BB&T Contributing Editor

ANAHEIM, California – This year’s American Association of Critical Care Nurses (AACN; Aliso Viejo, California) National Teaching Institute (NTI), held here in the latter part of May, hosted 6,700 attendees and about 450 vendors – a bit of a drop in the attendee numbers but status quo for the vendors. This is a conference that enables critical-care nurses to earn continuing education credits inside of vendor booths from presentations given by the vendors or someone the vendor hires. Rumors were circulating at this year’s conference that this might be the last year for that practice, primarily due to some of the presentations being little more than thinly disguised sales pitches.

To be fair, some of the vendors don’t even mention their products as they educate nurses on topics such as 12-lead ECGs, pulmonary artery pressures and other topics, but there is a perception that the vendors will at least bias a presentation towards their product. This practice is not only evident on the exhibit floor but also present in the NTI News, a paper that is handed out daily at the convention; some of the articles based on products or devices are written by nurses who work for vendors in attendance at the conference.

The vendors we spoke to indicated that they may not continue to attend the conference if the practice of CEU (continuing education unit) presentations is discontinued. It will be interesting to see at next year’s NTI, to be held in Atlanta in May 2007, if the attendee numbers change and especially if the vendor numbers decrease.

The NTI opening ceremony highlighted stories of what nurses in New Orleans endured following Hurricane Katrina. Nineteen members of the Greater New Orleans Chapter of AACN were sent to the NTI through donations received from other AACN chapters across the country.

There was also a presentation concentrating on updating avian influenza information, given by John Beigel, MD, of the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health (both Bethesda, Maryland). Beigel emphasized the estimates that a third of the population could become infected and that 2 million people could die from a pandemic outbreak. He pointed out that critical care nurses would be on the front lines and encouraged hospitals to develop a plan for dealing with this potential crisis, but he had few details of what that plan might look like except for what a hospital already had in place: good hygiene, isolation and use of gowns, gloves, goggles and respirators for clinicians caring for febrile patients during a flu outbreak.

Beigel instead focused on vaccines, saying that they are the most likely intervention to reduce mortality, even if the vaccine strains are not a perfect match for the viruses circulating. He also mentioned the use of Tamiflu from Roche (Geneva, Switzerland) as being the most promising in fighting an H5N1 outbreak, but said that Tamiflu use as well as “social distancing” would not necessarily prevent the transmission of the virus but rather would delay the effect on the population.

On a similar note, there were but a few presentations offered at the NTI focused on managing and treating conditions resulting from bioterrorism, chemical damage or other terrorism-oriented injuries, and unlike the avian flu, the country has had ample warning and time to have these topics as at least a main track at conferences such as the NTI.

The Federal Emergency Management Administration (FEMA) had a small booth in the vendor area that focused on the National Disaster Medical System (NDMA), a federally coordinated public/private effort that manages and coordinates a national medical effort response to assist state and local authorities during disaster or terrorist events. FEMA was looking for critical care nurses to sign on to become part of this initiative, with the assurance (much like the National Guard) that if the nurse is deployed, he/she is assured of retaining their job after a two-week stint with NDMA. The U.S. Army also had a larger presence than in years past, with a booth and presentations at nearby local hotels and opportunities for the press to interview Iraqi-veteran nurses.

Post-cardiac arrest cooling gains ground

One of the interesting, still-unfolding topics that relevant companies featured at NTI was a recent American Heart Association (AHA; Dallas) standard stating that persons suffering a sudden cardiac arrest outside of a hospital setting due to ventricular fibrillation who return to spontaneous circulation should be core (internal) temperature cooled to 32 to 34 degrees Celsius for 12 to 24 hours. AHA says that for patients who suffer non-ventricular fibrillation cardiac arrest either in or out of a hospital, cooling therapy may offer similar benefits. The thinking is that mild cooling of patients is beneficial therapy for brain protection after restoration of spontaneous circulation. It is remarkable that this has become a standard of care as quickly as it has, apparently due to physicians taking note of the literature from Europe, where core cooling has been instituted post-cardiac arrest.

In a poster presentation given at the Society for Critical Care Medicine (Des Plaines, Illinois) meeting earlier this year, Dr. Mauro Oddo, of University Hospital (Lausanne, Switzerland), reported on a retrospective study of 109 patients admitted post-cardiac arrest from outside of the hospital. Oddo showed that 24 of 43, or 56%, of patients who received standard care along with cooling therapy returned home to independent living compared to 11 of 43, or 26%, achieving the same results with standard care alone. Mild reduction of temperature has the potential to reduce damage and improve recovery and quality of life, not only in those who suffer heart attacks and arrests, but also following strokes, brain injury, trauma and other critical illnesses, with much more research to follow. With 340,000 sudden cardiac arrests, 700,000 strokes and other brain injury and trauma, the growth in the use of mild hypothermia is significant.

There were a number of cooling companies making clinicians aware of this new standard for cardiac arrest patients that was finalized just this past December. The most aggressive company to feature this new use of cooling was Medivance (Louisville, Colorado), with its noninvasive Arctic Sun device. The Arctic Sun system uses water as the coolant and adheres to the patient’s skin so that the pads stay in place even with turning. The patient’s arms and lower legs are not covered, thereby allowing patient therapy. The cooling unit itself provides a trend indicator that provides indication of subtle changes in temperature before these changes manifest clinically. The display unit has minimal buttons that are graphically intuitive and the display can be detached and moved to an area away from the patient to allow more room for patient care.

Another noninvasive coolant company present was Cincinnati Sub Zero (CSZ; Cincinnati), which takes a different approach to cooling, advocating covering of the patient’s head as well as his or her chest. The main unit is a vest-like covering that adheres to itself, thus keeping it in place even during patient movement. The head wrap fits like a “winter cap,” leaving the patient’s face and ears exposed. CSZ believes that further research may prove the head wrap to be especially useful in stroke patients. The company also is exploring a unit that would be used by EMTs to initiate cooling even before cardiac arrest patients arrive in the emergency department.

Cincinnati Sub Zero is the manufacturer of the Blanketrol System, a name that has been in hospitals for a long time, allowing the company to offer cooling systems more cost-effectively than other systems. CSZ says that its systems are about a third of the cost of other companies’ cooling devices.

The only invasive cooling company present at NTI was Alsius (Irvine, California), which offers a triple lumen central venous catheter; one lumen for cooling (using saline), one for drug administration and the third for blood samples. The company’s CoolGard 3000 system circulates cool or warm saline in a closed loop through the catheter into multiple balloons that line the catheter shaft. The system senses patient temperature and compares it continuously to the target temperature, automatically adjusting the temperature of the saline flowing through the catheter.

Alsius believes that if a person suffers a cardiac arrest outside of the hospital, he or she will end up in a critical care area and will need a central line, so it advocates the use of its catheter for more refined cooling of patients. Alsius catheters have been used in many of the studies that have been published, not only for post-cardiac arrest, but also for neurological conditions such as stroke, epidural hematomas, acute brain injuries and head trauma.

The American Heart Association was present at the NTI with a booth highlighting its new “Get with the Guidelines” (GWTG) initiative that encourages hospitals to more aggressively treat both cardiac conditions and strokes. Although the GWTG program does not currently include mild cooling of patients, the vendors that are excited about their cooling products used, post-cardiac arrest, also said that research is beginning to indicate that mild cooling benefits stroke and other neurological patient conditions.

GWTG is an evidenced-based program focused on care team protocols that ensure that patients are treated with appropriate medications and receive risk modification counseling. This initiative is growing and there are currently more than 1,100 hospitals enlisted. Research is demonstrating an increase in the number of patients receiving more aggressive early treatment as well as follow-up treatment. The indication for use is support during high-risk angioplasty for up to five days as a left ventricular assist device.

From the exhibit floor

Abiomed (Danvers, Massachusetts) was showing its new Impella 2.5 minimally invasive ventricular assist device (VAD), which just received FDA approval to begin a pilot clinical trial. The Impella is in addition to the company’s AB5000 heart assist device, which provides temporary support for one or both sides of a patient’s natural heart in circumstances where the heart has failed, giving the patient’s heart the opportunity to rest and potentially recover or go on to heart replacement surgery.

The Abiomed representatives said that for some patients, if the AB5000 is used for up to 30 days as an assist device, they often do not need to undergo heart replacement – the challenge, according to the Abiomed clinicians, is to persuade surgeons to hold off aggressive treatment long enough to allow the heart to recover. The AB5000 console allows patients to leave their hospital rooms and walk within the hospital and on hospital grounds while heart recovery takes place. The transport capability of the AB5000 System also enables patients to be put on the system at their local hospital and then be transported to more advanced cardiac centers if necessary.

Philips Medical Systems (Andover, Massachusetts) reported the latest addition to its IntelliVue monitors, an enhancement taken from the pages of its neonatal monitors that focuses on clinical decision support. The latest software release allows clinicians to cross correlate parameters based on individual clinician preference for up to four measures. Philips was highlighting the ST Map and horizon trending as a way of illustrating the usefulness of this to clinicians, giving them information on the status of a patient’s heart at a glance.

In addition, Philips announced CareVue Chart C.0, a clinical information software release now set on a .net platform and running on Snowmed CT and a rules engine on the back end. These new additions to CareVue enable powerful data analysis and queries. Clinicians are not only alerted to clinical advisories but also have multi-parameter compliance alerts sent to them that must be acknowledged.

The example Philips used to demonstrate how the new features could be used was to document compliance with the guidelines for recognizing sepsis issued by the Surviving Sepsis Campaign. Urine output, central venous pressure, glucose levels, and blood cultures are all automatically collected, along with data from the patient monitors and other devices, giving clinicians a wide-range of data. Comprehensive reports also are generated that can be used for pay-for-performance and for documentation required for Joint Commission on Accreditation of Healthcare Organizations (JCAHO; Oakbrook Terrace, Illinois) and other standards.

Welch Allyn (Beaverton, Oregon) was showing its new Propaq LT, touted as three monitors in one: ambulatory, transport and bedside. The LT can be used on neonates, pediatric and adult patients and displays a 3- or 5-lead ECG, SpO2 and noninvasive blood pressure. The monitor weighs just under 2 pounds and has a shock resistance of up to 75 g, which means that it can withstand a six-foot drop. It can be used for spot check or continual monitoring modes with a battery life of up to 24 hours, based on 15-minute blood pressure checks. In addition, docked to the more capable cradle, the LT can be connected to a large color display on a separately purchased off-the-shelf monitor. The cradle also enables the transfer of data from the LT to a hospital’s Flexnet network. This versatile monitor is available retail for $6,195 basic, or $6,895 with the more powerful cradle.

Draeger Medical (Telford, Pennsylvania) was showing its coming – 510 (k) submitted – patient-worn telemetry system it calls Infinity TeleSmart. This is the only telemetry system built on WiFi technology and has a lightweight transceiver that will monitor ECG and SpO2 in both pediatric and adult patients. Draeger built TeleSmart after it spent many hours listening to clinicians as to what they wanted in their telemetry.

TeleSmart incorporates features such as much fewer wires in the lead system, a central charger where the telemetry units are stored when not in use and includes an “auto-discharge” of patient data so that the unit is ready for the next patient. The central charger not only charges the battery for the next patient but keeps the units centrally located and not “lost” in a drawer or elsewhere. While the units are on a patient, they can be docked when the patient is in bed so that the battery is being recharged; the battery status is displayed on the top of the unit with “bars” much like a cellphone display. When Draeger receives final FDA approval for TeleSmart, it should open many opportunities in hospitals for the company.

In addition to the coming WiFi telemetry, Draeger introduced a new web-based solution in its Infinity Symphony Suite that makes patient information available anywhere using the hospital intranet. This will empower clinician access to patient data, giving them a more complete picture of patient status as well as the results of medical interventions monitored from their home or office.

Overall, Draeger Medical has grown worldwide revenues for the past five years; in fiscal 2005, it was at EUR 1,106.4 million, an increase of 8.1% from 2004. In the U.S., Draeger began reorganization efforts in 2004, creating 70 management and specialist positions and purchasing Air-Shields from Hill-Rom (Batesville, Indiana). As one of the management team at the NTI told Biomedical Business & Technology, it is an exciting time to be working at Draeger, and many new and innovative ideas are coming soon.

Spacelabs Medical (Issaquah, Washington) was demonstrating its newer Ultraview 2600 monitors, which bring workstation functionality for charting and other applications to the point of care. The Ultraview 2600 is especially suited for ED, perioperative and neonatal applications and is network compatible with existing Spacelabs Ultraview monitors. There also is a wireless networking option available that supports central surveillance during patient transport. In addition, Spacelabs has partnered with Emergen (Boca Raton, Florida) to offer a new Clinical Event Interface for secondary alarm notification, enabling nurses to receive alarms directly even if they are away from the central station or bedside.

Nihon Kohden (NK; Foothills Ranch, California) announced a NTX software upgrade that enables integration of data from its vital signs monitors to its full-scale monitors and to the central station. Nihon Kohden said this is part of its overall patient-centric approach. As is NK’s corporate policy, if a hospital already has its monitors, any new software upgrade for those monitors is free. Nihon Kohden also reported a reworking of its web-based training for clinicians and biomedical engineers that enables the company to tailor the education to each user’s needs.

GMP Companies (Fort Lauderdale, Florida) was present, stating that the company is now Life Sync-focused. LifeSync System uses Bluetooth wireless technology and employs two-way radios to collect and transmit patient ECG and respiration data to a hospital’s existing ECG monitors. The system eliminates lead wires and trunk cables between patients and bedside, 12-lead or transport ECG monitors, allowing the patient more freedom of movement throughout the hospital without changes to a hospital’s infrastructure. GMP had used up most of its prior funding, but said it was expecting to receive an infusion of new cash shortly.

On a different note: due in part to the nursing shortage, the number of temporary nurse staffing services has grown exponentially over the last several years. JCAHO says that research conducted among accredited healthcare organizations (hospitals, clinics, etc.) indicates that 78% are using supplemental staffing services. In response to this practice, JCAHO has instituted a voluntary certification program for healthcare staffing firms that consists of an on-site evaluation covering the agency’s focus on leadership, human resource management, performance measurement and information management. The advantage to the agencies is that hospitals are willing to pay more for their nursing personnel and their insurance rates are better.