CRITICAL DIFFERENCE INC.
  PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
12/21/07   Issue LIII  850-477-1234   Toll Free 866-CDI-NURSE
Making A Difference
Have you noticed an awful lot of
nurses have been traveling to
California?  Did they mention how nice
it was to work where you have enough
staff?  Would they do it again?   The
answer to all of these questions is
YES.  What does California have that
we don’t have? A staffing law that
defines patient/ staffing ratios.  In
speaking to the director of U. of
Arizona’s Nursing program it is plain
her state is loosing a huge number of it’
s grads to California.  This year’s
staffing conference in Chicago pointed
out that most travelers prefer to go to
California.   Not because it’s closer,
nor because they earn more money
than Miami, not because it’s cooler in
July than in Cape Cod.  You guessed
it, because of nurse/ patient ratios.  It‘s
safer, less wearing to your soul, your
patients are happier, you’re less likely
to make a mistake and you get a
break.  You even get to sit down for
lunch.  Because of a ruling by Judge
Gail Ohanesian of the CA Appellate
Court, a patient in California has a
nurse, that does not already have a
patient load, to cover them when you’
re on a break. Your patients are not at
risk because you ate… what would that
be like?  Well, with a little work, it could
happen here!  HR 4138/ SB 73, a
national nurse/patient ratio bill, has
been submitted to House and Senate
Subcommittees for review.  Frequently,
this is where a bill is squashed by
powerful lobbyists who   care nothing
for your patient or you. It’s time to take
arms against this madness that
endangers our patients and destroys
our souls. The fact that you get this
letter is proof you have made a
difference in our community. It’s time to
increase that impact.
Please go to CDIstaffing.com.  Mid-way
down the first page, click petition and
make your mark.  Then go to Nurses
News page and see how a few letters
by you can change nursing in this
country forever.  You make a
difference every day for your patients.  
Nursing needs you now to make a
difference for all patients. This will not
happen without you.  Fire up your
computer, it’s time to roll.
800,000
The number of children, under the age
of 5, that die of malaria every year.  
Hope may have arrived. Vaccine
RTS,S/AS02D.  In phase 2 trials, the
vaccine was found to be safe in infants
and reduced new malarial infections by
65%.  The Manhica Health Research
Center starts final trials in mid 2008.
Want to help?  Buy some Glaxo Smith
Kline stock. (GSK)
http://ec.europa.eu/research/info/conferences/edctp/pdf/malaria_background_en.pdf
Post Op in the Obese
We all want our patients out of bed
and moving as soon as possible.  
Opoid administration in the obese
carries a warning.  Anesthetics and
opoids are lipophilic. Delayed release
of these drugs from adipose tissue into
the blood-stream can cause
resedation.  Crit Care Nurs Q
2003:26(2):105-16.  This can be
troubling as your patient may crump
while you have them out of bed. So get
them up, but get help and have a plan
on what to do if they start going down.
More Weight, More Damage
Bostanjian et. al. recommends getting
serial CPK measurements in post-op
obese patients as they are at risk of
rhabdomyolysis. Weight on a pressure
point is always a concern.  But when
you have this much weight on any
given area, any skin lesion should be
evaluated as it may point to extensive
myonecrosis or skeletal-muscle-cell
death.  
Med Error Reminder
When you are about to give a drug
that has a high potential for harm, or if
your patient is a child, have another
nurse double check the 5 rights prior
to administering it.  You do make a
difference, especially when you don’t
get distracted and don’t take short cuts.
How to get up with us
From anywhere on earth:        
CDIstaffing.com
From anywhere in the area M-F 9-5
850-477-1234
From anywhere in the states M-F 9-5
866-CDI- NURSE (866-234-6877)
Fax:  850-434-1515
Toll free fax:  866-473-3238
CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
4/10/08   Issue LIV 850-477-1234   Toll Free 866-CDI-NURSE

Making A Difference
The year is well underway.  It's a good time to
do your yearly evaluation... not the tedious
one your supervisor and you try to avoid.  
This is the one you have to be honest about.  
As a professional, you are responsible for a
list of things.  Can you recount some of
them? Yes… good for you, education.  We
are responsible for keeping up with our
CEUs, (you’re up to date, give yourself 10
points).   But that is just part of the
responsibility.  We are expected to keep up
with the profession.  This is going to require
reading at least one professional journal
every month.  If you subscribe already, and
are up to date on your reading …you get 5
points,  10 if you read it cover to cover, 15
points for reading 2 or more journals cover to
cover every month.
We should take a class every year.  No
time?  Welcome to my world.  Hop on line and
check out the free Berkley lecture series
using Google Video or You Tube.  Dr.
Diamond’s Integrative Biology 131 is
excellent. (Take a class this year, get 10
points.)
We should give a class a year.  It can be as
short as an hour or as routine as a CPR
class.  The person who learns the most in
any class… the teacher.  (Give a class, get
10 points, give 2, take 15.)
We are responsible for being politically
active.  Right now, there is a bill in Congress,
HR 4138, that will set nurse patient ratios
nationally.  Go to our website www.
CDIstaffing.com.  Midway down on the page,
hit the “political action page” button.  Use the
link to email the committee heads.  You did?
Give yourself 10 points.  You
mailed them and your representative in
support of the bill?  You get 15 points.
Community is something others do, not
you, loose 10 points.  Active in any
project, committee, organization that
supports your community, get 10
points.  Note: donating money is nice,
but it doesn’t count (unless you’re
Quint Studer, but he’s already maxed
out on points.)
We are responsible to be a member of
a professional organization: ANA, ENA,
ORNA etc. If you are, take 5 points.  If
you went to any of the meetings, take
10 points.        
You should read one  profession
related book a year.  Each of the
hospitals has a library, Amazon can
get you almost any book, cheap and
fast.  No excuse.  Read... you did!
Good work, take 10 more points.  
We are responsible to ourselves and
others to be in good working order.
That includes your weight being in
control, no smoking, BP numbers lower
than the national debt, flu shot
updated yearly, and daily exercise.  3
of the above 5, take 5 points, 4 of the
5, take 10,
5 of 5, take 15 big ones.  
So how did you do?  Score a 100 or
above, you deserve a raise.  Score
less, well there is next year.  Start
putting your house in order.  You know
what is expected.  Others watch you to
see if they measure up.  Set the
example.  It's how you make a
difference in this world.   
Watch Your Tone Young Lady
Professor Mehrabian at UCLA has
quantified what people use to decide
whether we like the person delivering a
message.  He says, voice accounts for
38% of our opinion, body language
55% and actual words just 7%.  
IV Fluid Controversy
At one time, things were pretty
simple, your trauma patient’s blood
pressure falls, you give more IV
LR.  Now, research shows that for
trauma patients, lactated Ringers
solution can accelerate systemic
inflammation by activating
neutrophils, which, in turn, spark
diffuse cellular injury that leads to
Acute Respiratory Distress
Syndrome and multiple organ
failure.
   
Surg Clin North AM, 87(1)55

Normal Isn’t Normal with Saline
Adding volumes of Saline stretches
the vascular pores, allowing fluid to
quickly escape from the vessels.
  
Crit Care Med, 34(9), 2456  
“In fact, 75% of a NS bolus escapes
the vascular bed instantly.”
    
J AM Coll Surg,204(4),665  
Use of aggressive NS IV fluid resuscitation dilutes hemoglobin,  
oxygenation and stimulates
rebleeding.                                                                            
       
  Crit Care Med, 34(9), 2456  
How to get up with us
From anywhere on earth:        
CDIstaffing.com
From anywhere in the area M-F
9-5
850-477-1234
From anywhere in the states M-F
9-5
866-CDI- NURSE (866-234-6877)
Fax:  850-434-1515
Toll free fax:  866-473-3238
CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
6/1/08   Issue LV 850-477-1234   Toll Free 866-CDI-NURSE
³http://www.pressganey.
com/files/nosocomial_infections_cost.pdf
Next
Document what the average numbers
of falls per 100 patients were per
year, in your area.  What was the
number of Nosocomial Infections?
How many pressure ulcers developed
last year?  Most of these numbers
have already been tracked for you…
you bet, by the bean counters.  Look
at your area’s patient satisfaction
numbers.  All right, we are ready to
begin.
Making A Difference
Every day, you make a difference in
your work place.  Yet, it is pretty easy
to think you’re not appreciated.  You
frequently work short handed.  Most
shifts you are working without getting a
break to eat.  Your back starts talking
to you 8 hours into a shift. The future
is wrought with deepening shortages.  
More and more baby boomer nurses
long for the day they can retire.  Cut
backs abound.  Is there a way out of
this mess?       
Surprisingly, yes, and it’s not difficult,
nor expensive, and there is very little in
the way of a learning curve.  It comes
from realizing we now work for a bunch
of bean counters who work for a bunch
of bean counters who answer to a
bunch …well you get it.  Nurses don’t
see the world the way they do, and we
suffer for it.  We have to show the
hospital that care on your unit saves
them big money.  Because of those
savings, your unit deserves
proportionately more staff, break
rooms stocked with soft drinks and
snack foods, and proper dinner
breaks, at the very least.

Let’s Get Started.
First, it helps to know where the money
losers are for a hospital.  If you are
working in med/surg, the list is endless
but here are some big ones.
Patient satisfaction polls:  if they are
lousy, you can kiss off any increase in
the unit’s budget.
Falls:  the average patient fall costs
the hospital around $40,800 ¹.
Pressure sores:  one of these guys will
extend a hospital stay like nobody’s
business and the hospital eats it.  Cost
per ulcer:  $23,000 locally ².
Noscomial Infections:  an average
infection will set the hospital back
$13,973 ³ and under new guide lines, it’
s the hospitals expense.
Document a decrease in your unit’s
falls by one, avoid one pressure ulcer
and cut out one Nosocomial Infection…
why you just justified the hospital giving
your  dept.one more FTE.
http://www.bedcheck.com/aged2.html
(2 falls - $81,600, 2 infections –
$27,946, 1 pressure ulcer - $23,000).  
Track your numbers on a board each
month.  In no time flat, your area,
district, and department will start to
shine.  These numbers now become
your leverage to get what you need.  
Every hospital administrator wants a
floor where they can place a loved one.  
Your area will be that area… the best
staffed by the most appreciated nurses
in the house and the most satisfied.  
The first step to changing to Tenable
Care is with you; talk up the idea with
coworkers.  Meet with your supervisor,
set up a meeting and draw up a pact
with each other as to what each has
agreed to do… hourly rounds, etc.  Put
it in writing.  Remember to discover what
the numbers are before you start so you
can document the difference you make.  
Look to see where the savings you
made can be spent to improve your
area.  Start a letter to administration,
leaving blanks where the dollar savings
amounts will go.  Need a place to meet?  
Our conference room is open to you.  
Need advice on Tenable Care?  Give us
a call.  You make a difference every
day, but you won’t believe how much a
difference you can make when you have
enough help.  
Evidence Based Money.
Now it is time to mine those dollars.  
We may not be able to calculate an
EBIDTA like the accountants, but no
one knows how to care for a patient
like a nurse.  First, let’s tackle falls and
patient satisfaction.  Both are
dramatically improved by doing nursing
rounds every hour.  We can do that.  
Next are pressure ulcers.  Turn you
patient every hour and the number of
them slips to almost nil.  We can do
that.  Noscomial Infections are mostly a
matter of hand washing and common
sense.  We can do that.  

Get Sign On From Others
This is where the work is.  You have to
develop this from within.  You’re going
to have to get a group of nurses on 2
shifts to agree to switch to Tenable
Care.  The problem may not be
pressure ulcers in your area, but in
every area of the hospital, something
is costing
patients, and the hospital, in some
way.  If you find just one and bring
down the cost to justify that
desperately needed FTE, everyone
wins.  Set a dollar savings goal