CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
3/9/05   Issue XLII   850-477-1234   Toll Free 866-CDI-NURSE
Making a Difference
Job satisfaction… not a term heavily used in nursing today.  We
face long hours, incredible workloads, staffing patterns that don’
t compare to California’s minimum/ nurse patient ratios, patient
and treatment complexity soaring,  coupled with demands at
home and inflexible cyclic schedules.  One can understand why
we will need 623,000 more nurses in the work force in the next
8 years.  Where will the additional 213 nurses a day come from?
(The FNA report  puts Florida’s needs in 5 years at 69,000
nurses, or 38 more nurses a day, starting yesterday.) When and
if we do find an answer, what is going to keep them here, and
not in California?  Don’t bet on the pay (though we can help you
with that ) nor increased longevity of nurses.  Nationally, most
nurses over 50 are heading for the part time door.  Already 52%
of us have chronic back pain and yet no overhead lifts are in, or
planned, for hospital renovations in our area.  Will the 38 extra
nurses a day come from the local schools where classes are
actually being canceled, instead of increased 10 fold?  
Doubtful.  Foreign students continue to fail the TOF Language
Exam on a regular basis; those that pass get hung up on the  
immigration Homeland Security Laws.  Those that get though all
that have a tough time with the nursing boards.  In order to get
38 more nurses a day we will have to virtually stop all nurses
from leaving the profession.  Staffing  has to be addressed.  
Mechanical lift devices have to be installed in our patient room
ceilings.  Why, in a profession that teaches our patients the
importance of back mechanics,  are we pulling patients on
plastic bags?  Shorter shifts - going part time is going to be a
strong trend as our nursing population gets older.  These folks
(myself included) are no longer interested in leaving a pound of
flesh on the floor each night.  Let’s set the stage to keep
them.  Hospital based 3 year nursing programs are going to
have to be brought back.  The 3 year program will supply some
of the needed 38 nurses a day, and provide for institutional
allegiance.  Their students are required to pull shifts, allowing
for more hands in the mix.  They return the staff nurse to an
educator/coordinator/ patient care dynamo instead of where we
are heading for now.  The infra-structure and professional
expertise that a nursing program brings to a hospital is any
nursing administrator’s dream.  All of it can be done, done well,
and if done now, will be flooded with applicants willing to pay to
become a nurse.
Long Hours Hurt
The risk of making an error increases as the number of hours per day
or week rose, according to a study commissioned by the Michigan
Nurses Assoc.  They found the RNs working 12.5 hour shifts had an error
rate 3 times higher than their counterparts working 8.5 hour shifts.  The
report concluded that with the cut in overtime, improved patient
outcomes and job satisfaction, Michigan hospitals would save several
hundred million dollars a year.
195,000 Deaths
The number of deaths due to medical errors per year in the US,
according to a study by HealthGrades Inc., now surpassing the number of
deaths due to Diabetes.  To give you an idea, that comes to almost 535
patients a day!

Medication Errors
According to a study by Leape et. al.:
39% of med. errors occurred on ordering the medication
12% during transcription process
11% during drug preparation
39% during administration
Remember to check to see if this
medication makes sense for this patient’s diagnosis.  Is the patient
allergic to the medication or a similar form of the medication?  Is the
medication you have mixed to the same concentration?  Are you sure of
the math for administration of this medication over the proper time?  Is
this medication a sustained release medication?  Will it conflict with other
medications later in the day?  Is the route of administration appropriate
for this patient?  Is this the right time for this medication?  Who is the
patient you have in front of you? Ask their name, check their name
against the MAR, and recheck the ID bracelet.  Don’t let yourself be
interrupted during the process, and if you are, start over.  As a nurse you
are a patient advocate. You stand between the patient and disaster.  
CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
11/9/04   Issue XL     850-477-1234   Toll Free 866-CDI-NURSE
Signs of Ovarian Cancer:
Heart burn, abdominal bloating, and
constipation.  26,000 women will die from some form of GYN cancer this
year.  Sure would be nice to catch the
symptoms early


Premature Infants
Are at a much higher risk of neuro-developmental disorders such as cerebral palsy, mental retardation, intraventricular hemorrhage, and
chronic respiratory and neurosensory impairment.  Average life time medical expense of someone born prematurely - $500,000.  Hospital
charges alone in 2001 - $13.6 billion.  American Journal of Maternal/Child Nursing. What is astounding is that a study out in Paediatric and
Perinatal Epidemiology reports that preterm inductions account for a significant portion of the preterm birth rate.  In fact, they point out
that preterm inductions have doubled from 6.7% in 1989 to 13.4% in 1998!  We are our brother’s keeper.  Is that induction this morning
necessary
CDIstaffing.com
Thanks to everyone who have stopped by the web site and offered suggestions.  
We have added the “Cheat Sheet” page
as requested.  Obviously, this is just a start.  If you don’t see a formula,
or mnemonic you will need, please let me know.   


600,000
The number of potential neurologic
problems that could be prevented in children annually if they were not exposed to
mercury through their mother’s diet during pregnancy .  
AJN Vol104-#3.    So avoid tuna and support “clean”coal burning power plant
reform.


Depressing News
Patients who used serotonergic (like Prozac) antidepressants had a nearly four
fold greater risk of needing blood transfusions post op than patients who
didn’t use any kind of antidepressant.
Making a Difference
What a great year it has been for nurses and our
patients.  New Jersey and West Virginia now have laws
prohibiting mandatory overtime for nurses.  A similar
proposal is in the US Senate.  The courts upheld
California’s staffing law.  Massachusetts is drafting it’s
own law that delineates staffing ratios (House Bill
1282). The word is getting out that what is safe is not
what is being done in most of the country.  Startling  
research out of the Journal of Health Care Finance (29
[4]54-76) shows that for every RN added to the
hospital’s staff, operating costs increased by 0.25%,
but, there was no decrease in hospital profits.  So, not
only does increasing RN staff decrease medical errors,
decrease staff turnover, and improve moral,  it proves
to the patients the hospital cares about them. It does
this at no cost to the bottom line. Not a bad way at all
to end a year.

Back to Sleep
In 1992 the American Academy of Pediatrics
recommended placing infants on their backs to sleep.  
Nurses have been teaching it ever since.  
Results…SIDS deaths have dropped by 50%.

COX  Enzyme
Something we block every day when we give NSAIDs
(Advil, Toradol).  Good for cutting a patients pain…but
it may be giving them another problem.  COX enzyme
is needed for bone repair. (J. Clin Invest 109(11):
1405-15)  In one study, patients who received Toradol
post op for spinal fusion were 5 times more likely to
have nonunion, or failure of normal bone healing
Spine 23(7):834-8.
Fatigue
The most common complaint by women prior to having an MI.  According to
an article in Circulation, 108(21),2619,                                  
95% of women had symptoms a month or more before an acute MI.  Less
than a third experienced chest pain.

Judge Gail Ohanesian
The California Supreme Court Judge that upheld mandated nurse to patient
staffing ratios.  Nearly 500 California hospitals joined in a lawsuit to stop
enforcement of the law.  This sainted judge has done more for the patients
and nurses of California than she will ever know.
CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
7/9/04   Issue XXXIX   850-477-1234   Toll Free 866-CDI-NURSE
Making a Difference
In this world, change is a constant.  For CDI, these
changes have been positive.  We have always done
business by placing trained professionals in their areas of
expertise.  We abhor the warm body myth.  If you are not
trained in a discipline, you are not going to give safe care,
you are not going to be organized.  You certainly are not
going to be a welcome sight to the floor staff you have
arrived to "help."
Fortunately, the hospitals are getting it, JCAHO is starting
to require it, and everyone benefits.  It is a win win
situation. When the hospitals see an opening on the
horizon,  they communicate with us so we can start to line
up coverage. This allows for a properly trained nurse with
credentials to back fill a position.  It gives the unit time to
find a qualified replacement and time for a  hospital and
unit orientation,  something that can take weeks, possibly  
months to accomplish.  Such communication with the
facilities has been a huge step forward.  Failing to do so
leads to endless problems for the unit, not the least of
which is floating, disaffection, and increased staff
turnover.   
Everyone Wins
The patient is now getting the continuity of care that is desired, floor staff
have a nurse on board that knows what she is doing, and
credentials become manageable.
A perfect fit.  Cost savings and staff retention all through a little
preplanning and communication.
CDIstaffing.com
Well it has been a while in coming, but our web site is up and running.  
Now if you want to read the newsletter, start the application process, catch
up on some nursing news or just leave the company a note, our website is
calling.  At present we are getting our feet wet.  Please take a look and
offer suggestions or insights as to how we can do a better job on it.
Thanks.

Six Percent
The RN shortfall in the year 2000.

Twenty-nine Percent
The expected RN shortfall by the year 2020, according to M.Gravis MSN, JD’
s article in RN.
CRITICAL DIFFERENCE INC.
PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
5/29/04   Issue XXXVIII  850-477-1234   Toll Free 866-CDI-NURSE
Let’s Find Out.
We are setting up the test on our office computer.  CDI nurses
who have worked at least two days a week for the past 4
weeks,  can come in and test.  Pass… and win a weekend
cruise.  Not a CDI nurse?…all is not lost, though I do feel bad
for you.  If you are now actively working as a nurse in the
community: make an appointment, fill out an application, take
and pass the test.  You will be entered into a drawing for the
same cruise.   Tired of cruises?  Want to stay anonymous?  
Forgot a pen, or just want to see if you have the 10 functions of
the liver down pat?  Can you recite cranial nerves and the citric
acid cycle?  Take the test.  How ? Make an appointment and
you can test for free.  Your second passing of the boards  will  
in no way make you feel like your first did, but as you’re
sipping your Pina Colda as the ship slips into the sunset, you
will still feel pretty good. Now study.  You only get one chance
to pass this test. The exams are given by appointment only
(call between 9a and 5p please, I need my beauty rest.)  
Testing begins this week and ends the last week of July.  So, if
you are chosen to precept a new grad, remember you are
working with someone who has the knowledge to put you
aboard a cruise.

Pulling The Gauze Over Our Eyes
Study in Am J Surg shows that bacteria take only a few minutes
to penetrate two or more layers of sterile gauze and are readily
dispersed into the air during dressing changes.  Might be time
to rethink gauze dressings.

50%
Stop smoking after your first MI and statistics show a 50%
reduction  in the risk of dying in the next 5 years according to
New England Journal of Medicine.
Making a Difference
The change in season brings with it so many wondrous things.  Of all
of them, few of us are looking forward to the new grads.  Snatched
up by the truck load, hospitals will shortly be dropping these
wonderful folks in your lap.  Our job will be to bring the little they
know about a huge amount of things into focus, while still juggling
our full list of responsibilities.  This drill has been done by you and
tens of thousands of seasoned nurses before you.  Perennially, we
miss a huge opportunity.  They, after all, have something that we
may have lost… no, not youth.  They have the ability to pass their
boards. With all their clumsiness, inexperience, and lack of
organization, they possess a breadth of knowledge held sacred by
every one of us.  Doubt we did, the depth of our knowledge as we
took the boards, and again as we reviewed test questions with fellow
grads.  The affirmation that you posses the knowledge base and are
now a licensed nurse floods your being as you open your letter from
the Board of Nursing.   Ah, but could you pass those boards today?  
Customer Service 101
Due to incredible demand (2 calls)  CDI’s popular state approved
Customer Service 101, self study 2 contact hour
module, is available for pick up/correction Monday mornings until
July 19th.  Free for CDI folks and only $6.00 for the rest of the
universe.  

Size Does Count!
For decades we have heard about the French Paradox.  Somehow
the French
have been able to consume more
cholesterol in their diet, and sustain fewer heart attacks than folks
in the U.S.  Evidence now points less to the wine as a reason and
more to LDL size!  Here in the states we look long and hard at LDL
and HDL ratios.  Yet a significant number of folks in the U.S. are
dying with pretty good cholesterol levels.  Those labs don’t look as
good when the LDL size was measured.  It turns out in folks with
"big guts, no butts" (sometimes called insulin resistance, or
Syndrome X) have much smaller LDL molecules, smaller than 60
angstroms in size.  This becomes important because the
endothelial cleft (opening into the vessel wall) is normally that size
or slightly larger.  Present thinking is that the small LDL uses this
entrance to  start cholesterol crystal formation eventually  leading
to atherosclerosis.  What is even more interesting is that this
process may be reversible, by loosing abdominal weight, exercising
and the use of medications (Statins and Niacin or Fibrates or
Resins),  LDL size increases.  Your patient teaching has never been
more important, and patient motivation never more difficult.  Points
like these help each and everyone of us reinforce the importance of
life long dietary and exercise habits.  Remember, one of the best
ways of teaching is by example.
Thanks for being a nurse

Douglas Terrell  RN
CEO CDI
© Critical Difference Inc. 2005
CDISTAFFING.com
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