Embed Size (px)
Citation preview
10/17/2011
1
ANA: Moving Nursing’s Agendain Healthcare Reform…
and Beyond
ANA: Moving Nursing’s Agendain Healthcare Reform…
and Beyond
ANA’s Belief
Quality, affordable
health care is not a privilege, but a basic human right.
ANA’s Four Pillars of Health Care Reform
10/17/2011
2
ANA Health System Reform Agenda
Access – health care services must be:
– Affordable
– Available
– Acceptable.
ANA Health System Reform Agenda
Quality Aims – health care must be:
– Safe
– Effective
– Patient‐centered
– Timely
– Efficient
– Equitable
ANA Health System Reform Agenda
Cost of care – strike a balance between:
High‐technology treatments and
Community‐based and preventive services.
10/17/2011
3
ANA Health System Reform Agenda
Workforce – there must be an adequate supply of:
Well‐educated
Well‐distributed
Well‐utilized
REGISTERED NURSES
“We in America do not have government by the majority. We have government by the majority
who participate.”
Thomas Jefferson
10/17/2011
4
The Affordable Care Act
The Patient
Protection and
Affordable Care Act
was signed into law
on March 23, 2010.
ACA ‐What’s Already in Effect
Children with Pre‐Existing Conditions
• Cannot be denied coverage
• New Plans
• Grandfathered group plans
• Up to age 19
Adults with Pre‐Existing Conditions
• No discrimination, beginning 2014
ACA ‐What’s Already in Effect
Coverage for Young Adults
• All parent health plans which cover children must make available until age 26.
• Includes married adult children.
Tax Credit For Small Businesses/Nonprofits
• 35/25 percent of employers’ contribution to coverage for employees
10/17/2011
5
ACA ‐What’s Already in Effect
Ending “rescission” of insurance coverage
• Insurers can no longer end health insurance when someone gets sick.
No more Lifetime or Annual limits to insurance coverage
• Health plans can no longer impose lifetime or annual limits on benefits.
ACA‐What’s Already in Effect
Help with the Medicare “Donut Hole”
•$250 rebate checks for Part D beneficiaries
•Donut hole currently $2,830 to $6,440
•50 percent discount ‐ brand‐name drugs
•Increasing discounts ‐ generic drugs
•“Donut hole” closes completely by 2020
ACA ‐What’s Already in Effect
Wellness Visits
• Medicare now offers one annual wellness visit, at no charge.
Preventive Health Services
• All new health plans & all Medicare plans must cover certain preventive services at no charge.
10/17/2011
6
ACA – Major Changes to Come
2014: State Health Insurance Exchanges
• State, regional, federally run
• 2014: Individuals & Employers of 50‐100 workers
• 2017: Employers of over 100 workers
• Certify & offer private, cooperative plans
• Inform consumers & Medicaid/CHIP eligible
• $6 Billion‐Consumer Operated & Oriented Plans
ACA – Major Changes to Come
2014: Expanding Medicaid Eligibility
To 133% of poverty level (non‐elderly).
Cover 40% of uninsured / 12 million people.
Projected cost to States: $20 billion / 10 years.
2014‐2019 costs:• MD: $338 Million
• PA: $468 Million
• WV: $118 Million
ACA – Major Changes to Come
2014: “Individual Mandate”
• US citizens must have health insurance coverage or pay a fine:
• $95 in 2014
• $325 in 2015
• $695 in 2016
• Caps: Individuals‐2.5% of AGI; Families‐$2,250
• Fine is ½ for children
10/17/2011
7
ACA – Major Changes to Come
2014: Fines for Businesses
• Not offering health insurance for employees
• $2,000 or $3,000 per employee
2018: Taxes on “Cadillac Plans”
• Taxes on employer plans costing over $27,500/family or $10,200/individual
ACA & Nursing Practice
The Affordable Care Act supports a larger role for RNs & APRNs in our health care delivery system, through– Education
– Reimbursement
– New Models of Care
– New Patient Services
– Quality Assurance
ACA & Nursing Education
ACA Supports Title VIII Nursing Workforce Development
Programs:
• Loan repayment and scholarship programs
• Nurse faculty programs
10/17/2011
8
ACA & Nursing Education
ACA Supports:
• Nursing Student Loan Program
• Nurse Loan Repayment and Scholarship Programs
• Advanced Education Nursing‐Midwifery Programs
ACA & Nursing Education
ACA Supports:
• Nurse Education, Practice, & Quality Grants
–HHS grants for nursing career advancement
–HHS awards for enhanced collaboration &
communication
ACA & Nursing Education
ACA Supports:
• Nurse Faculty Loan Program
– Increase from $30,000 to $35,000/year
– $10,000‐$20,000/year for MSN/PhD faculty members
• Nursing Workforce Diversity Grants
– Expanded to include RN to BSN, accelerated programs
10/17/2011
9
ACA & Nursing Education
Graduate Nursing Education (GNE) for APRNs
– $50 Million/year – for FY 2012 – 2015
– Medicare GNE Demonstration Program
– NPs, CNSs, CRNAs, CNMs
– Hospitals partner with nursing schools, community
health
ACA & Nursing Education
Other Educational Support:
• Pediatric Health Care Workforce
• Public Health Workforce Loan Repayment
• Allied Health Loan Forgiveness
• Mid‐career public & allied health scholarships
• Direct (Chronic/Long‐Term)Care Workers
• Geriatric Nursing Career Incentives
ACA & Nursing Education
For More Information
Visit HRSA Website
www.hrsa.gov
www.rnaction.org/healthcare
10/17/2011
10
Nurse‐Midwife Reimbursement
Certified Nurse‐Midwives
• Enrolled as Medicare providers/bill directly
• Were reimbursed at 65% of physician rate
• Beginning January 2011, receive 100% of physician rate
• CRNAs receive 100% ‐ no change
• NPs & CNSs still receive 85% ‐ no change
Primary Care Bonuses
Primary Care Practitioners
• In Health Professional Shortage Areas
• Including Nurse Practitioners & Clinical Nurse Specialists
• Receive 10 percent bonus
• Added to Medicare reimbursement
• FY 2011‐2016
Nurse‐Managed Health Centers
• $50 million in grants for NMHCs that:
• Provide primary care or wellness services
• Care for underserved or vulnerable populations
• Are associated with:
• Academic department of nursing
• Qualified health center
• Independent nonprofit health/social services agency
10/17/2011
11
School‐Based Health Centers
Two new grant programs:
• $50 million/year (FY 2010‐13) to construct & equip new Centers
• Priority – many Medicaid‐eligible children
• Funding for existing Centers
• Priority – Primary care shortage areas, many uninsured children
Nurse Home Visitation Services
“Evidence‐based nurse home visitation programs”
• Established by states after needs assessment
• Serve maternal, infant, early childhood
• Priority to supporting high‐risk populations
• Federal grant support
Independence at Home
Supports “home‐based primary care teams”
• Led by Nurse Practitioners and/or Physicians
• Serve chronically ill Medicare patients
• Incentives for lowering costs
• Priority for:
• High cost locales
• Experience with home health
• HIT & Individual care plans
10/17/2011
12
National Health & Public Health Service Corps
Several ACA provisions enhance primary care provided under the National Health Service Corps
Includes APRNs who participate
ACA Panels & Nurse Members
Almost 150 new national advisory panels, including
– Medicare Independent Payment Advisory Board
Patient Centered Outcomes Research Institute
– Debra Barksdale, PhD, RN – PCORI member
– Robin Newhouse, PhD, RN – Member, Methodology Committee
National Health Workforce Committee
– Peter Buerhaus, PhD, RN ‐ Chairperson
New Models of Care
Accountable Care Organizations
• Medicare “shared savings” program
• Hospitals, providers form ACO to manage $ coordinate care for Medicare patients
• Must meet quality performance standards, financial benchmark
• Payments based on cost savings
• Must include primary care professionals –including Nurse Practitioners & CNSs
10/17/2011
13
New Models of Care
Medicaid/CHIP Pediatric ACOs
• Demonstration project
• State Medicaid/CHIP beneficiaries
• Incentive payments for
• Achieving savings target
• Meeting performance standards
New Models of Care
Medicare Medical Homes
• HHS grant program to States
• Establish community‐based, interdisciplinary “health teams”
• Support primary care practices
• Nurses & Nurse Practitioners specifically included in “health teams”
New Models of Care
Center for Medicare and Medicaid Innovation
– Newly created, to examine & develop innovative ways to improve care & cut costs
Community‐Based Care Transitions Program
– To reduce recidivism, readmissions
– Based on research of Nursing Interventions that manage transition from hospital, etc. to home
10/17/2011
14
New Models of Care
Health Care Innovation ZonesPlanning grants for teaching hospitals, etc.– To address increasing costs
–Provider collaboration to offer full spectrum of care, share data
ACA & Quality of Care
Decreasing Hospital Readmissions
• Hospital readmissions reduction program – decrease payments to hospitals with readmissions and requires public reporting of readmission rates.
• Community based care transition –development of transition programs to decrease readmissions.
ACA & Quality of Care
Patient‐Centered Outcomes Research Institute
– Comparative Effectiveness Research (CER)
– Prevention, diagnosis, treatment, monitoring & management of health conditions
– AHRQ issues findings, relate to coverage decisions
Center for Quality Improvement & Patient Safety
– “Best practices” identification & assistance
– Quality Improvement Network Research Program
10/17/2011
15
Divided Government 2010 Elections
Executive Branch –
– White House, Federal Agencies, Etc.
Legislative Branch – SPLIT!
Political Landscape in Washington, DC
MAJOR SHAKE UP!!
Republicans now control House of Representatives (R‐ 242, D, 192 1 vac.OR (Wu)
Democrats still control Senate D–51, R‐ 47, I ‐2 Lieberman (D) Sanders (I)
Political Landscape in Washington, DC
MOC Different Priorities
Passing legislation will be ????? in the 112th
Congress.
10/17/2011
16
Double the Nurses in the House
Karen Bass (D‐CA)
Diane Black (R‐TN)
Ann Marie Buerkle (R‐NY)
Renee Ellmers (R‐NC)
Returning nurses: Reps. Capps (D‐CA), Johnson (D‐TX), McCarthy (D‐NY)
112th Congress & ACA
Efforts to repeal ACA
Hearings on ACA
Defunding parts of ACA
State Responses
Introduction of state laws reversing the insurance coverage mandate (more than 45 states; limit, alter or oppose selected state or Federal actions.) 17 passed binding leg. Opposing elements HCR.
State AG Filed lawsuits challenging the constitutionality.
Ballot questions during November elections
10/17/2011
17
State Challenges to ACA
26 State lawsuits challenge ACA constitutionality – mostly “individual mandate”– Most States simultaneously following ACA provisions, receiving ACA funding
Upheld in all but 2 federal court decisions– Supreme Court will have to decide
What Health Care Reform Means for the States…
We need an infusion of nurses at the table!
2011 Nursing’s Next Steps __________________________________________________________________
With HHS Secretary Kathleen Sebellius (center), November 2010
10/17/2011
18
The Regulatory Process –an Uphill Battle
We must be vigilant about how the law is implemented
ACA Regulations
Agencies implement & interpret laws through formal rule‐making, other actions.
Proposed & final rules are published in Federal Register, with opportunity for comments.
Final rules become part of the Code of Federal Regulations & have the force of law.
ACA Regulations
Many provisions in ACA are not effective until regulations are prepared & adopted.
Many notices of proposed rulemaking have been issued since ACA signed into law.
Process is moving quickly.
Main agencies: HHS, CMS, IRS.
10/17/2011
19
ACA Resources
www.HealthCare.gov
A federal government Website managed by the U.S. Department of Health & Human Services.
www.healthcareandyou.org
The Power of Grassroots:
Share Your Story!
www.rnaction.org/healthcarestory.
10/17/2011
20
www.rnaction.orgEducate consumers and patients about how the new law will impact them.
Get involved. Serve on a state task force or committee that will shape reform at the state level.
Keep the pressure on legislators when there are attempts to de‐fund health care reform.
Nurses Make a Difference…
“Never doubt that a group of thoughtful, committed citizens can change the
world. Indeed, it is the only thing that
ever has.”
‐‐Margaret Mead
10/17/2011
21
The Cost of Nursing: The Dollars and Sense of Caring
PA State Nurses Association Annual Summit
October 28, 2011
Handout/Note Pages
Spanning the Continuum of How Nurses Matter: Nurse Staffing and Inpatient Martality, and Nurse Practitioners Providing Primary Care for Medicare Beneficiaries – Peter Buerhaus, PhD, RN, FAAN
1. Discuss the association of hospital nurse staffing and inpatient mortality.
2. Describe RNs views of issues affecting the nursing workforce.
3. Describe the American public’s attitude, knowledge, and behavior toward nurses; and of how health policy thought leaders view the nursing and health workforce. 4. Describe at least 5 implications for nursing regulatory policy.
Lateral Accountability – Denise Lucas, RN, MSN, NEA-BC and Suzanne McCullough, BSN, RNC
BULLYING: Everyone has the power
to make a Difference
Presenters: Denise Lucas, RN, MSN, NEA-BC Vice President Patient Services/Chief Nursing Officer DuBois Regional Medical Center 814-375-3491 [email protected] Suzanne McCullough, RN, BSN Supervisor, Neonatal Intensive Care Unit DuBois Regional Medical Center 814-375-6754 [email protected] Program Objectives: At the conclusion of this program, participants will be able to: 1. Describe factors in the current healthcare environment that foster bullying and identify the behaviors in the current culture 2. Define Bullying and its ten most frequent forms 3. Explain the leadership role in building a culture of respect and costs of Bullying culture 4. Explain three strategies to stop Bullying 5. Describe a practical application of "No Bullying" strategy in a clinical department 6. Identify practical tips for a "No Bullying" implementation strategy
BULLYING: Everyone has the power to make a Difference
A. Environmental Factors 1. Value based purchasing/ quality, safety, and service mandates 2. Economic forces 3. Workforce supply/ diversity 4. Leadership effectiveness to manage within current scope of responsibility
B. No Bullying Definition and Common Forms
1. Nonverbal innuendo 2. Verbal affront 3. Undermining activities 4. Withholding information 5. Sabotage 6. Infighting 7. Scope quality 8. Backstabbing 9. Failure to respect privacy 10. Broken confidences
C. Leadership Role and Organization Costs of Bullying
1. Leader Responsibilities a. Daily practice
b. Vigilant oversight c. Zero tolerance
2. Costs a. Quality, Safety, and Service
b. Work environment c. Financial D. Strategies to stop Bullying
1. “I” message 2. “OUCH” 3. Crucial conversations
E. Clinical Department Implementation F. Practical Implementation Tips
1. Executive Role 2. Training 3. Organization wide approach 4. Committed core team
Additional Note Page for Bullying presentation
Safety Behaviors to Decrease Medication Errors- Samuel Miranda, Jr., MS, RN, NEA-BC
1. Examine the elements associated with the definition of a Medication Error. 2. Discuss the elements associated with a “Near Miss” 3. Develop a listing of prevention strategy including process of the Medication User
System 4. Describe the development of a measuring and monitoring Medication Use System 5. Identify the safety components of Safety Reports Events System related to
medication safety for trending and prevention purposes. 6. Incorporate the principles of “Just Culture” in the evaluation of Medication Error
Reduction efforts.
ANA: Moving Nursing’s Agenda in Healthcare Reform…. And Beyond – Rachel M. Conant
1. Discuss the health care reform debate from nursing’s perspective. 2. Describe why nurses are at the health care reform table and how nursing can
continue to influence the debate.
See attachment entitles Healthcare Reform
Improving Outcomes with Compassion – Karen Carman, RN, MSN 1. Identify at least four elements of compassion. 2. Describe three strategies for providing compassionate care to all patients. 3. Describe at least two benefits to both nurse and patient that compassionate care
provides.
State of the Nursing Workforce: Intersection of Demographic Trends, Economic Recession and New Public Policy Initiatives - Peter Buerhaus, PhD, RN, FAAN
1. Identify how the recession has impacted hospital RN employment and earnings. 2. Describe strategies to prepare for the impact of a recovery in economic growth and
overall employment in the national economy. 3. Identify the latest forecasts of the future age and size of the RN workforce. 4. Describe the current status of the National Health Care Workforce Commission and
implications to the nursing workforce. 5. Describe 5 actions that can be taken to strengthen the nursing workforce
PA State Nurses Association
Practice Showcase
Abstract Compilation
October 28, 2011
Abstract 1 ‐ Developing an Educational Clinical Practicum to Assist in Translating Evidence‐Based Research into
Practice to Improve Patient Care in a Tertiary‐Care Magnet Hospital.
Vera C. Brancato, Ed.D., MSN, RN
Objective: Describe the process of (i) developing and implementing an educational practicum to facilitate
application of evidence‐based theory by nursing students to actual clinical problems and (ii) assessing the
effectiveness of the practicum on student learning.
Abstract: The Institute of Medicine’s report Health Professions Education: A Bridge to Quality (2003) proposed that
health care professionals be educated on the use of evidence‐based practice (EBP). As applied to nursing, EBP
incorporates the most current and best knowledge to enhance the likelihood that patients will receive the most
effective nursing care possible. This is accomplished through an integration of clinical expertise with external
research. Moreover, the October 2010 Robert Wood Johnson Foundation Initiative on the Future of Nursing
exhorted nursing educators to employ educational initiatives to improve nursing competencies in decision‐making
skills, clinical judgment, critical reasoning and evidence‐based practice.
The call for use of EBP in nursing has been heeded in a number of ways. For example, regulatory agencies such as
JCAHO have standards requiring health care providers to utilize best practices based on research, and EBP has
become an essential component of Magnet hospitals. However, because RNs in practice report that their
educational preparation in EBP is lacking, it is evident that more needs to be done by nursing educators to
effectively teach EBP and how to apply it in clinical practice settings.
A nursing educator in an RN to BSN program developed an innovative clinical practicum to help nursing students
translate EBP theory taught in the classroom into the reality of the practice environment. The presentation will
describe how the educator overcame potential barriers to the use of EBP and how she set up the clinical practicum
to successfully achieve the practicum’s goals and objectives and assess the effectiveness of the practicum on
student learning. Necessary resources such as tutorials and websites to access the best available external research
will be outlined. This presentation also will focus on how to combine active learning strategies to educate nursing
students on how EBP can be used to make decisions that can improve patient care delivery. Qualitative research
findings will be described that indicate the progress which nursing students made in their skill/knowledge
development, their comfort level with EBP, and their capacity to value a lifelong learning approach to EBP. Benefits
to the hospital and patient care delivery also will be included.
References:
Brancato, V. C. (2006). An innovative clinical practicum to teach evidence‐based practice. Nurse Educator, 31(5),
195‐199.
Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of
Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from
http://www.iom.edu/Reports/2010/The‐Future‐of‐Nursing‐Leading‐Change‐Advancing‐Health.aspx
Greiner, A. C. & Knebel, E. (Eds.), Committee on the Health Professions Education Summit. (2003). Health
professions education: A bridge to quality. Retrieved from The National Academies Press website:
http://www.nap.edu/catalog/10681.html
Koehn, M. L. & Lehman, K. (2008). Nurses’ perceptions of evidence‐based practice Journal of Advanced Nursing,
62(2), 209‐215.
Melnyk, B. M. & Fineout‐Overholt, E. (2005). Evidence‐based practice in nursing & healthcare: A guide to best
practice. Philadelphia, PA: Lippincott Williams & Wilkins.
Messear, D. C. & Tanner, C. A. (2009) Evidence‐based practice. In L. A. Joel, Advanced practice nursing: Essentials
for role development (pp. 244‐259), Philadelphia, PA: Davis.
Pravikoff, D. S., Tanner, A. B., & Pierce, S. T. (2005). Readiness of U.S. nurses for evidence‐based practice. American
Journal of Nursing, 105(9), 40‐51.
Abstract 2 – Social Choice: THE COSTS OF CONVERSATONS OR CRITICAL CARE BEDS?
Susan B. Dickey, PhD, RN
This poster seeks to enlighten nurses in the membership of the Pennsylvania State Nurses Association (PSNA) and
possibly others about the recently published ANA Position Statement on end of life care. It is imminently practical
in depicting many evidence‐based ways in which professional nurses at any level of education can improve
conversations among nurses, patients and their families, and members of all other disciplines, including health
care providers, clergy, medicine, social work, law and more. An extensive literature review was conducted by
members of the ANA sub‐committee who wrote the document, followed by intense scrutiny at the subsequent
levels of the ANA Advisory Committee on Ethics and Human Rights, the ANA Commission on Nursing Practice and
the ANA Board of Directors. When nurses and other health care providers seek to educate and then find out what
patients and their families really want for their end of life care, or when they care for persons with life‐threatening
or health‐threatening illnesses, much pain (emotional and physical) can be averted and much aggravation, dashed
expectations, frustration, anger and money can be saved. It takes a nurse!
References
American Nurses Association (2010). Position Statement: Registered Nurses’ Roles and Responsibilities in Providing
Expert Care And Counseling at the End of Life – 6/14/10[PDF]
Cruzan v. Director. (1990). Nancy Beth Cruzan, by her Parents and Co‐Guardians. Lester L. Cruzan et ux. V. Director,
Missouri Department of Health, et al., 497 US 261. (1990). http://www.law.cornell.edu/supct/html/88‐
1503.ZS.html
Dickey, S.B. (2006). Informed consent: Ethical issues. In V.D. Lachman, Ed. Applied Ethics in Nursing. New York:
Springer.
Schwarz, J.K. (2007). Exploring the option of voluntarily stopping eating and fluid within the context of a suffering
patient’s request for a hastened death. Journal of Palliative Medicine, 10(6): 1288–1297.
Bibliography
American Nurses Association (1991). Position Statement: Nursing and the Patient Self‐Determination Acts –
11/18/91
American Nurses Association (1992). Position Statement: Foregoing Nutrition and Hydration – 4/02/92
American Nurses Association (1994). Position Statement: Assisted Suicide 12/08/94
American Nurses Association (1994). Position Statement: Active Euthanasia – 12/08/94
American Nurses Association (2001). Code of Ethics for Nurses. Washington, D.C.:
author. http://www.nursingworld.org (Nursesbooks.org)
American Nurses Association (2003). Position Statement: Nursing Care and Do‐Not‐Resuscitate Decisions – 12/03
[PDF]
Abstract 3 ‐ : Nurse Practitioners, High Quality and Cost Containing in the Hospital Setting
Theresa Eiser‐Brown, MSN, CRNP, ANP‐BC and Sandhra Thekkumthala, MSN, CRNP
In both the outpatient and in‐patient environment time is money, the more a work product has faster turnaround
time; the more work can be accomplished thus lowering costs and increasing revenue. When the work product is
human lives in the hospital settings, quality must be maintained. Then the question becomes how can costs be
streamlined while preserving the integrity of the work product? Nurse Practitioners have a long, rich history of
providing quality, comparable healthcare while lowering the costs as well as increasing volume. In a 2005 study
Barnett noted that the use of Nurse Practitioners in a pre‐operative setting lowered costs by 79% for same day
surgeries and by 44% for admitted patients. In the pre‐procedure arena, preparing the patients for invasive cardiac
procedures, state, regional and local standards of care must be met, all the while moving the patients through the
process in an expedited fashion. Through the use of Nurse Practitioners to perform histories and physicals, the
collaborative Attending physician is able to accommodate more patients, thus increasing volume and revenue.
Cardiac outpatient office (attending notes) history and physicals from a variety of situations including private
practices and a university setting practice, where compared to the history and physicals performed by the Nurse
Practitioners by means of evaluating the comprehensiveness of the past medical and surgical histories, medication
lists, and review of systems. It was revealed that not only were the Nurse Practitioner history and physicals more
inclusive, the costs of this care were controlled.
References
Barnett, J. (2005). An emerging role for Nurse Practitioners‐ Preoperative assessment. AORN Journal. 82(5) p 825‐
834
Gershengorn, H. B., Wunsch, H., Wahab, R., Leaf, D., Brodie, D., Li, G., & Factor, P. (2011). Impact of Nonphysician
Staffing on Outcomes in a medical ICU. Chest. 139: 1347‐1353.
Abstract 4 ‐ Heart Failure: Reducing Readmissions Through Continued Education and Monitoring in Outpatient
Cardiac Rehabilitation.
Susan Gills RN, BSN
Introduction: Heart Failure is the leading diagnosis for hospitalized patients over the age of 65 and more Medicare
dollars are spent for diagnosis and treatment of heart failure than any other illness. It is the leading cause of
morbidity and mortality and is associated with decreased quality of life. The American College of Cardiology and
the American Heart Association guidelines refer to patient education, attention to monitoring for symptoms and
provider follow‐up as the most effective and underused practices in the treatment of heart failure.
Purpose: Patients participate in cardiac rehabilitation post hospital discharge for a period of six to twelve weeks
creating an opportunity for continued education and monitoring and follow‐up for symptoms. Participation will
lead to increased compliance to prescribed regimens and decreased readmissions for heart failure as well as
increased quality of life. Continued monitoring will lead to early intervention.
Methods: All patients in cardiac rehabilitation with a primary or secondary diagnosis of heart failure were
educated on all of the following: medications, diet instructions, daily weight, activity guidelines, worsening signs
and symptoms, heart failure zones and physician follow‐up. Methods of education included Teachback Method,
Brown Bag Medication Reconciliation, written educational materials including heart failure zones and critical
thinking skills in a one‐on‐one setting. All charts were reviewed from January 2010 until June 2011 to see if any
patients were readmitted for heart failure.
Results: Patients enrolled in cardiac rehabilitation with a diagnosis of heart failure charts were reviewed
retrospectively from January 2010 through June 2011. Only one patient was readmitted during that 18 month
period with a diagnosis of heart failure and anemia requiring transfusions.
Of note this 90 year old patient’s baseline BNP upon entering the program was 1623 (normal B‐type natriuretic
peptide < 100; measures heart failure) and had only attended three sessions before readmission to the hospital for
“sudden onset of CHF”.
Conclusions: Heart failure is associated with high readmission rates to the hospital causing both an economic and
emotional strain. Readmissions are often due to preventable complications, lack of knowledge and self‐care
abilities. Educating patients promotes self‐care, early intervention for symptoms and reduces readmissions.
Cardiac rehabilitation offers the perfect setting to continue post hospital discharge education. We need to
encourage referrals to cardiac rehabilitation in the future.
References
American Heart Association www.americanheart.org
Heart Failure Society of America www.hfsa.org
AACVPR www.aacvpr.org
Institute for Healthcare Improvement www.ihi.org
Health Literacy Council www.nchealthliteracy.org
Aligning Forces for Quality www.forces4quality.org
Abstract 5 ‐ Chief Quality Officer Rounds: Charting A New Course for Performance Improvement
Nicole M. Hartman, MSN, RN
Reimbursement changes from the Centers for Medicare and Medicaid Services and value based purchasing
systems have made performance improvement more crucial then ever. A voluminous amount of data collection is
the norm within medical‐surgical practice environments, however, robust analysis of and subsequent action plans
that truly enhance quality outcomes is often lacking.
This presentation describes a successful performance improvement model on a 30‐bed medical‐surgical oncology
unit in an academic, community Magnet hospital. Root cause analysis and an evidence review prompted
development of a quality model inclusive of four key elements: prioritization and exclusivity; staff awareness of
data; transparency of outcomes; and, ownership and accountability. One of the more unique aspects of this
innovative model is the implementation of daily Chief Quality Officer Rounds (CQOR) by the unit educator to
facilitate real‐time learning to improve patient care focusing on one quality indicator at a time. The educator
assesses each patient situation, assures appropriate interventions are implemented, and educates the staff
regarding opportunities for improvement. The unit staff are held accountable for their ability to improve quality
indicators via goals tied to their annual performance appraisal, which focus on the utilization of data transparency
and quality rounds to improve outcomes.
Since initiating CQOR focusing on reducing falls, the unit has seen a reduction in fall rates from 4.14 to 2.97 in 10
months. Learners attending this session will gain pragmatic strategies to create a culture of inquiry and passion for
quality improvement in any medical‐surgical patient care setting.
Reference
Burritt, J., Wallace, P., Steckel, C., & Hunter, A. (2007). Achieving quality and fiscal outcomes in patient care: The
clinical mentor care delivery model. Journal of Nursing Administration, 37(12), 558‐563.
Clutter, P., Reed, C., Cornett, P., & Parsons, M. (2009). Action planning strategies to achieve quality outcomes.
Critical Care Nursing Quarterly, 32(4), 272‐286.
Doherty, L. (2008). Nurses urged to help develop indicators for measuring quality. Nursing Standard, 23(12), 10.
Hall, L., Moore, S., & Barnsteiner, J. (2008). Quality and nursing: moving from a concept to a core competency.
Urologic Nursing, 28(6), 417‐426.
Abstract 6 ‐ The Academic Electronic Health Record and Multiple Clinical Information Systems; Price vs. Value in
Nursing Education
Julie Greenawalt, PhD, RNC and Theresa Calderone, EdD, MEd, MSN, RN‐BC
Introduction ‐ The growth of emerging technologies in twenty first century health care has enabled nurses to apply
information technology and communication tools to nursing care. Nursing schools and undergraduates may
experience a gap in informatics skills needed in this environment due to the high cost of educating a new
workforce ready graduate due to the high cost of technology, time and talent. Indiana University of Pennsylvania’s
(IUP) Nursing and Allied Health Department will implement an Academic Electronic Health Record and Telehealth
Information System in the Community Health curriculum. Our framework is based upon the national HIT agenda
that calls for an electronic health record for every American by 2014 and the Technology Informatics Guiding
Education Reform (TIGER) Initiative. We will share with you the cost in terms of equipment, resources, time and
talent that it has taken to initiate a workforce ready graduate.
Project Implementation ‐ The purpose of our presentation is to present our project from conception to inception
of how a simulated medical records documentation environment for undergraduate nursing students was
developed. We’ll discuss the integration of our simulation rooms, academic electronic health record, and
telehealth information system. A challenge is the creation of a “simulated” integration of two clinical information
systems to give students an experience of a seamless real‐world work environment. We will share our
implementation project plan, funding for this project, partnerships with technology vendors, and faculty adoption
strategies for this technology intensive environment that was established with variable funding mechanisms that
were garnered in this tight economic era.
Conclusions/Next Steps ‐ Our project is a work in progress and we plan to implement in the Fall of 2011. The ability
to provide nursing students with cutting edge educational modalities in the practice environment is our goal. Our
project team continues to develop a Simulated Medical Center for the prospective future nurse.
References
Hebda, T., Calderone, T. (2010). What nurse educators need to know about the TIGER Initiative. Nurse Educator,
Mar‐Ape; 35(2), 56‐60.
Abstract 7 ‐ Huddle Up! Collective Responsibility to Positively Impact Workflow and Patient Safety
Christine Marakovits, BSN, RN and Jessica Beaver, BSN, RN
The workflow on a medical‐surgical unit frequently changes within minutes and nurses can begin to fall behind and
become stressed, leading to potentially negative outcomes. When this happens, a method to assure situational
awareness among all staff members can turn the tide to assure delivery of safe and effective care.
This issue was identified and addressed by members of a shared governance nurse practice council on a 30 bed
medical‐surgical unit in an academic community Magnet hospital. Their search for best practice led them to
discover concepts associated with Crew Resource Management, specifically Safety Huddles to improve patient
safety and teamwork. The premise of Safety Huddles is designed to bring the entire team together to discuss the
current and potential workflow of the entire unit and the all patient safety issues. Each team member attends the
brief check‐in, and using an internally developed template gives a concise update on their assignment, identifying
high risk patients and issues that could impact their planned workflow for which they may need assistance.
Additional impromptu huddles may be initiated by any staff member at any time and, are also held following an
untoward event as a debriefing.
The scheduled huddles have been hard‐wired into the daily unit operations. In addition, impromptu huddles are
initiated on average twice per week. Qualitative evaluation demonstrates improved communication and a culture
of collective responsibility. Quantitative evaluation demonstrates reduction in falls, catheter associated urinary
tract infections, pressure ulcers, and length of stay.
References:
Cronin G; Andrews S., 2009. After action reviews: a new model for learning. Emergency Nurse. Jun; 17 (3): 32‐5
Shea‐Lewis A. 2009. Teamwork: Crew resource management in a community hospital. Journal for Healthcare
Quality. Sep‐Oct; 31 (5): 14‐8
Shermont H; Mahoney J; Krepcio D; Baccari S; Powers D; Yusah A. 2008. Meeting of the minds. Nursing
Management. Aug; 39 (8): 38‐40, 42‐4.
Thompson D, Holzmueller C, Hunt D, Cafeo C, Sexton B, and Pronovost P. 2005. A morning briefing : setting the
stage for a clinical and operationally good day. Joint Commission Journal on Quality and Patient Safety. Aug;
31(8): 476‐479
Abstract 8 ‐ Enhancing Patient Care, in the Physician Office, through Utilization of Health Literacy Toolkit
Jane A. Oyler, MSN, RN
Introduction ‐ As part of a Learning Collaborative, five physician practices, in two counties, were chosen to
implement tools from the Health Literacy Universal Precautions Toolkit. Dr. Darren DeWalt, of the University of
North Carolina, acted as consultant to the collaborative.
Background ‐ The Agency for Healthcare Research and Quality (AHRQ) commissioned the University of North
Carolina at Chapel Hill to develop and test the Health Literacy Universal Precautions Toolkit. The physician leading
the project was Dr. Darren DeWalt.
The Aligning Forces for Quality (AF4Q), a Robert Wood Johnson Foundation grant and Highmark provided financial
support to a project, in two central Pennsylvania counties, to assist physicians and their office staff to learn to
communicate more effectively with their patients through the use of tools from the Toolkit.
Strategy ‐ Through the use of the methodology of Plan‐Do‐Study‐Act, the physician office practices were able to
implement rapid cycles of change. These cycles were discussed on webinars that included Dr. DeWalt, his
assistant, the practice coaches, the physicians, and practice leaders.
Outcomes ‐ The physicians and their staff did realize the importance of speaking clearly and in plain language so
their patients would be capable of understanding their role in their health and what to do when they got home.
This realization was shared at a Physician‐Clinical Learning Network meeting.
Several lessons were learned including change takes time and tremendous amounts of energy and reinforcement
of automated messages is necessary to ensure patient understanding therefore compliance.
Implications for Nursing Practice ‐ Two outpatient units, within the hospital, have begun using tools from the
toolkit with focus on Teach‐Back which has demonstrated positive impact on the transition of care.
References
DeWalt, D., Callahan, L., Hawk, V., Broucksou, K., Hink, A. Rudd R., Brach C. Health Literacy Universal Precautions
Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research.
The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014). AHRQ Publication No.
10‐0046‐EF) Rockville, MD. Agency for Healthcare Research and Quality, April 2010.
Rudd, R. (2010). Improving Americans’ health literacy. New England Journal of Medicine. 363 (24), 2283‐2285.
Sand‐Jecklin, K., Murray, B., Summers, B., Watson, J., (July, 23, 2010) Educating nursing students about health
literacy: From the classroom to the patient bedside. OJIN: The Online Journal of Issues in Nursing Vol. 15 No. 3.
Abstract 9 ‐ CSI: Critical Sepsis Identification…Earlier Recognition, Earlier Treatment
Erin Sarsfield, RN, MSN and Cheri West, RN, MS
The 2008 Surviving Sepsis Campaign established evidence‐based guidelines for the management of sepsis. At our
Academic Medical Center, a review of over 800 patient charts estimated that at least 60 deaths might have been
avoided if sepsis had been recognized earlier, and anchor antibiotic and fluid resuscitation administered earlier.
From January 2009 until September 2010, septicemia was the top diagnosis on our University Healthcare
Consortium (UHC) Excess Death report. A multiservice, interdisciplinary team was formed in 2010 and focused on
admissions to our Emergency Department (ED) and adult Intensive Care Units (ICUs). A sepsis bundle protocol,
antibiotic algorithm and electronic order sets were developed and implemented. Nursing and physician computer‐
learning modules with clinical vignettes were developed. The ED/Critical Care Nurses had 95% compliance with the
education in just six weeks. Posters, reference pocket guides, antibiotic infusion and documentation tips were
posted on our hospital Intranet. Nurses were empowered to initiate the sepsis protocol and notify Attending
Physicians if Resident Physicians did not respond to nursing assessments of potential sepsis. Our rapid cycle team
eliminated 25 sepsis‐related deaths over the initial nine months of our implementation. Septicemia was eliminated
from our Excess Death report for the first six months. One of our most significant results was demonstrated in the
arrival‐to‐initial antibiotic infusion and fluid resuscitation time which was reduced from an average of 4‐6 hours to
1‐3 hours. We reduced our sepsis mortality from 18.77% to 13.64% and our sepsis observed‐to‐expected mortality
from 1.3 % to 0.78%. We also accomplished substantial financial reductions by decreasing ICU length of stay
slightly more than 0.5 days and average total costs by almost $2,000 per patient in the first six months. There were
marginal setbacks observed initially this year, which were related to capacity issues. We continue to strive toward
initial antibiotic and fluid resuscitation within the first hour of ED admission, and earlier identification of Systemic
Inflammatory Response Syndrome (SIRS) criteria. Our focus on earlier identification and treatment of sepsis
resulted in an annualized cost avoidance of over $700,000. We have significantly improved the care of these
patients and saved many lives.
References
Dellinger, R.P. et al, (2008) Surviving sepsis campaign: Intensive Care Med 34:17‐60.
Gaieski, D. F., Mikkelsen, M. E., Band, R. A. (2010). Impact of time to antibiotics on survival in patients with severe
sepsis or septic shock in whom early goal‐directed therapy was initiated in the emergency department. Crit Care
Med. 38,(4), 1045‐1053.
Otero R. M., Nguyen, H. B., Huang, D. T. et al. (2006). Early goal‐directed therapy in severe sepsis and septic shock
revisited. Chest. 130; 1579‐1595.
Rivers, E., Nguyen, B., Havstad, S. et al. (2001). Early goal‐directed therapy in the treatment of severe sepsis and
septic shock. New England Journal of Medicine. 345, 1368‐1377.
Abstract 10 ‐ Sepsis Protocol: The Nurse’s Role in Reducing Cost and Mortality
Adelle Lotinsky, RN, BSN and Shera Stack, RN, BA
In 2003, the Surviving Sepsis Campaign (SSC) was launched by the European Society of Intensive Care Medicine,
the International Sepsis Forum, and the Society of Critical Care Medicine. The Surviving Sepsis Campaign is a global
initiative to create an international effort to improve the treatment of sepsis and reduce sepsis mortality.
According to the Surviving Sepsis Campaign, there are approximately 750,000 new cases of sepsis reported each
year in the United States, resulting in a minimum of 210,000 fatalities. Purpose: To explore the effectiveness of a
nurse driven sepsis protocol in reducing cost and patient mortality. Method: A preliminary thematic analysis of the
literature was conducted. Results: The research suggests that patients experience a delay in the recognition and
treatment of sepsis. This rapidly progresses to severe sepsis and septic shock and is associated with a cost of tens
of billions of dollars annually. The timely implementation of an early goal‐directed therapy protocol is critical in
preventing the mortality of patients with septic shock and severe sepsis. This results in an average cost reduction
of 25% per patient. Implications for practice: The research recommends involving the nurse to recognize the early
signs and symptoms of sepsis via a standardized screening tool, implementing the Surviving Sepsis Campaign’s
recommended early goal‐directed therapy protocol, and monitoring compliance.
References
Crowe, C., Mistry, C., Rzechula, K., Kulstad, C. (2010). Evaluation of a modified early goal‐directed therapy protocol.
American Journal of Emergency Medicine, 28, 689‐693. doi:10.1016/j.ajem.2009.03.007
Gurnani, P., Patel, G., Crank, C., Vais, D., Lateef, O., Akimov, S., Balk, R., Simon, D. (2010). Impact of the
Implementation of a Sepsis Protocol for the Management of Fluid‐Refractory Septic Shock: A Single‐Center, Before‐
and‐After Study. Clinical Therapeutics, 32(7), 1285‐1293. doi: 10.1016/j.clinthera.2010.07.003
Lin, S., Huang, C., Lin, H., Liu, C., Wang, C., Kuo, H. (2006). A modified goal‐directed protocol improves clinical
outcomes in intensive care unit patients with septic shock: a randomized controlled trial. Shock, 26(6), 551‐557.
doi: 10.1097/01.shk.0000232271.09440.8f
MacRedmond, R., Hollohan, K., Stenstrom, R., Nebre, R., Jaswal, D., Dodek, P. (2010). Introduction of a
comprehensive management protocol for severe sepsis is associated with sustained improvements in timeliness of
care and survival. BMJ Quality & Safety, 19(e46), 1‐7. doi:10.1136/qshc.2009.033407
Shorr, A., Micek, S., Jackson Jr, W., Kollef, M. (2007). Economic implications of an evidence‐based sepsis protocol:
Can we improve outcomes and lower costs? Critical Care Medicine, 35(5), 1257‐1262. doi:
10.1097/01.CCM.0000261886.65063.CC
Talmor, D., Greenberg, D., Howell, M., Lisbon, A., Novack, V., Shapiro, N. (2008). The costs and cost‐effectiveness
of an integrated sepsis treatment protocol. Critical Care Medicine, 36(4), 1168‐1174. doi:
10.1097/CCM.0b013e318168f649
Tromp, M., Hulscher, M., Bleeker‐Rovers, C., Peters, L., T.N.A. van den Berg, D., Borm, G., … Pickkers, P. (2010). The
role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A
prospective before‐and‐after intervention study. International Journal of Nursing Studies, 47, 1464–1473.
doi:10.1016/j.ijnurstu.2010.04.007
Westphal, G., Koenig, Á., Filho, M., Feijó, J., Trindade de Oliveira, L., Nunes, F., … Gonçalves, A. (2011). Reduced
mortality after the implementation of a protocol for the early detection of severe sepsis. Journal of Critical Care,
26, 76‐81. doi:10.1016/j.jcrc.2010.08.001
Abstract 11 ‐ Enhancing Perioperative Teamwork to Improve Patient Safety
Hope L. Johnson, RN, MSN, CNOR
Description: A “Culture of Patient Safety” survey conducted in 2008 revealed a lack of patient centered focus,
teamwork, and positive communication amongst the majority of perioperative staff members at a Pennsylvania
multi‐campus health network. After reviewing the results of the survey which identified 53% of the staff were
afraid to ask questions when something seemed amiss and 43% of the staff were unwilling to challenge authority,
members from the Operating Room (OR), Anesthesia, and the Department of Surgery knew action needed to be
taken. Key members from these departments joined forces with the Division of Education to develop a mandatory
training program focusing on teamwork, open communication, and stressing the patient as the most important
person in the OR. After incorporating various techniques and vignettes demonstrating beneficial methods of
communication, comprehensive, mandatory patient safety training was created. This poster will focus on the
development and implementation of the safety training program and how it positively transformed workplace
culture.
References
Marshall, D. (2009). Crew Resource Management: From Patient Safety to High Reliability. Denver, CO: Safer
Healthcare Partners, LLC.
Patterson, K., Grenny, J., McMillan, R. & Switzer, A. (2002). Crucial conversations. Tools for talking when stakes
are high. New York, NY: McGraw‐Hill.
Weaver, S.L, et al (2010). Does teamwork improve performance in the operating room? A multilevel evaluation.
Joint Commission Journal on Quality and Patient Safety, 36(3), 133‐142.
Wolf, Francis A. MD; Way, Lawrence W. MD; Stewart, Lygia MD (2010). The Efficacy of Medical Team Training:
Improved Team Performance and Decreased Operating Room Delays: A Detailed Analysis of 4863 Cases. Annals of
Surgery, 252(3), 477‐485.
Abstract 12 ‐ Post Thoracotomy Pain Syndrome: The Patient Experience
2010 Nursing Foundation of Pennsylvania
Pauline Thompson Clinical Nursing Research Award Recipient
Kathleen Garrubba Hopkins MS RN
and
Leslie A. Hoffman PhD RN
Introduction: Surgery is the first option for patients with early stage lung cancer. After surgery, regardless of the
procedure (open thoracotomy, minimally invasive), pain may persist for a year or longer in as many as 50% of
patients. This outcome, termed post thoracotomy pain syndrome (PTPS), is the focus of this study. PTPS is defined
as pain that recurs or persists along a thoracotomy incision at least 2 months following the surgical procedure.
The purpose of this study was to compare the symptom experience of patients with and without PTPS.
Setting: University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center
Inclusion criteria: 1) diagnosed with Stage 1, 2, or 3a lung cancer; 2) managed surgically; 3) between 2 and 12
months post‐operative; 4) 40‐85 years of age. Exclusion criteria: 1) diagnosed with metastatic lung cancer; 2)
unable to read and write English.
Methods: Subjects completed a visual analog scale (VAS) that rated pain using the scale 0=none to 10=maximum,
the Functional Assessment of Cancer Therapy‐Lung (FACT‐L) which measures participants’ well‐being using five sub
scales (physical, social/family, emotional, functional, and lung related concerns) and the McCorkle Symptom
Distress Scale (SDS). FACT‐L and SDS subscores were also used to rate frequency of pain and medication
effectiveness. Demographic data were collected from the medical record. Data were analyzed using descriptive
statistics and independent t‐tests.
Results: Subjects were 32 patients, 47% women, aged 62.1 (±10.8) years. There were no statistically differences
between PTPS (n=17) and non PTPS (n=15) patients for socio‐ or surgical demographics. The average VAS pain
score was 3.41 ± 3.14 for PTPS patients (range 0‐7, median=1). All non PTPS subjects rated pain as “0”. 8/17 PTPS
patients rated their usual pain level as “0” by VAS. However, 4/8 rated pain intensity as moderate and not
controlled by medications when pain did occur. 6/17 participants rated pain as moderate in response to
questionnaire items and 3/6 participants rated their medications as ineffective. 3 PTPS participants had severe
pain and were being seen at pain clinic with some pain control.
Conclusion: Post‐surgical lung cancer participants’ diagnosed with PTPS experience pain on an intermittent basis
that varies in severity from moderate to severe. Improved understanding of factors producing pain could improve
functionality and reduce associated costs. The study is ongoing with the goal of further defining the symptoms,
influencing factors and performance limitations associated with PTPS in a larger sample and with qualitative
methodology.
References
1. American Cancer Society (ACS). Facts and Figures 2009.
2. American Lung Association (ALA). (September, 2008). Trends in Lung Cancer Morbidity and Mortality
2008. American Lung Association Epidemiology And Statistics Unit Research and Program Services Division.
3. Auvil‐Novak, S., Novak, R. D., Smolensky, M. H., Kavanagh, J. J., Kwan, J. W., & Wharton, J. T. (1988).
Twenty‐Four Hour Variation in Self‐Administration of Morphine Sulfate (MS) and Hydromorphone (H) by Post‐
Surgical Gynecological Cancer Patients. Annual Review of Chronopharmacology , 5, 343‐346.
4. Cella, D.F., Bonomi, A.E., Lloyd S.R., Tulsky, D.S., Kaplan, E., and Bonomi, P. (1995). Reliability and validity
of the Functional Assessment of Cancer Therapy ‐ Lung (FACT‐L) quality of life instrument. Lung Cancer 12(3):199‐
220.
5. Daniel, M. (2009). Persistent Smoking After a Diagnosis of Lung Cancer Is Associated With Higher
Reported Pain Levels. The Journal Of Pain , 10 (23), 323‐328.
6. Dajczman, E., Gordan A., Kreisman H., and Wolkove, N. (1991). Long‐term postthoracotomy pain. Chest.
99: 270‐274.
7. Demmy, T. L. (2009). Chest‐Tube Delivered Bupivacaine Improves pain and Decreases Opioid Use After
Thoracoscopy. The Annals of Thoracic Surgery , 87, 1040‐1047.
8. Dumrongpakapakorn, P., Hopkins, K., Sherwood, P., Zorn, K., & Donovan, H. S. (2009). Computer‐
Mediated Patient Education: Opportunities and Challenges for Supporting Women With Ovarian Cancer. Annual
Review of Nursing Research.
9. Frola, C., Serrano, J., Cantoni, S., Turtulici, I., and Loria, F. (1995). CT Findings of Atrophy of Chest Wall
Muscle After Thoracotomy: Relationship between Muscles Involved and Type of Surgery. AJR 164 599‐601.
10. Fogel, J., & Fogel, J. (2003). Internet Use for Cancer Information Among Racial/Ethnic Populations and Low
Literacy Groups. Cancer Control , 10 (5 Suppl), 45‐51.
11. Karasaki, T., Nakajima, J., Murakawa, T., Fukami, T., Yoshida, Y., Kusakabe, M., Ohtsu, M., and Takamoto,
S. (2009). Video‐assisted thoracic surgery lobectomy preserves more latissimus dorsi muscle than conventional
surgery. Interact CardioVasc Thorac Surg. 8:316‐320.
12. Keenan, R. J. (2004). Segmental Resection Spares Pulmonary Function in Patients With Stage I Lung
Cancer. The Annals of Thoracic Surgery , 78, 228‐233.
13. Landreneau, R.J., Mack, M.J., Hazelrigg, S.R., Naunheim, K., Dowling, R.D., Ritter, P., Magee, M.J.,
Nunchuck, S., Keenan, R.J., and Ferson, P.F. (1994). Prevalence of chronic pain after pulmonary resection by
thoracotomy or video‐assisted thoracic surgery. Journal of Thoracic & Cardiovascular Surgery. 107(4):1079‐85.
14. Lenz E, Gift A, Pugh L, & Milligan R. (1997). Middle‐range theory of unpleasant symptoms, An update.
Advances in Nursing Science. 19:14‐27.
15. McGill, R. (2009). the website: http://www.ama‐cmeonline.com/pain_mgmt/pdf/mcgill.pdf.
16. Merskey, H. (1986). Classification of chronic pain: description of chronic pain syndromes and definition of
pain terms. Pain. 3(Suppl):S138–S139.
17. Montazeri, A. (1998). Quality of Life in Patients With Lung Cancer: A review of Literature From 1970 to
1995. CHEST , 113 (2), 467‐481.
18. National Cancer Institute. (1975‐2005). SEER Cancer Statistics Review.
19. Shaw, A. & Keefer, F. (2008). Genetic and Environmental Determinants of Postthoracotomy Pain
Syndrome. Thoracic Anesthesia , 21 (1), 8‐11.
20. Wright, K.D., Asmundson, G.J., and McCreary, D.R., (2001). Factorial validity of the short‐form McGill pain
questionnaire (SF‐MPQ). European Journal of Pain. 5: 279‐284.
![ANA’s Principles for Delegation - nursingworld.org for practice in situations across the continuum of care ... as well as assignment, ... (Creative HealthCare Management [CHCM],](https://img.dokumen.tips/doc/110x75/5aeb3f607f8b9a90318cc123/anas-principles-for-delegation-for-practice-in-situations-across-the-continuum.jpg)
