HIV viruses. All HIV strains infect cells by attaching to the CD4 protein on the surface of target cells. The virus also must bind to another cell protein, called a coreceptor, to gain entry. Most HIV strains use the protein CCR5 as a coreceptor. Once HIV binds CD4, it changes shape to expose the part of the virus that binds CCR5.
Armed with this knowledge, the researchers decided to create a fusion protein with a form of CD4 on one end and a crucial piece of CCR5 on the other. This fusion protein, called eCD4-Ig, might potentially block both points of viral binding. The study was funded by NIH’s National Institute of Allergy and Infectious Diseases (NIAID) and National Cancer Institute (NCI). Results appeared in a recent issue of Nature.
On March 10, 2015 the U.S. Food and Drug Administration announced the approval of Unituxin (dinutuximab) as part of first-line therapy for pediatric patients with high-risk neuroblastoma, a type of cancer that most often occurs in young children.
Neuroblastoma is a rare cancer that forms from immature nerve cells. It usually begins in the adrenal glands but may also develop in the abdomen, chest or in nerve tissue near the spine. Neuroblastoma typically occurs in children younger than five years of age. According to the National Cancer Institute, neuroblastoma occurs in approximately one out of 100,000 children and is slightly more common in boys. There are an estimated 650 new cases of neuroblastoma diagnosed in the United States each year. Patients with high-risk neuroblastoma have a 40 to 50 percent chance of long term survival despite aggressive therapy.
Unituxin is an antibody that binds to the surface of neuroblastoma cells. Unituxin is being approved for use as part of a multimodality regimen, including surgery, chemotherapy and radiation therapy for patients who achieved at least a partial response to prior first-line multiagent, multimodality therapy.
The FDA granted Unituxin priority review and orphan product designation. Priority review shortens the timeframe for review of drug applications by four months, compared to standard reviews, and is granted to drugs that, if approved, will provide a significant improvement in safety or effectiveness in the treatment of a serious condition. Orphan product designation is given to drugs intended to treat rare diseases. With this approval, the FDA also issued a rare pediatric disease priority review voucher to United Therapeutics, which confers priority review to a subsequent drug application that would not otherwise qualify for priority review. This is the second rare pediatric disease priority review voucher granted by the FDA since inception of the rare pediatric disease review voucher program, which is designed to encourage development of new therapies for prevention and treatment of certain rare pediatric diseases.
The safety and efficacy of Unituxin were evaluated in a clinical trial of 226 pediatric participants with high-risk neuroblastoma whose tumors shrunk or disappeared after treatment with multiple-drug chemotherapy and surgery followed by additional intensive chemotherapy and who subsequently received bone marrow transplantation support and radiation therapy. Participants were randomly assigned to receive either an oral retinoid drug, isotretinoin (RA), or Unituxin in combination with interleukin-2 and granulocyte-macrophage colony-stimulating factor, which are thought to enhance the activity of Unituxin by stimulating the immune system, and RA.
Three years after treatment assignment, 63 percent of participants receiving the Unituxin combination were alive and free of tumor growth or recurrence, compared to 46 percent of participants treated with RA alone. In an updated analysis of survival, 73 percent of participants who received the Unituxin combination were alive compared with 58 percent of those receiving RA alone.
Unituxin carries a Boxed Warning alerting patients and health care professionals that Unituxin irritates nerve cells, causing severe pain that requires treatment with intravenous narcotics and can also cause nerve damage and life-threatening infusion reactions, including upper airway swelling, difficulty breathing, and low blood pressure, during or shortly following completion of the infusion. Unituxin may also cause other serious side effects including infections, eye problems, electrolyte abnormalities and bone marrow suppression.
The most common side effects of Unituxin were severe pain, fever, low platelet counts, infusion reactions, low blood pressure, low levels of salt in the blood (hyponatremia), elevated liver enzymes, anemia, vomiting, diarrhea, low potassium levels in the blood, capillary leak syndrome (which is characterized by a massive leakage of plasma and other blood components from blood vessels into neighboring body cavities and muscles), low numbers of infection-fighting white blood cells (neutropenia and lymphopenia), hives, and low blood calcium levels.
Federal and State Policy
The Center for Medicare and Medicaid Services (CMS) has clarified that CNSs, NPs, PAs, physicians can order a hospital admission if three requirements are met. Those are the practitioner must be (a) licensed by the state to admit inpatients to hospitals, (b) granted privileges by the hospital to admit inpatients to that specific facility, and (c) knowledgeable about the patient’s hospital course, medical plan of care, and current condition at the time of admission.
The ordering practitioner makes the determination of medical necessity for inpatient care and renders the admission decision. The ordering practitioner is not required to write the order but must sign the order reflecting that he or she has made the decision to admit the patient for inpatient services.
By law CNSs and other practitioners (NPs, PAs) cannot certify an admission. However, CMS’s current policy only requires a physician certification on outlier cases and stays of 20 inpatient days or more. Even if a stay eventually requires a physician certification, a qualified CNS would still be able to furnish the admission order for that stay as I indicated above.
This CMS clarification can be found in the January 30, 2014 guidance, section B.2 on page 4.
Health Resources and Services Administrator Mary Wakefield has agreed to serve as the Acting Deputy Secretary of Health and Human Services. Dr. Wakefield has been serving as the HRSA Administrator and has led HRSA and its 1800 employees through the time of healthcare transformation. She has improved access to health for millions of patients, strengthening America’s health care workforce, and modernized HRSA’s organizational infrastructure. Using her skills as a nurse, manager, and academic leader, she has helped HRSA not only meet its mission, but has fostered an environment of innovation and collaboration that is evident in the work that HRSA does across the Department and with its partners throughout the country.
As a nurse and healthcare leader, Mary’s career has been focused on developing systems and leadership to improve the health of Americans, and serving her home state of North Dakota. Before arriving at HRSA, Mary was the associate dean for rural health at the University of North Dakota School of Medicine and Health Sciences. Additionally, she served as the Chief of Staff for both Senator Kent Conrad and Quentin Burdick. Mary is a fellow in the American Academy of Nursing and a member of the Institute of Medicine (IOM).
NACNS, part of the national Nursing Community coalition, has agreed to advocate for the Nursing Community’s recommended funding levels. We will be advocating for $244 million for Title VIII Nursing Workforce Development Programs and $150 million for the National Institute of Nursing Research. These funding levels are for the FY 2016 federal appropriations bills that will be considered by Congress this spring.
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.