BBI Contributing Writer

ATLANTA, Georgia — This year's American Association of Critical Care Nurses (AACN; Aliso Viejo, California) conference, held here in early May, had 8,000 attendees — an increase over last year — in spite of all the world events of late. The 2002 AACN conference focused primarily upon the reality of the more-severe-than-first-thought nursing shortage. All keynote speakers and many talks called on nurses to address the shortage in many ways, including by being passionate advocates for the profession. There were numerous sessions highlighting the ominous specifics of the shortage and encouraging nurses to become involved with legislators and to educate the public. This shortage will ultimately have profound effects for medical device manufacturers.

Statistics show that currently there are 168,000 unfilled nursing positions in U.S. hospitals, up from the 143,000 reported last year. Fully 75% of this number represents registered nurses (RNs) and there is currently an 11% nationwide RN position vacancy rate. This rate is expected to peak at between 450,000 and 780,000 RN vacancies somewhere between 2006 and 2010. Research indicates that much of the imbalance between supply and demand for RNs is due to the aging of the baby boomers who will retire rapidly over the next decade. It also is known that fewer people (women in particular) are entering nursing because there are many more professions open to women — most of which are higher-paying. The current average age for RNs is between 40 and 45 years but varies depending upon the hospital area. Intensive care nurses are a bit better off, with an average age of only 37.4 years. These findings are the basis of what has already been reported about the looming nursing shortage.

The International Hospital Outcomes Study (IHOS), a study of nurses in five countries (the U.S., Canada, Germany, England and Scotland), brought new findings to those in attendance at ACCN — and the news was not good. One major finding of the IHOS was that the nursing shortage is a global problem, as all five countries represented had RN vacancies. Sean Clarke, RN, PhD, of McGill University (Montreal, Quebec), presented the IHOS details, including the news that younger nurses are not staying at the bedside. Clarke cited a turnover rate of 31% and 28% for RNs under the age of 24 and between the ages of 25 and 34 respectively. In comparison, the turnover rate for RNs age 55 and over was 9%.

The IHOS study (and others) also detailed the consequences of the nursing shortage. Every additional patient in an average RN's workload results in a 23% greater likelihood of reported patient falls and a 14% greater likelihood of family complaints. Every one patient-per-nurse increase in an RN's workload also was associated with a 7% increase in the risk of death within 30 days for an individual patient. Clarke also cited a study by Blegen that showed that simply increasing RN, LPN and nurse aide hours across the board did not decrease adverse occurrences. However, increasing the proportion of RN hours of care to each patient was associated with a decrease in medication errors, fewer decubiti (bed sores), fewer patient falls and fewer complaints about care, all of which are big cost savers. This makes it clear that medical device features that save RN time and allow RNs to give direct patient care will become very significant benefits.

Gone are the days, for example, when a critical care unit will have two monitors — one stationary bedside monitor and a second transport monitor. It simply wastes too much RN time (up to 45 minutes), transferring patients from one monitor to the other when the patient must leave the critical care area for tests, surgery or other reasons. In the future, every monitor will be a portable monitor. This will require redesign of many products currently sold by Datex-Ohmeda (Madison, Wisconsin), Philips (Andover, Massachusetts), Spacelabs (Redmond, Washington), Amphora/Mennen Medical (Clarence, New York) and other companies that have stationary bedside module configured systems.

Word of the nursing shortage and the implications has spread beyond the medical field as well. Clarke reported that in a June 2001 statement, Fitch Bond Rating Service said, "Fitch believes that the rising personnel expense, mainly due to the growing shortage of nursing, is the most significant long-term problem affecting hospitals and threatens to keep operating margins in check for the foreseeable future."

But there were some solutions — or at least areas of hope — offered relating to the nursing shortage. The IHOS study found that nurses in hospitals with the best organizational climates were 32% less likely to report an intention to leave their jobs within the next year. Best hospitals were institutions that encouraged excellent nurse managers and that had nurses in leadership who valued and supported decentralized decision-making, nurse self governance, scheduling, autonomy and influence over policies and resources, as well as supporting education of nurses. This focus includes nurses being able to select the equipment that they want to work with rather than being told to purchase a specific brand because of group purchasing organization contracts or solely based on physician decision.

It was sadly apparent at last year's AACN gathering that very few vendors were aware of the nursing shortage and the possible role that they could play in a solution. This year's conference was a very different story. Johnson & Johnson (J&J; New Brunswick, New Jersey) led the way and appears committed to the cause of nursing. J&J has started a "Dare to Care" campaign in which it offers television commercials positively depicting nurses — they were first aired during the Winter Olympics from Salt Lake City, Utah. J&J also sent nurse recruitment posters, brochures and videotapes to every high school in the U.S., is offering scholarships and has put a web site, www.discovernursing.com, in place. When we asked J&J about its commitment, company representatives pointed to the firm's credo — in place since 1942 — that states, "We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services."

Other vendors also are beginning to support nursing. For example, Bridge Medical (Solana Beach, California) is making available to hospitals an excellent video concerning medication errors. But so far there are very few medical device leaders in on the effort; many other companies need to wake up and get on board the nursing shortage bandwagon.

Medication error systems emerge slowly

In 2000, the Institute of Medicine (IOM; Washington) reported that 98,000 people die each year from medication errors and that the cost of these errors is $5.6 million annually per hospital. It was clear from data reported at this year's AACN meeting that the IOM numbers grossly underestimated the magnitude of the problem. The few medication error systems that are in place in hospitals are yielding further information on the actual magnitude of drug errors and specifics of where they occur. Pediatric patients are three times more likely to experience medication errors but intensive care patients suffer more life threatening medication errors than any other patient population. Some 39% of these errors occur at the time of ordering and 38% occur with the administration of the medication-that translates to doctors and nurses being at the forefront of this issue. With the nursing shortage already evident in hospitals, vendors offering solutions to medication errors were everywhere at AACN.

The simplest vendor solutions shown on the World Congress Center exhibit floor focused primarily on bar coding schemes. Bridge Medical's system uses bar codes to scan the ID of the nurse administering the medication, the patient ID (on their wristband) and the bar code on the medication to be given (on the external packaging). In addition, the system is capable of giving warnings such as sound-alike drugs or the fact that the patient was nearing the 24-hour maximum of the medication about to be administered. The Bridge system could be linked to a hospital's information and billing systems. B. Braun Medical (Carrollton, Texas) showed a similar basic bar code system for intravenous solutions called Horizon Outlook. The system has special tubing with a built-in sensor that fit into B. Braun's delivery system. Once the nurse scans the bar code on the IV solution (sent to the unit by the pharmacy), the delivery system automatically displays the medication, dose and rate.

Larger infusion companies such as Alaris (San Diego, California) are taking a more comprehensive approach to the medication error problem. Alaris introduced its Guardrail System at the AACN meeting. Guardrail is software designed for use with the Alaris Medley System of medication delivery modules. The software includes 10 patient profiles, from adult to pediatric and neonatal, that set upper limits for drugs, catch infusion device programming errors, dosage errors and other problems. Over a three-month period in one hospital, Guardrail documented 40,500 opportunities for error, 690 alerts (1.5%) and 159 programming changes (0.4%). Alaris is partnering with McKesson (San Francisco, California) and will be offering a more robust answer to the medication error in 1Q03, with details to be announced later. Baxter Healthcare (Deerfield, Illinois) is working with Welch Allyn/Protocol (Beaverton, Oregon) on a similar solution.

Some 91% of US hospitals use computer systems to process medication, but only 18% even have bar code or other basic safety nets in place to catch time, route and administration errors that occur after a medication order is placed. Some vendors, including Siemens (Danvers, Massachusetts) with its Infinity monitoring system, show medications and laboratory values on their monitor screens at the bedside. When we spoke to intensive-care nurses about the medication error problem, it was apparent that a total solution is still a distance down the road. The presenters at AACN pointed out that not only is there a nurse shortage, but a pharmacist shortage as well. As a result, critical care nurses stated that the current medication error systems have far too lengthy lag times. The major thrust of treatment in the critical care area is pharmacology-centered and a lag time of one hour or more for most of the drugs ordered has severe patient consequences. In the critical care setting (especially at night), medications often are pulled from the shelf and mixed by the nurses. A vendor that offers a viable solution to this reality will have hospitals beating a path to its door.

AEDs a hot topic

Another point of convergence for the nursing shortage is the American Heart Association's (AHA; Dallas, Texas) mandate that during an arrest situation, a hospital's first defibrillation attempt must happen within three minutes. Automatic external defibrillators (AEDs) were a hot topic at the AACN meeting. They ranged widely in functionality and price. At the higher end of the AED spectrum was the Medtronic (Minneapolis, Minneapolis) Lifepak 20, which sells for between $8,000 and $12,000. The Lifepak 20 is a combination defibrillator/monitor that could be used by first responders as an AED — with intuitive buttons and simple instructions, but it is an AHA Class 3 device. With the flip of a door panel, the Lifepak 20 becomes a manual defibrillator/monitor with waveform displays. In this manual mode, the user has access to advanced tools such as noninvasive pacing, Masimo's (Irvine, California) SET pulse oximetry, ECG display and synchronized cardioversion. This is a very versatile package for advanced users in a hospital ICU setting where pacing and cardioversion may also be required, but we don't see it being placed throughout the hospital or in the first responder market in an attempt to meet the AHA three-minute standard. It would be like placing a race car in areas where only novice drivers would be present — most of the powerful accessories would never be used and could be dangerous in the hands of unqualified personnel (not to mention the cost of placing such a unit in more than a few areas). Moreover, it is much too expensive compared to products like Zoll's (Burlington, Massachusetts) new AED.

Philips Medical (Andover, Massachusetts) was showing its Heartstream AED at a price of $3,000 for the basic setup. If the hospital wants to see the ECG waveform displayed, the price goes up to $3,400. Heartstream is simple and intuitive to use and is the first AED cleared for use on children and infants through the use of special electrodes that automatically decrease the amount of energy delivered in each shock as soon as the electrodes are attached. To Philips' credit, it is sharing its pediatric/infant intellectual property so that other companies can quickly adapt their systems for use on these patient populations.

Zoll was introducing a unique version of the AED called AEDPlus. AEDPlus was priced at $1,600 and was clearly aimed at the out-of-hospital user. The AEDPlus gives rescuers visual and verbal clues, taking them through an arrest step-by-step, starting with a reminder to "call 911." The two electrodes are attached to the unit and to each other by a middle piece to be placed over the patient's sternum. This centerpiece not only assures proper electrode placement, but assists in cardiopulmonary resuscitation (CPR) as well. The AEDPlus cues the rescuer to initiate CPR and then tells the rescuer whether their compressions are being delivered with too much or too little pressure. This unit operates on inexpensive lithium batteries that provide up to 30 shocks before needing replacement.

Solving the wireless band dilemma

Some new patient-worn telemetry solutions also were being shown at the AACN meeting. Viasys/ MDE (Palm Springs, California) was showing a clever solution to the current dilemma of which wireless band will end up best for hospitals, as it introduced the Angel wireless telemetry product. Angel is a 2.8 ounce, single-patient telemetry unit that measures 4" x 1.8" x 1.2" and is preassambled with integral leadwires, electrodes and batteries. It saves nursing time because all the parts are right there — no need to track down the leadwires, the application gel or anything else. Angel is applied in seconds and operates in the 608-614 MHz WMTS band, providing a complete solution to the recent FDA telemetry advisory on interference. No hospital capital funds are required because the units are sent back to Viasys/ MDE after each use: Viasys takes care of the cleaning, battery replacement and care prior to reshipping the ready-to-go unit. Angel is now in beta testing and is scheduled for release in August.

It is clear that vendors have a significant role to play in making caregiver workflow and safety improvements for hospitals and nurses. It will be interesting to see just what clever solutions vendors offer to hospitals, and to nursing in particular, in an effort to blunt the effect of the nursing shortage. The peak of the shortage is still five or so years away and once reached, no one ventures a forecast as to how long it will last, but the reality is that the face of nursing is in the process of changing. Lesser-qualified personnel will have increasing responsibility for procedures and administration of medication — in fact, all areas for which nursing currently has authority. Vendors need to focus even more than in the past on safety and ease of use as this transition occurs, as well as on improving workflow efficiency so that nurses can spend more time with patients.

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