Withdrawal of Life Sustaining Treatment

I am delighted to introduce guest blogger, Ruth Trinier, CACCN Treasurer to share information about the Critical Care Canada Forum held in Toronto from November 9 to 12, 2013.

Teddie Tanguay
CACCN President
________________________________________________________

Every year the Critical Care Canada Forum in Toronto offers professionals an opportunity to attend informative and interactive sessions focusing on the care of critically ill patients. The three-day conference, hosted by an international faculty, presents leading-edge science, research, practice innovations, products and services. Again this year, members of the Canadian Association of Critical Care Nurses, including members of the Board of Directors, attended the conference in addition to participating in the curriculum and some special meetings.

Of the many excellent sessions, we would like to report on two that we considered particularly relevant to members of CACCN.

In September, the National Board of Directors received an invitation to participate in a consensus meeting for the development of a Canadian document to guide health care providers on the procedure of withdrawal of life-sustaining treatment. The meeting, arranged by doctors Lisa Kenny, James Downar, Jesse Delaney and Laura Hawryluck of the Canadian Critical Care Society, was to be held during the CCCF. CACCN members attending the Forum were asked to participate in order that the unique knowledge and perspective of nurses was an active part of the evolving document.

The goal of the project is to develop interprofessional consensus guidelines including preparation of patients and families, symptom control, withdrawing specific therapies, and supporting family members and the healthcare team throughout the process. The end product will be a report entitled “The Canadian Critical Care Society’s Guidelines on the Procedure of Withdrawal of Life-Sustaining Therapy”.

After a brief overview of the literature, the law, and ethics in this area, participants met in one of four working groups:

  1. Preparation and support for patients, substitute decision makers / families and the health care team throughout the procedure of withdrawal of life support.
  2. Pharmaceutical management of distress.
  3. Assessment of distress.
  4. Withdrawal of life-sustaining therapies.

Some groups were unable to complete their work in the limited time available, and the large group was not able to reconvene as planned at the end of the session. It is anticipated that the work of this group will continue into the new year.

The Board of Directors would like to thank the following CACCN members for providing their time and expertise to this important initiative:

The second session that we would like to report on, “Obligations for End-of-Life (EOL) Care in ICU as of November 2013” concerned the implications from the decision of the Supreme Court of Canada in the case of Mr. Hassan Rasouli v. Sunnybrook Health Sciences Centre, Dr. Brian Cuthbertson and Dr. Gordon Rubenfeld, for which CACCN had been granted intervener status. (For information on CACCN’s role in this action please see CACCN Media.

The session, moderated by doctors Peter Cox and Brian Kavanagh, included an overview of the case by Dr. Stephen Lapinsky and the legal team of Erica Baron and Andrew McCutcheon. Dr. Andrew Baker presented an overview of the possible implications of the decision. This was followed by clarification by the legal team, questions from the audience, as well as suggestions for moving forward.

Some of the points made included:

  1. The majority of EOL situations will continue without controversy as they do now.
  2. It is not yet clear what the ruling will mean – it will take further cases/discussion.
  3. It is not yet clear what the ruling will mean outside of Ontario where there is no Consent and Capacity Board.
  4. In most instances, the decision will not make things materially different than what is being done now.
  5. Clear notes should be written noting that consent has been sought for withdrawal at EOL.
  6. Legally, informed consent needs to be obtained, but practically assent is likely acceptable in those cases where a SDM agrees with the decision but is unable to make it themselves (for whatever reason).
  7. It is likely a good idea to obtain a signature for consent.
  8. Because writing a DNR order does not involve touching the patient, it is likely that it does not require consent, however, there was no suggestion that not requesting consent would be the best route to follow. There are cases currently before the Canadian courts addressing the need for consent for a DNR order.
  9. The SDM has to be “rational”, i.e.: the argument of “I believe in miracles” is not rational, however, a confirmed religious belief of “life at all costs” may be valid.
  10. Consent for terminating CPR is not needed in the case of an unsuccessful code – it was felt that no court would uphold such a request, as it would be considered ridiculous.
  11. This case was not taken to the Consent and Capacity Board as it was felt that it was not a question of consent, it was felt to be a question of the meaning of treatment (further information concerning the reason this case was brought forward can be found on the Sunnybrook Hospital website.

Suggestions for the future included:

  1. Seeking legal consultation early in any situations that might be similar to the Rasouli case and forwarding it to the Consent and Capacity Board if the situation arises in Ontario.
  2. Sending all cases in Ontario to the Consent and Capacity Board to force clarification of the role of the CCB. This was seen to be impractical due to the impact of the delay in those situations that do not require the board.
  3. Going to law review to have the law clarified. This was seen as impractical as it would require agreement among all Canadian physicians.

We will continue to represent you, our members, as organizations across Canada look to CACCN as the “Voice for excellence in Canadian Critical Care Nursing”. Your comments, suggestions and feedback for all issues that are relevant to you will facilitate that representation.

Speaking with Conviction!

Ruth Trinier
CACCN Director/Treasurer

“Just a Nurse”??

I recently read a column entitled ”Don’t Call Me Just a Nurse”. The focus of this essay was the need for nurses to remove “I’m just a nurse” out of our collective vocabulary. This struck a cord with me as over my career I have too often used this phrase myself. When I reflect on the times when I have used  this  terminology  to describe my role and my contributions  to patient care it is typically when I have felt frustration at not being able to influence on behalf of my  patient. More often then not it was said with sarcasm – perhaps aimed a bit at myself and also indiscriminately at others or a ‘system’, which I felt, was limiting my contributions.

The public and even our families have limited understanding of exactly what critical care nurses do. It gives me pause to wonder how exactly the public could come to know and value our contributions better? “I’m just the nurse”  is not enough to uncover the truth and scope  of exactly how critical care nurses  assist  the most fragile of patients, contribute to scientific advancements and influence  health care in our hospitals.  Sometimes I fear, even health administrators and governments don’t understand the role of the nurse and the importance of having them provide care.

Nurses are essential to the safe monitoring of patients, the management of complex supportive technologies like ventilation, titrating life sustaining mediation infusions and all the while ensuring the essence of the person is respected and nurtured during these most venerable times. Over the course of a 12 hour shift, a critical care nurse will constantly monitor vital signs, interpret diagnostic test results, administer medications and provide comfort and support to the patient and their family. Nurses are  ever evaluating and adapting plans of care as the work alongside a diverse group of colleagues  to ensure the best outcomes possible for each and every patient. Nurses is the sole care provider that is constantly present with the patient and as such nurses are the first ones to notice critical changes and respond to ensure the patient receives the care they require.  We are the ultimate continuous improvement system.

To quote the author of the column

“I am the eyes, hands and feet of the physician. I am not their eye candy, or their inferior. I don’t stand up when they enter the room. I don’t just follow orders, I discuss the pathophysiology of the patient’s condition with them and together we make a plan. Often the things I suggest are the course of action we take, other times I learn something new I had not understood from this doctor. They don’t talk down to me, we discuss things together.”

Critical care nursing is rewarding, challenging and privileges nurses to make a direct difference in our patient’s life.  We have our unique science and evidence from which we act; we complement the roles and expertise of our medical and allied health colleagues. The sum of all of is is greater then the reduced individual parts.

No one group is better placed than nurses to share a more accurate portrait of our work and expertise: it is time that we speak about what our role is in caring for patients.

Let’s begin with our families.  Make sure they understand what a critical care nurse does, how you are an integral part of the health care team that provides life support when patients are at the sickest and most vulnerable. Let’s make sure that we articulate who we are clearly and how we impact our patient’s and their families.

Thankfully as I became more aware of the impact of what it is we say about ourselves – as well as what I do, I have been better able to articulate my work and my science.  I have made a commitment to stop using the phrase ‘Just a nurse’.  I ask that all of you strive to do the same. Let’s speak with conviction and educate our family on friends on the true  impact of a critical care nurses.

Take care and speak with conviction.

Teddie Tanguay
President, CACCN 

Don’t Call Me Just a Nurse: Kateri Allard, Huffington Post
http://www.huffingtonpost.com/kateri-allard/just-a-nurse_b_3881551.html

World Sepsis Day – September 13, 2013

Today is World Sepsis Day!   The Canadian Association of Critical Care Nurses  (CACCN) is asking CACCN members and all healthcare professionals to approach your institution/organization for support for World Sepsis Day on September 13,  2013.  

World Sepsis Day is an initiative from the Global Sepsis Alliance and its founding members, the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM), the World Federation of Intensive and Critical Care Societies (WFPICCS), the World Federation of Critical Care Nurses (WFCCN), the International Sepsis Forum (ISF) and the Sepsis Alliance (SA).  So far, over 180 national and international societies and non-profit organizations, 1,300 hospitals, and over 1500 healthcare professionals are supporting World Sepsis Day.

The message is simplesepsis must receive the utmost priority as a medical emergency, so that all patients can expect to receive basic interventions, including antibiotics and intravenous fluids, within the first hour.

Watch videos from around the world: WFPICCS and World Sepsis Day, Cali, Columbia

Register your support and encourage your employer to register to raise the profile of sepsis with the World Health Organization! 

Online Registration: www.world-sepsis-day.org/register

Show your support…
Comment on here on the blog
or
the CACCN Facebook page
or
Twitter #worldsepsis when you have registered.

Financial Responsibility…it’s a matter of dollars and ‘sense’…

I hope everyone is enjoying their summer thus far.  On behalf of the CACCN Board of Directors, we send our thoughts to our colleagues and friends in Calgary, AB who are experiencing extreme flooding and to those in Lac-Megantic, QC, who are experiencing the devastation caused by the train derailment.  Our thoughts are with everyone through these terrible events.

Before turning the blog over to my next guest blogger, I would like to mention the following items:

  1. Dynamics of Critical Care Conference:
    a. Preconference – plan to attend one of the three topics being offered at the preconference day!  Registration rates are $130 members; $230 non-members for a full day of education plus breaks/lunch! 
    b. Conference -  Early Bird Registration Deadline is August 16, 2013!  Save by registering now!
    c. Hotel Accommodation – book now as the room block often sells out – room block rates are available until August 19, 2013!
  2. CACCN Canadian ICU Week Spotlight Challenge – don’t miss your opportunity to win $ 450.00 to hold an event in your unit during Canadian ICU Week – October 27 to November 2, 2013!  Deadline for submissions is August 15, 2013. More information.
  3. Stop Sepsis, Save Lives:  World Sepsis Day – September 13, 2013 – please Speak with Conviction in support of increasing awareness of sepsis around the world. 

I am fortunate as President of CACCN to have a highly skilled team of Directors.  Each of these Board members is responsible for a specific portfolio and also is the chairperson on a number of committees that work towards furthering the goals of CACCN and critical care nursing.   I am delighted to introduce guest blogger, Ruth Trinier, Director/National Treasurer to engage you in a discussion about … Financial/Fiscal Responsibility.

Teddie Tanguay
CACCN President
________________________________________________________
As the National Treasurer of Canadian Association of Critical Care Nurses (CACCN), one of my responsibilities is to process the cheques and credit card notifications that come in to our office in payment for membership to our organization. With each payment I process, I appreciate that you have chosen to entrust me, and the other members of your National Board of Directors, to ensure value for your investment.

We, as members of the Board of Directors and representatives of our membership body, are committed to promoting and participating in activities that reflect the vision and mission of CACCN. At the same time, we must ensure that the organization remains fiscally sustainable. The Board meets several times each year, at which time decisions are made on your behalf. Sometimes these decisions are difficult, requiring a thorough review of the financial position of the organization and the potential liabilities that are implicit in the decisions that we make. I can assure you of the diligence of the entire Board of Directors as we look to set an annual budget that is affordable, sustainable, and responsible, while we maintain or initiate those activities that have been identified through membership feedback as important. We encourage you to include your voice in our decisions through that feedback.

The majority of Board communication is either electronic or via teleconference. We meet face-to-face annually in the spring and fall. This year, as we looked to make positive financial changes, we realized a significant savings in holding the spring meeting in Toronto rather than in the traditional location of our head office in London. Holding the meeting in the vicinity of the airport in Toronto allowed those travelling from out of town to fly directly to the meeting, removing the additional flight from Toronto to London and the associated costs.

Additionally during this meeting, we re-affirmed financial prudence as a predominant factor when arranging for accommodations for board members as they travelled on CACCN business. We reviewed the balance of cost and quality with plans to maintain and update the technology that we use to communicate and serve our members and we discussed new or special projects that we anticipate will enhance the membership experience. It’s a careful consideration between providing as many services as possible and maintaining a balanced budget.

To protect the organization from a financial collapse, funds that would cover operating costs for a period of three years are held in Guaranteed Investment Certificates. In recognition of price inflation, we directed an additional $10,000.00 to this secure form of savings and investment.

Each year, MacNeill Edmundson Professional Corporation of Chartered Accountants, at 82 Wellington Street, London, Ontario, completes a financial audit of the Association’s business. A complete report of the financial audit is made available for members to review at least thirty (30) days prior to the Annual General Meeting, held each year in conjunction with the Dynamics conference in September. Review of the audit, allows for our members to prepare to raise questions and participate in discussion when I present the association’s financial report during the meeting. For those members with questions or concerns at any time throughout the year or for those who are unable to attend the meeting, we encourage you to contact either myself at treasurer@caccn.ca or any other member of the National Board of Directors through the CACCN National Office at caccn@caccn.ca.

Sincerely,

Ruth Trinier
Treasurer – CACCN

Image 1:  http://www.colourbox.com/preview/3507070-522286-dollar-signs.jpg
Image 2:  http://www.sterling-il.gov/photos/AuditAssurance1.jpg 

CACCN Mentorship

As President of CACCN I am fortunate to work with a highly skilled team of directors. They are all responsible for a variety of porfolios and committees that further the goals of CACCN. For this reason I have asked some of them to be guest bloggers to share with you some of their exciting projects.

I am delighted to introduce my first guest Karen Dryden-Palmer, Vice President of CACCN.

Teddie Tanguay
CACCN President
_______________________________________________________

I would like to begin by saying what a privilege it is to be able to address you as members through such a relaxed and direct way. We are so very fortunate that technology is available for us to connect across vast geographical regions linking all of the varied and rich practice contexts represented in our organization. This is one of the reasons the Board of Directors is so excited by the opportunities present through electronic mentorship for our members.

The CACCN Mentorship Program was launched a few short weeks ago and has inspired a number of questions and applications.  I hope to address some of the more common questions through this blog and information is available for you at anytime on the web site.

The CACCN Mentorship Program is open to all active CACCN members who are interested in advancing their careers, knowledge base or professional affiliations in the specialty of Critical Care Nursing.

Participants enter into a voluntary relationship facilitated via the CACCN online discussion forum. Mentees choose to apply to ‘rooms’ (discussion threads in the forum) based on their objectives and their interest in the discussion taking place.

The Mentors are all volunteers who are recognized as nurse leaders, and content experts. Mentors are willing to engage on-line with the participant Mentees in order to assist them in meeting their learning and/or developmental goals.

The CACCN Mentorship Program was developed in response to a 2010 survey of a representative group of CACCN members and feedback from a focus group session carried out at Dynamics that same year. Members spoke clearly that they wished access to mentor relationships. Although face to face style mentoring was preferred an on-line option was also of interest. Members were keen to participate as both mentees and mentors and by preferenced these preferred these relationships to be created outside of their work connections. Identified topics of interest were primarily education based and far reaching including: research, rapid response teams, advanced practice, end of life care, entrepreneurship, publication skills, new graduate integration and late career nursing.

To launch the CACCN Mentorship Program, we have opened up two specific topic rooms. The first, Writing for Publication, is mentored by Dr. Paula Price. Paula brings vast expertise to her role as Mentor, as our Editor for Dynamics: Journal of the CACCN and in the domains of education. Dr. Price’s status as a national nursing leader and her sincere commitment to developing others has lead to this mentor room being completely filled in the first week.

Our second room, Building Professional Presentation Skills, is ready to go live in the very near future Eugene Mondor is the Mentor for this room. Many of you are familiar with Eugene’s fabulous and dynamic presentations and we are thrilled to have him providing mentorship in this area for our members. Eugene brings his enthusiasm and extensive background in education, as well as his presentation experience to his role as Mentor.

The goals of the CACCN Mentorship Program are;

  • To provide an accessible and useful mentorship to our CACCN members;
  • To promote the development of mentorship skills through the education and support of mentors and mentees;
  • To provide a nationally accessible strategy for advancing individuals and specialty knowledge within the context of the CACCN mission and objectives.

I hope you each take the time to look though the information on the CACCN web site about our Mentorship Program.

If you have any questions, suggestions or ideas for rooms you are interested in or wish to apply as Mentor or Mentee please do not hesitate to contact us. It is our plan to evaluate the program in six months and will share our findings with you at that time.

“Learning is finding out what you already know. Doing is demonstrating that you know it. Teaching is reminding others that they know just as well as you. You are all learners, doers, and teachers.”

Karen Dryden-Palmer
CACCN Vice-President

Bach, R. (1977). Illusions: The adventures of a reluctant messiah. New York: Dell Publishing Co., Inc.

CACCN Mentorship Program

* image from:  http://careerocity.com/featured/career-mentorship/

CACCN Online Community…

I have been following the discussion on the CACCN Member’s Only Forum regarding rapid response teams (RRTs) with great interest especially since my own unit has just implemented a rapid response team. What strikes me about this forum thread is the open sharing of successes, challenges and best practices with rapid response teams between discussion participants.

The experiences shared have had many similarities in goals, barriers and the impact of their team. However each team has customized how they function to fit their institution. Whether it is the profile of team members i.e. RN/RT led or MD/RN each of these creative solutions fit the unique context of each hospital thus maximizing their success.

With our forum serving as the vehicle for sharing amongst our critical care nuring community, our members have a fabulous opportunity to connect with rapid response teams across the nation. Just by reading the postings or posting questions yourself, we can learn from each other and new ideas can take root.

Our promise to you as an executive is to find ways to support more informed practice and improve care for our patients. An excellent example of the power of CACCN membership is found in this discussion thread. I know when I read your conversations on the forum I learn new perspectives, approaches and ways of achieving best care. The opportunity to reflect on my own practice is invaluable. I encourage you all to do the same. Sometime it can be intimidating to take the chance to respond or maybe the technology is unfamiliar. Please be assured that any contribution to this shared community is valuable and well worth the effort.. Certainly, the more you utilize the forum platform the easier and more comfortable it becomes. Remember that you can always email caccn@caccn.ca if you are really having trouble posting your reply.

I know that a large majority of our membership work in Critical Care Units that house rapid response teams as part of their service profile; take a minute and join the conversation and share creative solutions to some of the barriers that you encountered on your journey in implementing Rapid response teams. Networking on the forum regarding critical care practice strengthens us as a CACCN community. There are many topic areas that you could share your practice or questions about practice so take this opportunity to speak with conviction.

Take care and Speak with Conviction.

Teddie Tanguay
CACCN President

Thank you to the Rapid Response Team at the Royal Alexandra Hospital in Edmonton, AB for sharing their team photos.

Links:
CACCN Website
CACCN Members Only:  RRTs Discussion

CACCN Membership

 

Canadian Intensive Care Week

The Intensive Care Team – there for YOU in critical moments

I have just returned from another successful CACCN Dynamics of Critical Care Conference. Dynamics was held at the Westin Bayshore Vancouver in Vancouver, BC and was a wonderful opportunity to network with many colleagues from across the country. The Board of Directors was happy to welcome many new members to CACCN and we are sure you will enjoy the benefits of being a member for many years to come.

The conference program was well rounded with many exceptional presentations by critical care nurses from across the country. We were very happy to welcome Mary Stahl, Immediate Past President of the AACN to Dynamics this year. Mary presented with Kate Mahon, Past President of CACCN in a plenary session highlighting how involvement in your professional association can enhance your leadership and communication skills and how these skills not only help your career but your personal life as well.

With Dynamics 2012 complete, CACCN is now focusing on Canadian Intensive Care Week. Canadian Intensive Care Week was originally proclaimed in 2002, led by the Canadian Intensive Care Foundation. This week was celebrated for 2 years before the idea lost momentum. The National Board of Directors of CACCN felt that reviving this week would help to raise the profile of Critical Care to the public and government.

CACCN has been the catalyst in bringing together the Canadian Society of Respiratory Therapists, the Canadian Critical Care Society, the Critical Care Trials Group and the Canadian Intensive Care Foundation to collaborate in the planning and celebration of Canadian Intensive Care Week.

Canadian Intensive Care Week will be celebrated October 29 to November 4, 2012. The theme for the week is “The Intensive Care Team – there for YOU in critical moments”. During this celebratory week we will be highlighting the importance that teamwork in the ICU plays in improving patient outcomes.

I challenge all of you to Speak with Conviction during Canadian Intensive Care Week and I ask you to take the initiative to plan an activity at your hospital to raise awareness of Intensive Care.

I am very interested in hearing your plans for Canadian Intensive Care Week. Please share this information with me here on the CACCN President’s Blog, our FaceBook Page, Twitter or by emailing caccn@caccn.ca.

Teddie Tanguay
CACCN President

Download the poster –  visit CACCN Media 

Critical Care Nursing…more than “just doing my job”…

CACCN has partnered with The DAISY Foundation, a program that recognizes nurses who provide not only excellent clinical skill but incredible compassion and empathy to their patients and families.

When speaking with the founders of The DAISY Foundation, Bonnie and Mark Barnes at AACN/NTI, they expressed their gratitude for the care that nurses provided to their son Patrick during his illness and stay in the ICU. They also described how modest nursing is when being thanked by their family for the care they provided to their loved on. On reflection Bonnie and Mark are correct. When someone mentions to us how much they appreciate the support and care that we are providing we usually say “it is nothing”, “just doing my job” and other clichés. To us it is ‘nothing’, but to the patients and families, it means the world.

The Daisy Foundation at AACN/NTI

Recently some of my friends and colleagues have been on the family side of the critical care unit. For those of us that have been on this side of the ICU, we know that it is very different from what we experience working in the unit. It is at these times we truly realize how much the patient and families value the compassion and empathy. We also begin to realize how important it is to ensure that the family feels part of the care that is being provided to their loved one.

One friend shared that the care their family member received was excellent in every way. However they indicated they didn’t actually feel like part of the care until the decision to withdraw treatment had been made. Up to that point there were times they felt that they were in the way of the health care team. This was certainly not deliberate on the part of the team, and as a nurse she was able to provide an explanation to the rest of the family. As her loved one had a head injury the medical team was trying to minimize stimulation to help decrease ICP, however imagine if this family had not had a nurse to explain this to them.

Would the feeling of being an intruder or outsider been what they would have been left with from their experience in the ICU?

It is by sharing our experiences of what it is like to be the family that we have an opportunity to improve the care that we provide to not only our patients but to their families as well.

The DAISY Foundation awards recognize nurses who deliver exceptional compassionate care to patients and families. Please take a moment to share your personal stories about exceptional nurses who have made the road easier for families in ICU and please consider bringing this wonderful program to your hospital..

Take care and speak with conviction.

Teddie Tanguay
President
_________________________________________________________

Visit The DAISY Foundation booth at Dynamics 2012 in Vancouver!

CACCN: The DAISY Foundation

The DAISY Foundation

Professional “R” and “R”…

In a continuation of my last blog on rejuvenation and renewal I want to share a bit about the inspirational experiences of this last week at the American Association of Critical-Care Nurses annual National Teaching Institute and Critical Care Exposition conference in Orlando, Florida.

Attending this impressive gathering of North America’s critical care nurses and premier nurse leaders in our specialty provided excellent opportunities for expanding knowledge, networking with our American colleagues, reconecting to Canadian nurses working in the United States, meeting with Canadian nurses attending the conference and focusing efforts together with my fellow CACCN board members on building our organization. The sessions presented by critical care nurses from not only the United States, but also Canada, provided attendees with exposure to new innovations and evidence in critical care nursing. While attending sessions I was reflecting on the new ideas and advances to our craft and I am inspired to implement improvements to care and patient outcomes.

CACCN / AACN Partnership

NTI is not just about the educational sessions. Your CACCN executive was pleased to connect further with the Executive of the AACNextending our collaboration and building our partnership in critical care nursing leadership. At this meeting we focused on topics common to both organizations; membership connection and enhancing organizational success. For this our second meeting with our AACN friends we spoke further about our respective president’s themes. Both echo the importance of the critical care nurse voice and perspective in forwarding health care in both our countries. The CACCN has already experienced benefits form this new partnership with the AACN shared marketing of our respective conferences in our national journals has resulted in new American members to our association, as well as an increase in the number of abstracts from American nurses for the Dynamics conference in Vancouver, this coming September. The AACN, has enjoyed an increase in Canadian participation in the NTI program this year.

Canadian Award Recipients

Pam Hruska, Clinical Nurse Specialist from Calgary, Alberta accepted the ICU Design Award Citation from the AACN, the Society of Critical Care Medicine and the American Institute of Architects on behalf of Foothills Medical Centre for the design of the new Intensive Care Unit at the centre.

The Carlo & Angela Baldassara & Family Cardiovascular ICU, University Health Network-Toronto General Hospital received a gold level Beacon Award for Excellence in sustained performance and patient outcomes.

CACCN congratulates Foothills Medical Centre and the Carlo & Angela Baldassara & Family Cardiovascular ICU on their accomplishments!

The DAISY Award Program received the GE Healthcare-AACN Pioneering Spirit Award at the conference. The CACCN Executive was fortunate to meet the founders of the DAISY Foundation, Bonnie and Mark Barnes, as well as Peter Maher, CFO at the NTI conference. We were truly inspired by their story and strength to give back following the passing of their son Patrick in 1999 from auto-immune disease, ITP (idiopathic thrombocytopenia Purpura).  The DAISY Award program offers meaningful recognition for nurses in the United States, Canada and abroad.  We have noted the following Canadian hospitals participate in the DAISY Award program:

  • Hospital for Sick Children (Toronto, ON)
  • Leamington District Memorial Hospital (Leamington, ON)
  • Lennox and Addington County General Hospital (Napanee, ON)
  • Toronto General Hospital (Toronto, ON)
  • Windsor Regional Hospital (Windsor, ON), and
  • Alberta Health Services – Heme/BMT (Alberta, Canada)

CACCN will be partnering with the DAISY Foundation in the coming months with the intent to expand this wonderful recognition program for critical care nurses in Canada. Stay tuned for more information on how your hospital can participate!

Presentations by CACCN Members

Kate Mahon, immediate Past President of CACCN, from White’s Lake, NS presented “I Am a Critical Care Nurse: A celebration of the Joys of Caring for Critically Ill Patients and Their Families”. The focus of the presentation was to celebrate being a critical care nurse. Kate’s presentation also encouraged nurses to reflect on their own clinical practice, to recall and relive the joys of caring for critically ill patients and their families, as well as providing ways for critical care nurses to maintain their personal resilience by finding ways to nurture their hearts, spirits and souls.

Kara and Daniel Livy, of Edmonton, AB presented two sessions titled, “Beyond Grays Anatomy: Improving Procedural Competency Through the Clinical Application of Anatomy”. Kara and Dan’s presentation took the attendees on a guided visual anatomical tour through a patient’s body during invasive procedures. The “tour” was instrumental in enhancing participants’ knowledge of surface, gross, and radiologic anatomy while improving the ability to perform these advanced procedures safely and skillfully. When speaking to an American nurse practitioner who attended, she commented on the excellence of the presentation and how the knowledge gained would improve her ability to perform procedures on her patients thus improving her care.

Eugene Mondor of Edmonton, AB presented at NTI for the second year in a row. Eugene offered two presentations: “Gut Wrenching and Stomach Churning: Gastrointestinal Emergencies in Critical Care” and “Symptoms and Seizures, Surgery and Survival: The Anatomy of Acute Traumatic Brain Injury”. Eugene’s presentation on GI emergencies in critical care focused on the role of the critical care nurse in the immediate assessment and management of ruptured esophageal varices, acute pancreatitis, hepatic failure, intestinal ileus, ischemia, infarction, and abdominal compartment syndrome using interactive case scenarios. His TBI presentation offered insight into the role of the critical care nurse in maintaining hemodynamic stability, preventing complications, and supporting both patient and family through this unpredictable journey, using several interactive case scenarios to facilitate the application of evidence-based knowledge regarding TBI to clinical situations. While attending Eugene’s presentation on TBI, I was proud to say I was his colleague, when hearing many delegates tell him how beneficial they found the presentation and how it would help them improve care to their trauma patients.

I am proud of my Canadian colleagues who went to NTI to speak with conviction to improve care to all critically ill patients. I return from NTI with many new ideas to improve care to my patients and re-energized to continue striving for excellence in care.

My vacation in April was a personal rejuvenation and renewal; NTI was my professional rejuvenation and renewal

Take care

 Teddie Tanguay

What we “DO” needs to be heard! ~ Find Your Voice

As this blog goes live I am making my way to London, Ontario to participate in my final meeting as President of the Canadian Association of Critical Care Nurses Board of Directors (BOD). As such the “current” BOD will finish up business in an all day meeting on the first day while we handover and orientate the new board members taking over the various portfolios and then I and Joanne Baird will leave the next day as we conclude our terms. The Board will continue to meet with new President Teddie Tanguay as she leads a further two days of planning meetings. The three days of meetings at this time of year allow the planning work of the BOD to be efficient and supplements our other teleconference meetings throughout the year.

It has been a great five years for me on the Board of Directors and in the last two years as President I have come to appreciate how much energy there is in critical care nurses across the country. What I want to see is that same energy beginning to transform into nurses speaking up and speaking about what you do. As I write my last blog for CACCN, I would like to reflect on the President’s theme that I chose for my term of “Find Your Voice!” I chose this theme because I truly believe that the work that we “do” in critical care needs to be made visible by speaking about what we “do” every chance we can get.

Personally I am tired of the “guardian angel” theme that you hear so often when people describe nurses. Caring is a very positive virtue for nursing (and angels too!) but it is not all we “do.” In many of my blogs I have spoken about the caring aspect of nursing as an essential component of the therapeutic relationship we have with patients and their families, but equally important is the knowledge we acquire that enables us to diagnose what is happening with our patient and the technical abilities we must master to keep them alive. There will always be people who require acute care and intensive care and it concerns me that the focus of acute care hospitals continues to shift the emphasis (and resources) away from what is required to look after really sick people in the name of promoting primary health initiatives. It almost stigmatizes those that become acutely or critically ill, implying that they could have prevented an illness or injury and sadly it can minimize the contribution of Registered Nurses (RN’s) in making really sick people well again.

In the ICU we know what we have to “do” to make this a reality and it is those kinds of things that I think we need to speak about more often to ensure the full image of nursing is appreciated by the public and by those who determine resource allocation for services. I very much believe in primary health and injury prevention strategies, but it must also be recognized that people get sick…really sick and they should not bear any blame in that regard and it takes expert and knowledgeable nurses to look after them when they end up in an intensive care unit to make them well again or to allow them to die a peaceful death.

Across the country the role of the Registered Nurse is being challenged to describe it in terms of a cost/benefit analysis at these times of fiscal restraint. Can we afford the care that RN’s provide in the same numbers we have in the past? This question remains in spite of the abundance of research evidence that demonstrates repeatedly that patient outcomes are better and overall costs are less through reduced lengths of stays and decreased complication rates in those units and hospitals with a higher ratio of RN’s to other care providers (some unregulated). Increasingly there is a movement (often led by nurses themselves) to divide the patient into “tasks” that need to be completed and assign the tasks to various care providers, while the role of the RN is seen as best used as the coordinator and planner of care. In the Intensive Care Unit we need to be very cautious how this model of care “movement” impacts things like appropriate and safe RN:Patient ratios (CACCN is working on developing a position statement on this issue later this year) and the ability to have time to form therapeutic relationships with patients and families when there are no “tasks” that need to be done.

As an administrator myself for over 25 years in critical care, I have seen and been part of the development of nursing workload measurement systems from their infancy in the early 90′s that attempt to measure how long it takes on “average” for a nurse to perform certain tasks and functions for the patient. This data then gets analyzed and through mathematical formulas computes how many hours of care a patient requires per day. I have seen how these tools can do harm if not used by administrators with the appreciation of their limitations of what they actually measure in describing the time that nurses need to do their work. These workload tools never capture what the nurse was unable to “do” for her/his patient because there was not enough time to “do” everything that the patient and their family needed. The danger lies within these workload tools when administrators expect nurses to work to these “numbers” as if it was all the evidence they need to measure how well a unit is functioning or how hard the staff is working. I know as I have been challenged by senior hospital administrators to reduce hours per patient day based on this “numbers” game when I knew that the numbers were only a partial view of the PICU I managed.

Like the expert bedside clinician the expert administrator “knows” the unit she/he manages and what it takes to keep the staff motivated and the unit staffed appropriately to allow the RN’s to perform their job expertly and with job satisfaction to get good patient outcomes and satisfaction with the care they received. So working to achieve targeted hours per day to measure productivity might be ok if we were producing donuts but it is not ok when critical care is needed in a timely manner by knowledgeable and skilled RN’s at the bedside. The danger lies within when we come to believe that all patient care is “average” and the experience of the nurse and context of care in which she/he practices is the same every day, so the formula can be applied uniformly. These workload measurement systems seldom take into account the time that is needed for nurses to continually acquire new knowledge and update and practice new skills to keep patients safe. The real danger lies when administrators fail to listen to the voice of RN’s that they need more time, not less time to be with their patients. If we fragment RN care by delegation of tasks to other (let’s admit it)…cheaper staff, then the safety net around patient care is being weakened and may be developing some holes. There is a tipping point that will be reached if the drive to decrease costs overtakes the quality of care for the “whole” patient that the RN currently provides in many areas of acute care but probably the greatest impact being in the ICU.

But before you think I am against any different way of looking at collaborative models of care, I want you to know that I am totally supportive of any role that assists the work of the RN in critical care to enable the nurse to focus on the assessment and ongoing care of her/his patient. The continuity of hands-on-care in the ICU is what keeps patients safe. If tasks like baths are delegated to another type of care provider, then the bedside RN will fail to see the beginnings of skin redness, so that she/he can reassess nutritional requirements and have the discussion with the Dietician and Clinical Pharmacist about feeding and/or TPN before skin breakdown results or fail to see the subtle skin mottling that tells a story of decreased tissue perfusion that requires adjustment of vasoactive intravenous medications. When doing the bath, if the blood pressure and heart rate or intracranial pressure changes, these are all things the RN “puts together” to make adjustments to the care plan. It is often at these most intimate times that the RN forms the deepest therapeutic relationship with the patient as the conversation that takes place, although may appear superficial to others overhearing it, is really about finding out so much more about your patient as you perform the bed bath. It is a continuous assessment. This view cannot be fragmented without an impact on the coordination of care that is expected of the RN.

What I AM for, is support for nurses through appropriate and safe staffing levels that enables another person to assist the RN with the bed bath and turning the patient, and the bed change so she/he does not struggle to do this independently. What I AM for is the investment in safe “lift” systems by hospitals so that the nurse uses technology to preserve her/his back. Within the ICU there needs to be secretarial and ward aide support staff scheduled around the clock to take phone calls and perform cleaning tasks, restock supplies and do paperwork and not just on the day shift. We all know in critical care how many “tasks” we pick up from other professions (particularly physiotherapy or a clinical pharmacist) because they are not scheduled 24 hours. Those are the kinds of models of care we need to support the work of the ICU RN.

If we fail to “find our voice” and fail to describe what we “do” and leave the image of nursing focused only on the caring virtues of nurses then we have failed ourselves. If we can’t describe the work we “do” in more concrete terms to the public (who already trust us highly second only to firefighters) then RN:patient ratios will be determined by imperfect workload measurement systems and processes that are designed to find a cheaper way to deliver the “tasks” of care.

So as I leave the Board of Directors, I encourage a Call for Action where ever you may work…watch how the image of nursing and nurses is portrayed in your ICU, your hospital and in your province and have your voice heard in a meaningful way. We cannot be quiet about such things. You can tell your stories of extraordinary patient care that you deliver every day without violating patient confidentiality by focusing on the expert knowledge that you have in meeting the patient’s needs and by describing what you “do” every day as the ICU nurse to keep the patient alive. These are the images I want people to remember of critical care nurses…not the angel!

Stay tuned and watch this blog in a couple of weeks as your new President, Teddie Tanguay and the 2012-2013 Board of Directors announce an exciting new and action oriented President’s theme building on the theme of Find Your Voice!

It has been a privilege to serve critical care nurses in Canada in my time on the National Board and I am proud and honoured to have been your President for the past two years. I hope to cross paths with many of you in the months ahead.

Until then and as always…take care of yourself and each other,

Kate Mahon
President