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Clinical Rounds

doi: 10.1097/01.NURSE.0000531021.93707.d3
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Nurses are tough critics



Many studies conducted worldwide have shown high levels of patient satisfaction with nursing care among members of the public, but most patients aren't well equipped to judge specific aspects of nursing care—unless they're nurses themselves. Seeking more educated opinions, researchers collected data from the Patient Satisfaction with Nursing Care Quality Questionnaire from a sample of 231 RNs from eight hospitals in Jordan. All participants had either been hospitalized for at least 24 hours or served as a family caregiver for a hospitalized close relative within the prior year. Most of these RNs were female with less than 10 years of work experience, and the average age was 31.

Reflecting only a moderate level of satisfaction with nursing care, the average score was 2.96 out of 5. Of the 19 items on the satisfaction scale, none exceeded the moderate level. The highest mean satisfaction level score was 3.20 for the skills and competence of nurses; the lowest mean score was 2.68 for care coordination after discharge. The researchers say their findings may help nurses become more aware of unmet patient needs.

Source: Elayan RM, Ahmad MM. A new approach in exploring satisfaction with nursing care by nurses themselves. J Clin Nurs. [e-pub Jan. 18, 2018].

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Tool helps patients make good decisions

Research has shown that many women with breast cancer aren't well informed about the pros and cons of various treatment options. A comprehensive interactive online decision tool called iCanDecide was developed to help women make informed and personalized treatment decisions. The tool is designed to systematically walk patients through key facts about breast cancer surgery, such as the likelihood of needing additional surgery. A second module helps patients understand options about chemotherapy. Interactive features let patients drill down for more information.

Conducting a randomized controlled trial, researchers examined the tool's effectiveness at clarifying surgical options compared with static online information. The study included 537 newly diagnosed patients with early stage breast cancer enrolled at the first visit in 22 surgical practices. Participants were surveyed 5 weeks post enrollment after treatment decision making (N = 496). The primary outcome was a high-quality decision including two components: high knowledge about treatment options and a values-concordant treatment decision.

The findings: Compared with control patients, significantly more patients using the tool had high knowledge (61% versus 42%) and felt prepared for decision making significantly more often than control patients (50% versus 33%).

To incorporate patients' values into their decisions, the tool also took them through a series of hypothetical scenarios and created personalized bar graphs of surgical options reflecting their stated preferences. For example, the lumpectomy bar would be higher if a patient valued keeping her natural breast. The study showed that most patients in both groups (about 80%) felt their decisions were consistent with their values.

“The values clarification is important,” commented lead author Sarah T. Hawley. “If you don't combine the knowledge and the values, you get people making values-based choices that may not be fully informed.” Further refinements of the tool are planned.

Sources: Hawley ST, Li Y, An LC, et al. Improving breast cancer surgical treatment decision making: the iCanDecide randomized clinical trial. J Clin Oncol. [e-pub Jan. 24, 2018]. Interactive tool improves patient knowledge of breast cancer treatment options. Michigan Medicine—University of Michigan. News release. January 30, 2018.

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Wound complications? There's an app for that

Surgical site infection (SSI) is the leading cause of readmission among surgical patients, but patients may not recognize signs and symptoms. To help reduce SSI rates, researchers developed and tested a mobile health protocol involving remote wound monitoring using smartphone technology. Following vascular surgery, 40 patients were shown how to transmit digital images of their wound to their provider. They were asked to submit data daily for 2 weeks after discharge and answer survey questions about their experience with the protocol. The overall submission rate was 90%.

Reviewing submissions within 9.7 hours of submission on average, providers detected seven wound complications and one false negative. Both patients and providers reported a high level of satisfaction with the remote monitoring system. Commenting on the feasibility of remote post-op monitoring, the researchers concluded that “preliminary results indicate the ability to detect and intervene on wound complications.”

Source: Gunter RL, Fernandes-Taylor S, Rahman S, et al. Feasibility of an image-based mobile health protocol for postoperative wound monitoring. J Am Coll Surg. [e-pub Jan. 19, 2018].

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Updated practice guideline issued

The American College of Cardiology and American Heart Association released a new clinical practice guideline relating to hypertension in adults in November 2017. As recently summarized by the researchers in an online article, the 2017 guideline has several key revisions that differ from prior guidelines, such as a different classification system for BP. It also emphasizes out-of-office BP measurements to assess BP and monitor response to treatment, and advocates team-based care and use of the electronic health record and telehealth strategies to improve patient care. Find the entire summary at the source below.

Source: Carey RM, Whelton PK; 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Ann Intern Med. [e-pub Jan. 23, 2018].

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Symptoms may linger after treatment

After undergoing standard antibiotic treatment for Lyme disease, 10% to 20% of patients continue to experience posttreatment Lyme disease syndrome (PTLDS), defined by the Infectious Disease Society of America as development of significant fatigue, widespread musculoskeletal pain, and/or cognitive difficulties that arise within 6 months after completion of antibiotic therapy for physician-documented Lyme disease and last for at least 6 months.

To investigate this poorly understood syndrome, researchers from Johns Hopkins University recruited 61 patients diagnosed with PTLDS and paired them with 26 control patients. All subjects underwent a comprehensive battery of clinical and lab tests, including an extensive neurologic assessment. Subjects also provided patient histories to a trained interviewer and answered questionnaires about their symptoms and quality of life.

Although patients in the PTLDS group showed few objective clinical abnormalities, researchers found that these patients “exhibited levels of fatigue, musculoskeletal pain, sleep disturbance, and depression which were both clinically relevant and statistically significantly higher than controls.” As the incidence of Lyme disease continues to rise, the researchers see a growing need to educate healthcare professionals about integrating assessment and management of PTLDS into patient care, noting that “our study shows that PTLDS can be successfully identified using a systematic approach to diagnosis and symptom measurement.”

Sources: Rebman AW, Bechtold KT, Yang T, et al. The clinical, symptom, and quality-of-life characterization of a well-defined group of patients with posttreatment Lyme disease syndrome. Front Med (Lausanne). 2017;4:224. Severe and lingering symptoms occur in some after treatment for Lyme disease. Johns Hopkins Medicine. News release. February 1, 2018.

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In April, celebrate

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Substance use screening recommended



Evidence about the risk of long-term substance use in children diagnosed with attention-deficit hyperactivity disorder (ADHD) has been inconclusive. Researchers sought to assess this risk in an observational follow-up study involving a diverse sample of 547 children, mean age 8.5, diagnosed with DSM-IV combined-type ADHD, and 258 classmates without ADHD, termed the local normative comparison group (LNCG). These subjects completed the Substance Use Questionnaire up to eight times from mean age 10 to mean age 25. Analysis revealed these findings:

  • weekly marijuana use (32.8% ADHD versus 21.3% LNCG) and daily cigarette smoking (35.9% versus 17.5%) were more prevalent in adulthood among those in the ADHD group.
  • early substance use in adolescence was also more prevalent in the ADHD group (57.9% versus 41.9%). This included first use of alcohol, cigarettes, marijuana, and illicit drugs at a younger age.
  • alcohol and nonmarijuana illicit drug use escalated slightly faster in the ADHD group in early adolescence. Early substance use predicted faster substance use escalation and more substance use in adulthood for both groups.

The authors write, “We suggest that screening for, and interventions to prevent, early [substance use] before it escalates to intractable levels is critical for all high-risk adolescents and especially for children with ADHD.”

Source: Molina BSG, Howard AL, Swanson JM, et al. Substance use through adolescence into early adulthood after childhood-diagnosed ADHD: findings from the MTA longitudinal study. J Child Psychol Psychiatry. [e-pub Jan. 8, 2018].

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Nurses need their sleep



In a recently issued position statement, the American Academy of Nursing urges nurse employers to adopt policies and practices that reduce nurse fatigue related to sleep deficiency and work hours, especially irregular working hours and night shifts. After identifying educational resources and programs available to address the issue of nurse fatigue, the statement urges employers to incorporate evidence-based practices into work schedules and policies. It also calls on employers to promote a workplace culture that supports sleep health and “to recognize the role of shift work, long shifts, and nurse fatigue on turnover, absenteeism, patient safety, and related costs.” Both employers and nurses are encouraged to educate themselves about the health risks associated with fatigue and the evidence-based resources and strategies that can reduce those risks.

Source: Caruso CC, Baldwin CM, Berger A, et al. Position statement: reducing fatigue associated with sleep deficiency and work hours in nurses. Nurs Outlook. 2017;65(6):766-768.

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