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Serving Those Who Have Served:
Practical Approaches to Addressing the Invisible Wounds of War
in Post-9/11 Service Members and Veterans
An associate chief nurse (ACN) is a member of the nursing executive leadership team who is responsible for ensuring that competent and compassionate patient care is uniformly provided to patients in inpatient, ambulatory and community settings through development, implementation and evaluation of policies, programs and services consistent with the hospital’s mission and department’s vision and philosophy. Actively participates in the development of the Department’s strategic plan and provides direction and support to the unit leadership triad toward attainment of short- and long-term goals and objectives.
The American Hospital Association is a national organization, founded in 1898, that represents and serves all types of hospitals, health care networks, and their patients and communities. The AHA provides education for health care leaders and is a source of information on health care issues and trends. Through representation and advocacy activities, the AHA ensures that members' perspectives and needs are heard and addressed in national health policy development, legislative and regulatory debates, and judicial matters. Our advocacy efforts include the legislative and executive branches and include the legislative and regulatory arenas. Nearly 5,000 hospitals, health care systems, networks, other providers of care and 37,000 individual members come together to form the AHA.
Perception of innocuous stimuli (light touch, warmth) as pain
The American Nurses Association (ANA) is the only full-service professional organization representing the nation's 2.9-million registered nurses (RNs) through its 54-constituent member associations. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.
The Agency for Healthcare Research and Quality (AHRQ) is the nation's lead federal agency for research on health care quality, costs, outcomes and patient safety. AHRQ is the health services research arm of the U.S. Department of Health and Human Services (HHS), complementing the biomedical research mission of its sister agency, the National Institutes of Health. The agency is home to research centers that specialize in major areas of health care research, including: clinical practice and technology assessment, health care organization and delivery systems, and primary care. AHRQ is a major source of funding and technical assistance for health services research and research training at leading U.S. universities and other institutions. As a science partner, the agency works with the public and private sectors to build the knowledge base for what works—and does not work—in health and health care and to translate this knowledge into everyday practice and policy-making.
Drug used to prevent clot formation or to prevent a clot that has formed from enlarging. Anticoagulant drugs inhibit clot formation by blocking the action of clotting factors or platelets. Anticoagulant drugs fall into three groups: inhibitors of clotting factor synthesis, inhibitors of thrombin and antiplatelet drugs. The FreeDictionary (accessed Dec. 2, 2014)
A technical aid, communication device or medical aid modified or customized, that is used to increase, maintain or improve the functional abilities of people with disabilities. Assistive technology can include mobility devices such as walkers and wheelchairs, as well as hardware, software and peripherals that assist people with disabilities in accessing computers or other information technologies. For example:
Death by brain criteria is defined under Massachusetts state law as the total and irreversible cessation of spontaneous brain functions, in which further attempts of resuscitation or continued supportive maintenance would not be successful in restoring such function. Stated more simply, brain death is the irreversible loss of all function of the brain, including the brainstem. A patient determined to be brain dead is legally and clinically dead. (MGH Policy on Brain Death, 2.1)
Centers for Disease Control and Prevention is one of the major operating components of the Department of Health and Human Services. Its mission is to collaborate to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.
The Centers for Medicare and Medicaid Services (CMS) is a federal agency within the US Department of Health and Human Services. CMS administers the Medicare program and works in partnership with state governments to administer Medicaid and other programs. CMS’ mission is to make sure beneficiaries are aware of services for which they are eligible, and that services are provided in an effective manner.
In order for a health care organization to participate in and receive payment from Medicare or Medicaid programs, it must comply with standards called Conditions of Participation (CoP’s). In lieu of conducting surveys to monitor compliance, CMS accepts findings of accrediting agencies such as The Joint Commission and grants them “deemed” status. CMS does, from time to time, conduct their own survey to validate the findings of the accrediting agencies.
A central line is an intravascular catheter that terminates at or close to the heart in a large blood vessel. A central line can be used to give fluids, antibiotics, medical treatments such as chemotherapy, and liquid food if a patient is unable to eat or digest food normally. Central lines are also sometimes called central venous lines or central venous catheters. Examples of central lines are PICCs (peripherally-inserted central catheter), Hickman catheters (tunneled catheter), and Port-A Caths (implanted port).
Central line days
The total number of days a central line is in place for patients in surgical, intensive care, and certain other hospital units. In units where this is monitored, the count is performed at the same time each day. Each patient with one or more central lines at the time the count is performed is counted as one central line day.
An antiseptic agent with topical antibacterial activity. Chlorhexidine is positively charged and reacts with the negatively charged microbial cell surface, thereby destroying the integrity of the cell membrane. Subsequently, chlorhexidine penetrates into the cell and causes leakage of intracellular components leading to cell death. Since gram positive bacteria are more negatively charged, they are more sensitive to this agent.
Central Line-Associated Bloodstream infection (CLABSI). When a patient gets a bloodstream infection after having a central line put in and the bloodstream infection is not related to an infection in another part of the body it’s considered a CLABSI. According to the Centers for Disease Control and Prevention (CDC), an estimated 248,000 CLABSIs occur in U.S. hospitals each year. These bloodstream infections often lead to longer hospital stays, higher costs, and an increased risk of dying. CLABSIs can be prevented through proper insertion and care of the central line.
The Clinical Nurse Specialist (CNS) is a master's-prepared nurse with an area of specialization who promotes competent, compassionate and professional nursing care for patients/families across the continuum through direct patient care and by influencing nursing personnel and systems to facilitate expert care. The role includes patient care, teaching, consultation and research and is the clinical arm of the unit leadership triad.
Disparities in care are differences in the delivery of health care, access to health care services and medical outcomes based on ethnicity, geography, gender and other factors that do not include socioeconomic status or insurance coverage. Understanding and eliminating the causes of health care disparities is an ongoing effort of many groups and organizations.
The Department of Nursing (DON) – The clinical departments and programs of Patient Care Services (PCS) that are within the discipline of nursing.
The Department of Public Health (DPH) is a state agency within Massachusetts Health and Human Services (HHS). DPH has several bureaus and programs that strive to promote the health and well being of all people in the Commonwealth and to ensure that safe, effective; high-quality care is provided in all settings. HHS administers Medicaid (Mass Health Program) which is the second largest insurer in the state. DPH ensures that hospitals comply with Center for Medicare and Medicaid Services standards in order to receive payment through Mass Health. DPH does not routinely conduct comprehensive on-site surveys, but does conduct surveys related to specific programs such as Transplant and Infection Control. DPH may also choose to conduct a review of a specific patient’s care triggered by hospital self-report of a serious incident or by a patient/family complaint
Dreyfus Model of Skill Acquisition
Based on the work of Drs. Hubert and Stuart Dreyfus, both professors at the University of California at Berkeley. This is a situational model of skill acquisition. It is the development of skilled know how. The model states that a person passes through five stages of qualitatively different perceptions of his/her task and/or mode of decision-making as his/her skill improves. It is neither expected nor possible for all individuals to proceed in a linear fashion. Skill according to this model is based on innate ability, experience and environment.
Evidence-based practice (EBP) is a method of clinical decision making used by many healthcare disciplines. The term was first defined by Dr. Sackett from McMaster University in Canada in the early 1990s. EBP takes into account the best available information, or evidence, along with the clinical expertise of the healthcare practitioners and the values and preferences of the patient to determine the best treatment for an individual.
Excellence Every Day
At Massachusetts General Hospital, Excellence Every Day means striving to provide the best possible care to every patient and family in every moment of every day. It is our philosophy and our commitment. Our efforts to achieve Excellence Every Day include validation by external regulatory agencies in the form of on site surveys and through our designation as a Magnet hospital. We are all focused upon meeting the needs of patients and creating systems that support the highest level of quality and safety.
Health Care Proxy
This term refers to the form-not the person. The preferred form of advance directive in Massachusetts under Massachusetts General Laws Chapter 201D Health Care Proxies. The form appoints a health care agent (the person) to make health care decisions for the patient if he/she loses the capacity to make their own decisions.This legal document does not require an attorney to fill out. It must be signed in front of two adult witnesses who are not the appointed agent. In some states this document is called a Durable Power of Attorney for Health Care.
The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. — Healthy People 2010, U.S. Department of Health and Human Services
Hidden/ Invisible Disabilities
Those disabilities that can not be directly identified through observation. They can include cognitive, chronic health, and psychological disabilities. These Disabilities can sometimes or always limit daily activities, range from mild challenges to severe limitations and vary from person to person - Invisible Disabilities Association - IDA
A phenomenon of a heightened perception of and response to pain.
-- Primary Hyperalgesia: An exaggerated pain response (primary hyperalgesia).
-- Secondary Hyperalgesia: The extension of an area of hyperalgesia to adjacent body parts so that an uncomfortable stimulus applied near injured tissue evokes an exaggerated pain response.
The Institute for Healthcare Improvement (IHI) is an independent nonprofit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Mass., IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.
“Innovation in service delivery and organization is a novel set of behaviors, routines and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness of users’ experience and are implemented by planned and coordinated actions.” (Greenholgh, 2005)
The Institute of Medicine (IOM) is a nonprofit organization and honorific membership organization that works outside the framework of government to ensure scientifically informed analysis and independent guidance on matters of biomedical science, medicine and health. The Institute provides unbiased, evidence-based and authoritative information and advice concerning health and science policy to policy-makers, professionals, leaders in every sector of society and the public at large. IOM's book on quality and safety, Crossing the Quality Chasm: A New Health System for the 21st Century, partially funded by the Robert Wood Johnson Foundation, reported that a huge divide exists between the care we should receive and the care that we get. Crossing the Quality Chasm introduces the notion that health care needs to take a page from industry and use its engineering improvement methods to aim for top quality, efficiency and safety. The report lays out six goals that would become akin to a mantra for the quality improvement movement: care should be "safe, effective, patient-centered, timely, efficient and equitable." IOM's 2003 landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care demonstrates the reality and effect of health disparities and quality-of-care differences for persons of racial and ethnic minorities.
Moral distress has been defined as physical and/or emotional suffering that is experienced when internal or external constraints prevent a person from taking the action that one believes is right (Pendry, 2007)." (From OJIN Vol 15 - 2010No3 Sept 2010 Vol 15 No. 3, Sept 2010 "Creating Workplace Environments that Support Moral Courage," by Cynthia Ann LaSala MS, RN and Dana Bjarnason, PhD, RN, NE-BC)
"Nursing care today is provided in very complex environments. This complexity can lead to moral distress and the need to demonstrate moral courage. Moral courage involves the willingness to speak out and do that which is right in the face of forces that would lead a person to act in some other way."(Iseminger, K., (September 30, 2010) "Overview and Summary: Moral Courage Amid Moral Distress: Strategies for Action" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3, Overview and Summary.)
Abnormal pain secondary to nerve illness or injury.
Never Events are medical mistakes that should never occur under any circumstance.
Nursing Sensitive Indicators (NSIs)
such as falls and pressure ulcers, are those aspects of patient care for which there is empirical evidence linking nursing interventions to improved outcomes. link to Caring Headlines article
Patient fall (NDNQI definition)
A patient fall is a sudden unintentional descent, with or without injury that results in the patient coming to rest on the floor, on or against some other surface.
Performance Improvement is the concept of measuring the output of a particular process or procedure, then modifying the process or procedure to increase the output, increase efficiency, or increase the effectiveness of the process or procedure.
A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are associated with formation of pressure ulcers. (National Pressure Ulcer Advisory Panel, 2011)
Process Improvement is a methodology that seeks to engage front line staff in the problem solving process. Process Improvement can involve clinical, as well as administrative functions and may occur in emergency rooms, inpatient settings, ambulatory practices or other hospital operational areas.
Quality measures are mechanisms used to assign a quantity to quality of care by comparison to a criterion.
Research is a scientific process that seeks to validate, refine and extend existing knowledge and generate new knowledge that directly influences the work of a discipline or group. .Nursing research focuses on the development, validation, testing and refinement of knowledge that advances nursing science and informs professional practice to improve patient care.
Per The Joint Commission, in its broadest sense, restraint is the direct application of physical force to a patient with or without the patient's permission to restrict his or her freedom of movement.
A service animal is defined by the Americans with Disabilities Act (ADA) as a dog that is individually trained to do work or perform tasks for a person with a disability. If they meet this definition, animals are considered service animals under the ADA regardless of whether they have been licensed or certified by a state or local government. All entities must permit service animals to accompany people with disabilities in all areas where members of the public are allowed to go. People with disabilities who use service animals cannot be isolated from other patrons, treated less favorably than other patrons, or charged fees that are not charged to other patrons without animals. Allergies and fear of dogs are not valid reasons for denying access or refusing service to people using service animals.
Some examples of tasks that service dogs provide include: Guiding people who are blind, alerting people who are deaf or hard of hearing, pulling a wheelchair, alerting and protecting a person who is having a seizure, reminding a person with mental illness to take prescribed medications and calming a person with post traumatic Stress Disorder (PTSD) during an anxiety attack.
Individuals with mental disabilities who use service animals that are trained to perform a specific task are protected by the ADA. The rule permits the use of trained miniature horses as alternatives to dogs, subject to certain limitations.
Dogs that are not trained to perform tasks that mitigate the effects of a disability, including dogs that are used purely for emotional support, are not service animals.
Transparency is the process of collecting and reporting health care cost, performance and quality data in a format that can be accessed by the public and is intended to improve the delivery of services and ultimately improve the health care system as a whole.
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