Magnet Recognition Program

The Magnet Recognition Program has been around since the 1980s and has been the focus of nurse administrators for excellence in nursing practice and outcomes of patient care. To date, there are 165 acute-care hospitals with this status. In the 1980s, despite a large nursing shortage, certain facilities had created environments, which attracted and retained nursing staff. A task force recommended that the American Academy of Nursing authorize a study to identify a national sample of "magnet hospitals" and the seminal study, Magnet Hospitals: Attraction and Retention of Professional Nurses began in 1981.

The team of nursing administration experts nominated 165 acute-care hospitals with a positive reputation, and of this purposive sample, 41 were selected because of their outcomes. By late summer 2005, 162 healthcare organizations were designated as Magnet, and approximately 250 organizations were in the pipeline for designation.

With the explosion of interest in the Magnet process, the American Nurses Credentialing Center (ANCC) had decided that the time had arrived for a period of self-reflection and renewal. The primary purpose of the evaluation is to help those who hold a stake in whatever is being evaluated, often consisting of many different groups, making judgments or decisions. Research seeks conclusions, whereas evaluation leads to judgments. Research looks for causal relationships, whereas evaluation seeks to describe.

Evaluations are typically judged in four areas:

1. Accuracy (the extent to which the information obtained is an accurate reflection)

2. Utility (the extent to which the results serve practical information needs of the intended users)

3. Feasibility (the extent to which the evaluation is realistic, prudent, and diplomatic)

4. Propriety (the extent to which the evaluation is done legally and ethically, protecting the rights of those involved.

The evaluator conducted two focus groups of appraisers and staff to identify the knowledge, skills, and abilities of the appraisers. She also launched and analyzed a survey on the knowledge, skills, and abilities of the successful appraisers among the stakeholders, which included 52 Magnet CNOs, 70 appraisers, 6 Magnet commissioners, and 8 Magnet Program staff. The paradigm shifts identified are as follows:

[black right pointing small triangle] Appraisal process: traditional to best practice and evidence based

[black right pointing small triangle] Colleague review to peer review

[black right pointing small triangle] Passive learning to learning community

[black right pointing small triangle] Low technology to high technology

[black right pointing small triangle] Small business model to professional business

[black right pointing small triangle] Competency based to performance management model

[black right pointing small triangle] Compensation from static model to pay for performance

[black right pointing small triangle] Blind to transparen.

The authors are a clinical professor from the University of Texas Health Science Center of Houston, the Director of the Magnet Recognition Program, and the Executive Director of the ANCC. They agree that the factor that held this evaluation was trust and leave the reader with a short list of lessons learned:

1. Cut through the bureaucratic red tape and shorten response time.

2. Adopt a "no fear" approach, believing that the analysis was necessary for the future of the program.

3. Develop a foolproof transition schedule, dealing with budget and staff implications for 2006-2007 budgets.

4. Communicate, communicate, and communicate.

5. Double the time; this is a long process.

Triolo, P.K., Scherer, E.M., & Floyd, J.M. (2006). Evaluation of the magnet recognition program. Journal of Nursing Administration, 36(1), 42-48.

Total Knee Replacement

This article is an interesting account of a physician who had one total knee replacement, and is concerned about his potential second, from his personal perspective. His first surgery was painful, complicated with shaking chills and 104[degrees]F temperature, eventually leading to osteoarthritis. He proposes that healthcare professionals begin to see patients and their lives not "out there" but as mirrors of their own lives, "in here." He tells the story of Mahatma Gandhi, asked to help a diabetic child stop eating sweets and starches, but before he was willing to do so, Gandhi stopped eating them himself for a few weeks. Only then could he say to the child, "I, too, have felt what I am asking you to feel." Only then, and not before, he was able to help.

In anticipation of having his second knee replaced, this author is issuing a request for proposals (RFPs) with five specifications linked to quality care. They are as follows:

Specification 1: No Needless Deaths

Simply put, he says, "Don't kill me." He suggests that he could be killed through an infection during surgery, by giving him the wrong transfusion, and by failing to prevent a pulmonary embolism or pneumonia. He could also be given the wrong drug, or the wrong quantity with the misplacement of a decimal. He suggests that patients have a right to have an access to hospital-specific information on complications on admission.

Specification 2: No Needless Pain

What he means by this is, "Assuming you don't kill me, don't hurt me either." This particular specification has three subparts: A, B, and C. Specification 2A is to not do things to him unless they will help him, to act on evidence, not on hope, and to let him know when firm, scientific evidence is not there.

Specification 2B says, "Reduce the burden of disease I have from my bad knee and do not do things that will hurt me." Let the patient make the decision with the surgeon for the type of prosthesis and function. Although risks and results are a trade off decision, he wants to be involved in that trade off. Once the plan is in place, he requests that the surgical team make every effort to choose the approach to anesthesia, prosthetic implant, and postoperative recovery, on the basis of credible, scientific, and clinical evidence.

Specification 2C simply says, "Relieve my pain." He includes physical and emotional pain in this statement. The physical pain can be managed (and this author had a totally pain-free experience twice at Virginia Mason Clinic in Seattle, Washington) whereas emotional pain is more complicated. He asks for the promise of having his wife and children in the intensive care unit, recovery room, or emergency department whenever he wants them. He wants straight answers to his questions.

Specification 3: No Helplessness

He describes the indignity of being hospitalized: His clothes are taken away along with his privacy, he is told about rules and when to eat and sleep, which make him feel undignified and vulnerable. He asks for a place that will not let this happen. He also asks for two things: to share information and make choices. This starts with an access to his medical record, and he speaks of "patient's orders" as well as "doctor's orders." (If this makes him, in your eyes, a difficult patient, please do not submit an RFP.)

Another process suggested to not let the patient feel helpless is to have an access to the surgeon by e-mail. He feels that as the knee will be around for quite a while, there should be a follow-up by the surgeon-an extra credit if one has a "total knee" registry.

Specification 4: No Unwanted Waiting

Prevention of delays is critical, whether they be in the physician's office, on the units, or in the operating room. There are so many opportunities like tests and discharges to get it right. The author has a file at home that contains all of his past X-rays, MRIs, and CT scans of his knee. It is a complete file. Healthcare workers seem never to have all the items together unless the patient takes these to them. He advocates for individuals to have access. The lesson here is not that every patient be given the existing X-rays or MRIs; this would create a mess. The author argues for a system where patients could be given the opportunity to keep a copy of every bit of medical information recorded about them. Some Veterans Health Administration sites have direct access to their own medical records.

Specification 5: No Waste

The average cost of healthcare per person in the United States is $4,800 per year, as opposed to $2,000 to those who belong to the Organisation for Economic Co-operation and Development (countries that provide universal healthcare). The author sees waste as a symptom of a defective process. He wants his knee to be handled by people who are intolerant of the disorder, duplication, unpredictability, and inattention to detail that lie at the root of waste. Orderly, coordinated, anticipatory, and attentive care is his goal.

Naming Names

The author goes on to name the hospitals and organizations that mostly match his requirements for care. These are the hospitals where one is likely to avoid surgical infections, where there is a lowest incidence of ventilator-dependent pneumonia, where his wife and children can visit 24 hours a day if he was in the intensive care. He leaves the healthcare professionals with the notion that they will honor and respect the wishes of their patients and their families when they have trusted and respected their own.

Berwick, D.M. (2005). My right knee. Annals of Internal Medicine, 142, 121-125.

Extended-Release Epidural Morphine

Epidural morphine has been around for many years, administered as a single or an intermittent bolus, a continuous infusion, or as a patient-controlled analgesia. Each method has been effective in controlling pain but has not been without its limitations. A single epidural injection can last up to 24 hours, but this is not sufficient for some patients postoperatively. Those patients with indwelling epidural infusions run the risk of infection, as well as complications with removal in patients receiving prophylactic anticoagulants.

The U.S. Food and Drug Administration has approved a unique form of epidural morphine called the extended-release epidural morphine (EREM) that may provide a longer acting result for some surgical procedures. A single epidural bolus of EREM provides pain relief for up to 48 hours, which provides orthopaedic patients a promising option for pain management.

Pharmacology

This new drug, DepoDur, is different from Duramorph or Astramorph by its unique delivery system called DepoFoam, which has multiple, microscopic, liposomal (fat-based) particles. These liposomes have aqueous chambers that encapsulate preservative-free morphine. The morphine is released slowly by the liposomes over a period of 48 hours by erosion or reorganization of the lipid membranes. A benefit of EREM is that it produces analgesia without the motor or sensory deficits that can occur when combining epidural analgesia with local anesthetics.

This drug is metabolized by the liver and excreted by the kidneys like other opioids. Because of the single bolus administration, the morphine metabolites should not accumulate, even in patients with hepatic or renal function insufficiencies. In addition to the extended drug release, the delivery system avoids excessive peak concentrations and the adverse effects that accompany them.

Dosage and Administration

This drug is used in the cesarean section deliveries, lower abdominal or pelvic surgery, and orthopaedic surgery of the lower extremities. It is intended for single bolus use only, and the orthopaedic dose is 15 mg. For C-sections, 10 mg is recommended, and for lower abdominal or pelvic surgery, 10-15 mg is recommended. It should not be given intrathecally (spinal) or through iv or im routes. It should be administered by a qualified anesthesiologist or certified registered nurse anesthetist (CRNA). Epidural local anesthesia should not be given with EREM because it can produce a physiochemical interaction and can reduce the extended-release mechanism. It has been studied only in adults, so it is not recommended for infants and children. Supplemental doses of nonopioid and opioids should be given for breakthrough pain.

The authors present several research studies demonstrating the efficacy of EREM. In a placebo-controlled, double-blind, multicenter study of 200 total hip arthroplasty patients, patients were given 15 mg, 20 mg, or 25 mg of EREM or an epidural injection of saline before the induction of general or spinal anesthesia, approximately 30 minutes before surgery. When asked for pain medication, all patients received 25 mg of iv fentanyl, after which they could self-administer it for the remaining 48-hour period. There was a 75% reduction in fentanyl consumption in all of the EREM groups, as compared with the placebo group. Many in the EREM group did not require any opioid (45% during first 24 hours, 16-30% depending on EREM dose) for the first 48 hours.

Common adverse effects were nausea and pruritus. Three adverse events were attributed to the study drug: one patient (20 mg) had hypotension, and another (25 mg) had hypotension along with respiratory depression. Naloxone was administered to 5 patients in the first 24 hours for respiratory depression and to 2 patients for somnolence. No naloxone was required after 24 hours post-EREM dose.

Nursing Implications

The authors emphasize the importance of education in the principles of EREM before it is used for the first time. Standardized preprinted orders help the safety goals and monitoring parameters are met. Communication, of course, is the key-they recommend for a brightly colored label on the patient's medical record or a bracelet-alerting staff.

Assessment and monitoring patients after EREM administration are the same as after other epidural opioids. Pulse oximetry or apnea monitoring is not recommended unless the patient's condition warrants it. What is critical is the patient's sedation level and respiratory status for every 1-2 hours during the first 24 hours.

Pasero, C., & McCaffery, M. (2005). Extended-release epidural morphine (DepoDur(TM)). Journal of PeriAnesthesia Nursing, 20(5), 345-350.