BBI Contributing Writer

ANAHEIM, California – The American Association of Critical Care Nurses (AACN; Aliso Viejo, California) held its 28th annual National Teaching Institute in the newly refurbished Anaheim Convention Center in May. The major thrust of the conference was the coming (in fact, here already for critical-care areas) nursing shortage, which some companies in the sector are turning into market opportunity.

Peter Buerhaus, RN, PhD, of the Vanderbilt School of Nursing (Nashville, Tennessee), presented recent research that highlights why the looming nursing shortage is different than shortages in the past – and why it is much more ominous. Buerhaus presented his findings to the 5,000 nurses in attendance in terms of supply and demand. On the demand side, Buerhaus cited not only the obvious aging of the 80 million baby boomers over the next two or three decades, but also the changing lifestyle of the "boomlets" (those just now entering their teens) and their propensity toward riskier behaviors.

But it was the supply side of Buerhaus' talk that pointed to the potentially gloomy state of things to come. The most important factor on this side of the equation is the aging of the registered nurse (RN) workforce. He said that RNs, as an occupation, are aging twice as fast as all other occupations in the U.S. At the present time, 60% of RNs are over the age of 40, while 9% are under the age of 30. This is a radical change from 30 years ago, when one-third of all RNs were less than 30 years old.

Buerhaus noted that when the current 40- and 50-year-old nurses entered the workforce, they entered in record numbers because it had become socially acceptable for women to work. However, the career choices at the time were primarily teaching and nursing. Currently, the majority of nurses are 40-year-olds – a number four times that of nurses in their 20s. By 2010, the majority of nurses will be in their 50s, and retirement will be a significant factor beginning in 2008. Another supply reality is that fewer women are opting for nursing as a career, choosing instead to become doctors, dentists and lawyers – professions that pay more and provide more status.

The news is even worse for critical-care areas where the aging meltdown has already begun. With fewer young people entering nursing in general, the traditionally youthfully staffed critical care areas are facing a shortage now. That was evident on the conference floor, where 150-plus career opportunity exhibitors vied for the attention of a dwindling number of attendees (down from 6,000 at last year's NTI and 6,500 at the 1999 conference).

The bottom line is that hospitals need to prepare for an older workforce and to re-engineer patient care delivery to best use the diminishing pool of available RNs. Buerhaus noted that hospitals need to look beyond traditional places for replacements in the workforce. He said that only 12% of nurses currently are from ethnic minorities and that there has not been a substantial increase in the number of men entering nursing over the past few decades.

Buerhaus's research also proved a direct correlation between RN staffing patterns and patient outcomes. He and another researcher followed 14 different patient medical and surgical codes and subsequent death rates. Their research was the first to include nursing assistants, as well as RNs and LPNs, in the data collection. They found that when RNs represented a greater percentage of the total staffing, the death rate for each category dropped by 3% to 12%.

Denise Thornby, current president of the AACN, highlighted the real and current impact of the shortage of critical care nurses by telling the attendees that on one day in February, all of the hospitals in Richmond, Virginia, closed their emergency rooms for four hours because they lacked critical care nurses to staff the units. Wanda Johanson, CEO of the AACN, spoke of the ripple effect on general surgeries being postponed in her hospital due to previously delayed heart surgeries. The heart surgeries were not performed on schedule due to a lack of critical care nurses, which subsequently backed up the entire surgical schedule.

Johanson went on to announce that the AACN would be working toward a joint solution with the American College of Chest Physicians (ACCP), led by Robert Johnson, MD. The AACN also has partnered with other nursing organizations to address public policy and workplace issues. They are devoting time and resources to determine ideal staffing needs and their impact on patient outcomes.

The implication for vendors

Most of the vendors at this year's AACN gathering were aware of the critical-care nursing shortage at some level. Some acknowledged contributing to the nursing shortage by hiring nurses to sell and in-service their products, nurses who had previously worked in a critical-care areas. Only a few companies appeared to have paid attention to the current trends and to have reacted to them. It was really a matter of an altered mindset and a refocus from a "product" mentality to a "bigger picture" view. If ever there were a time for vendors and clinical practice to partner, it is now.

Siemens Electromedical (Danvers, Massachusetts), for example, was highlighting a new way of approaching the critical care environment. Siemens was talking about its "Best Practice Integration-Everywhere in Critical Care" approach. Siemens is offering an integrated solution that makes vital signs, laboratory information and patient demographics accessible at the point of care. That aspect may be new for Siemens, but other companies have already done all that.

Impressive were the presentations by Siemens personnel who talked about being "workflow oriented" and focused on the company's critical care workstation, which will be launched before the end of 2001. The Zeus workstation will allow images, lab results, monitoring and charting to be located at the critical care bedside. Because it is web-enabled, it allows physicians and nurses access to practical information on a wide range of subjects and a wide variety of devices – all without leaving the patient's side. The Chart Assist aspect of this workstation was working at the show and is impressive from a user interface and usability standpoint.

Hill-Rom (Batesville, Indiana) also was addressing the shortage of nursing, in its literature as well as in booth demonstrations. Hill-Rom personnel were there, they said, to "help nurses meet the increasing demands of their busy schedules." Ernest Waaser, president and CEO, said, "Hill-Rom hears the concerns of caregivers who are stretched too thin and needlessly risking injury daily." The company introduced its TotalCare SpO₂RT Pulmonary Therapy System at the AACN gathering. This new bed allows a nurse to care for a patient, even a large or comatose patient, without the assistance of other nurses.

The bed can be adjusted to the patient's height – shortened for petite patients and lengthened for taller ones, without the need for bed extenders. It has a turn assist mechanism that helps the nurse in the physical care of the patient or when the linen needs to be changed. The bed has a setting that will automatically turn the patient up to 15 times an hour, and it allows the nurse to set the degree of turn as well. The SpO₂RT also allows the percussion of a patient who may be in early stages of pneumonia via a module that may be added. One nurse-user we spoke with said that because of the patient being automatically turned, her ICU's incidence of pneumonia decreased dramatically. She also commented that patients who used to stay in her respiratory unit for up to 20 days were now being moved to the general floor in as quickly as seven days. The bed can also be transformed into a chair for patients who have been bedbound for days and are ready to begin to sit up. The SpO₂RT costs around $16,000 per bed, but may be rented from Hill-Rom if that is too high a price tag for given institutions.

This product represents the choice that hospitals are facing. They all have "functional" beds already and don't need new ones. Yet devices such as the SpO₂RT allow nurses to provide better care to more patients and dramatically improve outcome. Therefore, with a nursing shortage that is rapidly expanding from 250,000 to 400,000 by 2005 to 700,000 nurses short by 2020, it seems clear that hospitals must make changes. Hospitals need to approach this shortage of personnel by incorporating better technology aimed specifically at assisting the remaining nurses to minimize their workload and/or allowing a decreased workforce to continue to give quality care. Because costs are high and capital is short, rental and leasing programs may be the mechanism of the future for financing medical technology.

One of the more unique and forward-thinking approaches to the critical care crisis was offered by Visicu (Baltimore, Maryland), a new company with an innovative telemedicine idea. Visicu provides 24/7 remote monitoring and intervention services to support critical-care staff. The goal is identify potential problems and treat them early, before patients get into difficulty, using increasingly scarce intensivists and critical care nurses.

The remote team can monitor up to 40 patients at one or more locations. Visicu claims it can save hospitals money by reducing length of stay and lowering complication rates. In a trial involving 650 patients over a four-month period, Visicu achieved a 60% reduction in mortality rate, a 40% reduction in complications and a 30% reduction in cost of care, which translated to a $150,000 saving per ICU bed per year. Another advantage of this approach is point-of-care staff support – a real benefit in a busy critical care area that increasingly is staffed with newly graduated RNs or RNs brought in from foreign countries to supplement the dwindling pool of current critical care nurses.

Other vendor announcements

Agilent Technologies' Healthcare Solutions Group (Andover, Massachusetts), soon to be a unit of Philips Medical Systems, said it recently received FDA approval for automated external defibrillator (AED) pediatric paddles approved for use only with its AEDs. This is a major advancement for all areas that would benefit from pediatric defibrillation (day care facilities, public pools, etc.). Agilent also has received FDA approval for its hemodynamic assessment tool, which was jointly developed by Agilent and Pulsion Medical Systems (Munich, Germany). This continuous cardiac output (CO) approach requires that a 4 Fr femoral artery catheter and a central venous line be in place to attain semi-invasive CO readings. The recent controversy over right-sided (pulmonary artery) catheter use has added to the interest in this semi-invasive technology and it may become the replacement approach to pulmonary artery catheters. However, once the noninvasive technology proves reliable, this semi-invasive approach may become less appealing.

GE Medical Systems (Waukesha, Wisconsin reported that it will be integrating Masimo (Irvine, California) oximetry into all of its products within the next 12 months. GE Medical already has Masimo integrated into its Solar monitors and will have it in place in its TRAM monitors within the next 2 months.

GE's distribution of the BioZ system from CardioDynamics (San Diego, California) has increased nicely over the past six months, especially for its emergency department sales due to the reimbursable nature of noninvasive hemodynamic monitoring as a per-test fee in emergency departments. GE Medical now has a BioZ module and is offering non-invasive hemodynamic monitoring as a modular component for its Solar monitors. This is in addition to the bispectral index (BIS) module, which it also has added.

The interest in BIS monitoring for use in critical care areas for patients receiving conscious sedation has been growing. Aspect Medical (Newton, Massachusetts) had more than 300 nurses attending its sunrise session highlighting the advantages of BIS for patients requiring mechanical ventilation, neuromuscular blockade, bedside procedures or barbiturate coma. Activity at the Aspect booth was brisk and some 1,000 nurses participated in the courses offering CEUs. This is the year cited by Aspect to move BIS monitoring into the critical care setting. The company's success in doing so will result in its rapid growth and keep it ahead of rival Physiometrix (North Billerica, Massachusetts), now owned by Baxter (Deerfield, Illinois), which just began competing with Aspect in the OR setting. Readers interested in this market might find a new market study titled "U.S. Markets for Bispectral Index Monitoring" helpful. Available from Medical Strategic Planning (Lincroft, New Jersey), it provides a five-year forecast of the growth of this market in the U.S. and some worldwide markets, as well.

Capnography, called the ventilation vital sign, is becoming increasingly important for the monitoring of CO₂ in sedated patients. Recently, Agilent added the Oridion (Danville, California) capnography module to its Vuelink monitors. Oridion announced at AACN that Spacelabs (Redmond, Washington) also has added capnography as an option in its Flexport monitors.

Oridion also announced a new nasal cannula that delivers oxygen to patients (either mouth or nasal breathers) via tiny holes in the main tubing. The same cannula can be used to take CO₂ measurements from a non-ventilated patient with more accuracy because the CO₂ measurements are taken from the tips of the cannula (inserted inside the nasal cavities).

Multi-use devices

The companies that are actually reacting to the nursing shortage and who know the value of one piece of equipment to perform multiple tests, not to mention the comfort of the patient, are increasingly offering multi-use technology. As noted above, Oridion is now able to sample CO₂ from the same set of nasal prongs that the patient is using to receive his or her oxygen. Hill-Rom's SpO₂RT can change from a bed into a chair with the flip of a button and the presence of only one nurse. Siemens is "workflow" oriented.

And yet some companies still seem locked into narrow boxes that offer one parameter and often at increased patient discomfort. Deltex Medical (Branford, Connecticut), for example, continues to show its naso-gastric cannula/cardiac output device, which gathers information via an ultrasound sensor located in the tube. The requirement that this sensor be placed strategically behind the aorta necessitates the insertion of a semi-rigid tube through the patient's nose. We asked John Sandell, director of U.S. sales for Deltex, about the potential of partnering with, say, Datex-Ohmeda (Madison, Wisconsin) or any other company that also gathers information via a naso-gastric tube. He indicated that the sensitive positioning of the sensor necessitated that this technology not be coupled with other technology.

Biphasic waveform questions remain

In August of 2000, American Heart Association (AHA; Dallas, Texas) guidelines listed biphasic waveform defibrillators as the intervention of choice for advanced cardiac life support (defibrillation). Biphasic defibrillators deliver current in two pulses, one positive pulse and one negative pulse. They require less voltage and less peak current than older, monophasic waveform defibrillators. The underlying physiologic changes that occur using biphasic defibrillators are not yet clearly understood, but it is clear that biphasic defibrillators are more effective and have less potential to harm patients than monophasic defibrillators. For patients, the benefits are less damage to the heart, less chance of arrhythmias and lower chance of receiving skin burns as compared to older higher energy monophasic defibrillators.

The only unsettled issue surrounding biphasic waveforms is what the ideal shape of the waveform should look like. There is the biphasic truncated exponential (BTE) waveform and the rectilinear biphasic waveform. Different vendors are approaching this rapidly expanding market in one of the two waveform camps. The original BTE was developed by Heartstream (later acquired by Agilent Technologies) for internal use on surgical patients (open heart surgery defibrillation), and then adapted for external use. Medtronic Physio-Control (Redmond, Washington) also uses a BTE waveform and is claiming that there is a subset of patients who require a higher joule (shock) setting to interrupt their cardiac arrest state. Medtronic Physio-Control is advocating that it is best to defibrillate patients initially at lower settings but that if the lower settings are not effective, then joules as high as 200 to 360 should be available to clinicians. They also state that it is difficult to "retrain" the clinicians to use less energy and that clinicians are more comfortable using the higher settings.

Zoll (Burlington, Massachusetts) has a patent on the rectilinear waveform used in its defibrillators. Zoll says that the advantage to its waveform is that it maintains a constant current, thereby eliminating the potentially harmful effect of excess peak currents and overcoming patient impedance (e.g., size and shape of varying patient chest dynamics) more readily. Zoll is citing a recent study of 184 patients undergoing electrophysiology testing in which difficult-to-defibrillate patients were successfully defibrillated using a 120-joule shock with a rectilinear defibrillator 100% of the time on the first shock. This compares to a 63% success rate for the same group of patients on which a 200-joule shock setting on a monophasic defibrillator was used. It is a rather compelling outcome, but a definitive comparison between the two types of biphasic waveforms has yet to be published.

By fall, there will be more new technology and solutions announced impacting the critical-care area. Some will simply be product features; others will enable the shrinking pool of RNs to better care for the growing number and increasing acuity of patients. Standalone products with unique disposables will become increasingly difficult to market. Integrated technologies that improve outcome or reduce length of stay will be the winners. Focusing on only a single parameter in the future almost will ensure that a company cannot succeed.Those unable to show how their products benefit nursing workflow and patient outcomes will be the losers.