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Clinical Rounds

doi: 10.1097/01.NURSE.0000532757.49118.4f
Department: CLINICAL ROUNDS
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POST-OP CARE

Nurses' education linked to lower mortality

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In hospitals with more nurses holding at least a bachelor's of science in nursing (BSN) degree, researchers found lower mortality for patients with Alzheimer disease and related dementias (ADRD) undergoing surgery. The study was a cross-sectional analysis of linked datasets representing adult, nonfederal, acute care hospitals in California, Florida, New Jersey, and Pennsylvania (N = 531). Study participants were Medicare beneficiaries age 65 and older with and without ADRD undergoing general, orthopedic, or vascular surgery (N = 353,333; ADRD, n = 46,163; no ADRD, n = 307,170). Outcome measurements were 30-day mortality and failure to rescue (death after a complication).

The researchers write, “We found that, although all participants benefitted from being cared for in hospitals with more BSN nurses, the effect was greatest for those with ADRD. For 30-day mortality and failure to rescue, individuals with ADRD undergoing surgery had greater reduction in odds of each outcome with each additional 10% of BSN nurses than individuals without ADRD.” They say their study adds to the evidence supporting the transition to a largely BSN nursing workforce as recommended in the landmark Future of Nursing report issued in 2010 by the Institute of Medicine, now known as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine.

Source: White EM, Smith JG, Trotta RL, McHugh MD. Lower postsurgical mortality for individuals with dementia with better-educated hospital workforce. J Am Geriatr Soc. [e-pub March 20, 2018].

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TRANSGENDER PATIENTS

Mastectomies reveal breast lesions

More transgender men are undergoing mastectomy as part of gender-confirmation surgery (female-to-male gender-confirmation mastectomy). In a recent report, analysis of breast tissue from 344 transgender men undergoing mastectomy found malignant or benign breast lesions in 166 patients (48%). Invasive breast cancer was found in two patients, including one who was only 31 years old. The findings underscore the need for routine examination of mastectomy specimens from transgender men, says senior author Mieke Van Bockstal. “For some of these patients with breast cancer, chemotherapy and axillary lymph node examination will be necessary.”

Sources: Van Renterghem SMJ, Van Dorpe J, Monstrey SJ, et al. Routine histopathological examination after female-to-male gender-confirming mastectomy. Br J Surg. [e-pub April 5, 2018]. Breast cancer detected in transmen undergoing mastectomy. Wiley. News release. April 5, 2018.

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NURSING EDUCATION

Students fall short on psychosocial fundamentals

Findings from an international study indicate that although nursing students are well prepared to identify their patients' physical needs, they may be less aware of patients' psychosocial and emotional needs. Researchers presented three patient scenarios to 398 nursing students in Sweden, England, Japan, Canada, and Australia, and surveyed them about the fundamentals of care required for each hypothetical patient. These fundamentals were considered to include providing adequate nutrition, hydration, hygiene, and sleep, as well as maintaining patient dignity.

The results showed that students were likely to correctly identify fundamental needs relating to communication, education, comfort, and elimination, but were less likely to identify needs relating to respecting patient choice, privacy, and dignity. The researchers concluded that students are better prepared to recognize clinical needs than certain “less tangible” psychosocial needs, which are equally important. They write, “To promote students' ability to identify the integrated nature of the fundamentals of care, practicing clinicians and nurse educators need to role model and incorporate all the fundamental care needs for their patients.”

Sources: Jangland E, Mirz N, Conroy T, et al. Nursing students' understanding of the Fundamentals of Care: a cross-sectional study in five countries. J Clin Nurs. [e-pub March 11, 2018]. Nursing students not always ID'ing fundamental care needs. HealthDay News. April 3, 2018.

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PEDIATRICS

Quality initiative reduces unnecessary tests

As part of a quality improvement initiative, clinicians at a large urban pediatric hospital sought to reduce electrolyte testing by more than 25% within 6 months. Research has shown that electrolyte testing is overused in pediatric inpatient care. Unnecessary testing can significantly raise healthcare costs without improving patient care.

The project targeted six hospital medicine teams. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. The primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. Medical emergency team (MET) calls and readmission rates were tracked as balancing measures.

After 1 month of educational interventions, the rate of electrolyte testing declined by 35%, from 2 lab draws per 10 patient days to 1.3 lab draws per 10 patient days. In addition, use of the most expensive electrolyte panel decreased from 67% to 22%. The changes were sustained for 9 months with no increase in rates of MET calls or readmission.

The authors estimate that these results could save an estimated $292,000 in patient-level charges over the course of a year. They plan to maintain quality improvement efforts that include expanding on these results, improving electronic medical record decision support, and developing interventions related to nursing workflow that would help reduce unnecessary lab testing.

Source: Tchou MJ, Tang Girdwood S, Wormser B, et al. Reducing electrolyte testing in hospitalized children by using quality improvement methods. Pediatrics. [e-pub April 4, 2018].

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HEALTHCARE ETHICS

Public weighs in on refusal-to-treat issues

According to a recent HealthDay/Harris Poll, most American's don't think healthcare workers should have the right to refuse to treat patients for moral or religious reasons. The online poll, which included more than 2,000 adults, found that overall, most respondents (69%) don't think providers should be able to refuse to treat a patient based on religious objections or objections to a patient's sexual orientation. Only a minority of Republicans (22%) and Democrats (8%) believe that providers should be allowed to refuse to treat patients on these grounds. “In reply to all the questions, regardless of which services were being provided or which patients were being treated, only relatively small minorities of the public believe that providers should be allowed to refuse to provide care,” commented Deana Percassi, managing director, public relations research practice for The Harris Poll.

Source: Thompson D. HealthDay. February 8, 2018.

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STROKE

New software looks for vascular occlusions

Intended for use by neurovascular specialists, the Viz.AI Contact application has been approved by the FDA to aid in the diagnosis of stroke. This clinical decision support software is designed to analyze computed tomography (CT) images and send a text notification to a neurovascular specialist if it identifies a possible large vessel occlusion. The algorithm will automatically notify the specialist at the same time the first-line provider is conducting a standard review of the images, potentially involving the specialist sooner than is typical under the usual standard of care.

The notification can be sent to a smart phone or other mobile device, but the specialist must review the images at a clinical workstation. The FDA warns that the application is limited strictly to analysis of CT imaging data and isn't a substitute for a full patient evaluation.

According to an FDA spokesman, the new software “could benefit patients by notifying a specialist earlier, thereby decreasing the time to treatment. Faster treatment may lessen the extent or progression of a stroke.”

Source: FDA permits marketing of clinical decision support software for alerting providers of a potential stroke in patients. U.S. Food & Drug Administration. News release. February 8, 2018.

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In June, celebrate

Alzheimer's and Brain Awareness Month www.alz.org/abam

Men's Health Month www.menshealthmonth.org

National Migraine and Headache Awareness Month https://chronicmigraineawareness.blog

National Cancer Survivors Day (June 3) www.ncsd.org

National HIV Testing Day (June 27) www.hiv.gov/events/awareness-days/hiv-testing-day

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NCSBN RESOURCE

Anniversary gift for newly licensed nurses

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In honor of its 40th anniversary, the National Council of State Boards of Nursing, Inc. (NCSBN), has published a booklet for newly licensed nurses entitled NCSBN Welcomes You to the Nursing Profession. Available for free, the booklet is a resource designed to help new nurses better understand nursing regulations and their board of nursing. The NCSBN intends to provide the booklet to each newly licensed nurse in the United States.

Designed to ease the transition from student to working professional, the booklet offers information about the nursing licensure process, the appropriate use of social media, professional boundaries, and many other topics. It also provides links to other free online resources such as videos, brochures, posters, journals, and newsletters. It can be accessed or ordered online at www.ncsbn.org/12096.htm.

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CARDIOVASCULAR RISK

Urge patients to lose that thigh fat too

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Years ago, a well-publicized study suggested that fat in the thigh, hip, and buttocks (gluteofemoral fat) might help protect against cardiovascular disease and diabetes. Since then, researchers have wondered if losing weight from these areas offsets the cardioprotective benefits of visceral weight loss. Australian researcher Peter Clifton recently investigated this issue by analyzing data from 399 participants in seven previously published diet-induced weight loss studies. Examining participants' levels of glucose, insulin, total cholesterol, triglycerides, low-density lipoprotein cholesterol, and BP, he found that losing fat and muscle in the thighs, hips, and buttocks was “directly associated” with beneficial changes in heart disease risk markers. In addition, he found that loss of lean muscle weight didn't seem to have an adverse effect on cardiovascular risk. In an interview, Clifton commented, “The bottom line is that any weight loss—regardless of whether it is fat or lean, backside or abdomen—reduces cardiovascular risk factors.”

Sources: Clifton PM. Relationship between changes in fat and lean depots following weight loss and changes in cardiovascular disease risk markers. J Am Heart Assoc. 2018;7(8):e008675. American Heart Association. AHA: shedding so-called ‘protective’ thigh fat may help the heart. April 4, 2018.

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