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Clinical Rounds

doi: 10.1097/01.NURSE.0000531906.15349.26
Department: Clinical Rounds
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Ask patients about their bucket list



Researchers hypothesized that inquiring about a patient's bucket list might help clinicians provide “preference-sensitive” patient care. The bucket-list colloquialism refers to a list of experiences or achievements someone wishes to attain before dying.

In a cross-sectional, mixed-methods online study, the researchers asked participants if they have a bucket list and, if so, to list up to five items in order of importance. Study results were based on data collected from 3,056 people from all 50 states. The most common theme was a desire to travel. Other top themes were a desire to accomplish a personal goal, achieve a specific life milestone, spend quality time with friends and family, and achieve financial security. The researchers note that while many patients lack knowledge about treatment options and advance planning concepts, nearly everyone is familiar with bucket lists. They conclude that “clinicians can elicit the patient's bucket list and use it as a starting point to initiate goals of care discussions and as a strategy to craft personalized care plans based on a patient's own life goals.”

Source: Periyakoil VS, Neri E, Kraemer H. Common items on a bucket list. J Palliat Med. [e-pub February 8, 2018].

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FDA approves blood test for mild TBI

Standard assessment for patients with suspected mild traumatic brain injury (mTBI)/concussion includes neurologic assessment based on the Glasgow Coma Scale followed by brain computed tomography (CT). However, most patients with mTBI have no detectable brain lesions on CT. A new blood test may help clinicians evaluate the need for CT, preventing unnecessary neuro-imaging and radiation exposure. The Brain Trauma Indicator, recently approved for marketing by the FDA, measures levels of proteins, known as ubiquitin C-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), released from the brain into the bloodstream within 12 hours after a head injury. Levels help clinicians determine whether CT is likely to detect brain lesions. Results can be available in 3 to 4 hours. In a clinical trial involving 1,947 patients with suspected mTBI, the test accurately predicted that lesions would be visible 97.5% of the time, and accurately predicted that lesions wouldn't be visible 99.6% of the time. The FDA concluded that the test “can reliably predict the absence of intracranial lesions and that healthcare professionals can incorporate this tool into the standard of care to rule out the need for a CT scan in at least one-third of patients who are suspected of having mTBI.”

Source: FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults. U.S. Food & Drug Administration. News release. February 14, 2018.

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ACIP updates guidelines for adults

The latest guidelines from the CDC Advisory Committee on Immunization Practices (ACIP) are intended to “promote the integration of vaccinations as a part of routine clinical care for adults.” Changes include a preferential recommendation for a new recombinant zoster vaccine for older adults and a third dose of measles mumps rubella vaccine for any adults at risk for mumps during an outbreak. The new guidelines also revise vaccination schedules for the Tdap, A,C,W, and Y meningococcal, and human papillomavirus vaccines.

For complete recommendations, visit

Sources: Kim DK, Riley LE, Hunter P, on behalf of the Advisory Committee on Immunization Practices. Recommended immunization schedule for adults aged 19 years or older, United States, 2018. Ann Intern Med. 2018;168(3):210-220. Walker M. ACIP issues updated adult vax schedule. MedPage Today. February 5, 2018.

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Imagine bringing hospital care into the home

In a randomized controlled pilot study, one hospital system improved care and lowered costs by providing hospital-level care to selected patients admitted to the ED with infections or exacerbations of heart failure, chronic obstructive pulmonary disease, or asthma. Nine patients received care at home, and a control group of 11 patients received standard care in the hospital. Patients in the home-care group received daily visits from an attending physician and two daily visits from an RN. Their care also included 24-hour physician coverage, I.V. medications if needed, and electronic connectivity for continuous monitoring, video communication, texting, and point-of-care testing. Patients in both groups were interviewed about their experiences before treatment and 30 days after discharge.

Results showed no significant differences in reported patient experiences, quality of care, or safety. None of the patients in the home group experienced an adverse event versus one patient in the control group. Other findings included the following.

  • The median direct cost of the acute care episode was 52% lower for home patients than for the control group.
  • The median direct cost for the acute care plus the 30-day postdischarge period was 67% lower for home patients, with trends toward less use of home-care services.
  • Fewer lab orders and consultations were ordered for home patients.
  • Home patients were more physically active, with a trend toward more sleep.

The authors conclude that “the use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity.... Reimagining the best place to care for select acutely ill adults holds enormous potential.”

Sources: Levine DM, Ouchi K, Blanchfield B, et al. Hospital-level care at home for acutely ill adults: a pilot randomized controlled trial. J Gen Intern Med. [e-pub Feb. 6, 2018]. Pecci AW. “Home hospital” pilot halves acute care episode costs. MedPage Today. March 4, 2018.

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Treatment protocols needed, experts say

In-hospital ST-segment elevation myocardial infarction (STEMI) is a unique clinical entity with outcomes distinctly poorer than those of out-of-hospital STEMI, yet standardized definitions and treatment protocols are lacking. In a recent report, researchers note that patients with in-hospital STEMI are typically older, have more comorbidities, and are more likely to have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy. In addition, patients sedated for surgery may be unable to report chest pain. Patients with in-hospital STEMI are less likely to develop typical angina symptoms, leading to mortality ranging as high as 31% to 42%, according to some reports.

The three most significant shortcomings in treating in-hospital STEMI are delays in obtaining an ECG, delays in ECG interpretation, and delays in activating a STEMI system of care. To improve diagnosis, triage, and treatment, the research group proposes a quality improvement protocol based on these elements:

  • a low threshold of suspicion for STEMI throughout the hospital to drive clinicians to perform ECGs more quickly when patients develop hemo-dynamic decompensation or other signs of myocardial infarction.
  • a process for immediate interpretation of ECG findings.
  • a formal activation process for in-hospital STEMI. “The process of STEMI team or catheterization laboratory activation for an in-hospital STEMI should as much as possible mirror that for patients who present to the emergency department and are diagnosed as having STEMI,” the group writes.

Sources: Levine GN, Dai X, Henry TD, et al. In-hospital ST-segment elevation myocardial infarction: improving diagnosis, triage, and treatment. JAMA Cardiol. [e-pub Feb. 21, 2018]. Lou N. In-hospital STEMI still neglected, group says. MedPage Today. February 21, 2018.

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Midwifery associated with better outcomes



In a major study, a multidisciplinary team created a Midwifery Integration Scoring System (MISS) based on key items describing midwifery practice and interprofessional collaboration in all 50 states and the District of Columbia. Based on these data, they scored each state on factors such as scope of practice, autonomy, governance, and prescriptive authority. Higher scores indicated a higher level of integration of midwives across all settings. Scores ranged from 17 (North Carolina) to 61 (Washington).

The research showed that higher MISS scores were associated with “significantly more access to midwives, significantly higher rates of physiologic birth outcomes, lower rates of obstetric interventions, and fewer adverse neonatal outcomes.” It also highlighted the wide variety in state laws regulating midwifery. In many states, for example, midwives can be certified for practice without a nursing degree. This is the case in Washington, which had the highest MISS score.

The authors write that “the system of incentivizing institutional birth and physician management of healthy pregnancies has exacerbated the gaps between demand and available health human resources....Skilled midwives can assist a woman to assess her birth site options....Ideally, they would practice in a legal environment that allows them to practice to full scope, and collaborate seamlessly with other health professionals, across birth settings.”

Source: Vedam S, Stoll K, MacDorman M, et al. Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLoS One. 2018;13(2):e0192523.

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ICDs don't improve outcomes



Adults with chronic kidney disease (CKD) and heart failure (HF) are at risk for sudden cardiac death. Implantable cardioverter defibrillators (ICDs) have been shown to decrease the risk of arrhythmic death in patients without CKD who have HF with reduced ejection fraction (left ventricular ejection fraction ≤40%, known as HFrEF), but whether ICDs improve clinical outcomes in patients with HFrEF and CKD is unclear.

In a noninterventional cohort study, researchers identified 5,877 matched eligible adults with CKD, 1,556 with an ICD and 4,321 without an ICD. About 69% were men and 31% were women. The mean age was 72.9 years. They found no difference in all-cause mortality between patients in the two groups, but ICD placement was associated with an increased risk of subsequent hospitalization due to HF and in all-cause hospitalization. They conclude that “the potential risks and benefits of ICDs should be carefully considered in patients with heart failure and CKD.”

Source: Bansal N, Szpiro A, Reynolds K, et al. Long-term outcomes associated with implantable cardioverter defibrillator in adults with chronic kidney disease. JAMA Intern Med. 2018;178(3):390-398.

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In May, celebrate

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