Celebrating ANNA's 45th anniversary: specialty practice networks.
The Specialty Practice Networks (SPNs) of today were implemented at the 1983 ANNA National Meeting as Special Interest Groups (SIGs) to better engage ANNA members and facilitate opportunities for networking. Each member could select two SIGs to network with--one functional and one clinical--and the SIGs held networking sessions at the ANNA National Meetings. SIGs were created for Administration, Education, Research, Hemodialysis, Pediatrics, Peritoneal Dialysis, and Transplant. Over the years, additional SIGs were added for Renal Staff Nurses, Corporate Nurses, Advanced Practice, Chronic Kidney Disease, and Acute Care. The SIGs were redesigned periodically to better meet the needs of members and ANNA. In 1993, the SIG Committee Chairperson role was added to coordinate the work of all SIGs; this role evolved into the SIG Liaison role. During one redesign, each SIG had an appointed leader who, during the National Symposium, recruited about 10 members to be a part of the SIG Committee, which developed and worked on projects throughout the year, as well as lead networking sessions at National Symposiums. In 2010, ANNA developed a Task Force to improve the SIGs and get more members involved.
In 2012, the SIGS evolved into SPNs with a different leadership structure and membership focus. The change involved linking and interacting with online networks of members using ANNA Connected. Members who sign up electronically for a SPN on the ANNA website can communicate with others in the SPN. Each SPN has a facilitator to coordinate work throughout the year, as well as three team leaders responsible for Best Practice, Education, and Publication. These team leaders request help from the general SPN members through ANNA Connected for projects during the year. This is a great way to get more member involvement via online discussions on a variety of hot topics. It is also an easy way to get input from members. Members are able to ask questions and get answers from experts across the country. Everyone can see these discussions and contribute. We hear from members all the time about what a great benefit these discussions are to their practice! Our current SPNs are Acute Care, Administration, Advanced Practice, Chronic Kidney Disease, Hemodialysis, Home Therapies, Pediatrics, and Transplant.
Acute Care SPN
Judy Kauffman, MSN, RN, CNN, Acute Care SPN Facilitator
The Acute Care SIG was formed in 2005. Prior to this date, the nurses in acute hemodialysis (HD) were members of the Hemodialysis SIG. The acute care nurses recognized their needs were a bit different than nurses working in the chronic area. The Acute Care SPN has grown to more than 2,200 members.
The Acute Care SPN is very active in projects to help develop nurses in acute care across the country. The committee has written articles for the Nephrology Nursingjournal and published chapters for the Core Curriculum for Nephrology Nursing, Applying Continuous Quality Improvement in Clinical Practice, Nephrology Nursing Scope and Standards of Practice, and Nephrology Nursing Process of Care: Apheresis and Therapeutic Plasma Exchange and Continuous Renal Replacement Therapy, as well as developed the Acute Care Hemodialysis Orientation Manual and Assessment Tools.
The nephrology nurse in acute care has a wide variety of responsibilities, such as offering services of hemodialysis (HD), continuous renal replacement therapy (CRRT), apheresis, and peritoneal dialysis (PD). The adult and pediatric populations are served by acute services. Acute care nurses encounter long hours, varying schedules, multiple challenges, patients with high acuity, frequently changing environments, and high-tech environments. Nurses in acute care are highly engaged, innovative individuals who work autonomously in many settings. We recognize the degree of intensity that acute care nursing creates and want to provide a setting that allows dialogue with our colleagues. ANNA Connected has been a very active website for nurses in the acute care setting, allowing them to communicate on various topics, from practice to safety, with their peers.
Acute Care Memories
The following are some personal accounts of acute care nurses in nephrology through the years.
Nancy Pierce, BSN, RN, CNN. A high school girl who was in a car accident and was coded in the ER, made it through surgery to the ICU, then developed acute renal failure (ARF). She was on a respirator, had multiple broken bones (including a skull fracture), and her hemorrhaging spleen was removed. We dialyzed her every day for a month and a half using old technology of just slow frequent HD; it was about 1985, and there was no CRRT. She was a very beautiful 16-year-old girl with long strawberry blond hair and so much life yet to experience! We doggedly persisted in dialyzing her despite the thought of many physicians that she probably would not recover. After four weeks, I remember the nephrologist with tears in his eyes asking me if we should continue. It had been so long without much response, and it was hard in our small Montana dialysis unit to find staffing for daily dialysis in the ICU on top of our full outpatient clinic. For some reason I had a gut feeling that she would survive. I told the doctor that we could do it longer, so he canceled his vacation to Hawaii, and we struggled on with the acute dialysis sessions. Miraculously, she started responding and very slowly getting better. She was taken off the respirator, and her kidney function slowly returned. I cried with joy and gave her a big hug when, three months later, she was discharged from the hospital, walking with the help of a walker. Three years later, I got a surprise visit from her, and she was walking with just a very slight limp and looking absolutely beautiful. She wanted me to know that she was in college studying to become a physician, since she came to appreciate her heath care workers so much when we saved her life.
Mary Perrecone, MSN, RN, CCRN, CNN. It was summertime in Albany, New York, and I just assumed the position of Acute Adult Dialysis Manager at a Level 1 Trauma Center. My first job as manager was to complete the acute HD orientation of two nurses in chronic HD from an outpatient unit (so I could actually orient to the manager position). We had HD orders to perform a treatment in our CCU for a patient who was intubated, had a Swan-Ganz catheter, and was on multiple vasopressors in cardiogenic shock following an ST segment elevation myocardial infarction. Of course, there were no water doors, and we became the usual plumbers to hook up the gooseneck to the sink and place the drain lines in the toilet.
The portable reverse osmosis unit was archaic and had been retrofitted into an old emergency cart, so the drawers could be used for supplies, connectors, and the hoses. No locks on syringes or medication vials to lock with glove boxes on the top of the machine. The Joint Commission had not reached those patient safety standards yet. Our patient had an acute femoral catheter with poor blood flow but was stable enough for me to run around the corner to check on the other orientee dialyzing a patient who was post-coronary artery bypass graft surgery in our cardiothoracic unit. I was only gone 10 minutes, and there was a pool of water flowing out of the room into the hallway. The RN orientee was standing in the middle of the water, sneakers squeaking, fringes of her scrubs sopping wet, and her blue scrubs getting darker and darker as the water saturated her pants! The drain hose had fallen out of the toilet, which was only held down by the toilet seat on top of it. At that moment, I heard a voice behind me saying, "Do you know that you are leaking on my office?" The office of our Executive Vice President and General Director of Hospital Systems, along with the rest of administrative row, was right below the CCU rooms. The ceiling tiles were so saturated that they caved in like cardboard and fell on his desk. He took the time to listen to our confession, called plumbing (who designed a toilet boil clamp), and was quite remarkably the most understanding physician faced in that type of situation. The following April 1st, I told him kiddingly that I wanted to buy him an umbrella for his office. That year my capital budget for water doors was approved!
Mary Perrecone, MSN, RN, CCRN, CNN. We all have our patients on chronic dialysis who are "frequent flyers" to the emergency room for missed/skipped HD treatments. With the Emergency Medical Treatment & Active Labor Act (EMTALA) (Centers for Medicare and Medicaid Services [CMS], 2012), who can say "No" to dialysis at 3:00 a.m.? A young male of 28 years who had a failed kidney transplant from his mother was such a patient. His mom was his healthcare proxy due to his encephalopathy. Additionally, the patient had a ventriculoperitoneal (VP) shunt. If he went to other ERs in the area to get his dilaudid, he was immediately shipped to us because no one would care for a patient with a VP shunt. He was lovingly named "Voldemort," or "Mr. V," as I will call him. Not only was he catechetic from refusing to eat, he also had quite the vocabulary. Mr. V cussed at everyone on the unit using foul language. My staff members would always tell me when he was coming so we could create the plan for where, who, and how he would dialyze so he would not be disruptive to the other patients. On this particular day, a male nurse and a male tech were assigned to Mr. V. He always needed to be restrained because he would pull out his fistula needles. He was very angry on this day; his serum potassium was 7.6, and he refused to stay on dialysis. I decided to give it my best because our treatment plan included not giving in to his wishes to have dilaudid. The male RN went on lunch break, and another nurse took over while the tech watched over his fistula. Mr. V started cussing, and my tech said, "Don't talk to my boss or a lady that way." Mr. V was quite frustrated pulling at his restraints; however, he eventually settled a bit. In speaking with him, Mr. V. told me he needed something for pain, and the physicians wouldn't give him dilaudid. Looking in his chart, I found an order for po Tylenol[R]. I told him I would come back with something for him. He kept asking what, and I told him it was special. I went to get the special Tylenol and continued a lengthy questioning related to pain assessment along with what type of drink he would like to take the special Tylenol with, ice or no ice, straw or no straw, etc. After he took the "special pain medication," he actually said "thank you!" Mr. V then proceeded to ask me again what I gave him. I replied, "Special Tylenol." He said, "What makes it special?" I said, "Because I gave it." He smiled and fell asleep for the rest of his treatment. His nurse came back from break and asked me what I did to him. I just said I gave him special Tylenol!
David E. Simmons, Jr., MSN, RN, CNN. One night, at about 3:00 a.m., as darkness filled the surgical intensive care unit. I recall sitting in the corner of a patient's room with a diafilter, a blood pump, and a graduated cylinder. My patient was asleep, volume overloaded, and too unstable to dialyze. He appeared dead, but the ventilator, blood, and numerous infusions and pumps caused me to rethink my immediate response. A femoral catheter was the conduit used to remove and return the patient's blood. My orders were to gently remove 1.6 liters of volume. The time to accomplish this task was not specified. The patient was to maintain his hemodynamic stability during this procedure. Meticulous account of the patient's volume shift throughout this process had to be recorded on this unique document that was designed by the nephrology physicians and nurses. The SICU nurse and I were hell bound if we did not record our entries on this document. After five hours, I reached the net volume loss of 1.6 liters. Today, this arduous procedure is known as continuous renal replacement therapy or CRRT and is packaged in the form a machine with volumetric controls.
Helen Hutteri, RN, CDN, Administration SPN Facilitator; Mary Fenderson, RN, CNN, MSHSA, SPN Publication Leader
The spectrum of nephrology nursing has evolved over the years with expanding technology and the rapidly changing healthcare arena. The role of the nephrology nurse began to change as new scientific medical advances and technologies in the care of patients with ESRD were introduced over the years. With these changes, legislation, and ESRD regulation, nephrology nurses began assuming more diverse responsibilities encompassing leadership and administrative roles. For example, staffing in the outpatient dialysis facility has changed from primarily an all-nurse direct care workforce in the earlier years to one of mostly patient care technicians with nurses functioning in more of a supervisory role. The care of patients in the outpatient setting with complex long-term care concerns and ever-changing facility dynamics have challenged and influenced the role of the nephrology nurse. As managers and members of the facility's interdisciplinary team today, nephrology nurses utilize strong leadership and communication skills to deal with the challenges associated with patient safety, access to care, clinical outcomes, regulatory changes (such as the Conditions for Coverage [CMS], 2008) and administrative facility operations. Changes in reimbursement, time constraints, and educational needs to keep abreast of ever-changing technology are the challenges impacting nephrology nursing today.
The Administration SPN has been active since 1985, originally as a SIG, and now has more than 800 participants. Over the past eight years, the Administration SPN has been involved in multiple projects, including writing a chapter in Applying Continuous Quality Improvement in Clinical Practice and reviewing the Nephrology Nursing Scope and Standards of Practice.
The Administration SPN has always been innovative and creative. The Administration SPN was the first one that introduced the publication of "short articles" in the ANNA Update. The "short article" topics are always relevant to the work and real practice of the new nurse manager in the field. The SPN was a pioneer in that area, and currently, some of the other SPNs are publishing short articles as well.
We continue to encourage members to participate, and we welcome input through ANNA Connected. The more we share with each other across our nation, the more we can collaborate and build up our profession.
Advanced Practice SPN
Debra Castner, MSN, RN, APN-C, CNN, Advanced Practice SPN Facilitator
We have a lot to celebrate as advanced practice nurses (APNs) in nephrology care. Each year, more nurses are realizing what a perfect fit the APN role is in providing care for patients with chronic and acute kidney disease.
The first nurse practitioner program was started in 1965 at the University of Colorado developed by Loretta Ford, RN, and Henry Silver, MD. At that time, NP programs were certificate-based; now, the entry level for NPs is a master's degree and moving to doctoral preparation. There has been a large amount of research on NPs, much of which is focused on quality of care, patient satisfaction, and outcomes compared to other providers; studies indicate positive results for the NP role. In 2010, the Agency for Healthcare Research and Quality (AHRQ) reported that 52% of NPs were in primary care roles, and 48% were in specialties. Details of NP practice from the American Academy of Nurse Practitioners (AANP) (2014) are shown in Table 1.
Unfortunately, the numbers of NPs in nephrology, as in other specialties, have not been counted in a reliable fashion. There are several reasons for this, the most common being that NP billing for services is hidden behind the MD, especially in nephrology. Many nephrology NPs who perform rounds in dialysis units complete three of the four visits per patient per month. The MD usually does the fourth visit, with the bill going to Medicare in the MD's name. NPs can be seen in unique renal roles, such as vascular access management, CKD education, acute care, prevention, disease management, and research, which are not counted specifically in surveys from APN organizations.
ANNA has historical data about its membership composition. In 1985, 145 members reported working in clinical nurse specialist roles compared to 242 in 2013. In 1997, 100 members reported working in NP roles. The number grew to 465 members in NP roles in 2013. The APN SPN has 565 members on its listserv.
One member from New Jersey recalls cutting out and posting any job listing she could find for APNs in renal care as she finished her NP program in 1997. She did this to boost her confidence in finding a job at graduation because so many people thought she would "never find a job." Another member from Florida discussed the challenge of getting her dialysis colleagues to recognize her in her new role as a nephrology NR It took patience and time to educate them on her new role, which they learned to fully appreciate. She thinks she has made a difference in the lives of people with chronic kidney disease and would recommend the role of nephrology NP to others.
At this time of celebrating 45 years of ANNA, consider the traditional and newly emerging roles for nephrology NPs, make a commitment to mentor others to join us, and take pride in the important role you have with patients, families, and other providers.
Chronic Kidney Disease SPN
Cheryl L. Groenhoff, MSN, MBA, RN, CNN, CKD SPN Publication Team Leader
Chronic kidney disease (CKD) is a gradual loss of kidney function over time. According to the National Kidney Foundation (NKF) (2013), 26 million American adults have CKD, and millions more are at risk for developing CKD. Early detection is critical to delay progression of CKD. The number-one cause of death among patients diagnosed with CKD is heart disease; therefore, the number-one goal is to control hypertension, which can cause CKD. The number-two cause of death with CKD is diabetes. Elevated serum glucose levels circulating in the blood cause damage to many organs in the body, such as the kidneys and heart. Blood vessels, nerves, and eyes are all also damaged with high glucose levels. According to the U.S. Renal Data System (USRDS) (2013), 115,643 patients started treatment for ESRD, also known as CKD Stage 5, in 2011.
The renal community collaborated to identify stages of CKD, segmenting the patient population with CKD to deliver individualized care planning with the goal of preventing Stage 5 ESRD. Staging of CKD was established as practice guidelines in 2002 by the NKF Kidney Dialysis Outcome Quality Initiatives (NKF, 2002).
The growing research suggests that effective management of hypertension, diabetes, dyslipidemia, bone disease, anemia, nutrition, and cardiovascular disease can delay or cease progression. Screening clinics, such as the Kidney Early Evaluation Program (KEEP), identifies patients at risk for CKD. The South Florida Flamingo Chapter participated in many KEEP screenings in Miami. Norma Gomez, Marlene Ledo, Debbie Ayer, and I were amazed at how many patients presented with blood pressures over 150/90 and glucose levels over 200 mg/dL and had no clue they were at risk. Referring these patients to their primary care physicians and ultimately CKD clinics helped save many lives with such screenings.
The effectiveness of the CKD clinics was evident with the decision by the University of Miami (UM) Nephrology Division in 1997 to change the name of the clinic. The renal clinic was divided from one to three clinics, and algorithms were created to establish effective standards of care according to patients' glomerular filtration rates (GFRs), even before the NKF publication of the CKD taxonomy. The first of three clinics established was the early ID clinic that treated patients with eGFR greater than 59 mL/minute. The Renal Clinic treated patients with estimated GFR (eGFR) of 30 to 59 mL/minute. The third Clinic was called the pre-ESRD clinic and treated patients with an eGFR less than 30 mL/minute. Pre-ESRD was the precursor term used prior to 2000 when the nomenclature changed to CKD.
In the Early ID clinic, interventions included patient education, new diabetes training and diet, administration of diabetes medications, antihypertensive therapy, possible estrogen replacement, importance of exercise and weight management strategies, angiotension-converting enzyme inhibitors (ACEs) or angiotension-receptor blockers (ARBs), smoking cessation education, lipid-lowering diets, and other related medications. The Renal Clinic focus was evaluating and treating complications, such as anemia and bone disease, performing biopsies, and establishing causative renal disease. In the pre-ESRD clinic, now known as CKD, the focus became educating the patient on treatment options and preparation for RRT. Many clinics, such as those at UM, established Pre-ESRD Clinics and anemia clinics, all with the intent of effectively managing the CKD population with multidisciplinary teams. Kidney patient educators or treatment options educators empowered patients to make choices once renal replacement therapy (RRT) was imminent.
ANNA also recognized the need for educating nurses on CKD standards of care for patients in alternative settings. The CKD SIG was established in 2005 and led by Sally Campoy, an NP at the Veterans Administration in Denver. Sally co-authored Nursing Standards of Care for CKD Patients: CKD Clinics (Dutka, Burrows-Hudson, Campoy, & Petroff, 2006) in which the importance of establishing goals for successful CKD management is described. Sue Gary, an NP in Baton Rouge, Louisiana, and a past president of ANNA, who is a member of the CKD SPN, described how she was able to provide CKD education, including necessary diet information, to her patients with CKD who were in shelters during Hurricane Katrina.
The SPN created an educational series titled, Chronic Kidney Disease: What Every Nurse Should Know (ANNA, n.d.), which includes six modules: "Stage 5: Chronic Kidney Disease--Hemodialysis in the Long-Term Care Setting;" "Stages 3 and 4 Chronic Kidney Disease;" "Stages 1 and 2 Chronic Kidney Disease;" "Children Have Kidney Failure, Too;" "Chronic Kidney Disease--The Post-Transplant Patient;" and "Chronic Kidney Disease: Nursing Guidelines for Patient Education."
As we approach the 45th anniversary of ANNA, take a few moments to reminisce where we've been, a few moments to savor where we are, but many moments to rejoice in what the future brings to CKD and ANNA.
Joan E. Arslanian, MSN, RN, CNN, FNP, CS, Hemodialysis Publication Team Leader
It seems only appropriate as we celebrate our 45th anniversary of providing care to those with chronic renal failure that we take a look at how HD has evolved.
For some 2000 years, individuals with kidney failure died while physicians and scientists struggled to create a mechanical kidney with the ability to filter out the toxins and fluids that build up in the body. It took until the mid 1940s to develop the first, crude kidney dialysis machines. The development of dialysis from experimental concept to lifesaving treatment has met with many stops and starts, and more than a little resistance. Bouts of infection, massive epidemics of blood-borne disease (including hepatitis), and contamination of the dialysate solution have all created problems. Even when the dialyzers worked and lives were clearly being extended, the medical profession and public were wary.
The first historical description of any type of dialysis was published in 1913 (Coleman & Merrill, 1952). Abel, Rowntree, and Turner "dialyzed" anesthetized animals by directing their blood outside the body and through tubes with semipermeable membranes. The membranes were made from coliodion, a material based on cellulose. The procedure was known as vividiffusion. Abel and his colleagues used a substance known as hirudin to prevent the blood from clotting. Hirudin was first identified in 1880 by the British physiologist John Berry Haycraft and is the anticoagulant element in the saliva of leeches (Counts, 2006; Gottschalk & Fellner, 1997).
A German doctor by the name of Georg Haas performed the first dialysis treatments involving humans in 1924 (McBride, 1979). None of the patients survived, likely because of the critical condition of the patients and the insufficient effectiveness of the dialysis treatment. The Haas Dialyzer, which also used a collodion membrane, was built in a variety of models and sizes.
Haas, like Abel, also used hirudin as the anticoagulant in his first dialysis (Counts, 2006). However, hirudin often led to massive complications arising from allergic reactions because the substance was insufficiently purified and originated in a species very distant from humans. In the end, Haas used a substance known as heparin. Heparin is the universal anticoagulant in mammals and was first isolated in dog livers by an American named Jay MacLean in 1916 (McBride, 1987). This substance caused substantially fewer complications than hirudin--even when it was insufficiently purified--and could be produced in much larger amounts. Heparin became the anticoagulant of choice, with the development of better purification methods in 1937.
Dr Willem Kolff is considered the "father of dialysis." This Dutch physician constructed the first artificial kidney in 1943 (McBride, 1987). The creation of the artificial kidney began in the late 1930s when Dr. Kolff was working in a small ward at the University of Groningen Hospital in The Netherlands. There, Kolff watched helplessly as a young man died slowly of kidney failure. Kolff decided to find a way to make a machine that would do the work of the kidneys. Dr. Kolff searched the university library for information on removing toxins from blood and stumbled across an article about HD with animals published in 1913 by John Abel. Abel's writing inspired Kolff, and he became committed to the development of an artificial kidney (Cheng, 1991).
At about the same time that Dr. Kolff began his research, World War II erupted. Once the Nazis overtook The Netherlands, Kolff was sent to work in a remote Dutch hospital. Although materials were scarce, Kolff improvised, using sausage skins, orange juice cans, a washing machine, and other common items to make a device that could clear the blood of toxins.
In 1943, Kolff s invention, although crude, was completed (McBride, 1987). During the course of the next two years, he treated 16 patients with acute kidney failure but had little success. All that changed in 1945, when a 67-year-old woman in a uremic coma regained consciousness after 11 hours of HD with Kolff's dialyzer. She lived seven more years before dying of another ailment (Counts, 2006). After World War II ended, Kolff donated the five artificial kidneys he made to hospitals around the world, including the Mt. Sinai Hospital in New York.
In 1947, Nils Alwall from Sweden published a scientific work describing a modified dialyzer developed between 1942 and 1947 that could better combine the necessary processes of dialysis and ultrafiltration than the traditional Kolff Kidney (McBride, 1987). The cellophone membranes used in this dialyzer could withstand higher pressure because of their positioning between two protective metal grates. All of the membranes were in a tightly closed cylinder so that the necessary pressure did not have to come along with the blood but could rather be achieved using lower pressure in the dialysate.
In the late 1940s, Kolff came to the U.S., where he continued his research. The next few years saw many strides in dialysis. Kolff gave a set of blueprints for his kidney machine to George Thorn at the Peter Bent Brigham Hospital in Boston (Cheng, 1991). This led to the manufacture of the next generation of Kolff's dialyzer, a stainless steel Kolff-Brigham kidney. During the Korean War, Kolff-Brigham dialyzers were instrumental in the treatment of injured American soldiers.
By the 1950s, Willem Kolff's invention of the artificial kidney had solved the problem of acute renal failure, but it was not seen as the solution for patients with ESRD. In mid-20th century America, doctors believed it was impossible for patients to have dialysis indefinitely for two reasons. First, they thought no man-made device could replace the function of kidneys over the long-term. In addition, a patient undergoing dialysis suffered from damaged veins and arteries, so that after several treatments, it became difficult to find a vessel to access the patient's blood.
The answer for patients with ESRD came from a professor of medicine at the University of Washington, Dr. Belding Scribner. Scribner came up with the idea of connecting the patient to the dialyzer using plastic tubes, one inserted into the artery and one into a vein. After treatment, the circulatory access would be kept open by connecting the two tubes outside the body using a small U-shaped device, which would shunt the blood from the tube in the artery back to the tube in the vein (Blagg, 2007).
The Scribner Shunt, as it was called, was developed using a new material call Teflon[R]. With the shunt, it was no longer necessary to make new incisions each time a patient underwent dialysis. Although the Scribner Shunt is no longer used today, it was the first step to improved methods of access to the circulatory system, enabling dialysis to prolong the lives of chronic renal patients.
Dr. Kolff, by proving that patients could be successfully treated using artificial kidneys, started a flurry of activity around the world to develop improved and more effective dialyzers. The parallel plate dialyzer evolved as the most significant development of this period. Rather than pumping the blood through membranous tubes, it directed the flow of dialysis solution and blood through alternating layers of membranous material. This development began with the first Skegg-Leonards dialyzer in 1948, and reached its technological peak in 1960 with the presentation of the Kiil dialyzer from Norwegian Doctor Fredrik Kiil.
In 1962, Scribner started the world's first outpatient dialysis facility (Blagg, 2007). Immediately, the problem arose of who should be given dialysis because demand far exceeded the capacity of the six dialysis machines at the center. Scribner decided the decision about who would receive dialysis and who would not--a matter of life and death for patients involved--would not be made by him. Instead, choices would be made by an anonymous committee composed of local residents from various walks of life plus two doctors who practiced outside the kidney field. Although his decision caused controversy at the time, it was the creation of the first bio-ethics committee, which changed the approach to accessibility of health care in this country (Blagg, 2006).
The most important breakthrough in the field of vascular access came in 1966 from Brescia, Cimino, and their colleagues (McBride, 1987). Using surgery, Brescia and his colleagues joined an artery in the arm with a nearby vein. Needles could then be more easily placed in this "arterialized" vein, which lay beneath the skin, to allow repeated access. This technique lowered the risk of infection in the vascular access and permitted dialysis treatment over a period of years. The arteriovenous (AV) fistula remains the access of choice for patients on dialysis today.
In the 1960s and 1970s, the patient and family, some medical insurance, research grants, or private donations paid for costly dialysis therapy. The growing interest in dialysis and lack of facilities and reliable third-party payment resulted in a call to action. Patients, their relatives, and doctors bombarded their Congressmen with letters. Finally, public outrage caused Congress to face this issue directly. Shep Glazer, a patient and representative of the National Association of Patients on Hemodialysis (NAPH), testified while being dialyzed in front of the House Ways and Means Committee (Blagg, 2006). The government responded--shocked that America was rationing care.
On October 30, 1972, the national ESRD program--Public Faw 92-601--was passed as an amendment to the Medicare Act. The bill, signed into law by President Nixon, gave all Americans the right to treatment for ESRD, regardless of age. ESRD was and remains the only medical condition given this status. The law exceeded expectations and posed challenges due, in part, to its cost. At the time of its passage, the government expected to care for some 16,000 patients, a patient load reached by 1974. By 1999, there were one quarter of a million patients. Similarly, the annual budget was projected at $250 million; however, by 2000, it was more than $15 billion (Blagg, 2006).
Scientists and medical professionals continue to improve the quality of HD care and technology. Improvements in safety have been added to the machines, including the ability to assure the accuracy of fluid removal. Bicarbonate dialysate, a solution that is more biologically compatible, replaced acetate dialysate. The 1970s and 1980s saw development of new and more efficient dialyzers, particularly hollow fiber dialyzers, and the development of better membranes for dialysis. Attention and efforts to measure the adequacy of HD were made.
A series of back steps continued, including the idea of shortening dialysis times for U.S. patients to three hours or less. Patients began to be under-dialyzed, and the annual mortality of patients on HD in the U.S. reached nearly 24% by the mid 1980s. Since 1980, efforts have been made to improve dialysis by setting standards for the treatment of anemia, dialysis adequacy, nutrition, and blood access (Blagg, 2006).
One major advance in the treatment of patients on dialysis was the introduction of erythropoietin for the treatment of renal anemia in 1989. Before then, almost all patients on dialysis had to exist with a hematocrit in the low to mid-20s if they were to avoid the risks and costs of repeated blood transfusions. Quality of life for patients on dialysis has much improved with erythropoietin.
Therapy for kidney failure has improved dramatically since Shep Glazer's historic dialysis treatment before the House Ways and Means Committee (Blagg, 2006). He and other courageous patients received treatment from providers who did their best to manage complex problems, with inadequate support and resources from the medical and political establishment. Thanks to their groundwork and to steady medical progress, today's patients benefit from an integrated system of care that provides choice, stability, quality, and compassion. The ongoing commitment to quality improvement and to providing care for all who can benefit will continue to make the future even better for the expanding population of patients with ESRD.
As early as 1915, nursing literature mentions the care of patients with kidney disease. The Artificial Kidney (Coleman & Merrill, 1952) was the first article published in the nursing literature to describe the role of the nurse in dialysis. As the number of patients on HD has increased and the techniques advanced, it was no longer feasible or necessary for physicians to remain at the bedside during the treatments. Nurses assumed responsibility for the majority of HD procedures (Hoffart, 1989).
Some of my colleagues have been working in this field since 1973. Here are a few of their memories of HD.
"It is amazing how things have changed technically, and in some areas, has come full circle theoretically."
"Long gone are the days of 100 L tanks, where the bath had to be changed mid treatment. Your eyes served as the air and blood detectors. The venous pressure was monitored via a Mercoid. C-clamps were used on the venous line to increase the pressure in the dialyzer to remove more fluid. Hepatitis B antigen-positive patients were dialyzed in the same room with hepatitis B antigennegative patients--when those coil dialyzers ruptured, there was blood from one end of the room to the other. Infection control procedures, for the most part, were nonexistent."
"The advent of disposable plate dialyzers afforded the clinician the ability to use both negative and positive pressure (TMP). The dialyzers, however, were heavy and bulky. The first hollow fiber dialyzers were packed in formaldehyde. Dialyzers were often primed with blood for patients who had low hematocrits."
"Dextran was used for some patients who became hypotensive due to loss of blood volume after dialysis was initiated. Machines became more sophisticated with ways to monitor arterial pressure, negative pressure, TMP, and ultrafiltration control. Bicarbonate dialysate replaced the less biologically compatible acetate dialysate."
"In Europe, high-efficiency/high-flux dialyzers were introduced with the hopes of increasing the efficiency of the dialysis while reducing treatment time. It was then introduced to the U.S., and in a rather short period of time, Europe found that patients were underdialyzed, and mortality and morbidity increased with the shorter treatment time. More dialysis was found to be advantageous. The U.S. followed suit."
"Today, machines interface with software programs for more efficient monitoring of the treatment, and ultra-filtration control is more advanced; blood volume monitoring is available in some machines, all advances with the goal of improving the efficiency and safety of patient treatments."
"Hemodialysis is a very technical area, but after the technical piece is mastered, it becomes an art form, where you alter patient treatment parameters to minimize symptomatology, achieve estimated dry weight (EDW), and provide as comfortable a treatment as possible for the patient."
As the clinical use of HD became increasingly widespread, scientists were better able to invest the unique attributes of patients with chronic kidney disease. In contrast to the early years of dialysis, the lack of adequate treatment methods or technologies are no longer a challenge in the treatment of renal patients. The present challenges are multifaceted and come from the number of patients requiring dialysis treatment, the complications resulting from years of dialysis treatment, and a growing population of patients that presents demographic as well as medical challenges--a population that would be without help were it not for innovative researchers.
The role of the nephrology nurse in HD has grown in scope, practice boundaries have broadened, and the number of nurses in this specialty has climbed steadily. Nurses working with patients on HD deal with every organ system in the body, calling for a holistic approach to patient care that is both challenging and rewarding. Driven by technological and educational advances, this continues to be a dynamic field.
Care may be extremely complex--patients may have numerous co-morbid conditions, including, but not limited to, cardiovascular disease, diabetes, hypertension, infectious disease, bone disease, or psychiatric conditions. In addition, many face psychosocial issues. The nurse's role is to help patients manage their lives--succeed at work or school, socialize, maintain relationships, or enjoy hobbies--while effectively dealing with their health issues.
In outpatient HD settings, the nurse is an integral member of a multidisciplinary team that cares for patients with complex needs. The nurse in this setting functions as advocate, educator, consultant, care coordinator, and direct caregiver, and oversees long-term care of chronically ill patients. As such, the nurse can have a positive impact on the quality of parents' lives.
The care described in the literature decades ago still Serves as a foundation for current care; however, the level Of complexity has escalated. The number of patients is increasing. The average age of the patient is rising. The number of co-morbidities has dramatically increased. The need to increase and monitor quality care, with less resources; the need for organizational and unit level strategies and control over nursing practice; improving nurse staffing; and fostering a collegial relationship between nurses and physicians in dialysis facilities continue to be challenges.
Home Therapies SPN
April D. Peters, MSN, RN, CNN, Peritoneal Dialysis Publication Team, Leader
It's hard to imagine that PD has its roots firmly planted in a bottle of claret. The origins of PD stretch back to the 1740s, when Christopher Warrick used an intraperitoneal instillation of a combination of Bristol water and claret wine to treat a woman with ascites. Unsurprisingly, the patient did not tolerate this treatment, and it was discontinued, but she did survive, and the genesis of PD began (Baxter Healthcare Corporation, Dialysis Division, 1987). Since then, many researchers have added to our knowledge of the function and characteristics of the peritoneal membrane leading to the first attempt at using PD to treat renal failure in 1923. Georg Ganter used a sterile dextrose solution to treat a woman with post-partum renal failure, with improvement noted in her blood chemistries. Unfortunately, he discontinued the treatment when the bloodwork improved, and the patient died; Ganter had been unaware that the treatment needed to be continued to be effective.
Another milestone in PD occurred in 1936, when J.B. Wear, I.R. Sisk, and AJ Trinkle used continuous PD to treat a patient with obstructive renal failure (Baxter Healthcare Corporation, Dialysis Division, 1987). The treatment was discontinued when the obstruction was resolved and marked the first successful use of PD. Additional studies were done sporadically throughout the upcoming years. P.S. Kopp developed a gravity fill system in the 1940s using porcelain botdes to facilitate sterilization, and Arnold Seligman, Jacob Fine, and Howard Frank used PD to successfully treat a patient with acute renal failure in 1945. Access for dialysis was addressed when Paul Doolan developed a polyethylene catheter for long-term use with multiple drain holes. In 1962, Russell Palmer worked with Quinton to create a permanent flexible silicone catheter that could seal and prevent infection. Henry Tenckhoff, in 1968, further modified this catheter to include two felt cuffs and a curled or straight design, which is still used today (Baxter Healthcare Corporation, Dialysis Division, 1987).
In the meantime, research was done across the country. In 1959, Morton Maxwell of Los Angeles developed a simple method for PD involving repeated two-liter exchanges with 30-minute dwells (Baxter Healthcare Corporation, Dialysis Division, 1987). In 1960, Richard Ruben used the Doolan catheter as a permanent access to perform intermittent PD treatments, and the possibility of chronic PD became a reality. Peritoneal dialysis (Baxter Healthcare Corporation, Dialysis Division, 1987) began to grow, and procedures were developed by Boen, Tenckhoff, Lasker, and Oreopoulos in different areas across North America. Very different from the PD of today, it involved large bottles and reverse osmosis systems, and was usually performed in the patient's homes for long periods of time. I spoke with Linda Watson RN, who has worked in renal nursing in New York since 1966 to discuss her recollections of dialysis at that time. "I remember how heavy the glass bottles were and trying to warm them up without any reliable way to measure the temperature" (personal communication, January 9, 2014). Watson further described how difficult it was to work in a cutting-edge nursing career where all nurses, by default, were inexperienced. "It was such a new procedure, and we were all learning at the same time. Sometimes the patients talked us through some of the steps because it was all so new to everyone."
Despite the advances made in PD, it remained too cumbersome a process for the general renal population until the work of Drs. Jack Moncrief and Robert Popovich in Austin, Texas. Initially known as "long-dwell equilibrated PD," the technique for instilling two liters of fluid for four hours, draining, and then instilling another two liters of solutions, came to be known as continuous ambulatory peritoneal dialysis (CAPD) (Sorrels, 1979). Dr. Karl Nolph began to evaluate the use of CAPD in Missouri in 1977 (Baxter Healthcare Corporation, Dialysis Division, 1987; Krediet, 2007). Both programs found it effective; however, the incidence of peritonitis, exit-site infections, and protein loss were problematic. These issues continue to be the Achilles' heel of PD today and remain the focus of research. Dr. Dimitrios Oreopoulos in Toronto was made aware of the use of CAPD and began to use plastic containers for the dialysis solution, resulting in a closed system form of PD that could dramatically reduce the incidence of infection (Baxter Healthcare Corporation, Dialysis Division, 1987). In 1978, the findings of Popovich, Moncrief, and Nolph were published, and the FDA approved the closed system devised by Oreopoulos (Baxter Healthcare Corporation, Dialysis Division, 1987). As a result, this revolutionary treatment transformed the ability to provide PD to the ESRD population. Dr. Nolph recalled an incident of disbelief that such an innovation could have its beginnings away from the nationally recognized research hospitals in the United States. "A reporter from a New York newspaper called me to ask for the location of CAPD training centers in New York City. I explained that the only USA CAPD training programs (at the time of the call) were in Austin, Texas, and Columbia, Missouri. The reporter was incensed and said, 'Dr. Nolph, do you really expect me to believe that there is something available in Texas and Missouri that is not available in New York?'" (Nolph, 2002, p. 609)
Since the birth of modem CAPD, many advancements have occurred. Prevention and treatment of infections have improved, there is a better understanding of what constitutes adequate PD, and milestone studies of patient outcomes have been published. Anemia management, biocompatible solutions, automated PD, and the use of PD in patient populations that are high risk have all led to better quality of life for our patients with ESRD.
One thing that has remained constant throughout the modem age of PD is the unique relationship that develops between the nurse and the patient and his or her family. As Watson stated so well, "The one thing I remember most is how close you became to your patients as you worked with them and taught them how to do their own PD" (personal communication, January 9, 2014). Effectively teaching a self-care modality requires trust and openness as the nurse evaluates the patient's abilities, enters the patient's home, and interacts with family and other significant loved ones. This creates a singular bond and is one of the most satisfying aspects of working in PD. This was highlighted in my own experience several years ago when I cared for a patient who had become housebound and required frequent home visits. Pie was hospitalized, and his wife was complimenting the nursing care he received at our hospital. Suddenly, she stopped and said, "I keep forgetting you're one of his nurses too. We always think of you as a family friend who just happens to give him a shot and listen to his lungs when you stop by." This unique relationship helps define nursing with patients on PD and many nurses working in PD continue to occupy and enjoy the role of nurse/family friend in their patient's lives as well.
Malinda C. Harrington, MSN, RN, FNP-BC, ANCC, Pediatric SPN Publication Team Leader
Pediatric nephrology nursing is a growing subspecialty within the nephrology community. Pediatric kidney disease poses a unique challenge that must address the disease but also the many extra-renal manifestations that affect the patient and the family.
Specialized care for children was initially developed in response to societal needs. Sick children require special nursing and training. Pediatric nursing is "the practice of nursing with children, youth, and their families across the health continuum, including health promotion, illness management, and health restoration" (Bamsteiner, Wyatt, & Richardson, 2002, p. 166). Pediatric nephrology nurses must have knowledge not only about the primary kidney disease and all of the secondary co-morbidities, but also age-specific physiologic differences and developmental milestones. Because CKD is a fife-long disease, pediatric nephrology nurses have the unique opportunity of developing lasting and personally fulfilling relationships with both patients and families.
Diabetes and hypertension are the numbers one and two etiologies of ESRD in adults (USRDS, 2013). The etiology of pediatric ESRD is considerably different. The largest single disease group causing ESRD in children is cystic, hereditary, and congenital diseases (35.7%), followed by primary and secondary glomerulonephritis (33.6%). Hypertension and large vessel disease account for 5.4% of pediatric ESRD, while diabetes accounts for only 1% (USRDS, 2013). Preservation of residual renal function is paramount in delaying progression to ESRD, and measures to optimize function should be instituted. Special care must also be taken in pediatrics to ensure brain growth and physiologic development.
While the Pediatric SPN is one of the smaller SPNs, some of its nurses work with both pediatric and adult patients, while others are dedicated to pediatrics. The volume of pediatric patients with kidney disease pales in comparison to their adult counterparts, and it is often difficult to justify dedicated pediatric nephrology nurses and pediatric dialysis units. Fortunately, there are nephrology nurses who have a special interest in working with the pediatric population and are willing to take on the role of both pediatric and adult nephrology nurse. Because of ANNA's commitment to excellence in nephrology nursing, pediatric educational opportunities have, and will become, increasingly available.
Dina MacDonald, the University of California San Diego (UCSD) Medical Center/Children's Hospital. Having worked in all aspects of ESRD care and starting my career with adult patients on dialysis, I transitioned to pediatrics almost 20 years ago and never had one regret. The greatest thing for me about dealing with kids is their unbelievable ability to forgive. No matter what we sometimes put them through, they will put it aside and still color you a beautiful picture, give you a huge hug, or tell you their best joke. There's no end to the surprises they have given me and the fife lessons they have taught me about strength, courage, and perseverance.
John Romos, Virginia Commonwealth University (VCU) in Richmond, Virginia. Pediatric patients are always special to me. I worked with them in the Philippines, and I am very glad to be part of our pediatric nephrology core group and be able to share my experience to deal with our patients...neonates without kidneys, congenital hydronephrosis, children with both heart and kidney transplant, and many more.
Ladonna McCrory, James and Connie Maynard Children's Hospital at Vidant Medical Center in Greenville, North Carolina. I have always been an adult nephrology nurse. It is what I started my career as a nurse doing, and it's been my life. I love nephrology nursing because ... it's what I do! It wasn't until 2011 that I became a pediatric/adult nephrology nurse. The thought of performing PD on an infant was quite frightening to say the least. I have really grown to enjoy caring for the pediatric population. There is always so much to learn.
Jean Colaneri, ACNP-BC, CNN, Transplant SPN Publication Team Leader; Diane Derkowski, MA, RN, CNN, CCTC, Transplant SPN Facilitator
As all other areas of nephrology have evolved, renal transplantation has changed tremendously since the first successful transplant was performed almost 60 years ago. On December 23, 1954, at the age of 23, Ronald Herrick donated a kidney to his identical twin brother, Richard, at the Peter Bent Brigham Hospital in Boston. The recipient, Richard, lived for another eight years, while his donor brother Ronald died in 2010 at the age of 79 (NBC News, 2010). At the time, immunosuppression was rudimentary, as were anesthesia and surgical techniques. Deceased donation was unknown, and transplantation was only possible between well-matched living donors. Transplant nursing was many years away from becoming a specialty type of nursing care.
What is different 60 years later? Almost any healthy person can donate a kidney to someone with a compatible blood and tissue type. The majority of living donor kidneys are removed laparoscopically from the donor. While anonymous (stranger) donation still sparks controversy, it has given way to paired donation and chain donation in larger transplant centers.
With respect to deceased donation, brain death was not defined until the 1970s and was further refined through the early 1980s with the adoption of the Uniform Determination of Death Act (National Conference of Commissioners on Uniform State Laws, 1980). While the first deceased donors were young and healthy, today's deceased donors are older; may have had mild, treated hypertension or controlled type 2 diabetes; or have died of a stroke (extended criteria donors [ECDs]) (O'Connor, Delmonico, Gritsch, & Danovitch, 2010). Since rapid nucleic acid testing (NAT) is possible, transplant centers can quickly test deceased donors for hepatitis B and C, HIV, and other infectious diseases. Transplant centers require that recipients sign detailed consents for any deceased donor organs that they determine to be at a high risk for transmission of infectious disease to the recipient.
The first recipients of deceased donor kidneys in the 1970s were mostly young and free from other medical problems. Today's recipients of transplants are older and have more co-morbidities, especially cardiac disease (Bunnapradist & Danovitch, 2010). It is also now acceptable practice at many transplant centers to offer transplants to recipients who are HIV-positive with well-controlled HIV disease. This was not a standard practice at most centers until several studies in the 1990s showed that transplants given to individuals who were HIV-positive had comparable outcomes to those who were HIV-negative.
How has transplant nursing changed since ANNA began in 1969? Several of our SPN members remember being on transplant call prior to the use of cell phones. They remember scrambling to find change to put in phones and struggling to find phone booths with some privacy. When cell phones were first used, they were not commonplace, and SPN members reminisced over how large and cumbersome they were. They remember when patients needed to carry beepers wherever they went in order to get the call for the precious transplant. Today, efficient computer systems assist transplant coordinators: DonorNet (United Network for Organ Sharing [UNOS], 2014c), Tiedi (UNOS, 2014a), and electronic organ offers are all sophisticated computerized tools that are used. Cell phones have dramatically improved communication among coordinators, physicians, and patients.
Many SPN members began their careers as transplant coordinators prior to the establishment of UNOS in 1984. They remember the Southeast Organ Procurement Foundation (SEOPF), which established the Kidney Center in 1982. SEOPF provided 24-hour assistance in placing donated organs. UNOS separated from SEOPF in 1984, and in 1986, received the first federal contract to operate the Organ Procurement and Transplantation Network (OPTN), which continues today (UNOS, 2014b, n.d.).
ANNA did not establish SIGs at its inception. When the first Transplant SIG was started, there were 194 members. The purpose of the SIGs was to promote networking among nurses working primarily within their specialties. In 2013, the renamed Transplant Specialty Practice Network (SPN) had three times that number of members. Transplantation nursing has achieved a well-established niche as a specialty nursing practice area.
In 1969, the success rate of kidney transplantation was only about 50% at one year, with a mortality rate of 10% to 20% (Danovitch, 2010). Improvements in the success rate would not be achieved until the use of cyclosporine in the 1980s. Fast forward to 2014: there is a 10% or less incidence of acute rejection at most U.S. transplant centers with current immunosuppressive regimens (Wilkinson & Kasiske, 2010). One-year graft survival rates for living donor kidneys are more than 95%, and deceased donor kidneys are greater than 90% (USRDS, 2013).
Transplant medications are significantly more effective today. However, the complexity of the regimen, the number of medications that need to be taken, and the significant side effects continue to challenge practitioners and patients alike. The tasks for the future continue to be in the development of medications to control multi-drug resistant infections, cytomegalovirus (CMV), and polyoma virus infections while improving immunosuppression to prevent rejection and improve the longevity of renal allografts and the quality of life for patients.
Key Words: Administration, education, research, hemodialysis, pediatrics, peritoneal dialysis, transplant, special interest groups, home therapies, chronic kidney disease.
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Note: Authors' biographical statements can be found on the following page.
Nancy Pierce, BSN, RN, CNN, is the Dialysis Director, St. Peters Hospital, Helena, MT; the ANNA Specialty Practices Network (SPN) Liaison; and a member of ANNA's Big Sky Chapter. She may be contacted directly via email at email@example.com
Joan Arslanian, MS, MPS, MSN, RN, FNP-BC, CS, CNN, is the Clinical Director/Nurse Practitioner, the New York Hospital Queens--The Trude Weishaupt Memorial Satellite Dialysis Center, Fresh Meaadows, NY. She is currently the Hemodialysis SPN Publication Team Leader and a member of ANNA's Big Apple Chapter.
Debra Costner, MSN, RN, APN-C, CNN, is a Nurse Practitioner in Brick, NJ; a facilitator for ANNA's Advanced Practice SPN; and a member of ANNA's South Jersey Chapter.
Jean Colaneri, ACNP-BC, CNN, is a Nurse Practitioner/Clinical Nurse Specialist in Dialysis and Apheresis, Albany Medical Center Hospital, Albany, NY; and was a Nurse Practilioner/CNS in renal/pancreas transplantation for 24 years. She is the ANNA Transplant SPN Publication Team Leader, a member of the Nephrology Nursing Journal Editorial Board, and a member of ANNA's Northeast Tri-State Chapter.
Diane M. Derkowski, MA, RN, CNN, CCTC, is a Kidney Transplant Coordinator, Carolinas Medical Center, Charlotte, NC; the ANNA Transplant SPN Facilitator; and a member of ANNA's Greater Charlotte Chapter.
Malinda C. Harrington, MSN, FNP-BC, ANCC, is a Nurse Practitioner, James and Connie Maynard Children's Hospital, Greenville, NC; the ANNA Pediatric SPN Publication Team Leader; and the Treasurer of ANNA's North Carolina/Tar River Chapter.
Helen Hutteri, RN, CDN, works for Fresenius Medical Care in Home Therapies, Clearwater, FL; is the ANNA Administration SPN Facilitator; and is a member of ANNA's Suncoast Chapter.
Judy Kauffman, MSN, RN, CNN, is the Manager of the Acute Dialysis and Apheresis Unit, University of Virginia Medical Center, Charlottesville, VA; the ANNA Acute Care SPN Facilitator; and a member of ANNA's Central Virginia Chapter.
Mary Perrecone, MS, RN, CCRN, CNN, is a Clinical Manager, Fresenius Clinic, Charleston, SC; the ANNA Acute Care SPN Best Practice Leader; and a member of ANNA's Palmetto Chapter.
April Peters, MSN, RN, CNN, is a Clinical Informatics Specialist, Brookhaven Memorial Hospital, Patchogue, NY; the ANNA Home Therapies SPN Publication Leader; and a member of ANNA's Long Island Chapter.
Table 1. Nurse Practitioner Data More than 189,000 nurse practitioners (NPs) are practicing in the U.S. * An estimated 14,000 new NPs completed their academic programs in 2011-2012. * 95.1% of NPs have graduate degrees. * 96.8% of NPs maintain national certification. * 87.2% of NPs are prepared in primary care; 75.6% of NPs practice in at least one primary care site. * 84.9% of NPs see patients covered by Medicare, and 83.9% by Medicaid. * 44.8% of NPs hold hospital privileges; 15.2% have long-term care privileges. * 97.2% of NPs prescribe medications, averaging 19 prescriptions per day. * NPs hold prescriptive privilege in all 50 states and D.C., with controlled substances in 49. * In 2011, the mean, full-time base salary was $91,310, with average full-time NP total income at $98,760. * The majority (69.5%) of NPs see three or more patients per hour. * Malpractice rates remain low; only 2% have been named as primary defendant in a malpractice case. * NPs have been in practice an average of 11.7 years. Source: American Academy of Nurse Practitioners (AANP), 2014
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|Author:||Pierce, Nancy; Arslanian, Joan; Castner, Debra; Colaneri, Jean; Derkowski, Diane M.; Harrington, Mal|
|Publication:||Nephrology Nursing Journal|
|Article Type:||Author abstract|
|Date:||Mar 1, 2014|
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|Next Article:||The changing landscape of the nephrology nursing care environment in the United States over the last 45 years.|