MVC-AACN Newsletter

SPRING/SUMMER 2014

AACN has had a busy year so far in 2014! In April we had our New England Horizons conference in Portland, Maine. It was a well-attended event where lots of learning and good times took place! (See article and photos in this newsletter for more details)

In May we had NTI in Denver, Colorado. Our new AACN President, Teri Lynn Kiss, introduced her new theme for the upcoming year – Focus the Flame!

I N S I D E T H I S I S S U E To learn more go to: Welcome, NTI update 1 http://www.ntivoices.com/this-girl-is-on-fire/ 2 - 9 Sepsis, PAD & ABCDE program review 9 -10 Horizons Conference Review Part of her theme included FIRE – 11-12 June Program – Hope to see you there! Fearlessness, Inquiry, Resilience and 13 Fundraising update, Chapter Board members Engagement – an element made up of these four qualities, qualities that grow 14-16 Photos our profession and contribute to our best 16 Horizons 2016 information possible work.

Epinephrine may be added to and potentially

Newsletter 1 Bundles, Guidelines & PEARLs: Sepsis, PAD and ABCDE a review by Diane Meagher

On October 22, 2013 we held our fall program, Bundles, Guidelines & PEARLs: Sepsis, PAD & ABCDE, at the Westford Regency Inn & Conference Center. The topics, as the title indicates, focused on the latest guidelines for sepsis and PAD (Pain, Agitation and Delirium), as well as the ABCDE Bundle.

At last year’s NTI I had attended a session, “Sepsis – The Next Core Measure,” presented by Lisa Soltis, MSN, APRN, PCCN, CCRN-CSC, CCNS, FCCM, Cardiovascular/Critical Care Clinical Nurse Specialist at WakeMed Health and Hospitals, Raleigh, NC. I thought she was a phenomenal speaker so I contacted her to speak for our chapter. She accepted and presented an extended session, “Time is Tissue: Early Recognition and Management of Sepsis.”

She began with an overview of the inflammatory changes at the cellular level, including the normal function of the immune system and response to stress and infection. Next she discussed the pathophysiology of shock. Shock is the inability of the circulatory system to deliver enough blood to meet the oxygen and nutrient requirements of body tissues.

Hypoperfusion, activation of the inflammatory response, and hypercoagulability are universal conditions with shock, regardless of the clinical condition causing the cellular hypoperfusion. “Timely reversal of the shock state prevents development of multiple organ failure and death, hence the phrase ‘time is tissue.’”

The Systemic Inflammatory Response Syndrome (SIRS) is severe inflammation caused by major insults. The SIRS diagnostic criteria include 2 or more of the following: Temperature > 38.0 C or < 36.0 C Tachycardia (HR > 90)

Tachypnea (RR > 30 or pCO2 < 32 mmHg) WBCs > 12K or < 4 K/mm3

Newsletter 2 3) Administer broad-spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

To be completed within 6 hours: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO2)* 7) Re-measure lactate if initial lactate was elevated* *Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO2 of ≥70%, and normalization of lactate.

We should all be performing routine screening of potentially infected, seriously ill patients to allow for early identification and implementation of therapy. Cultures should be obtained as clinically appropriate before antibiotic therapy as long as it does not delay the initiation of antibiotics. Imaging studies should also be performed promptly to confirm potential source of infection. Administration of effective antimicrobials should begin within the first hour of recognition of septic shock and within 3 hours of severe sepsis without septic shock. Each hour delay in antibiotics increases mortality by 5%.

Crystalloids are recommended for initial fluid resuscitation. Hydroxyethyl starches are not recommended, however albumin may be administered for severe sepsis when large amounts of crystalloids have been unsuccessful. Each hour of delay in hemodynamic stability increases mortality by 7%. Vasopressors should be initiated for persistent hypotension despite fluid resuscitation with a target MAP of >65 mmHg. Norepinephrine is the first choice vasopressor.

Newsletter 3 concentration of 7.0 –9.0 g/dL in adults, except in days. Goals of care and prognosis should be extenuating circumstances such as myocardial discussed with patients and families as early as ischemia, severe hypoxemia, acute hemorrhage, feasible, but no later than within 72 hours of ICU or ischemic heart disease. Fresh frozen plasma is admission, and should be incorporated into not recommended to correct laboratory clotting treatment and end-of-life care planning, utilizing abnormalities in the absence of bleeding or palliative care principles where appropriate. planned invasive procedures. Platelet transfusion is recommended prophylactically when counts Next Lisa shared nursing considerations to are <10,000/mm3 (10 x 109/L) in the absence of complement the guidelines. First and foremost apparent bleeding, or when counts are < she discussed infection prevention through 20,000/mm3 (20 x 109/L) if the patient has a education, accountability, surveillance of significant risk of bleeding. Higher platelet counts nosocomial infections, hand hygiene, and (≥50,000/mm3 [50 x 109/L]) are advised for site/device specific considerations. Prevention of active bleeding, surgery, or invasive procedure. respiratory infection includes head of bed elevation greater than 30 degrees, regular oral Blood glucose management should target an care including chlorhexidine gluconate, and upper blood glucose ≤180 mg/dL. Insulin dosing consideration of endotracheal tube (ETT) with should commence when 2 consecutive blood continuous subglottic suctioning, silver coated glucose levels are >180 mg/dL, and blood glucose ETT, and polyurethane ETT cuff. values should be monitored every 1–2 hrs until glucose values and insulin infusion rates are Prevention of central line-associated bloodstream stable and then every 4 hrs thereafter. Glucose infection (CLABSI) includes central line bundles, levels obtained with point-of-care testing of maximal sterile barriers during central line capillary blood should be interpreted with insertion, chlorhexidine for skin prep, change IV caution, as such measurements may not sets every 96 hours, and consideration of accurately estimate arterial blood or plasma antibiotic impregnated central venous catheters. glucose values. Prevention of surgical site infection (SSI) includes antibiotic administration within 1 hour of A combination of pharmacologic therapy and incision, hair removal with clippers, post-op intermittent pneumatic compression devices for glucose <200 on day 1, and identification and deep vein thrombosis prophylaxis are treatment of remote infections before elective recommended whenever possible unless surgery. Prevention of catheter-associated urinary contraindicated. Stress ulcer prophylaxis using H2 tract infection (CAUTI) includes decrease duration blocker or proton pump inhibitor is of foley catheter use, maintenance of sterile closed recommended for patients who have bleeding risk drainage system, regular perineal hygiene, and factors. When stress ulcer prophylaxis is used, maintenance of unobstructed urine flow. proton pump inhibitors are preferred. Sepsis screening tools should be utilized in all areas of the hospital for early identification and Administer oral or enteral (if necessary) feedings, diagnosis of severe sepsis. Early warning systems, as tolerated, rather than waiting 48 hours. Avoid e.g., Code Sepsis Teams, Rapid Response Teams, mandatory full caloric feeding in the first week and protocols should be used to manage patients but rather low dose feeding (e.g., up to 500 early. Nurses should be empowered to implement calories per day), advancing only as tolerated. Use resuscitation bundles. Other supportive care intravenous glucose and enteral nutrition rather includes nutrition within 24-48 hours, eye care, than total parenteral nutrition (TPN) alone or and pressure ulcer prevention. (Cont…) parenteral nutrition in conjunction with enteral feeding in the first 7

Newsletter 4 The last portion of Lisa’s presentation focused Causes of increased SvO2 include decrease in O2 on hemodynamic monitoring and tissue demand (e.g., hypothermia, neuromuscular oxygenation, and she stated, “we manage what blocking agents, sedation, sepsis), increased we monitor!” She made the case that pressure CO/CI (e.g., positive inotropic agents, afterload (e.g., CVP) does not estimate volume because reduction, fluid administration), and increased compliance is dynamic and always changing. O2 supply (increased FiO2, increased SaO2, Causes of decreased compliance include increased PaO2). When O2 demand increases, ischemia, inotropes, increased afterload, the body attempts to increase delivery. If restrictive Cardiomyopathy, increased PEEP, cardiac output increases, SvO2 may remain increased pericardial pressure, and increased unchanged. If delivery does not increase in intra-abdominal pressure. response to the increased demand, the tissues will extract a larger amount of oxygen from the When metabolic oxygen demand is greater available supply and will result in a decrease in than oxygen delivery, anaerobic metabolism SvO2. results in lactate production, metabolic To improve tissue oxygenation, maximize the 3 acidosis, and dysoxia (impaired tissue major determinants of oxygen delivery: anemia oxygenation). The universal goal of critical care - consider transfusion if Hgb <7 g/dl (*Hgb in is to maintain adequate tissue oxygenation. banked blood >14 days old has decreased O2 Mixed venous (pulmonary artery) blood is a carrying capacity); cardiac ouput – keep CI >2.4 2 good indicator of systemic oxygen delivery and L/min/m ; hypoxia – keep SaO2 >90%. Cardiac systemic oxygen uptake. Mixed venous oxygen output is equal to HR x SV (stroke volume). saturation (SvO2) is the percentage of Hgb saturated with O2 in mixed venous blood. Determinants of SV are preload (increased preload = increased SV, decreased preload = Under normal circumstances, only about 25% decreased SV), afterload (inversely of oxygen is utilized by the cells (normal SvO2 = proportional to CO, i.e., high afterload = low CO, 75%). During sepsis, mitochondria can’t utilize low afterload = high CO), and contractility available oxygen and SvO2 is elevated >80%. (increased contractility = increased SV, SvO2 <60 indicates impaired O2 delivery, SvO2 decreased contractility = decreased SV). Up to <50 indicates global tissue dysoxia. A decrease 50% of patients resuscitated from shock may in SvO2 is one of the earliest signs of problems have continued global tissue hypoxia (i.e., with tissue oxygenation, i.e., the oxygen increased lactate and decreased ScvO2 or SvO2) demand is exceeding oxygen consumption. even with the normalization of vital signs and CVP. ScvO2 is a measurement of central venous oxygenation, drawn from a central line and is an acceptable alternative to SvO2 although can differ from SvO2 by up to 10%. SvO2 may be PAD decreased due to increased O2 consumption (e.g., hyperthermia, shivering, infection, pain), The next speaker was Leanne Boehm, MSN, RN, decreased CO/CI (e.g., decreased ACNS-BC, from the ICU Delirium and Cognitive preload/increased afterload, hypovolemia, Impairment Study Group at Vanderbilt sepsis (late), MODS), decreased O2 supply (e.g., University Medical Center, Nashville, respiratory failure, suctioning, increased work Tennessee. Her first presentation was, “Pain, of breathing, decreased alveolar/arterial Agitation, and Delirium: New Guidelines for oxygenation), and nursing interventions (e.g., Critically Ill Adults.” The new guidelines were position changes, chest PT, bathing, visitors). published in 2013 with recommendations as

MVC-AACN Newsletter 5 follows. Monitor pain routinely for all adult ICU outcomes (e.g., shorter duration of mechanical patients. For patients able to self-report use the ventilation (MV) and a shorter ICU length of Numeric Rating Scale (0-10). For patients stay (LOS)). unable to self-report use the Behavioral Pain Scale (BPS) or Critical Care Pain Observation Maintaining light levels of sedation increases Tool (CPOT).i,ii ,iii They do not suggest that vital the physiologic stress response, but is not signs be used alone for pain assessment in associated with an increased incidence of adult ICU patients but rather that vital signs myocardial ischemia. The association between may be used as a cue to begin further depth of sedation and psychological stress in assessment of pain.iv these patients remains unclear. They recommend that sedative medications be Assessing pain reduces sedative/ hypnotic use titrated to maintain a light rather than a deep and is associated with improved outcomes.v level of sedation in adult ICU patients, unless Other pain management recommendations clinically contraindicated. They recommend include: preemptively treating chest tube either daily sedation interruption or a light removal with either analgesics and/or target level of sedation be routinely used in nonpharmacologic therapy; preemptively mechanically ventilated adult ICU patients.vii treating other types of procedural pain with analgesic and/or nonpharmacologic therapy; Early deep sedation is associated with longer using opioids as first-line therapy for treatment MV and reduced 6-month survival.viii Research of non-neuropathic pain; using non-opioid demonstrates a trend towards more PTSD analgesics in conjunction with opioids to symptoms with deep sedation, and no reduce opioid requirements and opioid related difference in anxiety or depression scores. side effects; using gabapentin or Light sedation patients averaged 1 day shorter carbamazepine, in addition to intravenous on MV and 1.5 days shorter LOS.ix Daily opioids, for treatment of neuropathic pain; sedation interruption decreases duration of using thoracic epidural for postoperative MV. The process is to hold sedation infusion analgesia in patients undergoing abdominal until patient awakens and then restart at 50% aortic aneurysm surgery, and thoracic epidural of the prior dose. analgesia for patients with traumatic rib fractures.vi “Awake” is defined as any 3 of the following: open eyes in response to voice, use eyes to Recommendations for Agitation/Sedation follow investigator on request, squeeze hand assessment include: depth and quality of on request, and/or stick out tongue on request. sedation should be routinely assessed in all ICU Additional outcomes include fewer diagnostic patients; the RASS and SASS are the most valid tests to assess changes in mental status, no and reliable scales; they suggest using objective increase in rate of agitated-related measures of brain function to adjunctively complications or episodes of patient-initiated monitor sedation in patients receiving device removal, and no increase in PTSD or neuromuscular blocking agents; use EEG cardiac ischemia.x,xi They suggest that monitoring either to monitor non-convulsive analgesia-first sedation be used in seizure activity in ICU patients at risk for mechanically ventilated adult ICU patients; that seizures, or to titrate electrosuppressive sedation strategies using nonbenzodiazepine medication to achieve burst suppression in ICU sedatives (either propofol or patients with elevated intracranial pressure. dexmedetomidine) may be preferred over Maintaining light levels of sedation in adult ICU sedation with benzodiazepines (either patients is associated with improved clinical midazolam or lorazepam) to improve clinical

MVC-AACN Newsletter 6 outcomes in mechanically ventilated adult ICU incidence and duration of delirium.xxiii patients; that in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidine rather than benzodiazepine infusions be administered for sedation to reduce the duration of delirium in these patients.xii

ICU delirium develops in ~2/3 of critically ill ABCDE patients, hypoactive or mixed forms are most common, and it goes undiagnosed in up to 72% Next Leanne spoke about the ABCDE Bundle, of cases. The following are associated with an which provides the first steps in creating a increased risk of delirium: benzodiazepines, framework or backdrop for implementation of extended ventilation, immobility, coma and the PAD guidelines. The ABCDE protocol is dementia.xiii Sequelae of delirium include multiple components, interdependent, and increased mortality, longer intubation time, an designed to improve collaboration among average of 10 additional days in the hospital, clinical team members, standardize care higher costs of care, development of dementia, processes break the cycle of oversedation and long-term cognitive impairment, requirement prolonged ventilation. The components of the for care in chronic care facility, and decreased ABCDE Bundle are: functional status at 6 months.xiv,xv ,xvi ,xvii ,xviii ABC – Awakening and Breathing Each day of delirium in the ICU increases the Coordination hazard of mortality by 10%.xix Duration of D – Delirium Identification and delirium was an independent predictor of Management cognitive impairment - an increase from 1 day E – Early Exercise and Mobility of delirium to 5 days was associated with nearly a 5-point decline in cognitive battery Awakening and breathing coordination scores. A patient’s testimony, provides for synergy of daily awakening and “One quite literally loses one’s grip on what is spontaneous breathing trial, and an true and what is false because the true and the opportunity for more effective independent false are mixed together in a mess of breathing. Awakening and breathing safety experience.”xx,xxi screens should be performed prior to initiating a Spontaneous Awakening Trial (SAT) and They recommend routine monitoring of Spontaneous Breathing Trial (SBT). delirium in adult ICU patients - the CAM-ICU and the ICDSC are the most valid and reliable SAT safety screen includes no active seizures, delirium monitoring tools.xxii There is no no active alcohol withdrawal, no active published evidence that treatment with agitation, no active paralytic use, no myocardial haloperidol reduces the duration of delirium in ischemia (24h), and normal intracranial adult ICU patients. Atypical antipsychotics (e.g., pressure. quetiapine, ziprasidone) may reduce the SBT safety screen includes no active agitation, duration of delirium in adult ICU patients (must oxygen saturation ≥88%, FiO2 ≤50%, PEEP ≤8 monitor QT interval). They recommend cm H2O), no myocardial ischemia (24h), normal performing early mobilization of adult ICU intracranial pressure, and no significant patients whenever feasible to reduce the vasopressor or inotrope use.xxiv

MVC-AACN Newsletter 7 delirium, and optimize non-pharmacologic If the patient fails the SAT safety screen, try strategies. Non-pharmacologic interventions again the next day; if the patient passes, include sleep preservation and enhancement, proceed with SAT - sedation cessation. Turn environmental changes (e.g., noise reduction), off/hold all sedatives (off = zero). It is sensory aids (e.g., glasses), and reorientation appropriate to continue analgesic drips in post- and cognitive stimulation. Early mobility is the surgical, trauma, or chronic pain patients. only non-pharmacologic intervention shown to Closely monitor and provide reassurance and reduce ICU delirium.xxvii See the PAD guidelines repeated explanation of the circumstances. If above for recommendations for pharmacologic the patient fails the SAT (anxiety, agitation, management of delirium. pain, respiratory rate (RR)>35/min, SpO2 <88%, respiratory distress, acute cardiac The final component is Early Exercise and arrhythmia), restart sedation at 50% previous Mobility. The benefits of exercise include dose, titrate to goal, and try again the next day. functional independence at discharge, decreased duration of delirium, decreased time If the patient passes SAT, proceed with SBT. If on ventilator, decreased LOS, decreased costs the patient passes the SBT consider extubation; and improved neurocognitive if the patient fails (RR >35/min, RR <8/min, outcomes.xxviii,xxix ,xxx ,xxxi The Early Exercise and SpO2 <88%, respiratory distress, mental status Mobility Protocol begins with passive range of change, acute cardiac arrhythmias), resume full motion (ROM) and progresses to active ROM, ventilatory support. “Wake up & Breathe” sitting/dangling, transferring to chair, resulted in less benzodiazepine use, faster marching and walking. extubation, sooner ICU and hospital discharge, and better survival at 1 year.xxv The benefits of the ABCDE Bundle include liberation from the ventilator, earlier ICU and Delirium identification and management begins hospital discharge, return to normal brain with identifying risk factors and etiology, and function, independent functional status, and nonpharmacologic prevention and increased survival.xxxii The ABCDE Bundle management. “Stop and THINK” - should any requires the collaboration of the medications be stopped or lowered, especially interdisciplinary patient care team – nursing, sedatives; use the minimal amount of sedation respiratory therapy, PT/OT, physicians and necessary – light sedation, daily sedation pharmacists. For further information and cessation; assess for pain. Use the THINK resources, see www.ICUdelirium.org and mnemonic to identify the etiology of delirium: www.aacn.org. Toxic situations (CHF, shock, dehydration, HTN, ------new organ failure (liver/kidney)); Hypoxemia, http://www.survivingsepsis.org/Bundles/Pages/default Infection/sepsis (nosocomial); Immobilization; .aspx. Accessed 5/9/14.

Nonpharmacologic interventions (sleep http://www.survivingsepsis.org/Guidelines/Documents protocols, noise control, early mobility, hearing /Hemodynamic%20Support%20Table.pdf. Accessed aids, glasses reorientation, music); K+ or 5/9/14. electrolyte problems. xxvi http://www.survivingsepsis.org/Guidelines/Documents /Other%20supportive%20therapy.pdf. Accessed Assess for delirium with a validated scale, 5/9/14. identify and reverse/treat underlying causes of

MVC-AACN Newsletter 8 Endnotes:

MVC-AACN Newsletter 9 i Barr J, et al. Crit Care Med. 2013;41:263-306. ii Payen JF, et al. Crit Care Med. 2001;29(12):2258-2263. iii Gélinas C, et al. Am J Crit Care. 2006;15:420-427. iv Barr J, et al. CritCare Med. 2013;41:263-306. v Payen JF, et al. Anesthesiology. 2009;111:1308-1316. vi Barr J, et al. Crit Care Med. 2013;41:263-306. vii Barr J, et al. Crit Care Med. 2013;41:263-306. viii ShehabiY, et al. Am J Respir Crit Care Med. 2012;186(8):724-731. ix Treggiari MM, et al. Crit Care Med. 2009;37(9):2527-2534. x Kress JP, et al. N Engl J Med. 2000;342:1471-1477. xi Needham DM, et al. Crit Care Med. 2012;40(2):502-509. xii Barr J, et al. CritCare Med. 2013;41:263-306. xiii Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233. xiv Bruno JJ, Warren ML. Crit Care Nurs Clin North Am. 2010;22(2):161-178. xv Shehabi Y, et al. Crit Care Med. 2010;38(12):2311-2318. xvi Rockwood K, et al. Age Ageing. 1999;28(6):551-556. xvii Jackson JC, et al. Neuropsychol Rev. 2004;14:87-98. xviii Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999. xix Pisani MA. Am J Respir Crit Care Med. 2009;180:1092-1097. xx Girard TD, et al. Crit Care Med. 2010;38:1513-1520. xxi Misak CJ. Am J Respir Crit Care Med. 2004;170(4):357-359. xxii Barr J, et al. CritCare Med. 2013;41:263-306. xxiii Barr J, et al. Crit Care Med. 2013;41:263-306. xxiv Girard TD, et al. Lancet. 2008;371(9607):126-134. xxv Girard et al. Lancet 2008; 371:126-134. xxvi Jacobi J, et al. Crit Care Med 2002;30:119-141. xxvii Schweickert WD, et al. Lancet. 2009;373:1874-1882. xxviii Schweickert et al 2009; 373:1874-82. xxix Chiang et al 2006; 86:1271-81. xxx Needham et al 2010; 91:536-42. xxxi Morris et al CCM 2008; 36:2238-43. xxxii Morandi A et al. Curr Opin Crit Care,2011;17:43-9.

A Review of Horizons by a New Critical Care RN! Submitted by Krista DiPietro

Horizons 2014 was especially inspiring for me; it was my first as an RN. I have been a member of AACN since I was a nursing student and attended Horizons twice while in nursing school. I currently work on an IMC unit and feel that I was able to absorb a substantial amount of information from each and every session. From listening to AACN president, Vicki Good, give the keynote address with her inspiring words, to belly laughing while attending a humor session, there wasn’t a moment I didn’t like. There was a large variety of topics this year, ranging from sepsis to heart failure updates to street drugs and many more. Most of the speakers were so engaging that the hour long sessions felt like five minutes.

Vicki Good opened the conference with a presentation focused on her motivating AACN theme, “Stepping Forward.” She explained how the first step starts with a decisive moment that leads to transforming knowledge into positive action. This action leaves a “wake” representing our character that changes and grows as we gain experience. The wake we leave can be either choppy or smooth; it’s up to us to decide what kind of wake we will leave. Being new to critical care, this really spoke to me as I begin to envision my new career path.

Kathleen Vollman will always represent what I aspire to be….a true mentor. She spoke on several topics including mouth care and ventilator acquired pneumonia and the “power of one” that each of us are in this aspect of patient care. This session really opened my eyes about how only a few minutes can prevent a patient from becoming even sicker than when they were admitted. Kathleen has such a way of presenting the evidence to empower us to act on behalf of the patients entrusted to us. I left Kathleen’s sessions feeling driven to advocate for what our patients need and deserve.

The other speaker who left an indelible mark on me was Mary Bylone. Mary spoke about how to use our “bold voice.” Her presentation, Using Your Bold Voice: The Good, The Bad and The Ugly, concentrated on the healthy work environment and how patient outcomes are influenced by it. But, she also spent some time talking about how we have to become aware of our own values, strengths and weaknesses because that’s what the core for our bold voice becomes, and that what I feel is important in my organization. It is from this foundation that we can spread the message that patient safety is our goal as critical care nurses. She really broke down how to prioritize and approach various situations; particularly with skilled communication as the means to hold ourselves and others accountable. For my bold voice to be heard I have to develop strong communication skills to get the message of patient safety out there.

Finally, Sue Goran had me in tears with her session on humor, titled “Humor: Not Just a Laughing Matter!” I was laughing uncontrollably. She explained the difference between wit…the thought-oriented experience of humor, mirth…the emotional response (joy), and laughter…the physiological response. She went on, in her own unique comedic style, to point out all of the therapeutic physical and social effects of humor, as well as the benefits to the workplace. Sue ended her session by having the audience members sing the following to the tune of “Row, Row, Row Your Boat:” “Laugh…laugh…laugh out loud, Each and every day; Chuckling… chuckling…chuckling…chuckling, Health is on the way!

The Horizons conference is a breath of fresh air, with hundreds of nurses gathering together for a few days of learning, networking and fun. I am already looking forward to Horizons 2016 in Rhode Island. If you have never attended a Horizons conference, whether you are a nursing student or a veteran nurse, you are missing out on something special. Hope to see you in 2016!

Don’t forget to mark your calendar for the upcoming MVC-AACN program on June 10 th being held at the Radisson Hotel & Suites in Chelmsford from 7:30am – 4:30pm!

Deborah Tuggle MN, APRN, CCNS, FCCM will present “Critical Care Concepts” PROGRAM DESCRIPTION : This program is designed to provide participants with a comprehensive review of a variety of critical care topics, debunk a multitude of myths, and provide an update on the latest trends in evidence-based practice and critical care guidelines. Attending dynamic nursing conferences can be inspiring and uplifting to professional morale, but the exciting information and new ideas may never make it back to the bedside where it can benefit patients and staff. The final session will discuss methods for keeping up momentum and motivating others towards change. This program is intended for nurses at all levels and in every acute setting.

LEARNING OBJECTIVES: At the completion of this seminar the learner will be able to: Discuss the 4 steps of oxygenation. For each step, describe clinical measures, barriers to achieving and therapeutic interventions. Review the fluid compartments and fluid dynamics of the body. Discuss past and current methods for assessing preload and fluid responsiveness. Describe the effects of hypo, iso, and hypertonic fluids on the 3 fluid compartments. Review current recommendations for fluid maintenance and fluid resuscitation. Discuss the risk factors and clinical findings of DVT and PE including as seen in the ventilated patient. Review the pros and cons of various diagnostic tests used in diagnosing DVT & PE. Describe preventives therapy and management of DVT & PE in the critical care setting. Describe common misconceptions about the meaning of arterial blood pressure readings. Discuss how the blood pressure formula can be used to troubleshoot causes of hypotension. Review better measures and better support strategies for perfusion than those conventionally employed. Describe three techniques for turning other nurses on to the information you have obtained. Review 5 ways to raise the bar and cultivate a culture of evidence-based practice in your unit.

SCHEDULE: 7:30 – Registration/Continental Breakfast 8:00 – Oxygenation: Debunking Myths & Safeguarding Tissues 9:30 - BREAK 10:00 - The Sea Within: Fluid Replacement Therapy 11:15 – LUNCH (buffet lunch included) 12:15 - Pulmonary Emboli: The Silent Killer 1:30 - BREAK 1:45 - Hypotension & Shock: The Truth About Blood Pressure 2:45 - BREAK 3:00 - Take Your Knowledge And Run 4:15 – Evaluation

CONTACT HOURS: The American Association of Critical-Care Nurses is approved by the California Board of Registered Nursing, Provider Number 01036. This program has been approved for 7.50 Contact Hours, Synergy CERP Category A, File Number 00018749.

ABOUT THE SPEAKER: Deborah Tuggle, MN, APRN, CCNS, FCCM is a Clinical Nurse Specialist with over 35 years of experience in critical care. She is a published author, national speaker and chapter leader in the American Association of Critical Care Nurses (AACN) and an active committee member of the National Association of Clinical Nurse Specialists (NACNS). She is also a committee leader, Paragon Coach, and two-time Presidential Citation winner for the Society of Critical Care Medicine (SCCM). As founder of the continuing education and consultation company, Critical Care Curriculum, Deb has been instrumental in enriching patient care at hospitals around the country. She has a passionate commitment to life- long learning and a reputation for developing quality courses that are both evidence-based and patient-oriented. In addition, to cutting-edge and pragmatic content, her dynamic style and sense of humor keeps audiences engaged, entertained and motivated to improve their care. Deb's courses promote many best practice initiatives including AACN Practice Alerts, Surviving Sepsis Campaign interventions, ihi infection prevention bundles, Joint Commission's National Patient Safety Goals, and many more. She has developed learning opportunities for nurses, physicians, respiratory therapist, and other ancillary staff including ECG and hemodynamic monitoring accuracy, successful rescue responses, optimal ventilator management, collaborative communication skills, and healthy work environments. Her consultation with hospitals on critical care competency has brought them in alignment with AACN expectations and promoted greater confidence and attainment of CCRN and PCCN credentials. Deb is a graduate of the University of Kentucky and the University of Washington Schools of Nursing and employed as a Critical Care CNS at Norton Women's Hospital in Louisville, KY.

FOR MORE INFORMATION: Diane Meagher 978-455-4167 or Email: [email protected]

Thank you to all who participated in the Chapter Tastefully Simple Fundraiser in support of “Cardiac Quest” - (three 7th grade girls raising money to place AEDs on local playing fields and parks). The girls have placed 3 AEDs in the past year and have plans for 2 more with help from our Chapter! $120 was raised for this worthwhile cause! Thank you! 2014 Chapter Board Members:

Chrissy Cebollero will be finishing up her year as President as of June 30, 2014. Michele Woonton will become the new Chapter President as of July 1, 2014. Sue Wheeler is the President-Elect and she will be taking over in July 2015! Sue Sadowski – Scholarship chairperson Linda McGowan and Doris Barreiro - newly appointed to Scholarship committee Diane Meagher – Programs Ellen Stokinger – Membership Chrissy Cebollero – Webmaster Eileen Scondras – past President Sue Ouellette – secretary Dianne Forsyth – treasurer Valerie Fernald - publications

If you would like to find out about how to become more involved in the Chapter please reach out to any board member.

Go to the www.AACN.org website and at the bottom of the page click on “Chapters”. Next click on Massachusetts, Merrimack Valley, and e-mail a chapter officer”, or simply click here: http://www.aacn.org/dm/Chapters/EmailOfficers.aspx?mid=2874

Photo Gallery Chapter Christmas Dinner at Cobblestones – Dec 2013

One of the 2013 Chapter Scholarship winners, Rebecca Order, with Sue Sadowski RN at the Transitions dinner in June 2013

2014 Scholarship winners are Thomas Coye from Georgetown, going to Salem State College and Devinne Healy from Dracut High, going to Rivier College. Chapter member Maureen McLaughlin presenting at NTI 2014

Horizons 2014 Portland, ME – out on the town

Horizons attendees enjoying the city of Portland after classes

HORIZONS 2014 in Portland, ME was a fun, well-attended learning event for critical care RN’s from New England and beyond. The Horizons planning committee works on this bi-annual event to make sure it is a worthwhile and fun time for all who attend.

Merrimack Valley Chapter member Laura Pruyn won the Nancy Houle Continuing Education Scholarship - a full three-day paid scholarship to attend this Horizons – Congratulations Laura!

The next Horizons is in 2016 and will be held in Providence, Rhode Island. Plan ahead to attend in April 2016!

If you would like to apply for the Nancy Houle scholarship for Horizons 2016 go to the website: www.Horizons2014.org.