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.
After two years of work, the Title VIII Nursing Workforce Reauthorization Act (H.R. 2713) was passed by the House Monday, November 14. This legislation, supported by NACNS and the Nursing Community Coalition (of which NACNS is a member), identifies and defines clinical nurse specialists and includes language that specifically articulates the availability of Title VIII funding for programs that educate CNS students.
Now it’s up to the Senate. It’s hoped that the bill will go to the Senate floor for a vote during the current lame duck session. We will keep you posted.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare Sustainable Growth Rate methodology for updates to the Physician Fee Schedule and replaces it with a new approach to payment called the Quality Payment Program. A summary of the major provisions of the bill and its implications for NACNS members has been prepared for your information. Links for additional information also are contained in the document.
Thirteen cases of Candida auris (C. auris), a serious and sometimes fatal fungal infection that is emerging globally, have been identified in the United States, according to the Centers for Disease Control and Prevention (CDC). Seven of the cases occurred between May 2013 and August 2016 and are described in CDC’s November 4 Morbidity and Mortality Weekly Report. The other six cases were identified after the period covered by the report and still are under investigation.
C. auris tends to occur in hospitalized patients. Six of the seven cases were identified through retrospective review of hospital and reference laboratory records. Identifying C. auris requires specialized laboratory methods because it can easily be misidentified as another type of Candida infection, in which case patients may not receive appropriate treatment. Working in higher acuity facilities or health care systems, CNSs may be consulted on patients who are failing normal treatment protocols.
All of the reported patients had serious underlying medical conditions and had been hospitalized an average of 18 days when C. auris was identified. Four of the patients died; it is unclear whether the deaths were associated with C. auris infection or underlying health conditions.
C. auris often is resistant to antifungal drugs. Samples of C. auris strains from other countries have been found to be resistant to all three major classes of antifungal medications. However, none of the U.S. strains were resistant to all three antifungal drug classes.CDC recommends that healthcare professionals implement strict Standard and Contact Precautions to control the spread of C. auris. Any cases of C. auris should be reported to CDC. CDC can assist in identifying this particular type of Candida. For more information on C. auris, click here.
NACNS is excited to announce the next webinars in its 2016-2017 webinar series.
DECEMBER 6, 2016 2:00 pm ET
The APRN Consensus Model has been a nursing policy initiative for the past 10 years. A growing number of states have embraced this Model and have worked to improve the scope of practice of APRNs, including the CNS. As with all large-scale change, there are unintentional consequences and issues that need to be addressed. The APRN Compact builds on the National Council of State Boards of Nursing initiative to provide multi-state licenses to nurses and now APRNs. Both speakers have extensive public policy experience and will discuss the specifics of both the APRN Consensus Model and APRN Compact as well as advantages and concerns that CNS have identified with aspects of these legislative proposals.
JANUARY 12, 2017 2:00 pm ET
Prescription for Nutrition: Comprehensive Nutrition Management of Adult Hospitalized Patients by the Clinical Nurse Specialist
Webinars are held monthly and provide CE at a reduced price of $25.00 for members. Group pricing is available. Please email email@example.com for specific group size information. Webinar pricing has been restructured for 2016-2017. *Your purchase of the webinar includes access to the national-level, CNS specific continuing education and one person’s CE. If multiple individuals are listening to the webinar, the CE will only be available for one attendee. If you wish to register a group on one call-in line, please contact firstname.lastname@example.org. A group discount will be given for each additional CE on a single line.All NACNS webinars are archived. Email email@example.com to order an archived webinar. Listen at your leisure and apply for CE certificate.
To register, visit the NACNS website.
*This activity has been approved for contact hours by the Alabama State Nurses Association. The Alabama State Nurses Association is accredited as an approver of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation. Each webinar is worth one CE credit.
Stand Up and Be Counted!
NACNS is pleased to have the support of two leading healthcare publishers in this important effort. Springer Publishing Company, LLC and Wolters Kluwer, publisher of NACNS' official journal the Clinical Nurse Specialist: The International Journal for Advanced Nursing.
CNSs, who complete the survey, will be automatically entered in a drawing for an Apple Watch, donated by Springer Publishing, and an iPad Mini, donated by Wolters Kluwer.
The 2016 CNS Census was produced in concert with PhD nursing students at the University of San Diego, who helped refine the questions and reduce the amount of time required to complete the survey. Information on the results of the 2016 CNS Census will be published and made available on the NACNS website.Don’t miss your opportunity to be part of this important initiative!
NACNS has teamed up with the Indiana University School of Nursing to provide “Developing Your Skills as a Clinical Nurse Specialist Preceptor,” an exciting new online training program for CNS preceptors working with students doing clinical rotations. This online self-study course will provide nursing programs and CNS preceptors with valuable tips and tools for working with students, and allow them to complete the course on their own schedule.
“Developing Your Skills as a Clinical Nurse Specialist Preceptor” was developed by expert CNS preceptors and faculty from several health systems and universities. It includes three modules: Organizing the Learning Experience, Engaging the Student, and Providing Useful Feedback. The course addresses how to start the process of talking with prospective students about expectations and fit; strategies and best practices for working with students and faculty; teaching approaches; CNS competency areas; and providing feedback to students and faculty members. Registration is NOW OPEN!
NACNS members will receive a discounted rate of $99/registration with verification of membership, so be sure to take advantage of this opportunity! The individual non-member price is $129, and groups of five or more can receive discounted pricing as well.
Preceptor Course Planning Committee:Sharron Coffee, MSN, RN, CNS-BC, Milwaukee, WI; Julie Darmody, PhD, RN, ACNS-BC, Milwaukee, WI; Janet Fulton, PhD, RN, ACNS-BC, ANEF, FAAN, Indianapolis, IN; Jennifer Kitchens, MSN, RN, ACNS-BC, Indianapolis, IN, 2014 NACNS Preceptor of the Year; Francesca Levitt, MSN, Indianapolis, IN, 2012 NACNS Preceptor of the Year; Lisa Wagnes, MSN, RN, Indianapolis, IN
We look forward to seeing y’all at the next Annual Conference in Atlanta, Georgia on March 9-11, 2017. Join us at the Loews Atlanta Hotel for three days of idea sharing, networking, and fun on the theme of Tomorrow Belongs to Us: The Clinical Nurse Specialist Conquering Change in the Healthcare Environment.
On Wednesday, March 8, we will hold our full day Pharmacology Pre-Conference Workshop. Attendees can register for a full day or a half day. On Thursday, our keynote speaker,Kathleen Vollman, MSN, RN, CCNS, FCCM, FAAN, will encourage attendees to, Know It, Drive It, Own it: Healthcare’s Change Agent Now and In the Future. Ms. Vollman is the President of Advancing Nursing, LLC in Northville, Michigan. Our Friday, general session speaker will be Barbara McLean, MN, RN, CCRN, CCNS-NP, FCCM of Grady Health System, and on Saturday, the closing speaker will be Michael H. Ackerman, DNS, RN, APRN-BC, FCCM, FNAP, FAANP. This is a great opportunity to earn CE credit. We anticipate approximately 16.75 hours will be offered for the main conference with an additional 6 hours available for the pre-conference workshop. Pharmacology contact hours will be available as well. Registration will open later this month.Students and Educators: Please note that the poster submission deadline is December 5, 2016. More information is available by clicking here.
The ANA Center for Ethics and Human Rights Advisory Board is reviewing and revising its position statement, Nutrition and Hydration at the End of Life and soliciting public comment on the revised statement. The deadline for comments is 5:00 p.m. EST December 1.
The purpose of the revised position statement is two-fold. The first is to clarify nurses’ roles in the care of patients at the end of life, for whom decisions regarding artificial nutrition and hydration are being considered. The second is to explain how nurses can work with other providers, and with surrogate decision makers who are representing the patient’s preferences, as the surrogates consider the risks and benefits, and alternatives to various forms of nutrition and hydration for patients who are dying. These considerations apply to decisions to forgo food and fluids, dietary supplements and/or artificially administered nutrition and hydration.
Antibiotic use is the single most important factor contributing to antibiotic resistance around the world. Antibiotics are among the most commonly prescribed drugs in human medicine. However, up to 50% of all the antibiotics prescribed are unnecessary or are not optimally effective as prescribed.
Hospitals have begun to address antibiotic misuse by implementing antibiotic stewardship programs (ASPs), which aim to ensure that these drugs are prescribed only when necessary. Implementing these programs in all inpatient facilities is one of the recommendations in the National Action Plan for Combating Antibiotic-Resistant Bacteria.
In 2014, the CDC conducted a comprehensive evaluation of ASPs in 4,184 U.S. hospitals to determine how many included all seven of CDC’s core elements of hospital antibiotic stewardship programs, i.e., the seven components recommended for successful programs. These core elements are:
The CDC found that hospital size, location, and the presence of specific core elements on stewardship programs may influence details. Just over 39% percent of the facilities had ASPs that included all seven core elements. Leadership commitment was the least commonly adopted core element. Among all facility characteristics and core elements, however, it was the strongest predictor for a hospital having a comprehensive ASP. Facilities that had written support from hospital administrators were seven times more likely to have a stewardship program that included all seven core elements. Salary for staff to engage in stewardship was also significantly predictive of a comprehensive program. These results highlight the importance of support from hospital leadership in implementing successful ASPs.
Timely administration of antibiotics is associated with reduced mortality among patients with cirrhosis and upper gastrointestinal bleeding (UGIB), according to a study published in the November 2016 issue of Clinical Gastroenterology and Hepatology. The study concludes that targeted efforts are needed to promote the appropriate use of antibiotics among patients with cirrhosis and UGIB.
Researchers looked at 6,451 patients with cirrhosis admitted in the Veterans Affairs system for UGIB from January 1, 2005, through December 31, 2013 (8655 hospitalizations). They found that timely antibiotic use (i.e., from eight hours prior to hospitalization through 48 hours afterward) was linked to a 30% lower rate of 30-day mortality.Timely administration of antibiotics occurred during 48.6% of admissions (n = 4210), increasing from 30.6% in 2005 to 58.1% in 2013. Independent predictors of antibiotic receipt included ascites, high model for end-stage liver disease score, esophageal variceal hemorrhage, and administration of octreotide or intravenous proton pump inhibitors. Variables associated with decreased odds of antibiotic provision included black race and nonalcoholic fatty liver disease.
A recent study by the Centers for Disease Control and Prevention (CDC) found an increased risk of sepsis following infection-related hospitalizations, possibly mediated by antibiotic-associated microbiome disruption, as demonstrated in animal models.
Using adult hospitalization and pharmacy data, the CDC researchers retrospectively identified a cohort of hospitalized patients and determined subsequent sepsis, based on ICD-9-CM codes, during a readmission within 90 days after discharge from the index visit. Their primary exposure was any antibiotic with a high risk for microbiome disruption administered during the index visit (e.g., 3rd-/4th-generation cephalosporin, fluoroquinolone, lincosamide, beta-lactam/beta-lactamase inhibitor combination, oral vancomycin, or carbapenem). Another set of drugs, including earlier cephalosporins, tetracycline, and sulfa drugs, was regarded as low-risk, while control antibiotics, such as penicillin, were thought to have limited potential to disrupt the microbiome.
Among 473 hospitals, they randomly selected 9,386,961 adult index visits without current or prior sepsis diagnosis; 0.6% had sepsis during readmission within 90 days of discharge. Exposure to a high risk antibiotic during the index visit was associated with a greater risk of sepsis during readmission compared to patients with no antibiotic exposure. Duration of therapy also played a role. Notwithstanding drug type, with an odds ratio of 2.4 patients treated for more than 14 days had twice the risk of later sepsis as those given shorter therapy.The observed increased risk for subsequent sepsis following receipt of antibiotics that significantly disrupt the microbiome, including a dose-response effect, supports the idea that microbiome disruption confers increased risk for subsequent severe infections. Better understanding the role of antibiotic-mediated microbiome disruption in sepsis will be important for future sepsis prevention. Providers and health authorities have one preventive measure that's currently available, improved antibiotic stewardship.
New research finds that hospital bedrails and the pockets and sleeves of healthcare workers' scrubs are the most likely sites for contamination in the ICU. Nurses and other hospital direct care workers need to be aware of the "transmission triangle"— patients, the environment, and the provider, according to a new study from Duke University Hospital.
The researchers took cultures from the sleeves, pockets, and midriff area of surgical scrubs of 40 ICU nurses at Duke University Hospital. The scrubs were new and the samples were collected at the start and end of each shift. Any type of activity in patient care, including walking into a patient room where care is provided, "truly should be considered a chance for interacting with organisms that can cause disease," Deverick Anderson, MD, the study's lead author, said in a statement.
In 2011, there were an estimated 722,000 healthcare-acquired infections (HAIs) in U.S. acute care hospitals, and about 75,000 patients with HAIs died during their hospitalizations.
For nearly a year-and-a-half, NACNS has been providing expert advice to the Senate Finance Committee's (SFC) Chronic Care Work Group (CCWG). CCWG is charged to explore cost-effective solutions to improve health outcomes for Medicare patients living with one or more chronic conditions. Spending on chronic illnesses accounts for roughly 93% of Medicare spending today. Without encouragement for providers to coordinate care, many Medicare patients have to visit multiple practitioners and specialists to receive the care they need.
In June 2015, NACNS submitted a letter to SFC Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) based on its perspective on the CCWG deliberations. NACNS drew on CNS research and extensive experience to offer recommendations including:
By December 2015, CCWG had used the submitted comments to draft an options paper. Policies in the options paper included allowing Medicare Advantage (MA) plans to tailor benefits specifically for chronically ill enrollees, and adding additional tools for Accountable Care Organizations (ACO). Other policies proposed were making permanent the Independence at Home (IAH) demonstration program that helps primary care providers give high-quality care in the home, and giving greater flexibility to MA and ACOs to deliver non-health services that are pivotal for beneficiaries with multiple, complex chronic illnesses.
NACNS responded to the options paper by leveraging its voice with two public policy coalitions in which it is a member, the Partnership to Fight Chronic Disease and the APRN Working Group. The APRN Working Group’s January 2016 letter to the CCWG holds that APRNs play a significant role in ensuring patient access to high-quality, cost-effective healthcare, which is particularly true in the management of patients requiring chronic disease management.
On October 27, the CCWG released bipartisan draft language for chronic care disease management legislation. The discussion draft, Creating High-Quality Results and Outcomes Necessary 6 to Improve Chronic (CHRONIC) Care Act of 2016, would emphasize coordinated, team-based care, extend by two years the IAH demonstration, let kidney-failure patients enroll in MA, ease telehealth restrictions, and change how beneficiaries could be assigned to ACOs.While SFC anticipates introducing the bill in December, it’s unlikely that action will be taken in this year’s remaining lame duck session. However, because the legislative language is bipartisan and was developed in a cooperative manner, CCWG remains optimistic that it is in a good position to introduce this bill and that it will have legs in 2017. A section-by-section summary of the discussion draft can be accessed by clicking here.
On September 28, CMS issued the first significant changes since 1991 to the requirements for long-term care (LTC) facilities participating in Medicare and Medicaid. Owing to the estimated financial burden and the complexity of the final rule, CMS has adopted a phased rollout. Implementation of the various requirements will be spread out over the next three years, beginning with phase 1 effective November 28, 2016.
As healthcare leaders in the more than 15,000 LTC facilities, CNSs will be instrumental in ensuring compliance with the LTC regulations. The new rule proposes to incorporate the full scopes of practice for non-physician practitioners related to actions that were formerly restricted to physicians. CMS notes, however, that the Social Security Act statute restricts some positions and tasks to physicians, such as requiring a physician supervise the care of every resident. Thus, where appropriate and permissible by statute, CMS has allowed for flexibility in who may perform certain tasks or services within their respective scopes of practice.
Nonetheless, this rule allows eligible practitioners (e.g., CNSs) the authority to write orders in their areas of expertise (e.g., laboratory, radiology, and other diagnostic service for a resident) when a physician delegates the responsibility and state licensing laws permit. Acknowledging the non-physicians’ full practice authority, including that of the CNS, will improve the care and safety of nearly 1.5 million LTC residents.
Other changes finalized in this rule include:
A federal interagency task force on October 27 issued a final report on actions and recommendations to better ensure compliance with health insurance coverage and parity protections for individuals with mental health and substance use disorders. Among other actions, the departments of Health and Human Services (HHS), Labor and Treasury also issued parity guidance, including information related to opioid treatment. In addition, HHS released a beta version web portal to help consumers with parity issues; the Substance Abuse and Mental Health Services Administration issued a consumer guide on coverage disclosure rights; and the Centers for Medicare & Medicaid Services announced $9.3 million in grants to help states monitor parity compliance. President Obama created the task force in March. For more information, click here.
The Department of Health and Human Services’ Health Resources and Services Administration (HRSA) is seeking new and experienced grant reviewers with expertise in these areas:
HRSA uses subject experts as peer reviewers to objectively evaluate a competitive group of grant applications. Reviewers are chosen based on their knowledge, education, and experience.
Each eligible grant proposal application is read by at least three reviewers who then discuss their evaluation and initial scores with other reviewers on their panel. This process is completed for each application using the Internet and telephone. It most often takes three days or less. Each non-federal participant receives an honorarium. Serving on a peer review panel for grant proposals provides insight into front edge research and is a professional development opportunity.All professionals working in or knowledgeable about healthcare services are invited to register through HRSA’s Reviewer Recruitment Module (RRM). The RRM platform uses standardized categories of information – e.g., degree, specialty, occupation, work setting, and in select instances affiliations with organizations and institutions that serve special populations – to find and select expert grant review participants.
In January 2014, the National Institute of Nursing Research (NINR), part of the National Institutes of Health, publicly launched Palliative Care: Conversations Matter®, an evidence-based communications campaign to increase awareness of and improve communications around pediatric palliative care. The first phase of the campaign included materials designed to assist healthcare providers with starting and continuing conversations about pediatric palliative care with their patients and patients’ families.
NINR currently is implementing the second phase of the campaign focusing on patients, their parents, and families, to raise awareness and empower families to begin a dialogue with healthcare providers. Survey findings will help determine if the campaign is effective, relevant, and useful to the families and caregivers of children living with serious illnesses.
The Conversations Matter® website provides information and resources for pediatric patients, their families, and their healthcare providers.
A new online patient safety tool being developed by AHRQ is intended to track adverse events in hospitals by capturing data from Medicare patients’ electronic health records. The Quality and Safety Review System (QSRS) will be tested by Johns Hopkins University and MedStar Health Research Institute as a replacement for the current Medicare Patient Safety Monitoring System (MPSMS). While substantial progress has been made in monitoring and measuring patient harms, MPSMS is limited because it relies on outdated software, can’t identify rare or unusual events and is unable to measure adverse events not currently defined by one of the system’s 21 measures.
The AHRQ-funded article, “Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future),” reviewed the strengths and limitations of MPSMS and other methods for measuring patient safety. Authors also explored expected future directions in patient safety measurement while focusing on issues that are informing the development and implementation of QSRS. You can access the abstract and a new AHRQ Views blog post, "New System Aims To Improve Patient Safety Monitoring."
AHRQ has updated its Hospital Guide to Reducing Medicaid Readmissions, which helps hospitals design and deliver transitional care that addresses medical, social and behavioral needs of Medicaid patients and other vulnerable populations. It provides guidance using the ASPIRE acronym: Analyze your data to understand existing readmission patterns and root causes; Survey your current readmission reduction efforts; Plan a multifaceted, data-informed portfolio of strategies; Implement whole-person transitional care; Reach out to collaborate with cross-setting partners; and Enhance services for high-risk patients. The guide includes 13 customizable tools and content for six webinars to support training on how to use it.
A report from the National Center for Health Statistics shows that the percentage of poor adults who lack insurance has declined to 26% from 40% under the Affordable Care Act, with uninsured rates among near-poor and not-poor adults also decreasing. Researchers also note that more low-income adults have a regular medical care provider and have seen or talked with a provider within the past year.
You can join more than nearly 2,000 thought leaders in American healthcare quality improvement at the CMS 2016 Quality Conference. This conference will explore how patients, advocates, providers, researchers, and the many leaders in healthcare quality improvement can develop and disseminate solutions to some of America’s most pervasive health system challenges. The 2016 CMS Quality Conference will be the most expansive yet, with both new and existing participants from programs across CMS, HHS, and community stakeholders. The collaborative format of the conference and strong focus on data-proven outcomes is underscored by this year's theme, Aligning for Innovation and Outcomes. For more information, visit the CMS Quality Conference webpage.
On October 19, the Trust for America's Health released its Blueprint for a Healthier America. The Blueprint features high-impact policies for the next Administration and Congress. The report calls for a new approach to health that prioritizes improving health and addressing major epidemics in the United States, and details pressing crises and how adopting proven health strategies could yield positive returns on investment. The Blueprint also highlights leading evidence-based strategies for improving health and policy, and models to help bring them to scale across the country. Here are a few related pieces:
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.