Notable NursingA 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

Executive EditorMichelle Dumpe, PhD, MS, RN

E-mail comments about Notable Nursing to dumpem@ccf.org

Editorial BoardClaire 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 clevelandclinic.org/nursing.

Table of Contentsp.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 SuccessFour 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.

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Notable Nursing Fall 2007

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/pul-monary). 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 dif-ficulty 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 Septem-ber 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 gradu-ate 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 respon-sibilities. 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.

From the

Chief Nursing OfficerAs 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 profes-sional growth, for advancement. The opportunities in all those areas have never been greater at Cleveland Clinic.

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 excit-ed 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 ad-vancement, 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

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Lauren Mattern RN, BSN | Age: 25

Clinical Instructor, Department of Nursing Education and

Professional Practice Development

Barbara Reece, RN, MSN | Age: 55

Director of Nursing, Medicine

and Behavioral Services

Rachael Lynn Taggart, RN, BSN | Age: 25

Registered Nurse, Heart Failure Intensive

Care Unit (H22)

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 2003.

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 Cleve-land 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

Professional Practice Development. I teach basic dysrhyth-mia 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.

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 avail-able. 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.

(After obtaining her MSN, she held two jobs elsewhere be-fore “coming home” to Cleveland Clinic years later as man-ager 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 manag-ers in leadership skills, specifically human resource man-agement. 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.

Education: BSN, The University of Toledo/ Medical Univer-sity 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 col-lege 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 associ-ate summer program. For 12 weeks, I worked side by side with the nurses (on M72/palliative care and pain manage-ment). 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 expecta-tions. 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.

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 mem-bership for exercising when the weather is cold or rainy. I also enjoy massages and fizzing foot scrub.

“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

quote

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The U.S. Bureau of Labor Statistics projects the current nurs-

ing shortage to reach 800,000 by 2020. 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, sched-

uled 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 effec-

tive 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 reten-

tion are in various stages of implementation.

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 assess-

ment and coaching to assist potential hires in determining

their best job fit are essential to successful hiring and contrib-

ute 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, ap-

plicants 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 dur-

ing 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 teach-

ing 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 shad-

owing experience. Participants enjoy complimentary dinner,

parking and an overnight stay in a hotel.

“Although the weekend program represents a major commit-

ment 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 employ-

ees 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 experi-

enced 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 equa-

tion 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 op-

portunities. 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 essen-

tially a nursing temporary agency, except that nurses who sign on

with the agency work exclusively for Cleveland Clinic hospitals.

Facing the Crisis: Cleveland Clinic Takes Practical and Proactive Steps to Tackle the Nursing Shortage

In the face of a national nursing shortage, Cleveland Clinic is addressing nurse hiring and retention from every angle and is con-stantly 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.

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clevelandclinic.org/nursing Fall 2007

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 Prac-

tice 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 educa-

tion 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.” Interven-

tions 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 conve-

nience, 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 profession-

al career education for our nurses.” It’s also a perfect comple-

ment 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.

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 knowl-

edge of senior nurses while satisfying the nurses’ desire for a

less-intensive work situation still within nursing.

Senior nurses also enjoy priority scheduling and opportuni-

ties 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.”

E-mail comments to youngc@ccf.org, dumpem@ccf.org, bockl@ccf.org and santalc@ccf.org.

The New Heart of Cleveland ClinicConstruction 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 compre-

hensive 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

clevelandclinic.org/heartcenter. To learn

more about nursing opportunities, visit

clevelandclinic.org/jobs/nursing.htm.

“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

quote

Nursing students in the computer lab of the Learning Center for Nursing Practice Excellence. Students receive instruction in the simulation lab.

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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.

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 under-

went coronary artery bypass graft surgery or valve surgery at

Cleveland Clinic in 2004.

“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 non-

emergency 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 iso-

lated 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, com-

mon 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. 68.5 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, respira-

tory complications and/or need for red blood cells after sur-

gery 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 respi-

ratory complications that occur even with excellent post-op-

erative 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.

E-mail comments to cwynarr@ccf.org and albertn@ccf.org.

Studying Nighttime Noise and Patient Satisfaction

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’ per-

ceptions 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 post-

operative 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 con-

sent 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 deter-

mine 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 night-

time noise on the floors by showing evidence of 15 different

factors, such as roommate snoring, nurses talking, and equip-

ment 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, medi-

cal condition or surgery variables influence patient percep-

tions of noise at night.

Data will be analyzed using descriptive statistics, correla-

tion 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 envi-

ronment as noisy can aid in planning to optimize sleep,”

says Murray, “which may, in turn, improve overall patient

satisfaction with the hospital experience.”

E-mail comments to murrayt@ccf.org or spencej2@ccf.org.

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.

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Breaking Bad NewsKathleen Lupica, RN, MSN, CNP, CCRN

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 distrac-

tions. 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 assump-

tions, 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.

E-mail comments to lupicak@ccf.org.

Kathleen Lupica, RN, MSN, CNP, CCRN

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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.

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.

Robotics for Surgical Specialtiesgeorges-Pascal Haber, M.D. | Section of Laparoscopic and Robotic Surgery, glickman urological and Kidney Institute, Cleveland Clinic

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 2000. They brought not only better visualiza-

tion, 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.

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Developing a Personal Formula for ContentmentScott Bea, Psy.D. | Clinical Psychologist, Department of Psychiatry and Psychology, Cleveland Clinic

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 bet-

ter 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.

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.

Georges-Pascal Haber, M.D.

Diana Baker, RN, BSN

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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 pa-

tients 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 overpro-

tecting 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.

Future of the OR: The goal is OPTIMAL

“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 dis-

covered 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 Euro-

pean operating rooms and corporations that had

developed new production facilities. Looking at

opportunities to improve performance, the team

determined the difference if patients were trans-

ferred 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 proce-

dures 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 opti-

mally 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

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 indi-

vidual, 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.”

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.

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.

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.

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Risk Management: Staying out of a CourtroomVicki Bokar, CPHRM | Director of Clinical Risk Management at Cleveland Clinic

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 impor-

tant 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.”

Rekindling the SpiritScott 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 par-

ticipants 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.”

Orthopaedic surgery ranks among the top five specialties in terms of being named most frequently in mal-practice 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 diag-nose 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.

Avoid disagreements with colleagues and/or making inap-

propriate 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 pro-

vided to patients. Date and time each note, avoid late entries

and never, ever alter a medical record. Review the documenta-

tion 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 ev-

erything 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.

E-mail comments to bokarv@ccf.org. 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 han-

dled the day. If you handled it poorly,

resolve to change your mind, which

takes courage.

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Rearranging the gI Tract: esophageal SurgeriesKathleen Tripepi-Bova, MSN, RN, CCNS, CCRN | Thoracic Surgery, Medical Cardiology and Transplant

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 tu-

mor 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 postop-

erative problems first.

E-mail comments to tripepk@ccf.org.

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.

Can We Reverse Coronary Artery Disease?

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 inde-

pendent 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 devel-

oped for early diagnosis of CAD, while the

plaque is still developing, Dr. Nissen said.

Better tools for moderating LDL, HDL, inflam-

mation and high blood pressure also should

be available.

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.

Steven Nissen, M.D.

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 15-17 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 interven-tional 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.

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Advances in Cardiac ImagingScott D. Flamm, M.D. | Head of Cardiovascular Imaging, Department of Radiology, Cleveland Clinic

Diuresis in Heart FailureNancy 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

help reduce volume overload in other ways. One is an inhibitor

of the anti-diuretic hormone – arginine vasopressin. Vasopres-

sin 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.

E-mail comments to albertn@ccf.org.

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 pres-

ence of pacemakers, ICDS and intracranial aneurysm clips,

and large body habitus.

Advances in CT technology, particularly the advent of multi-

detector CT, has greatly broadened its use in cardiac assess-

ment. 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. Ion-

izing radiation remains the main limit to wider use; a 64-slice

CT of the coronary arteries can provide the equivalent radia-

tion dose of 450 to 600 chest X-rays or more.

The newer CTs are now as much a functional as a morphologi-

cal tool as they convert two-dimensional scans into 3-D render-

ings. 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 proce-

dures, 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 distin-

guish 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.

Valvular Heart DiseaseDeborah 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 40-70 percent for those 70 and older), proper

medical management is a must. However, this requires iden-

tifying 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,

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 dila-

tion. 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 hyperten-

sion 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. Sur-

gical 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.

E-mail comments to kleind@ccf.org.

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.

Deborah Klein, MSN, RN, CCRN, CS

3rd Annual Meeting of the American Association of Heart Failure NursesDeveloping the Science of Heart Failure NursingJune 2007 | San Diego, California- Research: Understanding It and Applying

It to Practice- The Ins and Outs of PublishingAlbert NM, PhD, CCNS, CCRN, CNA

Society for Vascular Medicine and BiologyJune 2007 | Baltimore, MarylandSublingual Administration of Warfarin: A Novel Form of DeliveryBatke-Hastings S, MSN, CNP, MBACarman TL, M.D.

Society for Vascular Medicine and Biology’s 18th Annual Scientific SessionsJune 2007 | Baltimore, MarylandPoster Presentation: Sublingual Administra-tion of Warfarin: A Novel Form of DeliveryBatke-Hastings S, MSN, CNP, MBA

5th Annual Conference of State Nursing Workforce CentersJune 2007 | San Francisco, CaliforniaThe Other ShortageDumpe ML, PhD, MS, RNKavanagh J, MSN, RN

Western Thoracic Surgical AssociationJune 2007 | Santa Ana Pueblo, New MexicoPrognosis of Patients Removed from a Trans-plant Waiting List for Medical Improvement: Implications for Organ Allocation and Transplantation in Status 2 PatientsDiscussant: Robbins RC, M.D., Chairman, Cardiovascular Surgery, Stanford Univer-sity School of MedicinePresenter: Hoercher KJ, RN, Director, Kaufman Center for Heart Failure

Scholarship of Teaching and Learning (SoTL) in Nursing ConferenceAugust 2007 | Cincinnati, ohioCNS Student Competencies in Outcomes Planning and Evaluation: Curricular Considerations and ExemplarsCanfield 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 AmericaSeptember, 2007 | Washington, D.C. Expert Panel: Case Discussion in Heart Failure Hoercher KJ, RN, Director, Kaufman Center for Heart Failure

P u B L I C AT I O N S

Albert NMNon-ST-Segment Elevation Acute Coronary Syndromes: Treatment Guidelines for the Nurse Practitioner. Journal of the American Association of Nurse Practitioners. 2007;19:277-289.

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:10.1016/j.ahj.2007.03.030

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;13:189-198

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 So-dium Concentration and Clinical outcomes in Patients Hospitalized for Heart Failure: An Analysis From OPTIMIZE-HF Registry. European Journal of Heart Failure. 2007;doi:10.1093/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 RMRecognizing ventricular Arrhythmias and Preventing Sudden Cardiac Death.American Nurse Today.2007;2(5):38-44

Dumpe ML, Kanyok N, Hill KUse of an Automated Learning Management System to validate Annual Nursing Competencies.Journal for Nurses in Staff Development. 2007;6

Hill KContributor and Consultant.ECG Strip Ease.Philadelphia: Lippincott, Williams, and Wilkins, Inc. 2006.

Hill KThe Ps and Qs (and RSTs) of Assessing and Differentiating Chest Pain.Mosby’s Nursing Consultant. St. Louis: Elsevier, Inc. April 2007.www.nursingconsult.com/das/stat/view/69433923-2/cup.

Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, Blackstone EH.Improved Outcomes After Aortic Valve Sur-gery for Chronic Aortic Regurgitation With Severe Left Ventricular Dysfunction. Journal of the American College of Cardiology. 2007;49:1465-71

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. 2007 (in press)

Klein DGFrom Novice to Expert: Clinical Nurse Specialist CompetenciesAcute and Critical Care Clinical Nurse Specialist: Synergy for Best PracticesPhiladelphia, PA: Saunders (Elsevier); 2007.

Cleveland Clinic Nursing News

P R E S E N TAT I O N S

AORN 54th Congress of the Orange County Convention Center March 2007 | orlando, FloridaMaking a Difference Through ResearchSiedlecki SL, PhD, RN

AORN 54th Congress of the Orange County Convention CenterMarch 2007 | orlando, FloridaPoster Presentation: Making Research RealitySiedlecki SL, PhD, RN

Preventative Cardiology Nurses Association Annual SymposiumApril 2007 | Minneapolis, Minnesota Poster Presentation: Heart Failure Knowledge: What’s Race Go To Do With It?Albert NM, PhD, CCNS, CCRN, CANTrochelman K, MSN, RNHowey K, MS

10th Congress of Society of Chest Pain CentersApril 2007 | Nashville, Tennessee Case based treatment – Things to do right and what not to do wrongAlbert NM, PhD, CCNS, CCRN, CNA

Cardiac Surgery SymposiumApril 2007 | lima, ohioAdvances in Critical Care NursingHill K, MSN, RN, CCNS-CSC, CNS

33rd Annual Critical Care UpdateApril 2007 | las vegas, NevadaAnatomically Correct: How Cardiac Anato-my Impacts the Postoperative Course5 Things I Wish I Knew About Chest PainHill K, MSN, RN, CCNS-CSC, CNS

Northeast Ohio Case Management Network Annual ConferenceApril 2007 | Cleveland, ohioEthics, Case Managers, and Planning AheadHill K, MSN, RN, CCNS-CSC, CNS

Dimensions in Cardiac Care 2007April 2007 | Cleveland, ohio

- Case Studies in Heart Failure- Valvular Heart Disease- 12 Lead ECG Course- So You want to be an APNKlein D, MSN, RN, CCRN, CS, CNS

Ohio Consortium of Nursing Learning LabsApril 2007 | Findlay, ohioA New Menu for Skills Lab PracticumPrice K, BSN, RN

Midwest Political Science Association MeetingApril 2007 | Chicago, illinoisMedicaid Tele-Reimbursement Policy: Explaining State InnovationSchmeida M, PhD, MSN, RN, CNS

Pediatric Endocrine Nurses Society ConferenceApril 2007 | Portland, oregonAPN Case Study: Growth Failure in Patient with Down’s Syndrome, Hypothyroidism and Type 1 DiabetesSwitzer C, MSN, RN, CPNP, CDE, NP

Challenges in CardiologyDar Al Fouad hospitalMay 2007 | 6th october City, Egypt

- Clinical Management of Heart Failure- Drugs Used for Heart Failure- The Importance of Self-Care in

Managing Heart FailureAlbert NM, PhD, CCNS, CCRN, CNA

Heart Failure State of Science Conference American Heart Association Council of Cardiovascular NursingMay 2007 | Washington, D.C.State of Clinical PracticeAlbert NM, PhD, CCNS, CCRN, CNA

National Teaching Institute and Critical Care ExpositionMay 2007 | Atlanta, georgiaBeyond the Horizon: Drug and Mechanical Diuresis in Heart FailureAlbert NM, PhD, CCNS, CCRN, CNA

National Teaching Institute and Critical Care ExpositionMay 2007 | Atlanta, georgiaIssues in Heart Failure: Management Adherence and PolypharmacyAlbert NM, PhD, CCNS, CCRN, CNA

American Transplant CongressMay 2007 | San Francisco, CaliforniaCardiovascular Disease in Solid Organ TransplantationHoercher KJ, RN, Director, Kaufman Center for Heart Failure

American Geriatric Society ConferenceMay 2007 | Seattle, WashingtonPoster Presentation: Moving Forward by Looking Back: A Proactive Reminiscence Program for Depressed ElderlySimon J, BSN, RN, Rader E, Marrie K, MSN, RN, Campbell J, M.D.

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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 Cl