1. Section Editor(s): Kennedy, Maureen Shawn MA, RN
  2. Ferri, Richard S. PhD, ANP, ACRN, FAAN
  3. Sofer, Dalia

Article Content

Managing Atrial Fibrillation

Physician groups release evidence-based guidelines.


FIGURE. No caption a... - Click to enlarge in new windowFIGURE. No caption available.

The News column in the March 2003 issue of AJN reported a study that concluded that when treating atrial fibrillation (AF), warfarin therapy and controlling the heart rate were preferable to controlling heart rhythm. Now, after a review of that study and others, the American Academy of Family Physicians and the American College of Physicians have developed evidence-based guidelines for the treatment of newly detected AF in most adults. They include


* controlling the patient's heart rate, as opposed to controlling the heart rhythm, in conjunction with long-term anticoagulation therapy. Rhythm control isn't superior to rate control and, in some cases, may be inferior.


* prescribing long-term anticoagulation therapy with warfarin, unless patients are at a low risk for stroke or have contraindi-cations to warfarin use, such as recent surgery, trauma, throm-bocytopenia, or alcoholism.


* not prescribing digoxin (Lanoxin) as a first-line agent for rate control in AF. Atenolol (Tenormin), metoprolol (Lopressor and others), dilti-azem (Cardizem and others), and verapamil (Isoptin and others) are superior in controlling heart rate at rest and during exercise. Digoxin should only be used as a second-line agent because it's recommended for rate control only when the patient is at rest. * using (when cardioversion is desired) either direct-current cardioversion or pharmacologic cardioversion to achieve sinus rhythm. There is no evidence that one is superior to the other and no studies comparing the two methods have been conducted.


* using (when cardioversion is desired) either transthoracic echocardiography with anticoagulation therapy and acute cardioversion (except when there is intracardiac thrombus) or delayed cardioversion and anticoagulation therapy.


* not using maintenance drug therapy to control heart rhythm after conversion to sinus rhythm, since the risk of developing a ventricular arrhythmia outweighs any potential benefit. However, if the quality of a patient's life is compromised by AF, amio-darone (Cordarone and others), disopyramide (Norpace), propafenone (Rythmol), and sotalol (Betapace) are the preferred agents.



The guidelines do not apply to patients who develop AF postoperatively or after a myo-cardial infarction, nor do they apply to patients with the New York Heart Association class IV designation of heart failure, those with valvular disease, or those already being treated with antiarrhythmic drugs.


Snow V, et al. Ann Intern Med 2003;139(12):1009-17.


Dial M for Murder or L for Lawsuit?

Did a nurse kill patients and still get hired-again and again?


FIGURE. Charles Cull... - Click to enlarge in new windowFIGURE. Charles Cullen

Fourteen years and 10 hospitals later, Charles Cullen, 43, was charged last December with the first-degree murder of a patient and the attempted murder of another, both of whom had been under his care at Somerset Medical Center in Somerville, New Jersey. Upon his arrest, Cullen confessed to having killed as many as 40 patients during his career.


Investigators and prosecutors in the various counties of New Jersey and Pennsylvania where Cullen was employed must now sort through mounds of medical records, interview families of his former patients, and perhaps even exhume patients' bodies. But they aren't the only ones who have their work cut out for them. Hospitals, legislators, and nursing organizations are taking a close look at how the self-proclaimed serial killer was able to move from one hospital to the next without arousing suspicion and how similar incidents may better be prevented in the future.


What raised a red flag at Somerset were abnormal blood test results in six elderly patients cared for by Cullen: four had low blood sugar levels and two had extremely high levels of digoxin. Four of the six died. An internal hospital investigation led to the notification of the state health department and, subsequently, the county prosecutor. While three of these deaths were attributed to other causes, the death of Florian J. Gall, 68, remains a mystery. Another patient, 40-year-old Jin Kyung Han, nearly died of a toxic dose of digoxin. He recovered but died three months later.


Yet this was not the first time Cullen was suspected of wrongdoing. According to a recent article in the New York Times, while working at St. Luke's Hospital in Bethlehem, Pennsylvania, in June 2002, Cullen became the subject of an investigation when a nurse coworker discovered a sharps box filled with heart medications. She emptied the box, but on the following day found it full again and alerted hospital officials. As an internal investigation of 69 deaths of patients who had died while under Cullen's care began, Cullen resigned and found a new job-a solution that apparently worked for him at other hospitals. As early as 1993, the New York Times reported, Cullen had been the subject of investigations, but each time was fired or resigned before the investigation got under way. In all, he was fired from six jobs and quit three others, but none of the hospitals knew of his problems with his previous employers.


"One of the lessons of the Cullen case is that hospitals often take the easy way out," says Alan Meisel, professor of law and of bioethics at the University of Pittsburgh School of Law. "Because they are afraid that they will be sued by the fired employee, they often let him or her go without invoking the enforcement mechanisms that are available, and turf the problem to the next hospital." One "enforcement mechanism" is the National Practitioner Data Bank-established in 1990 to encourage state licensing boards, hospitals, and professional societies to identify and discipline those who engage in unprofessional behavior, and to restrict their ability to move from state to state without anyone discovering their employment record. Employers are supposed to search the data bank prior to hiring a new employee; however, mandatory reporting is only required for physicians and dentists. Nurses and other practitioners are reported on a voluntary basis.



Legislators at both state and federal levels are now holding hearings and proposing legislation to address loopholes in the system that allow a practitioner such as Cullen to operate below the radar for so long. Senators Jon Corzine (D-NJ) and Frank Lautenberg (D-NJ) have called on the Senate Committee on Health, Education, Labor and Pensions to hold hearings on the current system of screening health practitioners. The senators have recommended that the National Practitioner Data Bank include all nurses in the mandatory reporting category and that employers be required to report any actions taken against a health care practitioner, including reasons for dismissal.


New Jersey democratic senator Joseph Vitale has proposed the "Patient Safety Act," which would make all licensed New Jersey health care and psychiatric facilities accountable for reporting every serious preventable adverse event to the commissioner of the Department of Health and Senior Services and ensure that all patients are notified of the adverse event. As of this writing, the bill had been approved by the state Senate but not by the Assembly.


In New York, Governor George Pataki has proposed legislation that would require hospitals, nursing homes, and clinics to obtain an employment history of all licensed health care professionals and to share this history with prospective employers who inquire. (Currently, such employment histories are obtained only for physicians, physician's assistants, dentists, and podiatrists.) To protect health care workers from malicious reporting, the law would make the intentional filing of false information a criminal offense.


Cheryl Peterson, senior policy fellow at the ANA, agrees that better reporting of adverse events would be helpful and says that the ANA will be meeting with senators from New Jersey to discuss ways to strengthen reporting. "But the reality is that nurses who kill are often very clever, and their actions are very difficult to prove," she says. "An airtight system that would entirely stop something like this from happening-I'm not sure that exists." She adds that there are many questions to consider. For example, at what point does one report? What is considered "reportable" behavior? Does one report all investigations or only cases in which final action was taken? In addition to creating better systems for reporting, Peterson recommends establishing systems that emphasize the monitoring of medical errors.


"This [case] is a tragic aberration that sickens all of us who work to heal people and save lives," says Cheryl Johnson, president of the United Ameri-can Nurses. "Nurses I know would absolutely blow the whistle long and loud if they worked with anyone who was putting patients in danger. But the bottom line is, nurses don't hire nurses-management does."


Managers, already facing a severe nursing shortage, may relax standards when it comes to background checks; they may also be hesitant to report a fired employee to the National Practitioner Data Bank for fear of a lawsuit. "While hospitals may get sued by disgruntled fired employees," says Meisel, "they have little to fear in the way of liability if the employee was truly fired for good cause-as would have been the case for Cullen."-Dalia Sofer



Health coverage for all Americans by 2010 is the recommendation of a new report, Insuring America's Health: Principles and Recommendations, released January 14 by the Institute of Medicine. Noting that 43 million Americans lack health insurance (according to one report, 34 states have cut back Medicaid and children's insurance programs in the last two years), the report focuses on five principals that should guide coverage: health insurance should be universal, it should be continuous, it should be affordable to individuals and families, society should be able to afford and sustain it, and it should enhance health and well-being by promoting access to high-quality care. For the full report, go to


Pregnancy, nursing, and fish. The Food and Drug Administration and the Environmental Protection Agency have revised dietary recommendations on the consumption of fish by pregnant women and nursing mothers. Shark, swordfish, king mackerel, and tilefish contain higher levels of methyl-mercury than previously thought and should be avoided. However, a maximum of 12 oz. (two to three meals) of other fish and shellfish may safely be eaten weekly. Young children may eat fish two or three times a week, although portions should be smaller.


Men, Sexual Activity, and Angina

PDE-5 inhibitors complicate treatment.

Angina occurring during or within two hours of sexual activity (coital angina) is relatively uncommon, accounting for fewer than 5% of all episodes of acute angina. The self-administration of nitroglycerin has been the standard recommendation in such cases, except when the patient is being treated for erectile dysfunction with phosphodiesterase-5 (PDE-5) inhibitors such as sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis). Concurrent use of PDE-5 inhibitors and nitrates has been linked to severe hypotension and, in some cases, death.


A patient who experiences coital angina and has taken a PDE-5 inhibitor should not take nitroglycerin. Rather, he should call for transport to an emergency facility immediately. He should also inform all medical personnel that he has taken a PDE-5 inhibitor so that nitrates will not be administered. A patient who experiences anginal symptoms and has not taken a PDE-5 inhibitor should follow the standard protocol: three nitroglycerin tablets five minutes apart. If anginal pain doesn't resolve, he should seek emergency care.


DeBusk RF. JAMA 2003;290(23):3129-32.


World Health Roundup

A full cholera spectrum.

A mass campaign was launched in January in Beira, Mozambique, to inoculate 50,000 people against cholera. The disease has been particularly prevalent in this region and has averaged 4,300 cases annually for the last three years. The campaign is a combined effort of the World Health Organization, the country's ministry of health, and nongovernmental health groups and is the first attempt at mass vaccination against the disease worldwide.


Banning the ads.

New Zealand may ban direct-to-consumer advertising of prescription drugs. This is in accord with its recent agreement with Australia to jointly regulate the pharmaceutical and health-product industries in their countries. According to the British Medical Journal, if the ban is instituted, it would leave the United States the only developed country without such restrictions.


Novartis to the rescue.

The World Health Organization and the Stop TB Partnership will be able to provide free medication to 2.8 million people with tuberculosis, thanks to Novartis AG, which will manufacture special, easy-to-use patient medication kits. The medication will be provided for five years.


New Magnet Facilities

The American Nurses Credentialing Center has recognized nine more facilities with its Magnet Award for Excellence in Nursing Services: Dartmouth-Hitchcock Medical Center (Lebanon, New Hampshire); Delnor Community Hospital, (Geneva, Illinois); Forsyth Medical Center (Winston-Salem, North Carolina); Georgetown University Hospital (Washington, DC); Hartford Hospital (Hartford, Connecticut); Medical City Dallas Hospital and the North Texas Hospital for Children (Dallas); University of Iowa Hospitals and Clinics (Iowa City, Iowa); the Valley Hospital (Ridgewood, New Jersey); and William Beaumont Hospital, Royal Oak (Royal Oak, Michi-gan). There are now 102 Magnet facilities.



Temperature Changes In Neonates

Two studies focus on the tenuousness of thermoregulation in newborns.

According to University of Washington nurse researcher Karen Thomas, "Maintenance of [neonatal] body temperature is a longstanding nursing concern" related to the intricacies of the relationship of temperature to all body systems.


In a study published in the Journal of Perinatology, Thomas measured the effects of caregiving activities (during which incubator doors are opened) on skin temperature in 40 preterm infants in incubators. Incubator air temperature control was achieved through one of two methods: in some of the incubators it was regulated by the caregiver and in others it was adjusted automatically according to the infant's abdominal skin temperature, as determined with sensors. Neonatal skin temperature was recorded at one-minute intervals for 24 hours, and the air temperature was recorded continuously throughout that period. Results revealed that the abdominal skin temperature of infants in incubators in which the air temperature was set by the care-giver tended to decrease for as long as 20 minutes after caregiving activities were performed, while the skin temperature of infants in incubators in which the air temperature was adjusted automatically according to abdominal skin temperature tended to rise slightly (and that increase was sustained). Thomas says more research is needed to determine what clinical effects these thermal changes may have.


In a second study, published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing, Thomas examined temperature regulation in full-term and preterm infants at home when they had reached 44-weeks of postconceptional age. At home, smaller preterm infants tended to be overheated, while larger preterms tended to be underheated. Among full-term infants theses tendencies were reversed: smaller infants were under-heated and the larger ones overheated. Thomas suggests that parents may have perceived different risks to their infants and over- or undercom-pensated in terms of clothing, blanket cover, and ambient temperature. She urges nurses to include information on providing a proper thermal environment at home with other discharge teaching materials.


Thomas KA. J Perinatol 2003;23(8):640-5; Thomas KA. J Obstet Gynecol Neonatal Nurs 2003;32(6):745-52.


From the Center for Nursing Advocacy

The Center for Nursing Advocacy ( rates recent media characterizations of nurses and nursing.


* Angels in America (HBO, December 2003)-The Mike Nichols movie based on Tony Kushner's Pulitzer prize-winning play features extraordinarily good portrayals of nurses caring for AIDS patients in mid-1980s New York: the tough, witty ex-drag queen, Belize, fighting for afflicted friends and even notorious gay homo-phobe Roy Cohn, and the autonomous, expert nurse practitioner, Emily.


* Columns of Ronnie Polaneczky (Philadelphia Daily News, late 2003)-Polaneczky's columns about nurses on strike at a local hospital to end forced overtime provide an unusually vivid, sympathetic picture of courageous nurses trying to protect their patients from the dangers posed by short staffing in an environment focused on the bottom line.


* "My Fifteen Seconds, "Scrubs (NBC, November 20, 2003)-One subplot in this episode of the irreverent sitcom was nothing short of an attack on the nursing profession: it showed the physician characters convincing usually assertive nurse Carla Espinosa that physicians are in charge of patients and nurses and that nursing is simply following physicians' "orders."


* "Touch and Go, "ER (NBC, January 8, 2004)-The popular drama continues to marginalize nurses in an episode that showed physicians performing key nursing tasks, nurses meekly reporting their progress in a search for missing Valium to an ED physician, and a resident heroically nursing a critically ill pre-operative patient through computed tomographic scanning.