Notable Nursing. Facing the Crisis: A Publication For Nurses By Nurses Fall 2007

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1 Notable Nursing A Publication For Nurses By Nurses Fall 2007 Feature Story Facing the Crisis: Cleveland Clinic Takes Practical and Proactive Steps to Tackle the Nursing Shortage p. 04 Also Inside Profiles of Nursing Success p. 01 Studying Nighttime Noise and Patient Satisfaction p. 08 Can Nurses Decrease Length of Stay after Cardiac Surgery? p. 09

2 Notable Nursing Fall 2007 From the Chief Nursing Officer As you read this issue of Notable Nursing, you will see the word opportunity used many times in different contexts. I think that typifies nursing at Cleveland Clinic a wealth of opportunities for employment, for learning, for personal and professional growth, for advancement. The opportunities in all those areas have never been greater at Cleveland Clinic. Table of Contents p.04 Cover Story: Facing the Nursing Shortage p.08 Studying Nighttime Noise in Hospitals p.09 Can We Decrease Length of Stay after Cardiac Surgery? p.10 Urology/Gynecology Conference p. 14 Orthopaedics Conference p. 18 Cardiac Care Conference p. 22 Nursing News p. 24 Nursing Research Conference p. 25 Nurse of Note Profiles of Success Four Cleveland Clinic nurses who cultivated their own paths to career satisfaction No matter what their level of experience, nurses who join Cleveland Clinic can expect plenty of opportunities for advancement early in their careers. Some of those who have prospered in their profession began here as summer nurse associates or patient care nursing assistants during college. They worked alongside veterans who taught them about tending to patients needs and listening to their stories. By graduation, many aspiring nurses already know Cleveland Clinic is where they want to be. And when graduate school beckons, the hospital encourages nurses to continue working while pursuing their studies. This reinforces the desire to stay and carve out fulfilling long-term careers. Here are the stories of a few nurses who have utilized their opportunities at Cleveland Clinic to cultivate satisfying careers. On the employment front, the planned fall 2008 opening of the 250-bed Sydell and Arnold Miller Family Pavilion for the Cleveland Clinic Heart and Vascular Institute means that we are preparing to significantly expand our nursing staff. We are excited about the opportunity this presents for bedside nurses, nurse managers and advanced practice nurses to work in a state-of-the-art environment at the leading heart center in the country. By recruiting excellent nurses in all areas and helping them to grow in their careers here, we can build a solid nursing organization with a high level of knowledge capital. To support this goal, we offer phenomenal resources for career support and advancement, from new-hire support groups to career coaches, to preceptors and specialized orientations. Our new nursing clinical simulation lab, a replicated patient unit for hands-on learning and continuing education, is the latest example of the exceptional resources available here. This is a dynamic time for nursing at Cleveland Clinic as we grow in number, knowledge and opportunities. Whether you are an experienced nurse or a new graduate, we invite you to be part of it. Sincerely, Claire Young, MSN, MBA, RN Chief Nursing Officer Executive Editor Michelle Dumpe, PhD, MS, RN comments about Notable Nursing to Editorial Board Claire Young, MSN, MBA, RN Chief Nursing officer Mary Beth Modic, MSN, RN, CNS Diabetes and Patient Education Claudia Straub, MSN, RN, BC Nursing Education Robbi Cwynar, BSN, RNC Thoracic & Cardiovascular Surgery Nancy Albert, PhD, RN, CCNS Nursing Research Christina Canfield, MSN, RN, CNS Medicine Deborah Solomon, MSN, RN, CNS Surgery Barbara Reece, MSN, RN Director, Medicine and behavioral health Christine Harrell Managing Editor Michael Viars Art Director Deborah Durbin Marketing Manager To add yourself or someone else to the mailing list, change your address or subscribe to the electronic form of this newsletter, visit Christina Canfield, MSN, CNS Age 31 Clinical Nurse Specialist, Department of Nursing Education and Professional Practice Development Education: BSN, Kent State University, 2000; MSN/CNS, Kent State University, 2006; certified by the American Nurses Credentialing Center as an adult medical-surgical clinical nurse specialist When and why did you decide to become a nurse? I decided to become a nurse after weighing the benefits and disadvantages of several career options. I had considered majoring in education, physical therapy and pharmacy, in addition to nursing. I chose nursing because it was the best way to combine the best aspects of each profession. First job/unit assignment at Cleveland Clinic: My first position at Cleveland Clinic was as a patient care nursing assistant on G81 (internal medicine/otorhinolaryngology/pulmonary). I was hired into this position before I graduated. Describe your path from that first job to where you are now. I moved from PCNA to registered nurse when I graduated and passed my boards. I spent about 2½ years as a staff nurse on G81, learning to care for patients with complex head and neck surgeries and those who had difficulty weaning from mechanical ventilation. I served as a preceptor for new nurses, as a unit-based skin care nurse and a geriatric resource nurse. I have always been interested in teaching and, in September 2002, I became a clinical instructor responsible for coordinating orientation, teaching classes and providing in-service and continuing education. In July 2004, my supervisor created a position called the clinical nurse specialist intern, in response to a relative shortage of clinical nurse specialists. I attended graduate school while continuing to work, assuming more and more CNS duties. When I graduated in May 2006, I assumed full CNS responsibilities for two internal medicine units. One of the units I cover is where I began my career. The specialized knowledge I gained there has served me well throughout the years. Greatest accomplishment as a nurse: Attending graduate school and becoming licensed as a clinical nurse specialist. In my current position, I serve as a clinical expert and resource. What do you hope to achieve in the next few years? To successfully complete a nursing research project that impacts how we provide patient care. I would like to publish or present the results. How do you balance work, family and other leisure time? I have a very supportive family. They were willing to sacrifice a lot while I was in school, and they went the extra mile to make sure things ran smoothly while I juggled other responsibilities. I work with a lot of amazing people, and I m happy to say they re my friends both at work and outside of work. What helps you manage stress after a hectic day or week at work? I often take time during my commute home to reflect on the day s events. I try to pick at least one thing that went very well and one thing I learned each day. In an institution like Cleveland Clinic, there s always something. Focusing on these things keeps me going. 1

3 Notable Nursing Fall 2007 Lauren Mattern RN, BSN Age: 25 Clinical Instructor, Department of Nursing Education and Professional Practice Development Rachael Lynn Taggart, RN, BSN Age: 25 Registered Nurse, Heart Failure Intensive Care Unit (H22) 2 Education: BSN, Case Western Reserve University, 2004 When and why did you decide to become a nurse? My mother, a pediatric nurse, told wonderful stories about caring for children and their families. I never realized how much a nurse could impact someone s life until one day, as I was shopping with my mother, I witnessed a patient s family member make a point to stop and thank my mother. It made me smile and realize that I wanted to have that same feeling of accomplishment that comes from caring for others. First job/unit assignment at Cleveland Clinic: I started as a nurse associate on G91, cardiology step-down, in Describe your path from that job to where you are now. I worked the summer before my senior year of college and continued throughout the school year, following a nurse and developing clinical skills. After graduation, I joined Cleveland Clinic full time as a registered nurse on the same unit and provided care to step-down patients at the bedside. In 2007, after 2½ years as a staff nurse, I became a clinical instructor in the Department of Nursing Education and Barbara Reece, RN, MSN Age: 55 Director of Nursing, Medicine and Behavioral Services Education: AND, Kettering College of Medical Arts, 1975; BSN, University of San Diego, 1987; MSN, Case Western Reserve University, 1989 When and why did you decide to become a nurse? In high school, after working as a candy striper and then as a nursing assistant. Prior to this, I had always wanted to be a kindergarten teacher. First job/unit assignment at Cleveland Clinic: I started in 1975 as a staff nurse on a GI unit. After one month, the nurse manager let me transfer to psychiatry. I had been assigned to the psychiatric unit when I was a nursing assistant and became hooked. Describe your path from that job to where you are now. After two years as a staff nurse, an assistant nurse manager position opened on the child/adolescent psychiatry unit. Two years later, the nurse manager position became available. I was in that position for five years. In 1984, I went back to school for my BSN. After graduating, I returned to Cleveland and entered graduate school to become a clinical nurse specialist in adult psychiatric/mental health nursing. While in graduate school full time, I worked in Cleveland Clinic s weekender program. Professional Practice Development. I teach basic dysrhythmia and critical care to nurses in orientation and provide staff members with continuing education. Greatest accomplishment as a nurse: Having a patient ask for you by name. It is truly amazing how much trust and faith a patient has in a nurse. When this happened the first time, I realized how rewarding it is to be a nurse. What do you hope to achieve in the next few years? My goal for the coming years is to continue to provide our caregivers with the best possible education so they, in turn, provide our patients with the best possible care. To achieve that goal, I also plan on exploring educational options. How do you balance work, family and other leisure time? Carefully. It is often difficult to balance your career and your life. Planning and setting a schedule has been the best way. What helps you manage stress after a hectic day or week at work? I enjoy scrapbooking, baking and spending time with my family. (After obtaining her MSN, she held two jobs elsewhere before coming home to Cleveland Clinic years later as manager of behavioral services.) Within two years, the nursing division re-organized, and my position was upgraded. In 2005, I became director of medicine nursing, and I have managed both areas since then. What do you hope to achieve in the next few years? I hope to complete a coaching program and develop formalized mentoring for nurse managers and assistant nurse managers in leadership skills, specifically human resource management. Nurses become clinical experts, but there isn t as much emphasis on how to deal with people, especially in difficult situations. How do you balance work, family and other leisure time? My great nieces keep me energized and full of joy. Gardening is such a grounding activity. My sister and I plant a major vegetable garden each year. I love to read journals and fiction and try to leave large blocks of time on weekends to read. What helps you manage stress after a hectic day or week at work? I go home, eat a leisurely dinner and read the paper. I also love to sleep and make sure I get enough sleep to adequately do my job. quote Education: BSN, The University of Toledo/ Medical University of Ohio (consortium program), 2004; Sigma Theta Tau (nursing honor society); ACLS-certified When and why did you decide to become a nurse? My freshman year of college. It was very spur of the moment. I had wanted to concentrate on exercise physiology, but then decided on something more people-oriented. Struggling in chemistry class for that major, I was mortified at my grade despite my best efforts. A young lady in my dorm talked about how much she loved her nursing classes and how great her professors were. So, I told the nursing college counselor that I wanted to be a nurse. That was that. Looking back, that day was a major turning point. Both my grandmothers were registered nurses and very influential in my decision. One of them is still practicing. First job/unit assignment at Cleveland Clinic: With one year left in school, I was accepted into the nurse associate summer program. For 12 weeks, I worked side by side with the nurses (on M72/palliative care and pain management). I had been in a hospital only once before, with my grandmother on Take Your Daughter to Work Day. When the program ended, management offered me a position for the rest of the summer as a patient care nursing assistant. I worked as needed on holiday breaks and long weekends during my senior year. Several wonderful, very experienced nurses on that floor taught me so much about life, death, and everything else in between. I worked with Dyanne Thomas most often, and she always exceeded my expectations and patient expectations. She is one of those nurses who you would think has seen it all and dealt with it gracefully. She made me feel like I was born to do the job. She was funny, serious, soft and firm when she needed to be. I also fell in love with the patients and their stories. My career would not be the same had I not worked on that floor. Several wonderful, very experienced nurses on that floor taught me so much about life, death, and everything else in between. Rachael Lynn Taggart, RN, BSN Describe your path from that job to where you are now. After I graduated, I wanted to stay on M72. I was told by management that, while they liked me very much, they were not hiring new graduates. I was devastated. But I got gutsy and decided I might like the ICU. I had heard about H22 (heart failure intensive care unit). They were hiring new grads. I shadowed one day and loved it. Greatest accomplishment as a nurse: Being selected as Nurse of the Year. Also, I recently went to preceptor class and oriented my first new grad nurse for H22. Lastly, I took care of a man for several weeks who was very sick and on the transplant list. He ended up getting a heart and going for surgery on one of my night shifts. Just the other day, he walked back into our unit looking handsome, healthy and having had great biopsy results. I was so proud! What do you hope to achieve in the next few years? To take CCRN classes and get that certification, and maybe a master s degree so I can teach nursing someday. How do you balance work, family and other leisure time? It is difficult sometimes, working rotating shifts two weeks of days and two weeks of nights. Immediate family and friends have my work schedule, and I keep track of theirs. We end up doing things whenever I can. Working three 12-hour shifts each week and two weekends per month leaves room for mini-vacations and road trips. I play a lot of phone tag, listen to voice mail and send e- mails to keep in touch. What helps you manage stress after a hectic day or week at work? I recently bought my first house, so I have been doing yard work and gardening. I love going to the beach or a park and walking or rollerblading. I have a YMCA membership for exercising when the weather is cold or rainy. I also enjoy massages and fizzing foot scrub. 3

4 Notable Nursing Fall 2007 Facing the Crisis: Cleveland Clinic Takes Practical and Proactive Steps to Tackle the Nursing Shortage The U.S. Bureau of Labor Statistics projects the current nursing shortage to reach 800,000 by As a 1,000-bed tertiary care medical center, Cleveland Clinic constantly faces the challenges of recruiting and retaining qualified nurses at all levels. Add to that staffing requirements for the new 288 bed Cleveland Clinic Heart and Vascular Institute facility, scheduled to open in fall 2008 (see The New Heart of Cleveland Clinic, Page 7), and you have a nursing shortage issue that has elevated to top priority for the institution, according to Chief Nursing Officer Claire Young, RN, MSN, MBA. Retention is a two-fold challenge, Young says. One element is attracting and hiring the right people, and the second is retaining the high-quality people whom we hire. To address these needs and develop strategies for more effective recruitment and retention, the Cleveland Clinic Division of Nursing held a Retention Summit last fall. As a result of that meeting, at least 10 new projects related to hiring and retention are in various stages of implementation. In the face of a national nursing shortage, Cleveland Clinic is addressing nurse hiring and retention from every angle and is constantly exploring innovative approaches to maintaining the highest quality nursing staff. The issue has become even more significant as Cleveland Clinic prepares for a major expansion next year. Effectively Recruiting the Best Attendees at the summit agreed that the key to retaining nurses is the interviewing and hiring process, says Lois Bock, RN, BS, Director of Nurse Recruitment. Our goal is to place nurses in an environment where they will succeed, she says. We do this by matching their career interests and goals with the right position for each individual. The all-rn nurse recruitment team at Cleveland Clinic goes beyond the usual hiring practices and processes to achieve this perfect match. The team has found that career assessment and coaching to assist potential hires in determining their best job fit are essential to successful hiring and contribute significantly to retention, Bock says. Job applicants who are undecided as to where their interests lie are matched with a recruiter who will assist them through the hiring process, she explained. As part of that process, applicants are encouraged to job shadow. By following a nurse on the floor for an hour or more, the applicant experiences the work flow and pace and the unit s environment, she explains. Shadowing exposes potential hires to the ways in which Cleveland Clinic nursing differs from clinical rotations during nursing school, Young says. Cleveland Clinic is a unique place in its pace and patient acuity, and the better a nurse understands that going in, the higher the chance that he or she will be happy here and stay. An Innovative Partnership with Area Nursing Schools Recognizing that a shortage of nursing faculty to train new nurses underlies the nursing shortage, the division started a Deans Roundtable Faculty Initiative in 2005 with the deans of area nursing schools to discuss this aspect of the problem. Through the initiative, 275 Cleveland Clinic nurses were identified as potential faculty members and a Web site was developed that matches these nurses with available teaching opportunities at participating schools. Nurses who are interested in teaching log on to the Web site and submit a professional profile, and participating nursing schools post course profiles for which they are seeking faculty on the Web site. The Web site compares applicants and positions and assigns matches. The Deans Roundtable Faculty Initiative also provides ongoing support through a series of educational offerings, including one-day faculty development programs, continuing nursing education programs and quarterly newsletters that prepare potential faculty to become nurse educators. The initiative also helps Cleveland Clinic in its ambitious efforts to recruit new nursing graduates. We now are partnering with area nursing schools to let their graduates know that our arms are wide open to them and that we have all the tools to support them throughout their career at Cleveland Clinic, Young says. Cleveland Clinic s student loan assistance is one tool that new graduates may find very attractive. Through this program, Cleveland Clinic will pay up to $10,000 in student loans for nurses who qualify. In return, the nurse makes an employment commitment to Cleveland Clinic. To woo new graduates from farther away, Cleveland Clinic offers a weekend visitation option. At these once-monthly sessions, graduating nursing students who live more than 75 miles away visit Cleveland Clinic on a Saturday for a question and answer luncheon, a campus tour, an interview and a shadowing experience. Participants enjoy complimentary dinner, parking and an overnight stay in a hotel. Although the weekend program represents a major commitment on our part, it has been highly successful, Bock says. The hiring ratio from these events is about 80 percent, so it is well worth our while. Helping Newly Hired Nurses Adjust As a result of the Retention Summit, the Division of Nursing has enhanced its welcoming and orientation for newly hired nurses. Once a new hire is on board, every effort is expended to help him or her feel welcome and part of the team, beyond the formal orientation that all new Cleveland Clinic employees go through. The focus is on personalizing the experience to meet the new hire s needs based on his or her education and experience. Every new hire is matched with a Primary Preceptor, an experienced nurse who serves as a career resource, a listening ear and a sounding board, explains Carol Santalucia, MBA, Director of Nursing World-Class Service. Additional unit-based preceptors also assist the new nurse through clinical orientation, which focuses on clinical competence, patient care content expertise and socialization to the unit culture. On the social and personal side, new hires are invited to participate in informal support groups and quarterly division social events. Special Attention to Retention Attracting and hiring nurses is only one side of the equation for meeting staffing requirements, Young emphasizes. Keeping them is equally or more important, not only from the financial perspective because of the cost of hiring and training new employees, but also from a quality perspective, she says. Retaining our nurses is essential to maintaining a consistent quality of care, she says. Retention gives us a constant, high level of knowledge capital at the bedside. Retention is a complex issue, she added, particularly in the Cleveland Clinic environment, where nurses experience physical, mental and emotional labor all at one time. For many nurses, opportunities for professional growth and career advancement are important to their job satisfaction. By its structure as a large, multicenter health system, Cleveland Clinic abounds with career opportunities. We encourage nurses to move around if needed to find the position that is the right fit for them, Young says. Nursing at Cleveland Clinic is very diverse with many different types of opportunities. We don t believe that one size fits all when it comes to nursing positions. (For examples of nurses who have created rewarding career paths at Cleveland Clinic, see Page 1.) Another option for any registered nurse or licensed practical nurse who seeks more flexibility is Cleveland Clinic Agency Resources. This new Cleveland Clinic spin-off company is essentially a nursing temporary agency, except that nurses who sign on with the agency work exclusively for Cleveland Clinic hospitals. 5

5 Notable Nursing Fall Qualified nurses who are registered with the agency go online to check current temporary staffing needs, select the ones that fit their personal schedule and sign up to work those hours. Nurses must be clinically qualified for the job and must commit to working at three facilities within the Cleveland Clinic Health System, Bock explains. The agency gives nurses the flexibility they want and assures Cleveland Clinic of a qualified pool of professionals to meet temporary staffing needs. A State-of-the-Art Learning Center To support clinical learning and professional development, the Department of Nursing Education and Professional Practice Development recently opened a high-tech learning center that includes an eight-bed laboratory. The clinical simulation lab, funded by Hill-Rom Co., includes six patient beds in a standard patient care unit configuration, two intensive care beds and an infant intensive care crib. Everything in the lab is real, except the patients, says Michelle Dumpe, PhD, MS, RN, Associate Chief Nursing Officer, Nursing Education and Professional Practice Development. The lab is equipped with everything that a real patient unit or intensive care unit would have, including laptop computers for bedside charting, a crash cart and a supply room. All the equipment is operational. Six of the beds are occupied by interactive simulator models that can have their vital signs taken realistically and can be moved and repositioned in the beds. The two models in the intensive care unit are fully programmable to simulate real-life critical care situations such as ventilation, cardiac monitoring or intravenous fluid delivery. The lab, fully operational by January 2008, will have multiple uses, Dumpe says. We will be using it for continuing education for staff nurses to learn new techniques and technology, for clinical testing for job advancement and for validating a new hire s hands-on skills during orientation. Particularly for new hires, the lab is one way to help bridge the gap between nursing school and the reality of clinical practice. Interventions occurring in the lab will be videotaped for later review and discussion by the nurse and a preceptor, she added. The expanded Nursing Education and Professional Practice Development Department, which recently moved to new, totally redesigned quarters on the main campus, also includes a new 40-station computer center for online learning. Nurses now can enroll online for training, scheduling it at their convenience, and go to the computer center to take the course. Online offerings include in-service training as well as courses for personal development and career advancement, Dumpe said. Our staff of more than 30 nurse educators is continually developing new classes for staff education, she said. It s a part of Cleveland Clinic s commitment to ongoing professional career education for our nurses. It s also a perfect complement to the new simulation lab, she added, allowing nurses to take the didactic portion of a course in the computer center and go through a clinical check-off in the lab. quote Our goal is never to turn away a qualified nurse. And once they are here, we want to support them in their personal and career goals in every way possible. Claire Young, RN, MSN, MBA, Chief Nursing Officer An Emphasis on Health, Wellness and Life Balance Also the result of the Retention Summit, the division has implemented a nursing wellness initiative that addresses the health of the mind, body and spirit through exercise programs, nutrition education and other wellness-focused opportunities. At Cleveland Clinic we are passionate about patient advocacy and satisfaction, Santalucia says. The best way to achieve that is by taking care of our employees. The Parent Shift Program, an innovative scheduling approach, is another example of how Cleveland Clinic is trying to meet nurses personal needs in addition to their professional needs. Introduced three years ago, this popular scheduling option is designed for parents or caregivers who need to be home in the early morning and late afternoon but have several hours available in the middle of the day to work. The Parent Shift Program lets nurses work the mid-day hours without requiring a commitment to a complete shift, making it ideal for nurses with family responsibilities. Career Options Abound for Veteran Nurses Too Some senior nurses want to stay in bedside nursing, but for those who are seeking other choices, the Division of Nursing has created a range of nursing positions that are less stressful and intense. Positions such as Admitting Nurse give Cleveland Clinic and its patients the benefit of the experience and knowledge of senior nurses while satisfying the nurses desire for a less-intensive work situation still within nursing. The New Heart of Cleveland Clinic Construction is under way for a new Heart and Vascular Institute facility at Cleveland Clinic. Scheduled to open in 2008, the new 10-story hospital tower and technology center will provide a comprehensive model of care where patient care, research and education are offered in one location. Features include: Outpatient diagnostic facilities including 115 exam rooms and 170 physician offices Technology building for complex and highly technical procedures Inpatient facilities featuring 288 (mostly private) hospital beds Fully-equipped conference center For more information regarding the new Heart and Vascular Institute facility, visit To learn more about nursing opportunities, visit 7 Senior nurses also enjoy priority scheduling and opportunities to become instructors and preceptors. Senior nurses are foundational to building a solid nursing organization, Young said. It s very important that we keep these employees in whom we have put our faith and trust. comments to and Nursing students in the computer lab of the Learning Center for Nursing Practice Excellence. Students receive instruction in the simulation lab.

6 Notable Nursing Fall 2007 Studying Nighttime Noise and Patient Satisfaction A bright idea came to mind after many patients at Cleveland Clinic had told Terri Murray, RN, BSN, about nighttime noise disrupting their sleep: Let s do a study. Can Nurses Help Decrease a Patient s Length of Stay after Cardiac Surgery? Study findings indicate it s not likely Following a study of cardiac surgery patients, nurses at Cleveland Clinic concluded that bleeding, respiratory complications and/or the need for red blood cells after surgery delay the initiation of Coumadin, which prompts a longer stay for patients. 8 Murray and Jackie Spence, RN, nurse managers in the Heart and Vascular Institute s cardiothoracic stepdown units, set out to explore if a correlation existed. They assessed patients perceptions of noise and impact on sleep and whether perception of noise is based on demographic or surgery variables (age, gender, medical history, surgical procedure type, etc.) instead of unit environment. It s the first study of this kind, says Spence. The literature search only found other studies that measured noise level ranges in decibels. From January through May, the nurse managers surveyed a total of 150 randomly selected adult patients on three floors. The patients primary reason for hospital admission was postoperative recovery after coronary artery bypass graft and/or valve procedure. Exclusion criteria consisted of several elements: admission for a different reason; age less than 18 years; other surgery or medical condition; unwilling to give written informed consent to participate; unable to read or write English; mentally impaired close to discharge (when data are collected); or any psychiatric or psychological condition. After three nights in the unit, patients who qualified were asked to fill out a 24-item survey. This was designed to determine which factors tend to disrupt sleep and which are likely to promote relaxation between 11 p.m. and 6 a.m. The survey measured patients perceptions of average nighttime noise on the floors by showing evidence of 15 different factors, such as roommate snoring, nurses talking, and equipment moving in the hallway. A Likert-type scale first identified that the noise factor did indeed occur and then measured how often and severe it seemed. It also evaluated the extent to which it made falling asleep or staying asleep difficult. The survey also listed 10 sleep-promotion factors and asked patients if they benefited from any of them during their last two nights in trying to relax, sleep better, or block out noise. This included ear plugs, a CD player, television set, eye shields, medication, change of roommates, private room, room door closed, and nurses use of soft voices and making less noise. In addition, data collected in an ongoing registry of all open heart surgery cases will be used to determine if patient, medical condition or surgery variables influence patient perceptions of noise at night. Data will be analyzed using descriptive statistics, correlation statistics and differences between groups (high vs. low perceptions of nighttime noise). Once the final results are complete, Murray and Spence hope to publish their research. Understanding relationships of variables that we cannot change (age, gender, ethnicity, medical background, etc), those we can change and patient s perception of the environment as noisy can aid in planning to optimize sleep, says Murray, which may, in turn, improve overall patient satisfaction with the hospital experience. comments to or Patients taking Coumadin after cardiac surgery stay three days longer in the hospital on average than those who do not, based on Cleveland Clinic registry data. But it was unclear why and whether something could be done to intervene and alter hospital processes. Another unknown was whether nurses should focus attention on systems that prompt better post-discharge monitoring of clotting activity, so that patients could be sent home faster. With this as our background, we set out to get some answers, says Robbi Cwynar, RN, BSN, BC, Clinical Manager of Thoracic and Cardiovascular Surgery. Cwynar and two colleagues Nancy Albert, PhD, RN, CCNS, CCRN, CNA, Director of Nursing Research and Innovation, and Carol Hall, MSN, CNP, a nurse practitioner in Thoracic and Cardiovascular Surgery recently conducted the study that entailed retrospective chart review of patients who underwent coronary artery bypass graft surgery or valve surgery at Cleveland Clinic in I have been on the committee to look at length of stay and have been interested in length of stay for many years, says Cwynar, a Cleveland Clinic nurse for 28 years. The nurses used an Institutional Review Board approved registry that contains data on all patients undergoing cardiac surgical procedures. For inclusion in the study, patients had to be receiving Coumadin after surgery, but not beforehand, and their circumstances had to fit other requirements (e.g., a nonemergency surgical case and being younger than 85 years old). Once we had a list of all cases that met inclusion criteria, we randomly selected cases for review, based on hospital length of stay, Albert explains. Patients were grouped as short length of stay, defined as seven days or less for isolated coronary artery bypass grafting (CABG) and nine days or less for valve surgery or combination CABG and valve surgery; or long length of stay, defined as more than seven days after CABG or more than nine days after valve or combination surgery. Of the 82 patients, 33 underwent isolated CABG and 49 had valve or combination procedures. There were few differences between the groups in demographics, medical history, common complications such as atrial fibrillation or adverse events, and use of angiotensin-converting enzyme (ACE) inhibitors and beta-blocker therapies. Patients with longer length of stay had bleeding complications that extended their days in intensive care and overall time in the hospital. They also tended to be older (mean age 73.5 years vs years). Patients with longer length of stay exhibited more post-operative respiratory insufficiency and were more likely to receive red blood cells. In addition, they had more consultations for other services (e.g., pulmonary medicine). As for Coumadin therapy, patients with longer length of stay had a greater time lapse between the surgery date and start of the medication. The nurses concluded that bleeding, respiratory complications and/or need for red blood cells after surgery delay the initiation of Coumadin. This, in turn, prompts a longer stay, increases costs of care, and postpones recovery or rehabilitation. Ultimately, the factors that were found to lengthen hospital stay are not factors easily tweaked by nurses to change clinical outcomes, Albert says. We cannot control bleeding or respiratory complications that occur even with excellent post-operative management. And since so few patient variables were significant predictors of long length of stay, she continued, we cannot even create a risk score to determine who is at risk before surgery, and then try to be more vigilant in assessment and care delivery to prevent complications. However, the findings offer valuable insight. They can help healthcare providers identify intensive care unit patients who develop bleeding or respiratory complications, so that discharge planning could be started sooner. For instance, clinicians could assess clotting time earlier, possibly initiate Coumadin more quickly, and adjust dosing to achieve the target dose in less time. 9 comments to and

7 Breaking Bad News Kathleen Lupica, RN, MSN, CNP, CCRN 3RD Annual Urology/Gynecology Nursing Conference Cleveland Clinic s 3rd annual Urology/Gynecology Nursing Conference was held April 21 at the InterContinental Hotel and Bank of America Conference Center on Cleveland Clinic s main campus. The one-day conference was directed to nurses and other allied healthcare professionals. Topics included methods of prevention for HPV to eradicate cervical cancer; trends in treatment for benign prostatic hyperplasia; advances in treatment for urinary incontinence; conveying sensitive information to patients; and robotic surgery in urology. Breaking bad news is part of our job; a learned skill that is well worth our time and effort. There are six key steps to breaking bad news, and the first is learning how to start. Setting is vital; you want to do it in person, in a calm, private place without distractions. It is up to the patient to determine who else should be present. The next step is finding out what the patient knows. Start with no assumptions, and let the patient tell you what he or she knows. Use vocabulary similar to the patient s and pay attention to the patient s body language. The third step is finding out what patients want to know. For example, ask if they d like details or just main points about the tests that came back. Often your role is just to confirm what they already suspect. Fourth is sharing information in a therapeutic manner. It s best to start by listening to their concerns and responding in a way that is truthful, positive and realistically hopeful. Pause often and let them speak. Ask if they understand and be ready to clarify or repeat facts. When asked for a timeline, use ballpark figures and explain that statistics provide only a range. Next, respond to their feelings. Tell them it s OK to be angry. Offer a tissue if they cry and use therapeutic touch. Let them know that guilt is useless. Be sure not to provide premature reassurance; it s OK to remain silent rather than promise what you can t deliver. Lastly, after explaining the diagnosis, outline some treatment options, help create a possible plan and talk about what outcomes can be expected. Remind patients of the things that will help them cope their family, their faith. Finally, give them a specific next step, such as the date of their follow-up visit and leave the door open to any questions they may think of later. comments to Kathleen Lupica, RN, MSN, CNP, CCRN 3RD Annual Urology/Gynecology Nursing Conference 11 Course Co-Directors were: Susan Beam, RN, BSN; Brian Klein, RN, BSN, BA, CNOR; Janet Ursinyi, RN; Michelle Suhy, RN, BSN, CURN; Dorothy A. Calabrese, RN, MSN, CNP; Laurel Stevens, RN, BA; and Debra O Connor, LPN.

8 Robotics for Surgical Specialties Georges-Pascal Haber, M.D. Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic Developing a Personal Formula for Contentment Scott Bea, Psy.D. Clinical Psychologist, Department of Psychiatry and Psychology, Cleveland Clinic 3RD Annual Urology/Gynecology Nursing Conference Diana Baker, RN, BSN Clinical Coordinator, Glickman Urological and Kidney Institute, Cleveland Clinic Though robots have had a hand in urological surgery since the early 1990s, their role continues to evolve in exciting ways. Earliest robots, such as the Aesop, were little more than static holders of laparoscopic cameras. Then newer features were added, such as infrared sensors that enabled some robots (endo assist) to move in synchrony with the surgeon s hand. These earlier robots helped us see, but were still a limited preview of the life-like 3-D views we get from today s devices. The da Vinci surgical robots used widely today first entered the OR in late They brought not only better visualization, but improved dexterity. Unlike older designs, these new instruments can operate at a 90-degree angle, enabling precise movements even within a tightly confined surgical field. The robots in clinical use today don t provide tactile feedback to the surgeon, nor do they include various energy devices, such as laser tools. We are currently in the final stages of testing a laser tool for use in robotic prostatectomies and partial nephrectomies. The advantage of these lasers is that their beams can be tightly focused, reducing the amount of thermal damage and risk to nearby nerves. Georges-Pascal Haber, M.D. However, even with better robots, the surgeon who sits at an operating console across the room from the patient needs skilled assistance. An assistant surgeon remains at the bedside providing manual suction and clipping, and a nurse performs several key roles, including troubleshooting and docking the robot. Aside from making the next generation of robots smaller and less expensive (current designs are over $1.2 million), engineers are working to equip them with augmented virtual reality. These are GPS navigational systems that give precise feedback on the positions of each instrument. They also have a memory, allowing the surgeon to have an instrument return to any previous position. Further in the future are robotic devices that provide a surgeon with layered visualization and 3-D reconstructions of a tumor made from CT and MRI scans. Different colored zones are highlighted around the tumor providing a guide for optimal tumor removal. Happiness is not a destination, but a journey: not something you achieve, but rather something you must continually work at. Yet, coming to this realization isn t easy in a consumer-driven society where we re indoctrinated into thinking that happiness is about having stuff. We re busier than ever before, and working more hours, so it s hard to give relationships the time they need. Some of our unhappiness may also be a leftover from the conditioning of the early human brain. In order to survive, it had to stay focused on things that could kill us, no matter how nice the rest of our surroundings were. Anxiety was good; happiness a luxury. To overcome this history, we have to recondition how we see our environment. One step is to be a gift giver not of material things, but of your time, energy and attention. Another step is to complain less (70 percent of American conversations are characterized by complaint) and give compliments and praise more. Studies show that 16 instances of praise to every instance of criticism is an ideal ratio to keep people functioning well. A third is to be happier with who we are and not get caught up in the frustrating pursuit of trying to be like someone else. This requires us to be more aware of and take responsibility for what we really need and to not let others determine what is important. Forgiveness is another key step. We must understand that people come with a wide range of abilities, intelligence and other behavioral traits. We need to be more forgiving of others who may have less ability than ourselves. Like any good habit, learning to be happy takes practice. At bedtime each night, think of three good things you did that day. If you go to sleep with positive thoughts, you ll sleep better and wake up more refreshed. In the morning, make a list of the five things you re best at and during the day commit at least one random act of kindness. To reduce the impact of everyday worries, take 15 minutes each day to make a list of everything that s worrying you. When you make the list daily, it trains your brain to under-respond to the worries, diluting their impact on your state of mind. 3RD Annual Urology/Gynecology Nursing Conference Diana Baker, RN, BSN

9 7th Annual Orthopaedics: Excellence Through Education Conference Held in February at the InterContinental Hotel and Bank of America Conference Center on Cleveland Clinic s main campus, conference attendance skyrocketed with 254 registered participants, according to Co-Directors Deborah De Mars, RN, RNFA, ONC, Dawn Gerz, RN, RNFA, ONC, and William J. Wick, Coordinator of Orthopaedic Materials in the Department of Orthopaedic Surgery. The conference opened with broadcast of a live total hip arthroplasty, performed by Cleveland Clinic orthopaedic surgeon Lester S. Borden, M.D. In a Q&A session following the surgery, Dr. Borden and his nurse, Sharon Pivonka, RN, RNFA, reflected on the evolution in total joint surgeries. As a resident in the 1960s, Dr. Borden saw total hips take up to eight hours with high blood loss and infection rates of 15 percent. Initially, we didn t have the instrumentation to get these implants in and to resurface the bone, Dr. Borden explained. Instrumentation has made a huge difference. Today, we have higher quality implants, better instrumentation, less blood loss and much lower infection rates. Scars are smaller and rehabilitation is faster. Cement is out. We want the patient s bone to grow into the implant, he said. Bedside nurses should get patients moving. Hip and knee patients should sit in a chair the day following surgery, putting 75 percent of their weight on the unoperative leg. Physical therapy should begin the following day. There is no science in overprotecting patients, Dr. Borden said. He added, The sooner the patient gets moving, the better for them psychologically. Total hip patients use a walker or crutches for four weeks after surgery, followed by a cane for four more weeks, to give muscles around the implant time to heal. To avoid dislocating a new hip, patients avoid bending over to pick up an item or sitting with their knees above their waistline. Nursing Students Invited Conference planners invited professors and students from nursing programs at Cleveland State University (CSU) and Huron School of Nursing as guests. In academia, we don t get opportunities to see surgeries, said Marilyn Weitzel, Professor of Pediatric Nursing at CSU. I was glad the surgeon was so kind to the (patient s) family. Our nursing program stresses that a patient is more than an individual, each comes with a family. Seeing a live surgery reminds me of why I became a nurse, said Michael McQueen, senior at Huron School of Nursing. Nursing provides a great forum for collaboration, something is always happening and there is always something to learn. Huron School of Nursing students. Back row, from left: Bill Wingler, Michael McQueen, James Tighe. Front row, from left: Jennifer Dolence, Jennifer Tramte, Heather Pennington, and Huron faculty member Lydia Glaude, MSN, CNP, RN. Future of the OR: The Goal is OPTIMAL Operating rooms are typically overcrowded, paper-based and designed for 1970s procedures, said Jonathan L. Schaffer, M.D., M.B.A., of the Cleveland Clinic Advanced Operative Technology Group in the Department of Orthopaedic Surgery and one of the architects of the Cleveland Clinic project to develop, design and construct the Orthopaedic OR of the Future. The project was launched six years ago to improve quality, increase capacity and manage costs more efficiently. Most operating rooms run from 7:30 a.m. to 5:30 p.m. at an inefficient 42 percent utilization rate, Dr. Schaffer said. Access, quality and value will characterize optimal use in the future, he said. His project team came from every department and from among patients and families. They discovered many inconsistencies that wasted time: sterile gloves in different places and arthroscopy tables set up in different ways. In planning, the team discarded old assumptions and integrated new design elements from European operating rooms and corporations that had developed new production facilities. Looking at opportunities to improve performance, the team determined the difference if patients were transferred from the OR table to a bed on the count of two instead of three the second of time for each move could mean a theoretical $1 million savings in labor costs annually. OR nurses and technicians helped develop the new look and refine procedures and processes. We wanted the OR of the future to be easier on the nurses who spend eight to 12 hours there every day, Dr. Schaffer said. Three orthopaedic ORs were redesigned along with support areas and the sterile core between the rooms. Scheduled surgeries were re-routed and nurses extended the work day as needed to keep the schedule going and to avoid delays during construction. The commitment and efficiency of OR nurses meant a savings of 189 percent in construction program costs, he said. The new operating rooms are streamlined for optimal use. Supplies such as gloves are located in the same place in each room; arthroscopy tables have a consistent setup and the technical and implant rooms are optimally organized. A central documentation and control area in each OR has three computers. Controls for lights, cameras and pumps are within easy reach of the circulating nurse. Up to one additional joint procedure can be accommodated per day per room. These ORs are now coherent, properly functioning workspaces, said Dr. Schaffer. The future of the Orthopaedic OR is very bright. Metrics Used in Developing Plans and Processes for the OR of the Future: Increase efficiency and productivity of the surgeons, OR staff and hospital support personnel Improve patient outcomes Decrease pain Restore function Avoid complications Increase satisfaction Provide greater value to society 7th Annual Orthopaedics: Excellence Through Education Conference

10 7th Annual Orthopaedics: Excellence Through Education Conference Risk Management: Staying out of a Courtroom Vicki Bokar, CPHRM Director of Clinical Risk Management at Cleveland Clinic Orthopaedic surgery ranks among the top five specialties in terms of being named most frequently in malpractice claims. Nationally, some of these claims have resulted in large settlements, including a $7.5 million settlement for failure to diagnose Compartment Syndrome, and a $16.1 million settlement for failure to diagnose lower leg thrombosis that resulted in the death of a young patient. Surgeons and physicians aren t the sole targets. One claim was targeted toward a nurse who inadvertently used IV tubing that was not sterile. The most common allegations in orthopaedic claims include: Improper performance of surgery Improper management or judgment Failure or delay in diagnosis or treatment Postoperative complications Infections Complications under casts Wrong surgery Informed consent issues are often tagged onto the primary claim. Nurses, physicians and other practitioners play a role in every single situation listed above. Thus, each member of the team can take steps to avoid malpractice claims. Don t expect that certain diagnoses or complications will present with textbook signs and symptoms because the patient s presentation may be atypical. Unless you remember this, you may inadvertently miss important subtle clues that should be communicated to a physician. Observe and listen carefully to the patient. Limit distractions in your clinical practice and you will minimize your risk of making an error. Internal systems should be adequate and effective, such as tickler systems to assure that important test results are reviewed and reported in a timely manner. Ensure that every patient has one healthcare professional coordinating the plan of care wherever possible, particularly in the outpatient setting. This can help prevent things from falling through the cracks. Avoid disagreements with colleagues and/or making inappropriate comments within hearing of patients or families. Do not jump to conclusions or speculate when an event occurs. You may not have the whole story at the time. Introduce residents as members of the healthcare team to avoid additional risks to hospitals with teaching programs. Be aware that diagnostic errors often occur on weekends or holidays, so communication and handoffs must be thorough and complete. Don t rule out a problem without sufficient evidence to support that decision. Proper documentation should reference only information related to patient care. Include every phone call, care-related activity (including patient response) and any instructions provided to patients. Date and time each note, avoid late entries and never, ever alter a medical record. Review the documentation of others to assure that you know all pertinent information on your patient. Beware of clicking on the wrong menu item from electronic medical record s drop down menu. Patients sue primarily because their surgical outcomes do not meet their expectations. Prior to surgery, provide patients with written educational materials about their procedure and ensure they have realistic expectations. These materials may supplement the consent process and help patients to better understand potential risks and benefits. Inform surgeons if the patient has unrealistic expectations and/or does not seem to understand what was discussed during the consent process. Departure from the standard of care is one of the elements that must be proven in a malpractice case, so educate yourself regarding best practices. Nurses on a particular unit might want to identify their 15 best safety practices and ensure through ongoing monitoring that everyone follows them without deviation. Coach one another. Repeat back everything someone says to you. Know and follow the Universal Protocol. Wash your hands before and after patient care. If you remain vigilant and conscientious in your delivery of patient care at all times, you will have little reason to worry about a malpractice lawsuit. comments to Rekindling the Spirit Scott Sheperd, Ph.D., a nationally known speaker and author, invited participants to examine beliefs about stress and to rekindle their passion. Adults whine all the time, Dr. Sheperd said. When someone whines at lunch don t you try to top them with your own sad story? The audience erupted in laughter. Through humor and targeted examples, Dr. Sheperd challenged participants to stop using the word stress. Words have power, he said. They don t just describe a situation, they create it. Marriage, divorce, job changes and moves are not stressful at all, he said. Neither are holidays. We bring the meaning to the events of our lives. There are no stressful meetings, jobs or days. Stress is not a fact, but an opinion, he said. He wondered aloud why we let other people determine our mood. We can choose to be joyful and peaceful. Yet, we give away our personal power. We avoid responsibility for our lives and pass the buck every chance we get. I m a big believer in the power of the human spirit, he said. Decide that as long as you aren t dead, you will choose to be alive. Scott Sheperd, Ph.D. To Reclaim Personal Power Become aware of your attitude. Forgive. Think Rainbows Happen. Stop talking like a victim. Don t let routines become ruts. The only difference between ruts and graves is the depth. Make small changes and follow through. Don t wish life away. (I wish it was summer, Friday, vacation...) Slow down, feel the rhythm of being alive. Make every day a good day. Be with people you love and care about. Watch your words they have power to create. Do something every day that makes you feel passionate about life. Every night, ask yourself how you handled the day. If you handled it poorly, resolve to change your mind, which takes courage. 7th Annual Orthopaedics: Excellence Through Education Conference

11 26th Annual Dimensions in cardiac care Conference In its 26th year, the Dimensions in Cardiac Care nursing conference was a unique academic event designed to provide the latest trends in patient management and technology. The event was held April at the InterContinental Hotel and Bank of America Conference Center on Cleveland Clinic s main campus with the purpose of providing the nursing professional with a national forum to share knowledge and information regarding the care of the cardiac patient. Nurses representing interventional cardiology, cardiovascular medicine, cardiothoracic surgery and transplantation attended the event co-chaired by Nancy Albert, PhD, CCNS, CCRN, CNA; Kelly Hancock, BSN, RN and Kathleen Tripepi-Bova, MSN, RN, CCNS, CCRN. Rearranging the GI Tract: Esophageal Surgeries Kathleen Tripepi-Bova, MSN, RN, CCNS, CCRN Thoracic Surgery, Medical Cardiology and Transplant Though esophageal cancer is not very common, adenocarcinoma of the esophagus is the type most commonly seen in the United States. For those patients who are candidates for surgical resection of esophageal cancer, an esophagogastrectomy may be performed. In this procedure, the majority of the esophagus and a portion of the stomach are removed, and the now tubular stomach is brought up into the chest and is reconnected to the remnant esophagus in order to sustain function. Unfortunately, adenocarcinoma has no symptoms and is rarely diagnosed until the tumor blocks about 75 percent of the esophagus, causing dysphagia. Such late detection means a 5-year survival of only five to 20 percent. One diagnostic strategy occurs with patients who have signs and symptoms of GERD (gastric esophageal reflux disease). These people are susceptive to a condition called Barrett s esophagus, which may become adenocarcinoma of the esophagus. Regular GI surveillance identifies the cancer in its earliest stages before it can spread outward from esophageal lining to lymph nodes. Esophageal ultrasound plays a key role in the clinical staging of esophageal cancer. It is an outpatient procedure that looks at tumor depth and proximal lymph node involvement of esophageal cancer. This is very helpful in determining treatment strategies. Just what is involved in the esophagectomy varies with where the tumor is and what alternate conduits are available for use. The most commonly used alternate conduit is the stomach, which is remade into the tube that is connected to the remaining portion of the esophagus. If the stomach is not available, the jejunum, (Rous-En-Y) or midsection of the small intestine, is used. The duodenum (upper section) is avoided because of its attachments to the pancreas and biliary sytme. If neither of these options is available, the colon may be used (colonic interposition). Risk of complications after esophagectomy are increased by the fact that the GI tract is not a sterile environment. Risk of chylothorax is as high as 60 percent, and treatment requires a no-fat diet. However, a new procedure, a lymphangiogram, allows for identification of the area of leak so that the leak can be identified and sealed off. Despite ongoing advances, esophageal surgeries remain complex procedures with significant mortality and morbidity. Best results are obtained in specialized medical centers with experienced nursing care, as nurses usually identify postoperative problems first. comments to Can We Reverse Coronary Artery Disease? Steven Nissen, M.D., Chairman of Cleveland Clinic s Department of Cardiovascular Medicine, was one of the keynote speakers at the Dimensions in Cardiac Care Conference. In his speech, entitled Can We Reverse Coronary Artery Disease?, Dr. Nissen talked about how, despite ongoing good efforts, coronary artery disease remains a leading cause of death among men and women. He explained that for many years CAD was believed to be a disease of lumen narrowing, but recent evidence has shown this to be otherwise. The real problem, as revealed by intravascular ultrasound, is the accumulation of atherosclerotic plaque in the vessel walls. As the plaque builds up, it leads to outward displacement of the vessel wall, with the plaque accumulating for years or even decades before it starts to occlude the vessel and show up on an angiogram. So plaque is the tip of the iceberg of coronary disease, Dr. Nissen said, with the vast majority of it, some 99 percent, hidden from view. Yet, to effectively treat CAD, all of the hidden plaque needs to be treated. Many treatment efforts have been focused on lowering cholesterol, particularly LDL levels, using statins to get LDL down to 110 mg/dl in order to slow disease progression. But, Dr. Nissen said, the question remains as to whether disease progression could be halted or reversed if the levels were pushed even lower. Evidence from clinical studies (the Reversal Trial and the Prove IT trial) showed this could be done if LDL was lowered to 70 mg/dl. It also showed that the lower LDL was driven, the more disease progression was retarded. These studies had another important finding that aggressively lowering LDL also pushes down levels of C-reactive protein, a marker of inflammation. Statins appear to play a dual, helpful role, with each role apparently independent of the other. Dr. Nissen said some of the latest studies are looking at raising HDL, lowering blood pressure, or using even more potent statins to reduce plaque volume. In that last regard, there has been some exciting early evidence. In a study lasting only 24 months (the Asteroid trial), investigators were able to reduce plaque levels by nearly 7 percent by lowering LDL to 60 mg/dl. Over the next decade methods will be developed for early diagnosis of CAD, while the plaque is still developing, Dr. Nissen said. Better tools for moderating LDL, HDL, inflammation and high blood pressure also should be available. Steven Nissen, M.D. 26th Annual Dimensions in cardiac care Conference

12 Advances in Cardiac Imaging Scott D. Flamm, M.D. Head of Cardiovascular Imaging, Department of Radiology, Cleveland Clinic 26th Annual Dimensions in cardiac care Conference The application of MRI and CT cardiac imaging to clinical practice continues to evolve in exciting ways. Today, MRI is not only the gold standard for evaluating left ventricular function, it also is used to assess valve function and myocardial ischemia and viability. It is a noninvasive, non-ionizing, nontoxic approach that delivers high-resolution images with detailed information on both heart morphology and function. The main restrictions to its use include the presence of pacemakers, ICDS and intracranial aneurysm clips, and large body habitus. Advances in CT technology, particularly the advent of multidetector CT, has greatly broadened its use in cardiac assessment. Rapid patient throughput (up to 8 patients per hour) and improved image resolution (down to 0.5 mm) means it can now provide functional as well as structural feedback. Ionizing radiation remains the main limit to wider use; a 64-slice CT of the coronary arteries can provide the equivalent radiation dose of 450 to 600 chest X-rays or more. Diuresis in Heart Failure Nancy M. Albert, Ph.D, CCNS, CCRN, CNA Director, Nursing Research and Innovation, Cleveland Clinic We need a better way to measure and monitor hemodynamic congestion. Some internal monitoring devices that are part of an implantable cardioverter-defibrillator (ICD) provide additional information to track patient status. They indicate if there s been a new bout of atrial fibrillation, look at AT/AF ventricular rate during the day and night, provide heart rate variability data, and track patient activity over time. One company s internal monitoring ICD device provides a trend of internal left chest impedance cardiography. Because air offers greater resistance to electrical flow than water, a high reading means the patient is dry and a low reading tells us the patient is wet. The device is always on, eliminating the need for patient adherence, and data can be retrieved from any remote computer. While valuable data is obtained, this still provides just one part of the picture. Unlike traditional diuretics, which increase risk of mortality (by 37 percent) even as they improve symptoms, new drugs may The newer CTs are now as much a functional as a morphological tool as they convert two-dimensional scans into 3-D renderings. Such data allows us to reconstruct the beating of the left ventricle and yields quantitative data on LV function on par with echocardiography and MRI. The improved resolution of CT images makes it an important tool in planning valve procedures, as well as a postoperative check on placement. Despite the growing use of CT in cardiac imaging, the role of MRI has not diminished, but evolved. We are developing new ways to look at the aorta, both spatially and temporally, creating visualizations of valve function and turbulence, throughout systole and diastole. We are now performing stress perfusion protocols, and with newer contrast materials, that enable us to distinguish between reversible and irreversible areas of myocardial damage. A new type of MRI scan known as delayed-enhancement magnetic resonance imaging has a spatial resolution that is 5-10 times better than NMR or SPECT, and allows us to distinguish between heart muscle that is healthy and muscle that is dead. This type of study can be performed in less than an hour and with no ionizing radiation. Hemodynamic congestion is the No. 1 reason for the rehospitalization of patients with heart failure. Yet such congestion can be difficult to diagnose, which means that, too often, patients with decompensated heart failure may be sent home in a sub-clinical congested state, raising the risk of future rehospitalization. help reduce volume overload in other ways. One is an inhibitor of the anti-diuretic hormone arginine vasopressin. Vasopressin is a potent vasoconstrictor that regulates water and sodium reabsorption. Studies of this new drug show that those taking it, compared to placebo, had greater urine ouput and better normalization of serum sodium from baseline to discharge. Selective A1 adenosine receptor blockers have a direct impact on glomerular filtration rate, helping patients shed a bit more urine, and seem to provide optimal diuresis when used in combination with furosemide. Ultrafiltration, while not new, is an area of active research in patients with heart failure. Most trials are small, but show that ultrafiltration is a safe procedure and, compared to those patients receiving standard treatment, it decreased time to rehospitalization, days of rehospitalization and length of stay when hospitalized. comments to Valvular Heart Disease Deborah Klein, MSN, RN, CCRN, CS Cardiac ICU and Heart Failure Special Care Unit Through age and disease, heart valves that once opened like clockwork can become regurgitant, incompetent or stenotic, and generally fail to close completely. The types of possible dysfunction are several, as are the treatment options. Sometimes infective endocarditis can cause such valve problems, with the infection due to IV drug use, staph aureus migrating along a catheter line or a prosthetic heart valve. It presents as a rapidly developing high fever, with profound chills and sweats and requires a blood culture, physical exam findings and echocardiography to confirm diagnosis. Since it has such a high mortality rate (25 percent among general population, and percent for those 70 and older), proper medical management is a must. However, this requires identifying the source of the infection. Surgery may be indicated if hemodynamic instability develops, fever persists and there is evidence of valvular abscess or system emboli. The gradual buildup of lipid deposits on valve leaflets leads to calcification, impaired leaflet movement and a narrowing of the orifice, known as stenosis. Narrowing of the aortic valve (AV) orifice restricts blood flow and poses a burden on the left ventricle, leading to increased ventricular wall thickness and dysfunctional hemodynamics. Aortic stenosis can present as dizziness, syncope after exercise, chest pain, atrial fibrillation, ventricular fibrillation or ventricular tachycardia. Diagnostic scans are likely to show left ventricular (LV) enlargement, thickened leaflets and a significantly reduced AV area. Medical management may include diuretics, reduced dietary sodium, avoidance of vigorous activity as well as beta blockers, statins and vasodilators. Sometimes endocarditis, calcification or aortic root dilation can cause aortic valve leaflets to incompletely close, allowing backflow into the left ventricle known as aortic regurgitation (AR). It also puts hemodynamic stress on the LV. In acute cases, Deborah Klein, MSN, RN, CCRN, CS it presents as a sharp rise in LV and left atrial (LA) pressures, pulmonary edema and acute heart failure. With more chronic AR, there is left-sided heart failure over time. Once confirmed by echocardiogram, management may include a vasodilator and nifedipine if asymptomatic. Beta blockers are avoided since they lengthen diastole. Vasodilators can be given to slow LV dilation. Valve replacement is an option if management fails. Stenosis and regurgitation also occurs to the mitral valves. In mitral stenosis, there is LA hypertrophy, pulmonary hypertension and development of atrial fibrillation, since hypertrophy stretches the atrial conduction fibers. The expanded LA can also cause hoarseness if it compresses the laryngeal nerve. To manage stenosis and pulmonary congestion, diuretics and beta blockers are given; to treat atrial fibrillation, digoxin, calcium channel blockers and anticoagulant may be used. Surgical options range from a balloon valvuloplasty, to valvotomy, to MV repair or replacement. With mitral regurgitation, various drugs help reduce the leakage of blood (afterload) into the LA, including nipride, ACE-I, nitrates and hydralazine. Valve repair or replacement is also an option. comments to 26th Annual Dimensions in cardiac care Conference

13 Notable Nursing Fall 2007 Cleveland Clinic Nursing News 22 Presentations AORN 54th Congress of the Orange County Convention Center March 2007 Orlando, Florida Making a Difference Through Research Siedlecki SL, PhD, RN AORN 54th Congress of the Orange County Convention Center March 2007 Orlando, Florida Poster Presentation: Making Research Reality Siedlecki SL, PhD, RN Preventative Cardiology Nurses Association Annual Symposium April 2007 Minneapolis, Minnesota Poster Presentation: Heart Failure Knowledge: What s Race Go To Do With It? Albert NM, PhD, CCNS, CCRN, CAN Trochelman K, MSN, RN Howey K, MS 10th Congress of Society of Chest Pain Centers April 2007 Nashville, Tennessee Case based treatment Things to do right and what not to do wrong Albert NM, PhD, CCNS, CCRN, CNA Cardiac Surgery Symposium April 2007 Lima, Ohio Advances in Critical Care Nursing Hill K, MSN, RN, CCNS-CSC, CNS 33rd Annual Critical Care Update April 2007 Las Vegas, Nevada Anatomically Correct: How Cardiac Anatomy Impacts the Postoperative Course 5 Things I Wish I Knew About Chest Pain Hill K, MSN, RN, CCNS-CSC, CNS Northeast Ohio Case Management Network Annual Conference April 2007 Cleveland, Ohio Ethics, Case Managers, and Planning Ahead Hill K, MSN, RN, CCNS-CSC, CNS Dimensions in Cardiac Care 2007 April 2007 Cleveland, Ohio - Case Studies in Heart Failure - Valvular Heart Disease - 12 Lead ECG Course - So You want to be an APN Klein D, MSN, RN, CCRN, CS, CNS Ohio Consortium of Nursing Learning Labs April 2007 Findlay, Ohio A New Menu for Skills Lab Practicum Price K, BSN, RN Midwest Political Science Association Meeting April 2007 Chicago, Illinois Medicaid Tele-Reimbursement Policy: Explaining State Innovation Schmeida M, PhD, MSN, RN, CNS Pediatric Endocrine Nurses Society Conference April 2007 Portland, Oregon APN Case Study: Growth Failure in Patient with Down s Syndrome, Hypothyroidism and Type 1 Diabetes Switzer C, MSN, RN, CPNP, CDE, NP Challenges in Cardiology Dar Al Fouad Hospital May th October City, Egypt - Clinical Management of Heart Failure - Drugs Used for Heart Failure - The Importance of Self-Care in Managing Heart Failure Albert NM, PhD, CCNS, CCRN, CNA Heart Failure State of Science Conference American Heart Association Council of Cardiovascular Nursing May 2007 Washington, D.C. State of Clinical Practice Albert NM, PhD, CCNS, CCRN, CNA National Teaching Institute and Critical Care Exposition May 2007 Atlanta, Georgia Beyond the Horizon: Drug and Mechanical Diuresis in Heart Failure Albert NM, PhD, CCNS, CCRN, CNA National Teaching Institute and Critical Care Exposition May 2007 Atlanta, Georgia Issues in Heart Failure: Management Adherence and Polypharmacy Albert NM, PhD, CCNS, CCRN, CNA American Transplant Congress May 2007 San Francisco, California Cardiovascular Disease in Solid Organ Transplantation Hoercher KJ, RN, Director, Kaufman Center for Heart Failure American Geriatric Society Conference May 2007 Seattle, Washington Poster Presentation: Moving Forward by Looking Back: A Proactive Reminiscence Program for Depressed Elderly Simon J, BSN, RN, Rader E, Marrie K, MSN, RN, Campbell J, M.D. 3rd Annual Meeting of the American Association of Heart Failure Nurses Developing the Science of Heart Failure Nursing June 2007 San Diego, California - Research: Understanding It and Applying It to Practice - The Ins and Outs of Publishing Albert NM, PhD, CCNS, CCRN, CNA Society for Vascular Medicine and Biology June 2007 Baltimore, Maryland Sublingual Administration of Warfarin: A Novel Form of Delivery Batke-Hastings S, MSN, CNP, MBA Carman TL, M.D. Society for Vascular Medicine and Biology s 18th Annual Scientific Sessions June 2007 Baltimore, Maryland Poster Presentation: Sublingual Administration of Warfarin: A Novel Form of Delivery Batke-Hastings S, MSN, CNP, MBA 5th Annual Conference of State Nursing Workforce Centers June 2007 San Francisco, California The Other Shortage Dumpe ML, PhD, MS, RN Kavanagh J, MSN, RN Western Thoracic Surgical Association June 2007 Santa Ana Pueblo, New Mexico Prognosis of Patients Removed from a Transplant Waiting List for Medical Improvement: Implications for Organ Allocation and Transplantation in Status 2 Patients Discussant: Robbins RC, M.D., Chairman, Cardiovascular Surgery, Stanford University School of Medicine Presenter: Hoercher KJ, RN, Director, Kaufman Center for Heart Failure Scholarship of Teaching and Learning (SoTL) in Nursing Conference August 2007 Cincinnati, Ohio CNS Student Competencies in Outcomes Planning and Evaluation: Curricular Considerations and Exemplars Canfield C, MSN, RN, CNS, Coughlin R, MSN, RN, CNS, Jacobson A, PhD, RN, Jacobson K, MSN, RN, CCNS, Ludwick R, PhD, RN.C, CNS, Rock R, MSN, RN, CCNS, Soat M, MSN, RN, CCNS, Solomon D, MSN, RN, CNS Heart Failure Society of America September, 2007 Washington, D.C. Expert Panel: Case Discussion in Heart Failure Hoercher KJ, RN, Director, Kaufman Center for Heart Failure Publications Albert NM Non-ST-Segment Elevation Acute Coronary Syndromes: Treatment Guidelines for the Nurse Practitioner. Journal of the American Association of Nurse Practitioners. 2007;19: Fonarow GC, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, Mehra M, O Connor CM, Reynolds D, Walsh MN. Improving the Use of Evidence-based Heart Failure Therapies in the Outpatient Setting: The IMPROVE HF Performance Improvement Registry. American Heart Journal. 2007;doi: /j.ahj Albert NM, Fonarow G, Abraham W, Chiswell K, Stough WG, Gheorghiade M, Greenberg BH, O Connor CM, Sun JL, Yancy CW, Young JB. Predictors of Delivery of Hospital-based Heart Failure Patient Education: A Report from OPTIMIZE-HF. Journal of Cardiac Failure. 2007;13: Gheorghiade M, Abraham WT, Albert NM, Stough WG, Greenberg BH, O Connor CM, Pieper K, She L, Yancy C, Young JB, Fonarow GC. Relationship Between Admission Serum Sodium Concentration and Clinical Outcomes in Patients Hospitalized for Heart Failure: An Analysis From OPTIMIZE-HF Registry. European Journal of Heart Failure. 2007;doi: /eurheartj/ehl542 Albert NM, Zeller R. Development and Testing of the Survey of Illness Beliefs in Heart Failure Tool. Progress in Cardiovascular Nursing. 2007;22:63-71 Coughlin RM Recognizing Ventricular Arrhythmias and Preventing Sudden Cardiac Death. American Nurse Today. 2007;2(5):38-44 Dumpe ML, Kanyok N, Hill K Use of an Automated Learning Management System to Validate Annual Nursing Competencies. Journal for Nurses in Staff Development. 2007;6 Hill K Contributor and Consultant. ECG Strip Ease. Philadelphia: Lippincott, Williams, and Wilkins, Inc Hill K The Ps and Qs (and RSTs) of Assessing and Differentiating Chest Pain. Mosby s Nursing Consultant. St. Louis: Elsevier, Inc. April view/ /cup. Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, Blackstone EH. Improved Outcomes After Aortic Valve Surgery for Chronic Aortic Regurgitation With Severe Left Ventricular Dysfunction. Journal of the American College of Cardiology. 2007;49: Sharma MS, Hoercher KJ, Starling RC, Alster JM, Deglurkar I, Blackstone EH, Smedira NG. Seeing the Future: Strategic Decision Support for Heart Transplant. Journal of Heart and Lung Transplantation. 2007;26(Supplement, February 2007):S209 Magyer D, Smedira NG, Hoercher KJ, Navia JL, Mihaljevic T, Taylor DO, Starling RC, Gonzalez-Stawinski. Outcomes of Female Heart Transplant Recipients Bridged to Transplantation with a Ventricular Assist Device. Journal of Heart and Lung Transplantation. 2007;26(Supplement, February 2007):S89 Smedira NG, Hoercher KJ, Feng J, Klingman L, Starling RC, Blackstone EH. Transplant Should Not Be Delayed While Awaiting Functional Recovery in Patients on Mechanical Circulatory Support. Journal of Thoracic and Cardiovascular Surgery (in press) Klein DG From Novice to Expert: Clinical Nurse Specialist Competencies Acute and Critical Care Clinical Nurse Specialist: Synergy for Best Practices Philadelphia, PA: Saunders (Elsevier);

14 Notable Nursing Fall 2007 Awards Nancy Albert, PhD, CCNS, CCRN, CNA Inductee, American College of Critical Care Medicine Society of Critical Care Medicine Nancy Latza, RN Certification Certified Registered Nurse Infusion (CRNI) examination Cheryl Switzer, MSN, RN, CPNP, CDE Kathy Bielek, BSN, RN, CPON Barbara Donaho Distinguished Leadership in Learning Award Kent State University Rose Vamos, ENA Class of 2007 Valedictorian Cleveland State University Nancy Albert, PhD, CCNS, CCRN, CNA Chair of the Science Sub-Committee for Advanced Heart Disease Taskforce Council of Cardiovascular Nursing of the American Heart Association Betty Ching, MSN, RN Secretary, Board of Trustees Heart Rhythm Society Betty Ching, MS, RN Invited Chair and Faculty 28th Annual Scientific Session of the Heart Rhythm Society May 2007 Denver, Colorado Susan Curtis, MSN, RN, CCRP Chair, Northeast Ohio Local Chapter The Society of Clinical Research Associates Appointments Paul Egan, MS, RN Invited Faculty 28th Annual Scientific Session of the Heart Rhythm Society May 2007 Denver, Colorado Georgina Rodgers, BSN, RN, OCN Review Board Appointment Clinical Journal of Oncology Nursing Mary Schmeida, PhD, RN, MSN, CNS Chair, National Panel on Implementing Health Policy Midwest Political Science Association April 2007 Cheryl Switzer, MSN, RN, CPNP, CDE Treasurer Pediatric Endocrinology Nursing Society Nurse of Note Debra Albert, RN, MBA, CNAA, believes in making the most of the professional opportunities that come her way. This attitude has been the impetus for her evolving career at Cleveland Clinic during the past 20-plus years, and helped her progress from bedside nursing as a new graduate to her present position as Associate Chief Nursing Officer. As her own career path exemplifies, Cleveland Clinic is a great organization where you can always count on new opportunities, Albert says. We are always changing, leading to new and exciting opportunities for nurses at every level throughout the organization. Debra Albert, RN, MBA, CNAA Early on, I had to prove myself to physicians who questioned my ability but who gradually came to respect me as a peer, she comments. Ultimately, this was probably the position in which I grew the most, personally and professionally. 24 3rd Annual Nursing Research Conference Making Nursing Research a Reality: Perils and Practical Solutions Leah Curtin, DSc, RN, clinical professor of nursing at the University of Cincinnati College of Nursing and Health, set the tone for the 3rd annual Nursing Research Conference May 10 with her keynote address, The Metaphysics of Health and Disease. The purpose of the Department of Nursing Innovation and Research s conference was to encourage and inspire registered nurses to participate in meaningful research. Curtin s lively review of recent studies on the relationship of social, demographic and psychological factors to health and disease provided fertile ground for new research. Research in this field, dating back to the 1970s, demonstrates that social conditions determine an individual s risk of disease and that an individual s early life determines future health events, Curtin explained. She traced the history of this concept by citing famous studies from each decade of research, including several recent papers that link early childhood nutrition and sensory stimulation to an individual s ability to cope with stress and, ultimately, to adult health status. Childhood influences determine coping skills, and early deficits cannot be overcome, Curtin stated. Those who are lacking in nutrition and social stimulation early in life have a vulnerability to disease. She concluded by challenging nurses to consider the questions of what creates a healthy population and where health funding should be spent. Knowing the impact of nutrition, low stress and social support on future health or illness, overlaid with the need to create a healthier population, we have to ask these questions, Curtin stressed. The opportunities for further research in this area are tremendous. Mentoring Helped Her Move Forward Albert began at Cleveland Clinic as a BSN student from The University of Akron in She worked as an aid and then as a staff nurse on the internal medicine and geriatric Albert was named Director of Surgical and Post-Acute Care Nursing in 1998, followed by a promotion in 2000 to Vice President for Nursing-Chief Nursing Executive at Euclid Hospital, an affiliate within the Cleveland Clinic Health System. unit for five years. In 1991, Albert s nurse manager quote This was a significant change, offering a different perspective on nursing, Albert reflects. encouraged her to consider a We are always changing, leading to new promotion to assistant nurse It was a chance to see another manager and then mentored and exciting opportunities for nurses at facet of nursing where patient Albert for two years. every level throughout the organization. acuity and focus was different Mentoring relationships like those she has experienced in her own career are an important element of nursing at Debra Albert, RN, MBA, CNAA than here at main campus. An Offer She Couldn t Refuse When Chief Nursing Officer Cleveland Clinic, Albert notes. I personally owe my success to good nurse mentors, and we have many of them here. I tell nurses not to be afraid to reach out for help, she says. I stand on the shoulders of my predecessors, and hopefully, new nurse leaders will stand on mine. After two years as an assistant nurse manager, Albert moved up to a position as nurse manager for Inpatient Rehabilitation and the Epilepsy Monitoring Unit. Coinciding with her promotion, she enrolled in a master s of business administration program to expand her knowledge of the business side of healthcare. She completed her degree in Claire Young, RN, MSN, MBA, called in January 2006 to recruit Albert to her current position, I couldn t refuse, Albert says. It was coming home. I grew up here personally and professionally, and I couldn t turn it down. Now pursuing a master s degree in nursing, Albert balances her professional career, education and a family that includes a husband and two young sons. On all fronts, I m always thinking about what s next, what can I do better, she says. The same desire to look to the future also infuses Cleveland Clinic, Albert says, and is one of the reasons she has found great satisfaction here. This is a place where everyone is motivated to constantly improve and strive to discover how we can A Career-Changing Opportunity provide better patient care. In 1996 Albert was promoted to director of neuroscience and rehabilitation nursing, adding the neurology and neurosurgery units to her responsibilities. Without prior experience If an individual wants a place to grow, this is it, she says. Anyone with a passion for nursing can accomplish great things here. in the neurosciences, Albert says she was challenged daily to comments to learn and expand her skill set. 25

15 Your Destination for Nursing Practice Save the Date: September 29, 2007 Nursing Open House 10 a.m. 2 p.m. Cleveland Clinic Lerner Research Institute First Floor Commons Area Find your perfect match at Cleveland Clinic, and create the kind of nursing career that best suits your interests and needs. By attending our open house, you can: Meet our leadership team and nursing staff Interview with our nurse managers Tour our exceptional facilities Apply online for available positions To learn more about nursing opportunities or to register online, visit 10th Annual Innovations in Neuroscience Nursing Conference October 4-6 Intercontinental Hotel and Bank of America Conference Center Cleveland, Ohio For information or to register, visit 9th Annual Pain Management Conference for Nurses and Allied Healthcare Professionals October 6 Executive Caterers at Landerhaven Mayfield Heights, Ohio For more information, visit Weekend Immersion in Nursing Informatics October Cleveland Clinic Lyndhurst Campus Lyndhurst, Ohio To register, contact Stephanie Vargo at or Dimensions in Cardiac Care March 9-11, 2008 Intercontinental Hotel and Bank of America Conference Center Cleveland, Ohio For more information, contact Kathy Hill at Heart and Vascular Institute Nursing Internship Cleveland Clinic has created an internship program specifically designed to develop new graduates into the finest cardiac nurses in the nation. As an intern in one of the three areas offered cardiothoracic, cardiac or transplant you will work alongside some of the best nurses and physicians in the country and will be able to work with state-of-the-art therapies and treatments for a variety of severe heart-related conditions. Don t miss out on this excellent opportunity to train in the nation s leading hospital for cardiac care. Applications are available online at and will be accepted through April For more information, please call The Cleveland Clinic Foundation 9500 Euclid Avenue / W14 Cleveland, OH 44195

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