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
The 2014 Bylaws Committee presented proposed bylaws changes to the membership at the 2015 NACNS Business Meeting at the NACNS Annual Meeting in March 6, 2015. The set of changes also sent to the NACNS membership for consideration and vote and were approved. The membership also approved a modification to the bylaws that was presented by a member at the Business Meeting to include the immediate past president as a member of the NACNS Board Executive Committee.
The other bylaws changes are:
NACNS is hosting two important annual meetings this summer in the Washington, DC area. The NACNS Educator’s Forum and the NACNS 16th Annual CNS Summit will be held on July 20th and 21st. The Educator’s Forum is designed to provide CNS educators from clinical instructors to program directors the opportunity to discuss key issues that impact CNS education. The preliminary agenda for this meeting includes a discussion of the DNP program for the CNS role. The current DNP Position Statement Task Force will be providing their position and seeking feedback from CNS faculty.
The NACNS 16th Annual CNS Summit will provide an opportunity for NACNS members and representatives from collegial organizations to discuss issues impacting the CNS work environment. The preliminary agenda for this meeting includes:
An exciting option may be added in 2015! Our meeting coincides with the ANA’s annual member Hill Day We are working with ANA to give our meeting participants the opportunity to join ANA in their Hill day on July 22nd.More details will be available on the NACNS website. Please go to www.nacns.org and click on the 2015 Summit for more information. Also, you can email your questions to email@example.com.
Across the United States, CNSs are making a difference in the lives of patients they serve as well as improving care delivery in hospitals and healthcare systems. NACNS is collecting these stories.
In an effort to educate policymakers, the public and leaders in the healthcare system about the important contribution of the CNS, NACNS is looking for stories from you – on how you have made a difference in your role. Whether it is decreasing length of stay for a patient population, decreasing the rate of wound infection, implementing new guidelines or regulations or organizing care to address a unique patient care need. You are working in collaborative teams or as individual change agents to enhance the patient care experience and improve outcomes.
NACNS will collect your innovative practice projects and initiative sand use them in a variety of ways to articulate the contribution of the CNS. We are asking members to send your stories – just a few paragraphs in length is needed – to firstname.lastname@example.org.
It is not necessary to use the following questions, but they might provide a nice guideline for your submission.
Please make sure that you do not use personal identifiable information related to patients in your story.Submit your stories to: email@example.com. Please put "innovative story" in the subject line.
NACNS is excited to continue our high quality webinar programming in 2015. This series of webinars is designed to provide the CNS with cutting-edge clinical and role information. The topics have been selected with an eye toward issues that cross specialties and may be seen in a variety of clinical situations. In addition, we have intentionally designed some of the sessions to provide much needed pharmacology CE! Please sign up for one or more:
Humpty Dumpty Syndrome: Putting the Septic Patient Back Together Again
Breaking the Pain Cycle - Pain Management Update
Looking Beyond the First Impression – Malnutrition Identification and Assessment
Moving toward a Violence Free Workplace
Malnutrition and the Hospitalized Adult – Essential Considerations in Identification and Management
*This activity has been approved for contract hours by the PA State Nurses Association. The PA State Nurses Association is accredited as an approver of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation.
The Future is Today: Entering a World of New Practice Challenges for the Clinical Nurse Specialist
Join clinical nurse specialists from around the country at the original capital of America. If you have never been to Philadelphia, this is your chance! Philly is a melting pot of races, traditions and immigrant cultures. This means lots to do and amazing culinary options! It is the home to the Liberty Bell and the Declaration of Independence, both tributes to the city's contribution to the founding of our nation. Details will be posted on the NACNS Web site – www.nacns.org
Abstract Submission Opens: June 2015
In 2014, NACNS conducted an online survey open to anyone who had graduated from a CNS education program. More than 3000 individuals responded to the survey. Each issue we publish a different fact from this survey. If you wish to view more details from the survey, go to www.nacns.org.
When asked what the respondent’s highest degree held:
ANA announced on March 30, 2015 that they are accepting nominations for appointment to the American Nurses Credentialing Center (ANCC) Board of Directors. ANA announced it is looking for appointments on four seats and will consider ANA Members (C/SNA-ANA or IMD) and non-members. The term of service will be January 1, 2016 – December 31, 2017.
Nominations will be accepted until 5 pm Eastern on Monday, June 1, 2015.A call for other appointed positions will be held in subsequent months.
Nurse Leader recently published an article by ANA staff person Andrea Brassard, PhD, FNP-BC, FAANP that provides an overview of how APRNs can be reimbursed. It covers issues such as reimbursement, hospital privileges, durable medical equipment and more. The article is available as an open access article for a period of time and is a good place to start if you want to understand some opportunities in these areas.
On March 9, 2015 the American Association of Colleges of Nursing (AACN) announced new data released on enrollment in baccalaureate, master’s, and doctoral nursing programs. The greatest gains were found in baccalaureate degree-completion programs and the practice-focused doctorate; students are returning to nursing school in record numbers to develop the skills needed to meet employer demands and patient care needs.
The national drive to enhance the nation’s supply of baccalaureate-prepared nurses is facilitated is by expansion in RN-to-BSN programs, which provide an efficient bridge for nurses looking to continue their education. These programs build on previous learning, prepare nurses for a higher level of nursing practice, and provide RNs with the education necessary to move forward in their nursing careers.
Since education level has an impact on patient care, hospitals and other nurse employers are moving to hire the best educated entry-level RNs possible. New research published by Drs. David Auerbach, Peter Buerhaus, and Douglas Staiger in the January-February 2015 issue of Nursing Economics found that the percentage of BSN-prepared nurses in acute care hospitals is increasing while the employment of associate degree nurses in these settings is decreasing. Further, AACN’s special survey on the Employment of New Nurse Graduates conducted last fall found that 79.6% of employers are now requiring or expressing a strong preference for nurses with a baccalaureate degree.Preparing more nurses in research-focused (PhD, DNS) and practice-focused (DNP) doctoral programs is a priority for the profession given the great need for nurses with the highest level of scientific knowledge and practice expertise to ensure high quality patient outcomes. According to the latest AACN survey, enrollment in PhD programs increased by 3.2% last year while escalating support for the Doctor of Nursing Practice degree generated a 26.2% increase in enrollments during the same timeframe.
On March 27th the White House released information on their plan to address antibiotic resistance in the nation. In a blog about the plan, White House spokesperson Secretary Sylvia Mathews Burwell, Secretary Tom Vilsack and Secretary Ash Carter note that "…the emergence of drug resistance in bacteria is undermining the effectiveness of current antibiotics and our ability to treat and prevent disease." The Centers for Disease Control and Prevention (CDC) indicate that approximately 2 million illnesses and 23,000 deaths each year can be attributed to drug-resistant bacteria.
In September 2014, the President issued Executive Order (EO) 13676: Combating Antibiotic-Resistant Bacteria, which outlines steps for implementing the National Strategy on Combating Antibiotic-Resistant Bacteria and addressing the policy recommendations of the President’s Council of Advisors on Science and Technology (PCAST)’s report on Combating Antibiotic Resistance. Furthermore, the President’s FY 2016 Budget released earlier this year proposed nearly doubling the amount of Federal funding for combating and preventing antibiotic resistance to more than $1.2 billion.
The recently released national action plan, the National Action Plan for Combating Antibiotic Resistant Bacteria(NAP), outlines a whole-of-government approach over the next five years targeted at addressing this threat:
1. Slow the emergence of resistant bacteria and prevent the spread of resistant infections
2. Strengthen national "One-Health" surveillance efforts
3. Advance development and use of rapid and innovative diagnostic tests
4. Accelerate basic and applied research and development
5. Improve international collaboration and capacities
On April 1, 2015 CDC announced the release of the first national study to look at behavioral therapy, medication, and dietary supplements to treat attention-deficit/hyperactivity disorder (ADHD) among children ages 4-17. This study shows that less than one half of children with ADHD were receiving behavioral therapy in 2009-2010. The Centers for Disease Control and Prevention (CDC) study, "Treatment of Attention-Deficit/Hyperactivity Disorder among Children with Special Health Care Needs," published today in The Journal of Pediatrics provides a snapshot of how ADHD was treated just before the release of the 2011 clinical guidelines for treatment of ADHD from the American Academy of Pediatrics (AAP).
According to the study, among children 4-17 years of age, about 4 in 10 with ADHD were treated with medication alone, 1 in 10 received behavioral therapy alone, 3 in 10 were treated with both medication and behavioral therapy, and 1 in 10 received neither medication nor behavioral therapy. Overall, about 1 in 10 children took dietary supplements for ADHD.
The data show that 1 in 2 preschoolers ages 4-5 with ADHD received behavioral therapy and about 1 in 2 were taking medication for ADHD. Almost 1 in 4 preschoolers were treated with medication alone. Among children ages 6-17 with ADHD, fewer than 1 in 3 received both medication and behavioral therapy.
"We do not know what the long-term effects of psychotropic medication are on the developing brains and bodies of little kids. What we do know is that behavioral therapy is safe and can have long-term positive impacts on how a child with ADHD functions at home, in school, and with friends," said CDC Principal Deputy Director Ileana Arias, Ph.D. "Because behavioral therapy is the safest ADHD treatment for children under the age of 6, it should be used first, before ADHD medication for those children."
In 2011, AAP released ADHD treatment guidelines recommending behavioral therapy alone for treatment of preschoolers and combination therapy of medication and behavioral therapy for children with ADHD between the ages of 6-17.The study shows significant state-to-state variability in the type of treatment used to treat ADHD in children 4-17 years of age. On average, states with higher behavioral therapy rates had lower medication treatment rates and vice versa. Rates of medication treatment among children with ADHD ranged from a low of 57 percent in California to a high of 88 percent in Michigan. Rates of behavioral therapy among children with ADHD ranged from a low of 33 percent in Tennessee to 61 percent in Hawaii. This analysis was from parent reported data from the 2009-2010 National Survey of Children with Special Health Care Needs.
On April 2, 2015 the CDC announced that international travelers are bringing a multidrug-resistant intestinal illness to the United States and spreading it to others who have not traveled. Shigella sonnei bacteria resistant to the antibiotic ciprofloxacin sickened 243 people in 32 states and Puerto Rico between May 2014 and February 2015. Research by the CDC found that the drug-resistant illness was being repeatedly introduced as ill travelers returned and was then infecting other people in a series of outbreaks around the country.
CDC and public health partners investigated several recent clusters of shigellosis in Massachusetts, California and Pennsylvania and found that nearly 90 percent of the cases tested were resistant to ciprofloxacin (Cipro), the first choice to treat shigellosis among adults in the United States. Shigellosis can spread very quickly in groups like children in childcare facilities, homeless people and gay and bisexual men, as occurred in these outbreaks.
In the United States, most Shigella is already resistant to the antibiotics ampicillin and trimethoprim/sulfamethoxazole. Globally, Shigella resistance to Cipro is increasing. Cipro is often prescribed to people who travel internationally, in case they develop diarrhea while out of the United States. More study is needed to determine what role, if any, the use of antibiotics during travel may have in increasing the risk of antibiotic-resistant diarrhea infections among returned travelers.
"The increase in drug-resistant Shigella makes it even more critical to prevent shigellosis from spreading," said Anna Bowen, M.D., M.P.H., a medical officer in CDC’s Waterborne Diseases Prevention Branch and lead author of the study. "Washing your hands with soap and water is important for everyone. Also, international travelers can protect themselves by choosing hot foods and drinking only from sealed containers."
CDC’s PulseNet lab network identified an increase in Shigella sonnei infections with an uncommon genetic fingerprint in December 2014. Further testing at CDC’s National Antimicrobial Resistance Monitoring System (NARMS) lab found that the bacteria were resistant to Cipro. PulseNet detected several large clusters: 45 cases in Massachusetts; 25 cases in California; and 18 cases in Pennsylvania. About half of the PulseNet cases with patient information were associated with international travel, mostly to the Dominican Republic and India. The San Francisco Department of Public Health reported another 95 cases (nine of them among those identified by PulseNet), with almost half occurring among the homeless or people living in single-room occupancy hotels.
Shigella causes an estimated 500,000 cases of diarrhea in the United States every year. It spreads easily and rapidly from person to person and through contaminated food and recreational water. It can cause watery or bloody diarrhea, abdominal pain, fever, and malaise. Although diarrhea caused by Shigella typically goes away without treatment, people with mild illnesses are often treated with antibiotics to stop the diarrhea faster. Until recently, Cipro resistance has occurred in just 2 percent of Shigella infections tested in the United States, but was found in 90 percent of samples tested in the recent clusters.
Because Cipro-resistant Shigella is spreading, CDC recommends doctors use lab tests to determine which antibiotics will effectively treat shigellosis. Doctors and patients should consider carefully whether an infection requires antibiotics at all.
To prevent the spread of shigellosis, CDC recommends that people wash their hands often with soap and water, especially after using the toilet and before preparing food or eating; keep children home from childcare and other group activities while they are sick with diarrhea; avoid preparing food for others while ill with diarrhea; and avoid swimming for a few weeks after recovering. Improving access to toilets and soap and water for washing hands may help prevent Shigella transmission among the homeless.
Travelers to developing countries can take additional precautions to avoid diarrhea and minimize infection with resistant bacteria. Choose safe foods and beverages, such as food that is steaming hot and drinks from sealed containers (download CDC’s app "Can I Eat This?" to help you make safer food and beverage choices when you travel). Wash hands frequently, particularly before eating and after using the toilet. Take bismuth subsalicylate to prevent travelers’ diarrhea and treat it with over-the-counter drugs like bismuth subsalicylate or loperamide. Try to reserve antibiotics for severe cases of travelers' diarrhea.Healthcare providers should test stool samples from patients with symptoms consistent with shigellosis, re-test stool if patients do not improve after taking antibiotics, and test bacteria for antibiotic resistance. To obtain the full MMWR report, please click here.
The nation is concerned about the increased use of opioids. As part of this trend, healthcare leaders are considering interventions to decrease opioid deaths. The CDC on April 24th suggests that allowing more basic emergency medical service (EMS) staff to administer naloxone could reduce drug overdose deaths that involve opioids. This recommendation is based on the results of a study, "Disparity in Naloxone Administration by Emergency Medical Service Providers and the Burden of Drug Overdose in Rural Communities," published in the American Journal of Public Health.
In 2013, more than 16,000 deaths in the United States involved prescription opioids, and more than 8,000 others were related to heroin. Naloxone is a prescription drug that can reverse the effects of prescription opioid and heroin overdose, and can be life-saving if administered in time.
According to the study findings, advanced EMS staff were more likely than basic EMS staff to administer naloxone. A majority of states have adopted national guidelines that prohibit basic EMS staff from administering the drug as an injection. As of 2014, only 12 states allowed basic EMS staff to administer naloxone for a suspected opioid overdose; all 50 states allow advanced EMS staff to administer the overdose reversal treatment.
To reduce opioid overdose deaths, particularly in rural areas, CDC recommends expanding training on the administration of naloxone to all emergency service staff, and helping basic EMS personnel meet the advanced certification requirements.
"Naloxone can be given nasally to a person suspected of overdose, allowing basic EMS staff to administer the drug without injection," said CDC Senior Health Scientist Mark Faul, Ph.D., M.A. "Naloxone is non-addictive, and expanding training on how to administer the drug can help basic emergency medical service staff reverse an opioid overdose and save more lives."
National Emergency Medicine Service Information System data for 2012 were reviewed to better understand factors associated with naloxone administration, including demographic data, 911 call information, and details about the scene of an injury or illness as reported by EMS staff.
The findings indicate naloxone was most likely to be administered to women, people between the ages of 20 and 29, and people living in suburban areas.
In general, the rate of opioid overdose death was 45 percent higher in rural areas compared with urban areas. The use of naloxone by rural EMS staff, however, was only 22.5 percent higher when compared with urban EMS naloxone use.
Department of Health and Human Services Secretary Sylvia M. Burwell has made addressing opioid abuse, dependence, and overdose a priority and work is underway at multiple HHS agencies on this important issue. HHS’ Health Resources Services Administration recently released a grant opportunity aimed at reducing opioid overdose deaths in rural communities through funding for communities to purchase naloxone and train health care professionals and emergency medical staff on its use.CDC works with states, communities, and prescribers to prevent opioid misuse and overdose by tracking and monitoring the epidemic and helping states scale up effective programs. CDC also improves patient safety by equipping health care providers with data, tools, and guidance so they can make informed treatment decisions.
An NIH-funded study found that two drugs already on the market — an antifungal and a steroid — may potentially take on new roles as treatments for multiple sclerosis. According to a study published in Nature on April 20, 2015, researchers discovered that these drugs may activate stem cells in the brain to stimulate myelin producing cells and repair white matter, which is damaged in multiple sclerosis. The study was partially funded by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health.
Specialized cells called oligodendrocytes lay down multiple layers of a fatty white substance known as myelin around axons, the long "wires" that connect brain cells. Myelin acts as an insulator and enables fast communication between brain cells. In multiple sclerosis there is breakdown of myelin and this deterioration leads to muscle weakness, numbness and problems with vision, coordination and balance.
"To replace damaged cells, the scientific field has focused on direct transplantation of stem cell-derived tissues for regenerative medicine, and that approach is likely to provide enormous benefit down the road. We asked if we could find a faster and less invasive approach by using drugs to activate native nervous system stem cells and direct them to form new myelin. Our ultimate goal was to enhance the body’s ability to repair itself," said Paul J. Tesar, Ph.D., associate professor at Case Western Reserve School of Medicine in Cleveland, and senior author of the study.
Adult brains contain oligodendrocyte progenitor cells (OPCs), which are stem cells that generate myelin-producing cells. OPCs are found to multiply in the brains of multiple sclerosis patients as if to respond to myelin damage, but for unknown reasons they are not effective in restoring white matter. In the current study, Dr. Tesar wanted to see if drugs already approved for other uses were able to stimulate OPCs to increase myelination.
OPCs have been difficult to isolate and study, but Dr. Tesar and his colleagues, in collaboration with Robert Miller, Ph.D., professor at George Washington University School of Medicine and Health Sciences in Washington, D.C., developed a novel method to investigate these cells in a petri dish. Using this technique, they were able to quickly test the effects of hundreds of drugs on the stem cells.
The compounds screened in this study were obtained from a drug library maintained by NIH’s National Center for Advancing Translational Sciences (NCATS). All are approved for use in humans. NCATS and Dr. Tesar have an ongoing collaboration and plan to expand the library of drugs screened against OPCs in the near future to identify other promising compounds.
Dr. Tesar’s team found that two compounds in particular, miconazole (an antifungal) and clobetasol (a steroid), stimulated mouse and human OPCs into generating myelin-producing cells.
Next, they examined whether the drugs, when injected into a mouse model of multiple sclerosis, could improve re-myelination. They found that both drugs were effective in activating OPCs to enhance myelination and reverse paralysis. As a result, almost all of the animals regained the use of their hind limbs. They also found that the drugs acted through two very different molecular mechanisms.
"The ability to activate white matter cells in the brain, as shown in this study, opens up an exciting new avenue of therapy development for myelin disorders such as multiple sclerosis," said Ursula Utz, Ph.D., program director at the NINDS.
Dr. Tesar and his colleagues caution that more research is needed before miconazole and clobetasol can be tested in multiple sclerosis clinical trials. They are currently approved for use as creams or powders on the surfaces of the body but their safety administered in other forms, such as injections, in humans is unknown."Off-label use of the current forms of these drugs is more likely to increase other health concerns than alleviate multiple sclerosis symptoms. We are working tirelessly to ready a safe and effective drug for clinical use," Dr. Tesar said.
Federal and State Policy
15. President Signs Bill Repealing SGR Formula and Increasing CNSs Ability to Order Medicare Services
On April 16, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MARCA)− permanently repealing the Sustainable Growth Rate (SGR) formula for payment of Medicare providers. The passage of this legislation ends a series of 17 so-called "doc fixes" since 1997 when the SGR formula originally was passed into law but never fully implemented because of physician uproar. The MACRA legislation averts what would have been a 21 percent cut to Medicare physician payment, replacing it with 0.5-percent "updates," or physician payment increases, in 2015, 2016, 2017, and 2018.
This legislation contains a number of significant features and provisions for APRNs including:
In its FY 2016 budget brief, the Department of Health and Human Services (HHS) is proposing to expand its basis for beneficiary assignment for Accountable Care Organizations (ACO) to include clinical nurse specialists, nurse practitioners, and physician assistants.
According to the budget brief, the proposal would allow the HHS Secretary to base beneficiary assignment in the Medicare Shared Savings Program on a broader set of primary care providers that includes clinical nurse specialists, nurse practitioners, and physician assistants. Current statute requires that assignment of beneficiaries to an ACO be based on the utilization of primary care services provided by physicians. Expanding the assignment of beneficiaries would broaden the scope of ACOs to better reflect the types of professionals who deliver primary care services to fee-for-service beneficiaries. It could also result in a greater number of Medicare fee-for-service beneficiaries being assigned to ACOs that rely on non-physician practitioners for a majority of primary care services, such as those in rural or underserved areas.
The Center for Medicare and Medicaid Services (CMS) has clarified that CNSs, NPs, PAs, and physicians can order a hospital admission if three requirements are met. 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.
In 2010, in response to a request from Congress, NIH (the National Institutes of Health) contracted with the IOM (Institute of Medicine) to undertake a study and make recommendations to elevate the public health awareness of pain as a significant public health problem in the United States. The IOM report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research released in 2011, called for a cultural change in how we address pain care, including prevention, care, education, and research. It also called for the development of a comprehensive population health-level strategy to address the issues with pain relief and management. The National Pain Strategy was developed by an Interagency Pain Research Coordinating Committee appointed by the Assistant Secretary for HHS (Health and Human Services). This work involved an oversight panel, expert working groups explored six areas of need based on the IOM report – population research, prevention and care, disparities, service delivery and reimbursement, professional education and training, and public awareness and communication. The working groups were composed of healthcare providers, insurers, people with pain and pain advocates. There were some nurses represented on some of the working groups. The result of their work is the National Pain Strategy: A Comprehensive Population Health Strategy for Pain.
NACNS in collaboration with the APRN Workgroup, a national coalition of APRN advocacy organizations, developed joint comments in response to the National Pain Strategy draft. The top three points the coalition emphasized in these comments were:
The ICD-10 code implementation is on schedule for October 1, 2015. In preparation for this important change, the Center for Medicare and Medicaid Services (CMS) has prepared resources to assist providers and others to get ready for this change. If you are looking for information on ICD-10, please check these resources:
Understanding the Basics
Communicating About ICD-10
Educational ICD-10 Videos
Medscape Education Resources
Conferences, Meetings, and Webinars
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.