Legislation -&

New Baby Doe rule would place signs in nurses’ stations W Signs would be posted in nurses’ sta- tions stating that “discriminatory failure to feed and care for handicapped infants is pro- hibited by federal law,” under a new proposed version of the so-called Baby Doe rule issued July 5 by the US Department of Health and Human Services (HHS). Deadline for com- ments was Sept 6.

The rule is a revision of one struck down by a federal court last spring. By allowing for public comment, providing more background infor- mation, and making several other changes, the government has tried to overcome the judge’s objections that the original rule was “arbitrary and capricious.”

The revised rule would require all hospitals receiving federal funds to post the notice in nurses’ stations of delivery, maternity, and pediatric units as well as nurseries. On the sign would be the hotline number for reporting al- leged incidents as well as an address and phone number for state child protective agen- cies. HHS has been operating the hotline since spring despite the ruling. In the original rule, the signs were to be posted in public areas of the hospital.

Surgeon General C Everett Koop, in an- nouncing the revision, explained that nurses were closer to the medical decision-making process and therefore better able than the general public to report the withholding of surgery or other medical treatment from de- formed newborns.

“The rule is putting nurses right square in the

middle,” said Nancy Sharp, RN, associate di- rector for practice and legislation of the Nurses Association of the American College of Obste- tricians and Gynecologists. The group called a meeting of nursing, medical, and women’s health groups in July to discuss concerns.

Jerry Cox, an attorney for the law firm that serves as AORN’s Washington monitor, at- tended the meeting for AORN to gather infor- mation. AORN was considering whether to take a position. Cox said the American Academy of Pediatrics was taking the lead in opposing the rule, as they did earlier when they filed suit against the government.

James Strain, MD, the academy’s president, said, “Claims by the Department of Health and Human Services that somehow the second measure will safeguard children are baseless. Once again, HHS has relied on heavy-handed federal enforcement involving hospital signs, anonymous hotlines, and investigative proce- dures.

“The previous regulation’s brief implemen- tation made clear that such methods only in- trude into extremely sensitive, complex medi- cal situations and that the health care of se- verely ill infants can actually suffer as a result. Furthermore, they place an added burden on families at a most anguishing time.”

The American Nurses’ Association (ANA), which also opposes the proposed rule, has developed an alternative, described by Thomas Nickels, legislative counsel. Hospitals would be required to set up a committee com- posed of individuals such as physicians, nurses, parents of handicapped children, and clergy to develop guidelines for care of these patients.

Independent community nursing cen-

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ters run by registered nurses could provide ambulatory care under Medicare and Medicaid if a federal bill (S 410) passes. The centers would be an alternative to costly institutional care.

The concept, described in the American Nurse, was developed by ANA, and the bill was written with ANA‘s assistance. Sponsors are Sen Daniel lnouye (D-Hawaii) and Sen Bob Packwood (R-Ore).

The legislation was on hold this summer awaiting a cost study by the Congressional Budget Office. Because the federal health budget is so tight, ANA officials acknowledged the bill would go nowhere unless a study proved it would save money.

The bill would create a payment mechanism for the centers to receive monthly fees in ad- vance for the care and services they provide. They would have to give care to two of the following groups

0 those who are eligible for Medicare home health services

0 children eligible for Medicaid well-baby care

0 persons eligible for Medicare and Medi- caid who have been discharged from an institution within the past two years and might have to return to one if they did not receive community center nursing care.

The centers could also provide other ser- vices, such as hospice care; early periodic screening, diagnosis, and treatment: and school health programs. To prevent duplica- tion, they would build on existing agencies, such as visiting nurse associations and nurs- ing units of city and county health depart- ments.

An independent committee with a majority of professional nurses would monitor the centers by reviewing nursing plans of care and by periodic visits. The program would also be re- viewed by the US comptroller general.

ANA was encouraging nurses to write their senators asking them to cosponsor the bill. Because the Congressional Budget Office has an extensive backlog, more cosponsors might encourage the office to expedite the cost study.

Nurses in Ohio were fighting a change in state law that would allow physician’s assis- tants (PAS) to work “under the supervision and

control” of employek, which could be hospi- tals, nursing homes, and other health facilities.

Ohio has a PA law now, but it only allows PAS to be employed directly by physicians. The new bill would also expand current law by al- lowing PAS to prescribe medications under a supervising physician. In addition, nurses would no longer bs&xcused from executing orders given by PAS, as they are under present law.

The state medical board would be au- thorized to develop and administer rules the PAS would work under. PAS would be regis- tered by the board only to work for a specific employer. When they changed jobs, they would have to register again.

The PAS would have to pass a national cer- tification exam to register. The medical board would grant temporary permits to those who are eligible for the exam and have applied to take it or are waiting for the results.

The Ohio Nurses’ Association (ONA) op- posed the bill because it did not ensure PAS would be adequately supervised, because they would be allowed to prescribe, and be- cause nurses would be expected to follow their orders. The group was seeking amendments to correct these problems. AORN sent a tele- gram to legislators supporting ONAs position.

At the request of Gov Harry Hughes, Maryland is starting to develop an examination for baccalaureate nursing graduates that may eventually become a licensing examination. The Governor’s Commission on Nursing Is- sues, among other recommendations, has ad- vised moving toward the BSN as the entry level for professional nursing.

Although other state boards have supported the goal of the four-year degree as the nursing entry level, the state is the first to start develop- ing an exam for BSN graduates, said Donna Dorsey, RN, executive director of the Maryland State Board of Examiners of Nurses.

“We don’t know yet what form the exam will take,” she said early in the summer. The task force assigned to develop the exam had not decided whether it would initially be mandatory or voluntary. The group was beginning its task by looking at the BSN competencies de- veloped by deans and directors of nursing education programs.

The state board did not have any immediate

450 AORN Journal, September 1983, Vol38, No 3

plans to seek legislation to require the BSN for entry into practice. That might come later after the exam is near completion, Dorsey said. If legislation is sought, a means would be de- vised for protecting currently licensed RNs.

The governor’s commission met from 1980 through 1982 to develop a state framework for determining policies on nursing. Of their rec- ommendations, the two to receive attention

first are the nursing exam and a system of articulation for the three types of nursing edu- cation programs. Another task force is working on this project, which involves streamlining transitions from associate degree and diploma programs to baccalaureate curriculums.

Patricia Patterson Legislative consultant

Emphysema affected by poor nutrition Patients with emphysema who are also malnourished seem to have a greater decline in lung function. The mortality rate among the malnourished group of patients was also higher. These are the findings of a study by Diana R Openbrier, RN, and Margaret Irwin, RN, both of Pittsburgh, that were presented at the joint annual meeting of the American Lung Association and the American Thoracic Society.

There were 14 patients in the study, and eight were malnourished. None of the six patients with better nourishment died during the study, but three of the malnourished patients died.

correlation between the degree of airflow obstruction and the degree of malnutrition. Better nourished patients also showed a decline in lung function, but this was not nearly as great as that in poorly nourished patients.”

Poor nourishment among patients with emphysema is common. All patients in the study lost weight even though they were counseled on the importance of diet and high caloric supplements. In presenting their study results, Openbrier and Irwin pointed out that “nutritional depletion in patients with emphysema may be due to a combination of inadequate food intake and higher than normal energy requirements.”

of other differences in the patient groups accounting for the variances in lung function and mortality rate. “Degree of shortness of breath, level of depression, living arrangements, age, and knowledge of nutrition were similar in both groups. None

The investigators said, “There was a high

Consideration was given to the possibility

of these factors, or caloric intake alone, which was somewhat low for both groups, seems to contribute to the differences observed,” Openbrier and Irwin said.

Self-care reduces hospital stay A seven-year study of 97 men and 97 women, each with severe chronic obstructive pulmonary disease, has shown that self-care techniques reduced their average hospital stay from 38 to 20 days per year.

study at Barlow Hospital in Los Angeles, asked patients to spend two weeks in the hospital to learn physical therapy, occupational therapy techniques that conserve energy, how to maintain their respiration equipment, proper use of medications, and side effects and symptoms to watch for. The patients also received intense psychological counseling and assistance from a social worker.

The cost of the two-week hospitalization is returned within the first ten months in decreased emergency hospitalization, and the study (now with 390 patients) is continuing, Johnson reported at an American Lung Association-American Thoracic Society Annual meeting.

The patients lived for an average of 2.8 years with the disease after entering the study and saved over $1 1,000 in hospital costs during their illness (based on a typical daily charge of $797 in 1981).

N Ragner Johnson, MD, who headed the

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