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CLINICAL ROUNDS

doi: 10.1097/01.NURSE.0000458936.27878.16
Department: CLINICAL ROUNDS
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GERIATRICS

Teach patients to remove dentures at bedtime

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Sleeping with dentures in place increases the risk of pneumonia and other problems for older adults. In a study of 524 men and women, average age 88, 453 were denture wearers and 41% wore their dentures while sleeping. These people were about twice as likely to develop pneumonia during the 3-year study period than those who removed their dentures at bedtime. In fact, the pneumonia risk was comparable to the high risk associated with cognitive impairment or a history of stroke and respiratory disease. Patients who slept with their dentures also had more tongue and denture plaque, gum inflammation, positive Candida albicans cultures, and higher levels of circulating interleukin-6.

Sources: Iinuma T, Arai Y, Abe Y, et al. Denture wearing during sleep doubles the risk of pneumonia in the very elderly. J Dent Res. [e-pub Oct. 7, 2014]. Preidt R. Seniors should remove dentures at bedtime. Healthday News. October 22, 2014.

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FOOD ALLERGIES

Many MDs not current on causes, treatment

Responding to a six-question survey, over 400 internists and pediatricians revealed that many myths and misconceptions about allergy causes and treatment persist. For example, 85% of internal medicine physicians believe incorrectly that people with an egg allergy shouldn't get the influenza vaccine. And only 50% know that epinephrine is the standard treatment for someone who develops urticaria and vomiting after eating a known food allergen. Among pediatricians, only 27% know that milk and eggs are the most common causes of food allergies in children younger than age 4 (34% cited strawberries, which isn't among the top eight food allergens).

Most physicians in both groups think they need to ask patients about shellfish allergies before prescribing a computed tomography scan or other imaging procedures using an iodinated contrast medium. Because shellfish contain iodine, many erroneously assume that patients with a shellfish allergy will react to the iodine in contrast media. In fact, reactions to contrast media have nothing to do with iodine or shellfish allergy; iodine, which is found naturally in the body, can't be an allergen.

The researchers reported their study at the annual meeting of the American College of Allergy, Asthma and Immunology in Atlanta.

Source: Best treatment for allergic conditions? Some doctors don't even know. American College of Allergy Asthma & Immunology. News release. November 7, 2014.

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WORKPLACE VIOLENCE

Healthcare workers face lasting consequences

Although healthcare workers are particularly vulnerable to experiencing or witnessing violence on the job, little research has been done on the consequences to them. A systematic review of 68 studies on the consequences of workplace violence identified seven types of consequences: physical, psychological, emotional, work-related, relationships with patients/quality of care, social/general, and financial.

Consequences with the most impact were psychological (such as posttraumatic stress and depression), emotional, and work-related (such as excessive sick leave and decreased job satisfaction). Among emotional consequences, anger, fear, sadness, and disgust were reported most often.

Ten of the studies reported consequences affecting the quality of patient care, such as feeling fearful around patients, no longer enjoying patient care, and spending less time with patients. The researchers call for more study of the direct and indirect consequences of workplace violence on healthcare workers.

Sources: Lanctot N, Guay S. The aftermath of workplace violence among healthcare workers: a systematic literature review of the consequences. Aggression Violent Behavior. 2014;19(5):492-501. Workplace violence in the health sector: what are the consequences? Medical News Today. October 10, 2014.

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ANALGESIA

Patients report less pain after surgery

Postoperative pain severity has decreased by 24% since 2003, indicating a vast improvement in pain management for surgical patients. Researchers surveyed 441 surgical patients before hospital discharge and at 1, 2, and 3 weeks after surgery. Patients were asked to grade their pain intensity level on a scale from no pain to extreme pain. Patients also rated their satisfaction with the pain medication they were given. Researchers compared the collected survey data with data from a similar study conducted between 1998 and 2002 and published in 2003.

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They found that the proportion of patients who experienced moderate-to-severe pain 2 weeks after surgery decreased from 63% in the 2003 study to 39% in the 2014 study. The proportion of patients reporting “no pain” remained at 22% in both studies. Most patients in both studies reported that they were “satisfied” or “very satisfied” with their pain management. Lead investigator Asokumar Buvanendran, M.D., says that this “shows that healthcare providers are implementing better pain protocols and heading in the right direction.”

Researchers presented their findings at the annual meeting of the American Society of Anesthesiologists in New Orleans.

Source: Pain after surgery greatly decreased in the last 10 years. American Society of Anesthesiologists. News release. October 14, 2014.

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ALARM FATIGUE

Researchers propose fixes for nuisance alarms

Clinicians overwhelmed with excessive audible and visible equipment alarms, many of them false or inconsequential, experience “alarm fatigue” and may fail to respond promptly to life-threatening changes in a patient's condition. In an ambitious study, researchers examined 2,558,760 unique alarms in five adult ICUs in a 31-day study period. Over 1,154,200 were dysrhythmia alarms, of which nearly 89% were false positives.

Conditions causing excessive alarms included:

  • inappropriate alarm settings
  • persistent atrial fibrillation
  • “non-actionable events” such as premature ventricular contractions and brief spikes in ST segments
  • low-amplitude QRS complexes in some, but not all, available ECG leads
  • wide QRS complexes due to bundle-branch block or ventricular pacemaker rhythm.

Of the 168 true ventricular tachycardia alarms, 93% weren't sustained long enough to warrant treatment.

Based on their findings, the researchers recommend designing medical devices so they use all available ECG leads to identify nonartifact leads and leads with adequate QRS amplitude. They also suggest designing prompts to let clinicians better tailor alarm settings to individual patients and limiting atrial fibrillation alarms to new onset and dysrhythmia termination. The researchers conclude that “the excessive number of physiologic monitor alarms is a complex interplay of inappropriate user settings, patient conditions, and algorithm deficiencies...Because computer devices are more reliable than humans, an opportunity exists to improve physiologic monitoring and reduce alarm fatigue.”

The Joint Commission has made reducing alarm fatigue a National Patient Safety Goal and is requiring accredited hospitals to establish policies to manage alarms by January 2016.

Sources: Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. PLOS One. 2014;9(10):e110274. Hospital logs staggering 2.5 million alarms in just a month. University of California San Francisco. News release. October 22, 2014.

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ALCOHOL CONSUMPTION

Are nursing students drinking too much?

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A study designed to estimate the frequency of alcohol consumption among nursing students indicates that “a considerable proportion of students show evidence of hazardous alcohol consumption.” Researchers assessed 1,060 nursing students during the 2012-2013 academic year. The Systematic Alcohol Consumption Interview and the Alcohol Use Disorders Inventory Test were used to collect data on the students' socio-demographic characteristics, lifestyle, and alcohol consumption. Researchers observed hazardous alcohol consumption in about 43% of students; about 15% of men and 19% of women met criteria for hazardous drinkers, with no statistical difference between men and women. “The frequency of hazardous drinkers was significantly higher among participants aged under 21 years, those living outside the family nucleus, and smokers.” The researchers recommend more alcohol-prevention activities in universities where future healthcare professionals are being educated.

Source: Sotos JR, Gonzalez AL, Martinez IP, Rosa MC, Herraez MJS, Hidalgo JL. Prevalence of hazardous drinking among nursing students. J Adv Nursing. [e-pub Nov. 3, 2014]

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STROKE

Risk of recurrence remains high for years

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Stroke survivors are typically monitored closely for 90 days, a period during which the risk of recurrence is known to be high. But new evidence suggests that this isn't nearly long enough. Records on about 24,000 patients discharged from a hospital following a stroke or transient ischemic attack (TIA) from 2003 to 2011 reveal that these patients remained at significant risk for another stroke or similar event for at least 5 years.

As reported at the Canadian Stroke Congress in Vancouver, Canada, patients who survive stroke or TIA have an almost 10% risk for a repeat stroke, myocardial infarction, dying, or being admitted to long-term care in the first year after the 90-day high-risk period. Death was the most common of these events in the first year, affecting about 5% of the patients studied. The event rate remained at about 5% for each of the next 4 years. After 5 years, the event rate for stroke survivors was twice that for people of the same age and gender without a history of stroke or TIA.

Researchers said the results are “surprising” and recommend that clinicians continue to closely monitor patients who've had a stroke and TIA for longer periods, even years.

Source: Stroke patients past the 90-day danger period remain at high risk for repeat event for years. Heart and Stroke Foundation of Canada. News release. October 7, 2014.

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In January, celebrate

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