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Clinical Rounds

doi: 10.1097/01.NURSE.0000546473.69584.10
Department: Clinical Rounds
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Vaccination rates wane as the day wears on



A quality improvement study of 11 primary care practices and 96,291 patients showed that influenza vaccination rates significantly declined as the clinic day progressed. However, a reminder alert (active choice intervention) delivered to medical assistants via the electronic health record (EHR) prompted them to ask patients about influenza vaccination during check-in was associated with a significant increase in influenza vaccination rates. Also included were template vaccination orders for clinicians to review during the visit.

As the workday progresses, clinicians may fall behind schedule and rush through appointments or become fatigued, which can affect their decision-making. In this study, the active choice intervention to remind staff about vaccination was delivered to medical assistants rather than physicians to eliminate the influence of “alert fatigue” on physicians. The results showed that the relative vaccination rate increased by nearly 20% compared with the preintervention period. However, even after the intervention, vaccination rates tended to decline as the day progressed.

Researchers say this is one of the first studies designed to evaluate variations in influenza vaccination rates according to appointment time. Previous studies have established a relationship between late-day healthcare appointments and other clinical lapses, such as inappropriate antibiotic prescribing practices and decreased hand hygiene compliance. The authors conclude that “approaches that leverage the EHR to deploy well-designed nudges may be a promising approach to improve medical decision-making behaviors, but further work is needed to address variations in vaccination rates by time of day.”

Source: Kim RH, Day SC, Small DS, et al. Variations in influenza vaccination by clinic appointment time and an active choice intervention in the electronic health record to increase influenza vaccination. JAMA Network Open. [e-pub Sep. 14, 2018]

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Probing the emotional burden for patients

Although the burden of healthcare-associated infection (HAI) on the healthcare system is well documented, little research has been conducted on the ongoing effects of HAI on patients. In a qualitative systematic review, researchers searched five databases to investigate adult patients' experiences with common HAIs. Included in the study were 17 studies (2001 to 2017) from five countries addressing five common HAI:

  • methicillin-resistant Staphylococcus aureus (MRSA) infection
  • surgical site infection (SSI)
  • Clostridium difficile infection (CDI)
  • S. aureus bloodstream infection
  • extended-spectrum beta-lactamase (ESBL)–producing bacterial infection.

For the purposes of this research, researchers considered both infection and colonization with healthcare–associated organisms an HAI.

Four themes emerged from the study: the continuum of physical and emotional responses, experiencing the response of healthcare professionals, adapting to life with an HAI, and the complex cultural context of HAI. These themes were interrelated, say the authors. “Irrespective of the type of HAI, daily living was often significantly affected, for many patients with MRSA or ESBL, excessively and unnecessarily so, and for patients with CDI and SSI, unexpectedly and alarmingly so.” Many patients feel stigmatized, both socially and within the healthcare system. “As with members of the wider society, [healthcare providers] may be concerned to distance or protect themselves from contagious patients,” the authors note. They call for increased awareness of the long-term, potentially life-altering emotional and social effects of HAI so healthcare professionals can support patients more effectively during treatment and recovery.

Source: Currie K, Melone L, Stewart S, et al. Understanding the patient experience of health care-associated infection: a qualitative systematic review. Am J Infect Control. 2018;46(8):936-942.

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New guidance on mTBI from the CDC

Based on a systematic literature review, the first evidence-based guideline details best practices for diagnosis, prognosis, and management of mild traumatic brain injury (mTBI) in pediatric patients. Issued by the CDC, the guideline includes 19 sets of recommendations, each weighted based on the strength of the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Among the recommendations:

  • Do not routinely use imaging techniques to diagnose mTBI to prevent exposing children to unnecessary radiation.
  • Use validated, age-appropriate symptom scales for diagnosis.
  • Assess patients for risk factors for prolonged recovery, such as history of mTBI or severe symptoms immediately after the injury.
  • Give patients specific, individualized instructions on return to activity.
  • Advise patients to return gradually to nonsports activities after no more than 2 to 3 days of rest; evidence has shown that children recover faster if they resume nonsports activities quickly.

For more information about mTBI, refer patients and parents to

Sources: Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. [e-pub Sep. 4, 2018]. Kids and concussions: UVA physician helps craft new CDC treatment guideline. University of Virginia Health System. News release. September 4, 2018.

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“Huge loss” for evidence-based practice

Established in 1998, the National Guideline Clearinghouse (NGC) has long been considered a trusted repository of practice guidelines meeting minimum quality criteria. Due to a loss of government funding, the NGC's user-friendly website ceased to exist in July 2018. Writing in the Annals of Internal Medicine, two commentators decry this development as a huge setback for the promotion of evidence-based care standards worldwide. “The NGC played a major role in motivating guideline developers to adhere to accepted standards for developing good-quality guidelines,” the authors write. “The decision to discontinue the NGC's funding is a step backward in evidence-based medicine that eventually will affect the quality of care provided to our patients.” They hope that another organization will pick up and maintain this important clinical resource.

Sources: Munn Z, Qaseem A. Disappearance of the National Guideline Clearinghouse: a huge loss for evidence-based health care. Ann Intern Med. [e-pub Aug. 28, 2018]. Experts address loss of the National Guideline Clearinghouse. HealthDay News. August 28, 2018.

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Do we ask questions the right way?

In the years before an Alzheimer disease (AD) diagnosis, many patients report cognitive difficulties. Response biases may undermine accurate interpretation of older adults' responses to questions about their cognitive status; this in turn affects the accurate assessment of AD risk. Using a convenience sampling of community-dwelling older adults without dementia, researchers sought to identify features of common cognitive self-report items that contribute to differing interpretations among respondents and older adults' decisional processes when responding. They found that “the most common sources of inconsistency in item interpretation and decisional processes were vague item wording, incorrect assumptions regarding consistency of cognitive problems across situations, and provocation of an emotional reaction that influenced responses.” The authors say that their findings identify modifiable sources of response bias that can be applied to improve and refine cognitive self-report items in assessment tools currently in use.

Source: Hill NL, Mogle J, Whitaker EB, et al. Sources of response bias in cognitive self-report items: “which memory are you talking about?” Gerontologist. [e-pub July 31, 2018]

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In November, celebrate

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Clinicians need to address unique issues



An estimated 1.4 million transgender adults live in the US, and the number is growing. In a narrative review, researchers addressed issues such as how to address transgender patients, obtain a health history that takes gender-affirming surgery into account, manage hormonal therapy and other clinical issues, and interpret lab values in light of hormone use. They noted that best practices in care for transgender patients include using a patient-identified name and pronoun, using gender-neutral terminology until learning the patient's preference, and including an anatomical inventory when assessing the patient's surgical history. Concerns related to healthcare systems include a lack of procedures for standardized collection of gender identity information and electronic health record platforms that are insufficiently comprehensive. In addition, hospitalized transgender patients may need additional institutional support when transitioning to outpatient care. The authors urge healthcare facilities to provide inclusive systems of care that account for the unique needs of transgender patients and create a welcoming environment for their care.

Source: Rosendale N, Goldman S, Ortiz GM, Haber LA. Acute clinical care for transgender patients: a review. JAMA Intern Med. [e-pub Aug. 27, 2018]

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New data shed light on inpatient suicide



The Joint Commission has issued the first evidence-based estimate of inpatient suicides occurring in US hospitals. The findings indicate that 49 to 65 hospital inpatient suicides occur each year, which is far below the widely cited estimate of 1,500 per year. Most (75% to 80%) were psychiatric inpatients. The estimated suicide rate among psychiatric inpatients was 3.2 per 100,000 admissions, compared with 0.03 per 100,000 nonpsychiatric admissions. More than 70% of deaths in both groups were by hanging. About half of suicides occurred in the bathroom and one-third in the bedroom. Less common locations were the closet and the shower. The most commonly used fixture point was a door, door handle, or door hinge.

The Joint Commission plans to step up its collection of sentinel alert data on inpatient suicide to help inform national improvement efforts and enhance patient safety.

Sources: Williams SC, Schmaltz SP, Castro GM, Baker DW. Incidence and method of suicide in hospitals in the United States. Jt Comm J Qual Patient Saf. [e-pub Sep. 3, 2018]. Bronk KL. First data-driven estimate of number of suicides in U.S. hospitals. The Joint Commission. News release. September 10, 2018.

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