Greetings!

Welcome to the Hartford Institute for Geriatric Nursing's March 2010 eNewsletter featuring articles, reference materials, useful links, calendar of events and other best practice information on the care of older adults.

This eNewsletter is sponsored by ConsultGeriRN.org.

ConsultGeriRN.org is the authoritative geriatric clinical nursing website of the Hartford Institute for Geriatric Nursing, New York University College of Nursing and the NICHE (Nurses Improving Care for Healthsystem Elders) program, www.NICHEProgram.org. ConsultGeriRN.org contains evidence-based protocols and topics for nurses and other healthcare professionals on the care of older adults. Content is updated regularly.

We would like to hear from you!

Delirium is a common syndrome in hospitalized older adults. Delirium is a disturbance of consciousness with impaired attention and disorganized thinking or perceptual disturbance that develops acutely, has a fluctuating course, and with evidence that there is an underlying physiologic or medical condition causing the disorder.

Although sometimes reversible, delirium is associated with increased mortality, increased hospital costs, and long-term cognitive and functional impairment. Delirium can be prevented with recognition of high-risk patients and the implementation of a standardized protocol.

Learn more about "Delirium and Older Adults" including references and assessment tools by visiting ConsultGeriRN.org.

Two new Try This:® Specialty Practice Series Issues authored by the Preventive Cardiovascular Nurse's Association (PCNA) have been released by the Hartford Institute, and are available on ConsultGeriRN.org:

Try This SP3: Cardiac Risk Assessment of the Older Cardiovascular Patient: The Framingham Global Risk Assessment Tools
By: Lola A. Coke, PhD, ACNS-BC, Rush University College of Nursing and Preventive Cardiovascular Nurse's Association

Try This SP4: Vascular Risk Assessment of the Older Cardiovascular Patient: The Ankle-Brachial Index (ABI)
By: Lola A. Coke, PhD, ACNS-BC, Rush University College of Nursing and Preventive Cardiovascular Nurse's Association

The Preventive Cardiovascular Nurses Association (PCNA) and the American Nurses Foundation have partnered to award a $5,000 grant to encourage the research career development of nurses. In support of the mission of PCNA, individuals whose research is focused on cardiovascular disease prevention may apply at: www.nursingworld.org.

The applicant may be a beginning or experienced researcher, with a minimum of at least one degree of BSN or higher. Proof of current membership of the American Nurses Association or a corresponding National Nursing Association member through the International Council of Nurses is required if this grant is awarded. The applicant must become a member of PCNA upon acceptance of the grant. Presentation of results is expected at the annual meeting of the PCNA within two years of completion.

Deadline for submission is May 3, 2010.

Last month we ran a poll asking "How much influence do you think nurses should have as health reform is implemented?" (See results on the right column) Incidentally, we found that the results closely matched those of a recent study by the Robert Wood Johnson Foundation (RWJF). RWJF wanted to know if nurses are key decision-makers when it comes to health care reform.To learn more, the Foundation commissioned an unprecedented Gallup study to examine what role the nation's opinion leaders think nurses are playing in health care reform, and what role opinion leaders think nurses should play when reform is implemented.

Gallup surveyed more than 1,500 thought leaders from insurance, corporate, health services, government and industry, as well as university faculty. The first-of-its-kind survey finds that an overwhelming majority of opinion leaders say nurses should have more influence in many areas, including reducing medical errors, increasing the quality of care, promoting wellness, improving efficiency and reducing costs. A clear majority say that nurses should have more influence than they do now on health policy, planning and management.

But when asked how much influence various professions and groups are likely to have in health reform, opinion leaders put nurses behind government, insurance and pharmaceutical executives, and many others-and they see real barriers to nursing leadership.

Read More on the Robert Wood Johnson Foundation Website
View Webcast

Now Online! NICHE Leadership Training Program

NICHE Launches Online Connect Webinars

Spring Series Focuses on "Interdisciplinary Innovations"

Ethel Mitty, EdD, RN
Long Term Care Consultant
Hartford Institute for Geriatric Nursing

NICHE Hospitals seeking to improve relationships with long-term care facilities/services and with hospice programs, in order to improve the quality of care for older adults, need to be aware of a growing problem of effective pain management. The Drug Enforcement Agency (DEA), an agency within the U.S. Department of Justice (DoJ), increased its enforcement of the Controlled Substances Act (CSA) to detect and prevent diversion of Schedule II - V drugs, in mid 2009. Among the oddities of the CSA is that nursing home (NH), assisted living community (ALC), hospice (H) and home healthcare (HHC) nurses are not legally permitted to create, transcribe or transmit Schedule II drug orders to a pharmacist, on behalf of a practitioner/prescriber. Why? Because the nurse is not an "agent" of the practitioner. (Yet, the practitioner's office nurse or secretary can create and transmit such orders.) As a practical matter, however, ALC and NH nurses (RNs as well as LPNs) transcribed a DEA-approved physician/practitioner's drug order - written in the chart (or via a telephone order) - to a pharmacy to be filled and dispensed. (The nurse is acting as an "agent" of the practitioner.) The facility would fax the original script of the Schedule II drug to the pharmacy within seven days, as required.

Apparently driven by complaints made by pharmacists that non-authorized individuals in the above-noted settings of care are illegally prescribing/ordering Schedule II drugs, pharmacists are reacting in diverse ways to DEA crackdown. Within and between states, pharmacists are making independent decisions about whether or not they will accept a fax script; some are requiring that the original script is in the pharmacy before filling/dispensing a Schedule II drug. In an increasing number of instances, practitioners are ordering a less effective medication (i.e., Schedule III) in order get some kind of pain relief to a resident/patient as quickly as possible. Some pharmacists will accept a fax for Schedule III, IV, and V drugs from an RN or an LPN and require an original script only for a Schedule II drug. The DEA also holds that a "chart order" written in the chart of a long-term care facility resident is not the same as an order written in a hospital chart: the latter can be filled; the former cannot. There is also a growing concern - but the extent to which it is substantiated is unknown - that non-licensed medication aides/technicians are diverting already filled Schedule II prescriptions for criminal use.

Medication reconciliation protocols need to address the transfer/transmission of properly written orders for Schedule II drugs - using the proper DEA-approved script. The DoJ is in perfect accord with the goals of the CSA, that is, to prevent drug misuse and to "facilitate appropriate medical care." The Centers for Medicare and Medicaid Services hold that pain is the 5th vital sign and go to strenuous lengths to assure that LTC residents/patients are assessed for pain and receive appropriate treatment. Yet, it can be argued, that the DEAs activities conducted in the absence of their thinking about the effect on pain control, seem to obstruct CMSs goals as well as abrogate patient/resident's rights to quality of care.

For more information, go to: The Quality Care Coalition for Patients in Pain (QCCPP). www.qccpp.org.

References:

• http://.justice.gov/dea
• Weich R. Letter from the Assistant Attorney Journal, Department of Justice, to H. Kohn, Chairman, US Senate Committee on the Aging. Dec. 2, 2009.
• QCCPP. The Quality Care Coalition for Patients in Pain. Issue Brief. Oct. 28, 2009.