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Department: CLINICAL ROUNDS

Clinical Rounds

doi: 10.1097/01.NURSE.0000459589.55525.29
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In Brief

HAND HYGIENE

Healthcare workers are lax at shift's end

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Nurses and other healthcare personnel who work in hospitals perform less and less hand hygiene as their workday progresses. In a study involving over 4,150 caregivers in 35 U.S. hospitals, researchers found that “hand hygiene compliance rates dropped by a regression-estimated 8.7 percentage points on average from the beginning to the end of a typical 12-hour work shift. This decline in compliance was magnified by increased work intensity.”

Interestingly, the more time off workers had between work shifts, the more closely they followed hand-washing protocol when they returned to work. Researchers hypothesize that a longer break helps restore workers' “executive resources”—cognitive resources that allow people to control behavior and emotions.

Healthcare workers represented in the study included nurses (65%), patient care technicians (12%), therapists (7%), and physicians (4%).

Sources: Dai H, Milkman KL, Hofmann DA, Staats BR. The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care. J Appl Psychol. 2014 Nov 3. [E-pub ahead of print]. American Psychological Association. Hospital workers wash hands less frequently toward end of shift, study finds. News release. November 10, 2014.

MYOCARDIAL INFARCTION

Fast, coordinated response saves lives

In a large project involving healthcare systems in 16 U.S. metropolitan areas, faster responses and better coordination between first responders and hospitals dramatically reduced death from out-of-hospital myocardial infarction. The nationwide project focuses on reaching patients faster, treating them aggressively in the field, and transporting them quickly to the nearest facility with appropriate resources, such as a cardiac catheterization lab. During the project's first year:

  • treatment within 90 minutes of first medical contact for patients arriving at the hospital via emergency medical services increased from 54% to 59%. In some metropolitan areas, the percentage improved by 15% or more.
  • mortality was 3.6% for patients who waited in the ED for 30 minutes or less. For patients who waited for 30 to 45 minutes, mortality was 7%. Mortality was over 10% for those who waited for over 45 minutes.

According to the American Heart Association (AHA), about half of patients who experience an ST-segment elevation myocardial infarction (STEMI) in the United States each year aren't treated within the recommended 90 minutes. The ambitious Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI ACCELRATOR is intended to eliminate treatment delays and improve STEMI survival rates by facilitating better coordination among first responders, hospitals, and community agencies. Preliminary results from the project were presented at the AHA's annual meeting in Chicago. For more information, visit http://www.heart.org and search for Mission: Lifeline.

Source: American Heart Association. Coordinated, faster emergency response associated with improved heart attack survival. News release. November 19, 2014.

DEVICE-RELATED TOXICITY

PVC exposure may endanger neonates

Di(2-ethylhexyl)phthalate (DEHP) is used to add flexibility to many medical devices made with polyvinyl chloride (PVC), including I.V. bags, tubing, and catheters. Because DEHP doesn't bind chemically with PVC, it can leech into fluids and body tissues. Testing the extent of nonendocrine toxic risks to critically ill premature infants, researchers made a startling discovery: Daily intake of DEHP in preterm neonates in the neonatal ICU can reach 16 mg/kg/day, “which is on the order of 4,000 and 160,000 times higher than desired to avoid reproductive and hepatic toxicities, respectively.”

Besides interfering with normal hormone function, exposure to DEHP has been shown to cause inflammation and liver damage, and interfere with development of the lungs, eyes, and brain in animal studies. Use of DEHP, the only phthalate approved for medical devices in the United States, is unregulated in medical devices. In children's toys and childcare products, however, it's limited to trace amounts.

In an interview, neonatologist and study leader Eric Mallow, MD, said, “It's remarkable that the care of sick and developmentally vulnerable preterm infants depends on an environment composed almost entirely of plastic...The role of these synthetic materials in the clinical course of our patients remains almost completely unexplored.” The researchers believe that the most effective initial step to protect infants would be to remove products containing DEHP from the neonatal ICU and replace them with alternatives that are free from this chemical.

On its web page devoted to DEHP, the FDA notes that the agency has identified “procedures that could result in exposure to relatively high levels of DEHP in sensitive patients (e.g., male neonates). We have recommended that devices made of alternative materials, or that are made of PVC that does not contain DEHP, be used for these procedures.”

Sources: Mallow EB, Fox MA. Phthalates and critically ill neonates: device-related exposures and non-endocrine toxic risks. J Perinatol. 2014;34(12):892-897. Johns Hopkins Bloomberg School of Public Health. Premature infants are exposed to unsafe levels of chemical in medical products used to save their lives. News release. November 14, 2014. Food and Drug Administration. DEHP in medical devices. 2014. http://www.fda.gov.

ANESTHESIA COMPLICATIONS

Huge database reveals dramatic drop in rates

Between 2010 and 2013, anesthesia-related complications declined by more than 50%, according to researchers who evaluated data from a registry of more than 3.2 million anesthesia cases. During the same period, overall mortality held steady at .03%, or 3 deaths per 10,000 procedures involving anesthesia. The most common minor complication was postoperative nausea and vomiting (35.5%). The most common major complication was medication error (11.7%).

Researchers also found that:

  • complication rates were no higher in procedures performed in the evening or on holidays than at other times.
  • patients age 50 and older had the highest complication rates.
  • minor complications were more common in elective daytime procedures on healthier patients.

The study was based on data collected by the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry. Researchers presented their findings at the annual meeting of the American Society of Anesthesiologists in New Orleans.

Source: Huge registry shows anesthesia complication rates dropped by more than half in four years. American Society of Anesthesiologists. News release. October 12, 2014.

PATIENTS WITH DISABILITIES

NIH funds research on interactive robots

The interagency National Robotics Initiative supports research to develop “co-robots”: interactive robots that work cooperatively with the user. Funded by the National Institutes of Health (NIH) and several other government agencies, the research supports development of co-robots designed to assist people with disabilities, such as patients with stroke-related disabilities, those confined to wheelchairs, and children with autism spectrum disorder (ASD). Promising examples include:

  • wearable exoskeletons to induce recovery of limb function. After a stroke, many patients struggle with impaired limb function. Placed on an affected arm, this lightweight device could be used at home to provide the kind of goal-directed, purposeful movement normally provided by rehabilitation therapists.
  • a computer vision-based active learning co-robot wheelchair. Designed for patients with limited hand movement who rely on a wheelchair for mobility, this equipment would be controlled by the user's head movements. During use, it would gather information about the patient's behavior and responses and tailor its functions accordingly.
  • music-based interactive robotic orchestration for children with ASD. Research shows that improvising with musical instruments or song can help children with ASD improve their social skills. With this system, a child with ASD could interact with a musical robotic companion in a safe and comfortable manner.

About $2.3 million has been earmarked to support robotic research over the next 5 years, subject to availability of funds.

Source: National Institutes of Health. NIH funds robots to assist people with disabilities. News release. December 8, 2014.

In February, celebrate

DRUG ABUSE

ED visits for “synthetic marijuana” on the rise

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Not derived from the marijuana plant, synthetic cannabinoid, also called synthetic marijuana, is a street drug promoted as producing the same effects as marijuana. Also known as K2 or spice, this unregulated product can contain potentially harmful contaminants that are sending more users to the ED. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), synthetic cannabinoid-related ED visits involving adolescents age 12 to 17 doubled from 2010 to 2011; among those age 18 to 20, the number quadrupled in that period. In 2011, males accounted for about 79% of synthetic cannabinoid-related ED visits, but visits by females tripled between 2010 and 2011.

Adverse reactions to synthetic cannabinoids include severe agitation, anxiety, nausea and vomiting, tachycardia, hypertension, tremors, seizures, paranoia, hallucinations, and even death. People who use the drug regularly may experience withdrawal.

“Synthetic cannabinoids are a growing public health risk,” says SAMHSA Administrator Pamela S. Hyde, “made even more dangerous by the widespread misconception that they are safe and legal. These injury reports compel us to get the word out to all segments of the community—especially youth—that these products can cause significant harm.”

Source: Emergency department visits linked to “synthetic marijuana” products rising. Substance Abuse and Mental Health Services Administration. News release. October 16, 2014.

GERIATRICS

U.S. falls short in care for older adults

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In a study of the health and healthcare experiences of older adults in 11 industrialized nations, the United States lagged behind in several key areas. For example,

  • older adults in the United States were sicker than their foreign counterparts.
  • out-of-pocket expenses were more problematic for Americans.
  • access to primary care and avoiding the ED “tended to be more difficult in the United States, Canada, and Sweden than in other surveyed countries.”

One-fifth or more of surveyed older adults in all countries except France reported receiving uncoordinated care.

On the positive side, patients in the United States were more likely to have discussed health-promoting behaviors and end-of-life issues with their healthcare provider than patients in the other countries. American patients were also more likely to have a healthcare plan tailored to their daily life.

The study was based on a telephone survey of 15,617 patients age 65 and older in the United States, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.

Source: Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Affairs. [e-pub Nov. 19, 2014]

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