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 Emily O'Connor at firstname.lastname@example.org.
On March 15 the Centers for Medicare & Medicaid Services introduced Connected Care. Connected Care is an educational initiative to raise awareness of the benefits of chronic care management (CCM) services for Medicare beneficiaries with multiple chronic conditions, and to provide eligible practitioners, including clinical nurse specialists, with support to implement CCM programs.
Connected Care is a robust website with a vast array of resources that provide information for health care professionals. For example, eligible practitioners often are not aware of the separate payments under the Medicare Physician Fee Schedule and are not receiving the full separate payments now available for CCM services under Medicare Part B. One Connect Care resource is a fact sheet of 2017 CCM changes including a list of the following services that are billable per service period (month):
The 2016-2017 NACNS Board of Directors met on March 7-8 in Atlanta, GA at the association’s Annual Conference. In order for the 2017-2018 Board members to meet each other and begin orientation, new members met on March 11 after the conference.
NACNS hosted its most successful Annual Conference to date at the Loews in Atlanta, Georgia on March 9 -11. One attendee commented that, “This was the best Annual Conference I have attended so far. The papers and posters were extraordinary, the hotel was beautiful and the key note speakers were right on target.” NACNS staff quickly accommodated more than 50 on-site full-meeting registrations, a sign of a popular meeting! NACNS members were able to discuss, question and interact with task force and committee members. There was standing room only during sessions on the Opioid/Pain Management Task Force; the Practice Committee, who is developing a Cost Analysis Tool Kit; and the Core Statement Task Force. The Chronic Conditions and Malnutrition Task Force also presented their work to the membership.
The CNS Journal will publish the top ten abstracts from the Annual Conference. Conference attendees can access handouts on the NACNS Web site.
The growing success of the NACNS Annual Conference is allowing us to expand the length of the conference by a half-day. The meeting will now start on Wednesday afternoon and end Saturday at noon. Pharmacology preconference will be held Wednesday morning. Mark your calendars for February 28 – March 3, 2018 and join us in Austin, Texas.
Days prior to the 2017 Annual Conference, NACNS announced the formation of a new institute to develop and promote education, innovations in clinical practice, and scientific research that will advance the clinical nurse specialist role and improve patient care. The CNS Institute is the charitable arm of NACNS. During the Conference, the Institute held a town hall for members and collected donations in exhibit hall. Thanks to the generous donations from members, the CNS Institute reached its initial goal of $10,000 at the Annual Conference.
The members of the CNS Institute Board of Trustees are:
Melissa Craft, PhD, APRN-CNS, AOCN (Chair)
Susan Fowler, RN, PhD, CNRN, FAHA (Vice Chair)
Anne Hysong, MSN, APRN, CCNS (Secretary)
Nancy Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FAAN (Treasurer)
Gayle Timmerman, PhD, RN, CNS, FAAN
“We are extremely excited to be launching this new venture,” said Dr. Craft. “The CNS Institute will help to improve CNS education, practice and research so that we can do even more to ensure that health care teams are effectively delivering high quality, evidence-based, patient-centered care.”
At its Annual Conference, NACNS released a new report - Malnutrition in Hospitalized Adult Patients: The Role of the Clinical Nurse Specialist. Produced by the NACNS Malnutrition Task Force, the report calls for CNSs to step in and help this vulnerable patient population.
Malnutrition among hospitalized patients is a pervasive problem in the United States. It affects 20% to 50% of hospitalized adult patients and the costs of treating malnutrition are estimated to be more than $11 billion per year. A lack of proper nutrition can cause muscle wasting, loss of functional ability and increased rates of hospital-acquired conditions like falls, pressure injuries and infections - all which can lead to increased morbidity and mortality, longer hospital stays and higher rates of readmission.
Sponsored by Abbott Nutrition Health Institute, the report includes a literature review, an online survey of CNSs, and a new malnutrition conceptual model for CNS practice. It finds that CNSs are well-positioned to intervene and reduce malnutrition in hospitalized adult patients, but many have limited knowledge of and experience using nutritional assessment and interventions. In the survey, NACNS found that just half of its members (50%) reported they received education on nutrition beyond an undergraduate course and three in five NACNS members (59%) indicated they have basic, or less than basic, knowledge related to nutritional status or the nutritional needs of hospitalized patients.
According to Susan Smith, Chair of the NACNS Malnutrition Task Force, “Clinical nurse specialists are an untapped resource for hospitals and health systems looking to cut rates of malnutrition and reduce the costs and complications resulting from it... Decreasing the risk of developing or continuing malnutrition will not only make a difference to patients, it also will reduce rates of readmission and infection and thereby reduce healthcare costs.”
The report recommends that CNSs use their full scope of practice, including prescriptive authority, to identify and treat hospitalized adult patients who are experiencing malnutrition or at risk for it. They can:
In order to accomplish this, more education and training is needed for the CNS. The report recommends that NACNS work to develop: nutrition-related resources, nutrition education webinars, stronger nutrition content in curricula, relationships with nutrition groups, and explore and document the cost/benefit of nutrition intervention for patients.
Members of the NACNS Malnutrition Task Force, who authored the report, are:
NACNS’ Annual award winners were honored at the 2017 Annual Conference in Atlanta. These awards focus on the extraordinary work advancing and showcasing the critical role CNSs play in health care.
The award winners are:
Board of Directors
According to a new study from Johns Hopkins researchers, the opioid addiction treatment drug buprenorphine is doing little to wean patients completely off opioids. More than two-thirds of the opioid addicts in the study received a prescription for opioid painkillers within a year of taking buprenorphine and 43% were taking painkillers while in treatment. Buprenorphine is a more accessible alternative to methadone that doesn't require patients to visit a special clinic. However, the survey of pharmacy claims for 38,000 users show most stopped treatment after three months and ultimately returned to using similar amounts of opioids as before.The findings, published February 23 in Addiction, demonstrate the need for greater resources devoted to medication-assisted treatment, a common clinical tool to address the epidemic. “The substantial overlap between buprenorphine and non-buprenorphine opioid use underscores the importance of coordinated efforts to manage opioid use disorder while addressing chronic pain,” the authors said.
According to a September 2016 Medscape article, physicians at the American Academy of Family Physicians (AAFP) 2016 Congress of Delegates voted to eliminate pain scores as the "’fifth vital sign’, partly in reaction to being seen as a scapegoat for the nation's opioid overdose epidemic... But physicians in many specialties have explained that they feel pressure to overprescribe opioids, and do so to attain higher patient-satisfaction scores for themselves and their hospitals.”
Since the AAFP is not the first medical society to take a stance against the fifth vital sign, Medscape conducted an online survey of physicians and nurses in December 2016 to determine support for the AAFP vote. They received more than 2100 responses. Of nurse respondents, 44% strongly agreed with the AAFP, 22% somewhat agreed and 19% strongly disagreed. When asked about how often nurses use pain scores when assessing a patient's pain, 79% said often or always and 18% replied sometimes or rarely. Regarding the use of a patient’s functional status for evaluating pain levels, 52% of nurses indicated often or always, 23% said sometimes, 13% rarely and 9% never.
The survey also asked how often providers felt pressure to prescribe pain medication in order to keep patient satisfaction levels high. Eleven percent of the nurses said they always felt a need to prescribe, 29% said often, 23% sometimes felt pressured, 12% chose rarely, and 22% said they never felt pressured to prescribe.
A study published in the Proceedings of the National Academy of Sciences found a variety of carbapenem-resistant Enterobacteriaceae (CRE) species in three Boston hospitals and one California hospital which suggests the potentially deadly superbug is more prevalent in U.S. hospitals than previously believed. CREs cause 9,300 infections in the United States each year and 600 deaths. With incidence rising, researchers say greater surveillance is needed.
CNSs have a keen interest in cardiac arrest – the third leading cause of death in the United States, following cancer and heart disease. The National Academies of Sciences, Engineering, and Medicine’s (NASEM) Health and Medicine Division (formerly the Institute of Medicine) released its 2015 consensus report Strategies to Improve Cardiac Arrest Survival: A Time to Act which evaluated the factors affecting resuscitation research and outcomes in the United States.
Following its release, NASEM was asked to hold a workshop to explore the barriers and opportunities for advancing the report’s recommendations. Held in July 2016, the workshop featured these topics:
Exploring Strategies to Improve Cardiac Arrest Survival: Proceedings of a Workshop, which recently was released, summarizes the presentations and discussions from the 2016 workshop.
Cardiac arrest chain of survival
SOURCE: Presented by Tom Aufderheide, July 11, 2016, A Dissemination Workshop on the Report Strategies to Improve Cardiac Arrest Survival: A Time to Act.
The health and economic impact of three cardiovascular disease (CVD) preventive services varies with demographic characteristics and clinical objectives, according to a study published in the January/February issue of the Annals of Family Medicine. Researchers used a single, integrated, microsimulation model to generate comparable results for three services recommended by the U.S. Preventive Services Task Force. Lifetime outcomes were compared from the societal perspective for a U.S.-representative birth cohort of 100,000 individuals with and without access to aspirin counseling for primary prevention of CVD and colorectal cancer, as well as screening and treatment for lipid disorders and hypertension.The researchers found health impact was highest for hypertension screening and treatment, followed by cholesterol screening and treatment, and lower for aspirin counseling (15,600, 14,300, and 2,200 quality-adjusted life-years, respectively). For women, findings favored hypertension over cholesterol screening and treatment. Across all services, opportunities to reduce disease burden were greatest for non-Hispanic blacks. According to the authors, “our findings affirm that aspirin counseling for primary prevention and asymptomatic screening and treatment of hypertension and lipid disorders should remain among the top prevention priorities for adults in primary care.”
The European League Against Rheumatism (EULAR) for the management of early arthritis recently updated its 2007 recommendations to put renewed emphasis on early intervention, preventive lifestyle measures, and careful clinical examination. According to the recommendations’ co-author, “We have now focused on clinical examination and downplayed the role of ultrasound... and other biomarkers in making an appropriate diagnosis. And we have put a warning on careless and unlimited glucocorticoid use, since new evidence points to side effects of long-term use." The 2016 update can be examined in the Annals of Rheumatic Diseases.
In the March 7 issue of JAMA, a study suggested that the suboptimal intake of 10 specific dietary factors was associated with a substantial proportion of deaths due to cardiometabolic diseases (CMD) – heart disease, stroke, or type 2 diabetes. The largest numbers of deaths in this comparative risk assessment of 2012 data were related to high sodium, low nuts and seeds, high processed meats, low seafood omega-3 fats, low vegetables, low fruits and high sugar-sweetened beverages. The researchers concluded that the study “results should help identify priorities, guide public health planning, and inform strategies to alter dietary habits and improve health.”
An online survey, sponsored by pharmaceutical company Merck, finds that many adults with diabetes are unaware of their increased risk for certain serious illnesses. Respondents were twice as likely to identify an increased risk of kidney disease and heart disease, which are common diabetes complications, compared with serious infection diseases such as pneumonia, meningitis or pneumococcal disease. The study’s author recommends that health care professionals must initiate discussions with patients to “bridge the information gap and ensure that risks relating to their diabetes are made clear, enabling greater preventive measures to be taken.”
A new study based on recent national surveys estimates that diabetes accounts for many more deaths in the United States than are being reported on death certificates and that diabetes is actually the third leading cause of death. The latest data from the National Health Interview Survey and the National Health and Nutrition Examination Survey indicate that about 12% of deaths in 30- to 84-year-olds from 1997 to 2011 could be attributed to diabetes. However, during that same time, only 3.3% of death certificates listed diabetes as the underlying cause of death.
The purpose of the Agency for Healthcare Research and Quality review was to assess the predictive utility, reliability, and ease of use of the total Glasgow Coma Scale (tGCS) versus the motor component of the Glasgow Coma Scale (mGCS) for field triage of trauma, as well as the comparative effects on clinical decision making and clinical outcomes. One of the key findings is that limited evidence suggests that the mGCS is easier to score correctly than the tGCS. For a copy of the review, click here.
According to a new study published this week in the Journal of the Pediatric Infectious Diseases Society, rising infections caused by a type of bacteria resistant to multiple antibiotics is causing longer hospitalizations and may mean a higher risk of death for U.S. children. The study found that three out of five children admitted to hospitals already had an antibiotic-resistant infection — suggesting these infections are spreading more often.
In analyzing data from 48 children's hospitals across the country between 2007 and 2015, the researchers focused on 107,000 children under age 18 who contracted infections caused primarily by Enterobacteriaceae, a family of bacteria that includes dangerous strains resistant to most antibiotics. The results showed that the proportion of multidrug-resistant Enterobacteriaceae infections rose sharply, from 0.2% to 1.5%, over eight years.
In a March 15, 2017 letter to the House committees considering the American Health Care Act, NACNS President Vincent W. Holly, MSN, RN, CCRN, CCNS, advocated for patient safety and quality care. He noted that “...public officials should work to provide all individuals with equitable access to comprehensive health care services, including preventive services, acute care and ongoing chronic conditions. In order to ensure a healthy nation, it is critical that equitable access exists to care for the full range of services including the medical conditions of mental disorders, alcohol and substance abuse, and addictions.”
The letter went on to say that “As currently written, the American Health Care Act threatens health care affordability, access, and delivery for individuals across the nation. The bill eliminates the Prevention and Public Health Fund, changes Medicaid to a per capita funding model, repeals income based subsidies on which millions of people rely and restricts millions of women’s access to critical health services.”
For your information, the Kaiser Family Foundation has developed a tool that provides a side-by-side comparison of the Affordable Care Act and four proposed Republican plans to replace it. Areas of comparison include pre-existing condition exclusions, annual and lifetime limits, standards for minimum coverage, tax credit provisions, health savings accounts, modifications to Medicaid funding, and whether children can remain covered by parents' insurance until the age of 26, among others.
The Congressional Budget Office (CBO) released its analysis of the proposed American Health Care Act on March 13, estimating 5 million Americans would lose Medicaid coverage and 6 million people would lose individual coverage by 2018. Twenty-four million more people would be uninsured by 2026. The report predicts a short-term increase in premiums under the legislation, but longer-term rates would decrease overall, although many Americans would pay a greater share under the proposal's tax credit structure and premium calculations.
Harvard University Medical School and New York University have released results from a joint study on the possible implications of repealing the Patient Protection and Affordable Care Act (ACA) for individuals with a mental health and/or substance use disorder (MH/SUD). Researchers released three tables that cover the issue:
Republicans are intent on repealing a public health fund created by the Affordable Care Act. However, with the current Administration also pursuing a dramatic reduction in domestic spending, federal lawmakers admit they do not know if they could make up the losses at one of the nation's most critical health agencies. The latest version of the GOP health care bill - the American Health Care Act - would end the Prevention and Public Health Fund, which provides nearly $1 billion annually, in 2019. Those dollars have become an integral part of the Centers for Disease Control and Prevention's (CDC) budget, accounting for one-eighth of its funding and providing more than $300 million for immunizations alone.
23. Health Professions and Nursing Training Programs Take a Hard Hit in Administration’s Proposed Budget
On March 16 the President released his FY 2018 budget – America First - A Budget Blueprint to Make America Great Again. The specific proposal affecting nursing states:
The released budget is considered a “skinny or slim” budget, which is standard in a new administration. It does not include many of the details about the actual programs under the various departments and agencies and only provides high-level initiatives. The $403 million dollar cut to “health professions and nursing training programs” does not provide specific details with respect to Title VII Health Professions Programs or Title VIII Nursing Workforce Development Programs. Another budget will be released in April with further details.
Members of the House of Representatives introduced legislation on February 7 to amend Title VIII of the Public Health Service Act, H.R. 959. Among several purposes, this bill, also referred to as the “Title VIII Nursing Workforce Reauthorization Act of 2017,” proposes to extend advanced education nursing grants to support clinical nurse specialist programs.
H.R. 959 states that eligibility for “advanced nursing education grants is expanded to include education programs for clinical nurse specialists... Clinical nurse specialists are advanced generalist clinicians who apply research and coordinate care in order to improve outcomes for patients. To be eligible for these grants, clinical nurse specialist programs must provide registered nurses with full-time clinical nurse specialist education that qualifies the nurses to provide a full range of care.”As a longtime nursing leader supporting Title VIII and its investments, NACNS public comments over the years can be examined on the NACNS website. As example, see the Testimony Regarding Fiscal Year 2017 Appropriations for Title VIII Nursing Workforce Development Programs. Or see the NACNS Board of Directors-approved 2016-2018 Public Policy Agenda, which promotes increased funding for policy initiatives, such as the Title VIII – Nursing Workforce Development Programs, that help alleviate the nurse and nurse faculty shortages and increase the retention and recruitment of RNs and APRNs.
Seema Verma won Senate confirmation as CMS Administrator in a largely party-line vote on March 13, placing an advocate of overhauling Medicaid at the program’s helm. With Ms. Verma installed in a 55-43 vote, the Administration is set to move forward with dismantling parts of the Affordable Care Act through executive action.
The Centers for Medicare and Medicaid Services (CMS) oversees health insurance programs for more than 100 million Americans, but it also runs key parts of the Affordable Care Act. Ms. Verma, a health policy consultant, made a name for herself as the architect of Indiana’s Medicaid expansion program under then-Governor Mike Pence. An analysis of the program conducted by the nonpartisan Kaiser Family Foundation found its design had mixed results, in part because the more complex enrollment policies and premium costs deterred some people from signing up for coverage.
Continuing a 16-year trend, the rate of drug overdose deaths increased in 2015, having the greatest impact among adults aged 45-54, according to a new study of national vital statistics published in February by the Centers for Disease Control and Prevention (CDC). The data brief overall shows there were 16.3 drug overdose deaths per 100,000 people in 2015, a rate that’s been increasing about 5.5% annually since 1999.
NACNS is a recognized national nurse leader addressing pain management issues. See the January 2016 NACNS Comments to CDC Guideline for Prescribing Opioids for Chronic Pain, its April 2016 press release to Join National Effort to Combat Opioid Abuse, and the September 2016 NACNS announcement of its Task Force to Study Opioid Use and Pain Management.
On March 1 the Oklahoma House overwhelmingly passed HB 1013 by a vote of 72 -20. This measure allows the APRN – which includes CNSs – full practice authority (FPA), permitting them to provide health care services consistent with their education and training, without a “collaborative agreement” with a physician. It modifies the definition of "Advanced Practice Registered Nurse" to allow this classification of nurse to serve as primary care provider; modifies standards to that effect; removes unnecessary language; and repeals the formulary advisory council. The bill now moves to the Senate for approval.
The Food and Drug Administration (FDA) has released an educational series of case studies with instructor guide files which can be integrated into schools of nursing curricula. Based on a real-world scenario, each case study promotes active learning through exercises, instructor-led discussions and quizzes. Titled “FDA MedWatch Adverse Event Reporting,” one of the two most recently published case studies focuses on developing a culture of safety, accountability and shared responsibility for students. The second case study, “Useful FDA Drug Information for Clinicians,” highlights available FDA resources to which practicing clinicians can refer for medical product information.
The Centers for Disease Control and Prevention (CDC) has issued a slide presentation "Zika Virus: A Primer for Nurses". In addition to the presentation slides, CDC also published the notes for the slides in a file titled “Zika Grand Rounds Facilitation Guide and FAQs: Nursing”. Topics include
HealthLeaders Media, in partnership with Truven Health Analytics, recently published a 2-page fact file on Mental Health and Substance Abuse Treatment Trends. Treatment costs for mental health (MH) and substance use disorders (SUD) are climbing, driven in part by the opioid epidemic. Projections estimate that by 2020, MH/SUD treatment spending will total $280.5 billion, a 63% increase from 2009. The fact file suggests that increasing use of SUD services “reveals an opportunity to expand treatment and prevention programs in-house or through partnerships. In addition, hospitals and health systems can respond to these rising costs and greater need by ensuring opioid prescribing patterns meet current guidelines and by instituting care management assistance when pain medications are necessary.”
Earlier this month, the CDC released a mapping tool that allows users to view the prevalence of certain chronic conditions, behaviors and risk factors that have a substantial effect on people’s health for 500 of the nation’s largest cities. The application is part of the 500 Cities Project, a partnership with the CDC and the Robert Wood Johnson Foundation.
According to Wayne Giles, M.D., director of CDC’s Division for Heart Disease and Stroke Prevention, “Having the ability to report and map health data at city and neighborhood levels is a game changer for public health... Local level data available through the 500 Cities website provide health information to better inform and target strategies that are proven to work in improving health.”
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.