No Country for Old Women

By Amy M. Collins, associate editor

For the past few weeks, my family has been living a health care nightmare. My 85-year-old grandmother, physically fit and as beautiful as an old-time movie star, but suffering from the first stages of Alzheimer’s disease, had a major meltdown. Her assisted living facility called to say she was harassing the residents and staff, claiming her belongings had been stolen, shouting at people at random, and even calling the police. Clearly not equipped to handle this level of agitation, the facility turned to us to pick her up and keep her for a few days.

The week that followed proved arduous—nobody seemed to know what to do with her. Her GP was at a loss, suggested that we bring her to the ED. Her neurologist prescribed Seroquel (after having to tackle and physically restrain her from the subsequent episode of screaming and pounding her fists on the wall, we called to tell the neurologist that the pill wasn’t working; he said to give her more; four pills later, she was still mildly agitated.) This went on for over a week. She came to live with us, where we listened, exhausted, to constant chatter that didn’t make sense. The talking never stopped—her voice grew […]

When Timely Nurse Removal of Urinary Catheters Reduces UTI Rate

By Christine Moffa, MS, RN, AJN clinical editor

Ever since we started the Cultivating Quality column at AJN, manuscripts featuring evidence-based quality improvement projects have been pouring in. There is a lot of great work being done at the bedside by practicing nurses, and this column provides the opportunity to share their ideas with others.

This month’s Cultivating Quality installment, Reducing Rates of Catheter-Associated Urinary Tract Infection, comes from Joyce Wenger, MS, RN, the infection control performance improvement coordinator at Lancaster General Hospital, Lancaster, PA. According to the CDC, urinary tract infections (UTIs) account for more than 30% of hospital-associated infections, and almost all are “caused by instrumentation of the urinary tract.” Nursing staff were able to reduce catheter-associated urinary tract infection (CAUTI) rates using a three-pronged approach “beginning with education, progressing to tests of new and better products, and ending with the nurse-driven protocol for catheter removal.”

That last part is my favorite. In most facilities a doctor or nurse practitioner has to write an order before a Foley catheter can be removed from a patient. Patients may end up spending several days at increased risk for UTI because of an unnecessary urinary catheter in place. This hospital came up with a plan to give nurses the autonomy to remove them—which makes sense, since they’re the ones checking the patient daily. The team at Lancaster General created the following list of criteria that patients need to meet in order to maintain […]

Sand, Surf, and CF

By Christine Moffa, MS, RN, clinical editor at AJN

Ever wonder how the staff at AJN decide what to put on our covers? We wanted an image that celebrated the summer, but we also wanted a tie-in with our CE feature. The August cover depicting children running down the beach at Sunny Shores Sea Camp, a four-day summer camp that caters to children with cystic fibrosis (CF) and their families, is a perfect fit. 

Some former colleagues once volunteered at the camp. Several years ago I was working on a pediatric floor where several of our patients had CF, ranging in age from toddlers to adults in their 30s. CF was long considered a childhood disease, due to a short life expectancy associated with it; even though life expectancy has drastically increased, these patients are still often treated on pediatric units, regardless of their age. This month’s CE, Original Research: Parents and Children with Cystic Fibrosis, is by Paula Harff Lomas, MAS, RN, CCRP, and Susan B. Fowler, PhD, RN, CNRN. According to Lomas and Fowler,

“More people with cystic fibrosis are living longer, reaching milestones like starting college, embarking on careers, and marrying. Many adults with cystic fibrosis are interested in starting families; one recent review notes that the number of live births to women with the disease has increased significantly. Thus, there’s a greater need for age-appropriate care in areas such as fertility and reproduction.”

The purpose of this descriptive study was to […]

Open Medical Records: A Question of Safety

By Christine Moffa, MS, RN, AJN clinical editor

We’ve all watched our health care provider writing or typing while we answered questions or described our symptoms. Before becoming a nurse I used to wonder what they were putting in my chart and if they got it right. And now that I am a nurse I can’t believe how often a medical assistant or nurse will take my vital signs and write them down without telling me what they are. How can it be possible that adults are kept from knowing their own or their children’s health information? Back when I worked on a pediatric floor my colleagues gasped in shock when I allowed a parent of one of my patients to look at his child’s chart. And I actually let them make me feel like I had done something wrong!

Last week this issue was the topic of a column by Dr. Pauline W. Chen in the New York Times, where two related blog posts (here and here) also received much reader commentary. The sudden flurry of interest in the subject was occasioned by an article published in the Annals of Internal Medicine detailing the preliminary findings of a study following a national project called OpenNotes, funded by the Robert Wood Johnson Foundation, in which “more than 100 primary care physicians and 25,000 of their patients will have access to personal medical records online for a 12-month period beginning in summer 2010.” Readers’ comments ranged from one extreme to the other, such […]

Reading this Blog Post May Lead to Blinking

By Christine Moffa, MS, RN, AJN clinical editor

“VA Hospital May Have Infected 1,800 Veterans With HIV”

I came across this headline when I was looking for the latest news on the Internet. It certainly got my attention. I immediately thought to myself, “Wow, haven’t these soldiers been through enough, and now they might have HIV.” I took the bait and did what the editors of the article hoped I’d do—I clicked on the headline. Sure enough, it was not exactly accurate. Yes, there was a risk that these patients had been exposed to bloodborne pathogens due to the improper cleaning technique performed on dental instruments at a VA hospital, but there was no specific reason to think they actually had that illness. It reminds me of a cautionary tale by Peter Jacobi I came across a number of years ago that demonstrates how statistics can be manipulated by writers: “100% of those who were born in 1850 and ate carrots are now dead. So carrots obviously lead to . . . death.”

While there are worse ones out there, this is an example of how headlines are manipulated to get readers’ attention. Don’t get me wrong: proper cleaning of instruments is an integral part of patient safety and all patients should be able to trust the facility providing them treatment. But wouldn’t it be more responsible to say, “VA hospital may have exposed 1,800 veterans to infection,” since we don’t […]

Checklist, Please!

Christine Moffa, MS, RN, AJN clinical editor

It’s embarrassing to admit how many times I’ve either locked myself out of my apartment or arrived at work and realized I’d left either my wallet or cell phone at home. That is, until someone very close to me taught me to say, “wallet, keys, cell phone, Metrocard” before walking out the door. Little did he know he was using a very powerful tool, the checklist.

As part of my money-saving strategies this year, I’ve resorted to using the New York Public Library to support my reading habit, instead of going to the various megabookstores in my neighborhood (I always fall for the “buy-two-get-one-free” deal!). That’s why I’m late to the party for The Checklist Manifesto, by Atul Gawande. After three months on hold, my turn finally came up—and boy was it worth the wait. There are so many great anecdotes about success stories (and some failures) of checklists—including patients surviving accidents and surgeries against all odds, averted airplane crashes, and well-orchestrated rock concerts—that it makes me want to start implementing checklists in every aspect of my life (including some at AJN). In fact, if I’d had a checklist for packing my bag for this weekend, I’d have remembered my flat iron, amongst other necessities. Now I’m forced to go the next 48 hours with serious frizz! 

My favorite part of the book, though, is that Gawande gives credit to nurses for being the originators of checklist usage in hospitals, citing vital sign charts, […]

Prospects for New Nurses: Thoughts on Graduating during a Downturn

By Christine Moffa, MS, RN, AJN clinical editor

Impending graduation is usually a happy, exciting time, especially for those who, after putting in years of hard work,  are finally about to get that college degree. In the mid-1990s I was in what I considered to be a pretty tough nursing program. For example, during my second semester of core classes we went from 30 students to 19; the drop-off was due to students failing out. Graduation couldn’t come fast enough.

However, when you find out that people who graduated one and two semesters before you are still looking for work, it can be a real buzz kill. That’s how it was for me in May 1995. During that time several hospitals were going through restructuring or reengineering (as this AJN article reported) and were replacing RNs with UAPs. It was next to impossible for a nurse without at least a year of recent experience to find a job in a hospital. Now, as a result of the recession, new graduates are  facing a similar situation. It took me almost a year to get my first job—and this was not without some sacrifices:  I had to relocate from New York to Miami and work the 12-hour night shift.

It ended up being worthwhile, but it was one of the hardest years of my life and potentially could have turned me off of nursing forever. Has anyone else out there had a similar experience? What […]

Medication Adherence in the Mentally Ill, the Mixed State of Cancer Survivorship Care, When Good People Faint, More

We’ve already noted one or two of them here in recent weeks, but here are some excerpts and links to several other articles of note in the April issue of AJN, in case you missed them:

The percentage of prescribed medications that are actually taken by patients is estimated to be as low as 60%—and among patients with chronic conditions, it may be even less. Patients with mental disorders may have even lower rates of adherence than those with physical conditions. Suzanne Hardeman, an NP and licensed professional counselor, and Meera Narasimhan, a physician, have culled from the available literature a list of strategies that have been shown to improve adherence in patients with mood and psychotic disorders.

That’s from a sensible and useful article on improving medication adherence in patients with mental disorders.

For a report on the good and bad news about where we are with providing cancer survivorship programs and support, read “Building Cancer Survivorship Care,” which points out some excellent resources, but also notes that “few cancer patients have access to survivorship care.” Still!

Laura Dean faints after witnessing an elderly man collapse with an apparent heart attack. James Parsons passes out as an RN begins venipuncture for collection of a lab specimen. Nursing student Melanie Simms faints while observing her first surgical procedure.

“Recognizing and Treating Vasovagal Syncope” gives a nice overview of this common problem, who is most likely to be afflicted by it, how to prevent injuries when it happens, and how nurses can […]

Turf Wars Aside, How Do NPs and MDs Really Differ?

By Christine Moffa, MS, RN, AJN clinical editor

There’s been a lot of talk lately about turf wars between NP’s and physicians, especially when it comes to the much discussed U.S. shortage of primary care providers. Before going back to school and getting a master’s in nursing education, I batted around the idea of becoming a nurse practitioner. It seemed like the ideal next step for someone who was happy being a clinician but wanted to take on an advanced role.

However, there was something that didn’t sit right with me about becoming an NP—namely, my fear of public perception. I’m not sure most people know exactly what the role of an NP is and how it differs from that of a physician, particularly in primary care. I’ve seen patients call their primary care NP “doctor [insert first name here],” which to me illustrates the confusion.

When people ask me the difference, I myself have a hard time articulating it. How do I respond when someone says something like this: “if entry to medical school and residency is typically more competitive than for advanced degree nursing programs, and if physicians spend a longer time attending tougher programs, how do you justify their doing the same work as NPs?” (For instance, when I was in school we, along with the NP candidates, were only required to take two semesters of pathophysiology!)

Now, I’ve been to an NP as a patient, and I was happy with the care I received. She certainly […]

“The Next Time She Needs a Pap Smear at 3 AM . . . “

Sunset, Turks and Caicos Islands


By Christine Moffa, MS, RN-BC,
AJN clinical editor

Vacations are an important part of keeping balanced in life and a good way to prevent career burnout. However, I’m sure that, like me, many of you have had to step out of relaxation mode to come to the aid of some unfortunate vacationer who either injured herself or himself trying a new activity, had a near drowning at the beach, or suffered some other tragedy.

I’ve just returned from a trip with six friends to Turks and Caicos. There was beach, sun, a lot of activities like snorkeling and the flying trapeze, and unlimited food and alcohol; in other words, it was the perfect set-up for a trip to the infirmary. (I once had a three-week nursing gig at a resort, so I know the usual ailments: overindulgence in food, alcohol, and sun; twisted ankles from people playing sports they haven’t attempted in the last 10 years; and the occasional serious accident or heart attack.)

Two days into the trip, one of my co-travelers fell ill with food poisoning, which resulted in a day’s worth of vomiting. At 2 a.m. my phone rang. It was this friend telling me that not only was she sick, but she’d just […]

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