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CLINICAL ROUNDS

doi: 10.1097/01.NURSE.0000464992.63854.8a
Department: CLINICAL ROUNDS
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NURSES' SALARIES

Female RNs still lag behind—substantially

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A new study shows that male RNs earn, on average, more than $5,000 per year than female RNs across most settings, positions, and all specialty areas except orthopedics. This earnings gap has persisted virtually unchanged since 1988.

Based on data from the last six quadrennial National Sample Survey of Registered Nurses and the American Community Survey, this major study revealed these salary gaps between men and women:

  • nurse anesthetists: $17,290
  • ambulatory care: $7,678
  • cardiology: $6,034
  • hospital settings: $3,873
  • middle management: $3,956.

The researchers note that while the gender gap has narrowed in many occupations since the Equal Pay Act of 1963, it persists in medicine and nursing. Over a 30-year career, a female RN will earn from $155,000 to $300,000 less than a male RN (based on adjusted and unadjusted survey data). Still predominantly female, nursing is the largest healthcare occupation.

Lead author Ulrike Muench, PhD, urges nurse employers to “examine whether there are legitimate reasons for paying these men more than women and take action to correct existing inequities.”

Sources: Muench U, Sindelar J, Busch SH, Buerhaus PI. Salary differences between male and female registered nurses in the United States. JAMA. 2015; 313(12):1265-1267. Maier S. Male RNs make thousands more in salary than female counterparts. University of California/UC Health. News release. March 26, 2015.

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PRACTICE GUIDELINES

Skip cardiac screening for low-risk patients

Based on a study of published systematic reviews, the American College of Physicians (ACP) advises clinicians against performing cardiac screening tests on asymptomatic, low-risk adults. These tests include resting or stress ECGs, stress echocardiography, and myocardial perfusion imaging.

“Cardiac screening has not been shown to improve patient outcomes,” the study author writes. “It is also associated with potential harms due to false-positive results given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions.”

Despite the evidence that cardiac screening tests are inappropriate for low-risk, asymptomatic patients, they're widely used in clinical practice, the author says. In one consumer survey cited, more than half of respondents said their physician recommended cardiac screening tests as part of routine healthcare.

The ACP recommends that clinicians forego these costly tests in these patients and focus on modifiable risk factors such as smoking, diabetes, hypertension, dyslipidemia, and excess weight.

Source: Chou R, for the High Value Care Task Force of the American College of Physicians. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015;162(6):438-447.

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INFORMATION TECHNOLOGY

Cultivate a safety culture

“A nurse noted that a patient had a new order for acetaminophen. After speaking with the pharmacist, the nurse determined that the order was placed for the wrong patient. The pharmacist had two patient records open, was interrupted, and subsequently entered the order for the wrong patient.”

As reported by The Joint Commission, this is one example of an adverse event associated with incorrect or miscommunicated information entered into health information technology (IT) systems. In a Sentinel Event Alert, The Joint Commission reports that 120 health IT-related sentinel events were submitted to The Joint Commission between January 1, 2010 and June 30, 2013. The top three factors leading to health IT sentinel events were related to:

  • human-computer interface (33%), including ergonomics and usability issues
  • workflow and communication (24%), such as IT support of communication and teamwork
  • clinical content (23%), described as “design or data issues relating to clinical content or decision support.”

To minimize IT-related risks, the Joint Commission makes specific recommendations in three crucial areas: safety culture, process improvement, and leadership. For example, to cultivate a safety culture, it calls for a “collective mindfulness” about identifying, reporting, and analyzing IT-related errors and near-misses. For details, visit http://www.jointcommission.org.

Source: The Joint Commission. Safe use of health information technology. Sentinel Event Alert, Issue 54. March 31, 2015.

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MENTAL HEALTH

Patient suicides linked to staffing problems

Use of inexperienced staff and agency nurses may increase the risk of self-harm among patients under observation for risk of suicide, according to a comprehensive report that analyzed all suicides among patients under observation for suicide during a 7-year period in the United Kingdom. The report incorporated results of an online survey of patients and staff about their experiences and additional data from six focus groups.

Investigators learned that 18 in-patients a year killed themselves while under observation, which usually meant a nurse checked the patient every 10 to 15 minutes. But in 9% of cases, patients were supposed to be under constant observation.

Researchers found that half of the suicides occurred when checks were performed by less experienced staff or agency nurses who were unfamiliar with the patient or facility protocol. Other factors increasing the risk were staff distractions or disruptions on the unit, busy periods, and poor unit design.

Among other findings:

  • Many nurses had a poor understanding of observation protocols. A nurse in one focus group commented that “very few nurses really understood what an observation meant. They thought it meant go away, see someone, come back and sign the sheet.”
  • Rather than feeling safe and cared for, many patients under observation felt a loss of dignity and privacy. One commented, “you feel like a prisoner...you are seen as causing them an extra burden.”
  • Although observation is intended as an opportunity for staff to “be with” patients rather than just watching them, this occurred infrequently.

The researchers recommend that suicide under observation be designated as a “never event,” and that observation be considered an acute intervention and a skilled task assigned to staff of “appropriate seniority.” They also call for better collaboration with patients to balance observation for suicide and active engagement, and suggest that patients participate in plans to transition to general observation.

Sources: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). In-patient Suicide under Observation. Manchester: University of Manchester; 2015. Mental health report finds that staffing problems linked to ward suicides. University of Manchester. News release. March 2015.

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SURVIVING SEVERE SEPSIS

Outpatient care helps prevent readmissions

Many patients who survive severe sepsis are rehospitalized within 90 days. In a study designed to find specific reasons why, researchers found that about 40% of readmissions might have been avoided if certain complications had been prevented or identified and treated early.

The study relied on data from the U.S. Health and Retirement Study, a national sample of households with adults age 50 and older, and Medicare claims from 1998 to 2010. Of 3,494 patients hospitalized for severe sepsis, 81% survived to discharge, and 43% were readmitted to the hospital within 90 days. Between 22% and 42% of those readmissions were potentially preventable with effective outpatient care. The most common reasons for readmission were sepsis, congestive heart failure, pneumonia, acute renal failure, and rehabilitation.

Sources: Prescott HC, Langa KM, Iwashyna TJ. Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions. JAMA. 2015;313(10):1055-1057. Barclay L.” Hospital Readmissions after Severe Sepsis Often Preventable.” Medscape. March 11, 2015.

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In June, celebrate

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KIDNEY TRANSPLANT

Older deceased donors can help older patients

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Most kidneys from deceased patients over age 65 are discarded rather than being made available for transplant. New research indicates that while these kidneys can't provide a lifetime of function for younger adults, they can benefit older adults with a shorter life expectancy. Making these kidneys available to older adults who need a kidney could shorten transplant waiting lists.

Investigators analyzed data regarding survival rates from patients in the United States and Europe who received a kidney transplant. Their findings indicate that people age 60 and older have a better chance of long-term survival if they get a kidney from an older donor within a year of being placed on the waiting list, rather than waiting a year or more for a kidney from a younger donor. The data also confirmed that kidneys from older donors don't provide a lifetime of function in patients age 50 or younger.

Researchers write that their findings should encourage transplantation of kidneys from older donors into patients age 60 and older and challenge the policy in the United States of allowing patients younger than 50 to receive a kidney from an older donor.

Sources: Rose C, Schaeffner E, Frei U, Gill J, Gill JS. A lifetime of allograft function with kidneys from older donors. J Am Soc Nephrol. [e-pub Mar. 26, 2015]. Preidt R. Kidneys from dead older donors may help seniors, study finds. HealthDay News. March 26, 2015.

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NEONATAL CARE

Babies do better in bodysuits

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Self-touch is an important way infants reduce stress and soothe themselves. Could wearing clothing that restricts these gestures have behavioral and physiologic consequences? Researchers set out to answer that question by evaluating the behavior of newborns wearing two types of clothing commonly used in a neonatal intensive care unit: light clothing (bodysuit and a light wrapping) or heavy clothing (pajamas, cardigan, and sleep sack).

The study involved 18 healthy, 34 to 37 postconception week-old preterm newborns. Researchers tracked their behavior during resting periods when they were undisturbed by any interventions. The percentages of time each infant spent in different postures were compared by clothing type.

The study showed that infants wearing lighter bodysuits bent their arms more and held their hands nearer their heads than those in sleep sacks. Infants in bodysuits spent more time touching their body or their surroundings; those in heavier clothing generally touched nothing. The researchers concluded that “heavy clothing may impair self-soothing behaviours of preterm newborn babies that already lack other forms of contact.” They recommend that clinicians pay more attention to “apparently routine and marginal decisions such as choice of clothing.”

Source: Durier V, Henry S, Martin E, Dollion N, Hausberger M, Sizun J. Unexpected behavioural consequences of preterm newborns' clothing. Sci Rep. 2015;5:9177.

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