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Clinical Rounds

doi: 10.1097/01.NURSE.0000547736.82178.aa
Department: Clinical Rounds
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Rates for healthcare workers still stagnant



Just over 78% of healthcare workers received the flu vaccine in the 2017-2018 flu season, about the same percentage as for the previous four flu seasons. Conducting an opt-in internet panel survey of 2,265 US healthcare workers, CDC investigators found that coverage was highest among those whose employers required vaccination (94.8%) and lowest among those working in settings where vaccination was not required, promoted, or offered on site (47.6%). Employee vaccination rates were lowest in long-term-care facilities compared with other healthcare settings.

Among respondents who work in long-term-care facilities, over 23% reported that their employer did not require, make available on-site at no cost, or promote vaccination in any way. The study authors note that workplace vaccination programs have successfully improved coverage in hospital settings and could be used to increase coverage in long-term-care settings as well.

Source: Black CL, Yue X, Ball SW, et al. Influenza vaccination coverage among health care personnel—United States, 2017-18 influenza season. MMWR Morb Mortal Wkly Rep. 2018;67(38):1050-1054.

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Privacy curtains harbor MRSA and other pathogens

In a longitudinal prospective pilot study, researchers found that hospital privacy curtains become progressively contaminated with bacteria, including methicillin-resistant Staphylococcus aureus (MRSA). Over a 21-day period, they obtained cultures from 10 freshly laundered curtains—8 test curtains surrounding patient beds in a burn unit and 2 control curtains from an unoccupied room. Culture specimens were taken from the edge hem where curtains are most often touched.

The findings showed that the test curtains became increasingly contaminated over time. By day 10, one curtain tested positive for MRSA; by day 14, five curtains were positive for MRSA. The two control curtains remained uncontaminated throughout the test period.

The authors write, “Given that we sampled areas where people hold curtains, it is likely that the increasing contamination was because of direct contact...These data suggest that interventions to clean or routinely replace curtains should occur approximately 14 days after the curtains are hung.”

Source: Shek K, Patidar R, Kohja Z, et al. Rate of contamination of hospital privacy curtains in a burns/plastic ward: a longitudinal study. Am J Infect Control. 2018;46(9):1019-1021.

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Most adults report experiencing ACEs

Based on a large, diverse, and representative sample of adults in 23 states, researchers say that over 60% of adults have experienced at least one adverse childhood experience (ACE). Emotional abuse was the most commonly reported ACE, followed by parental divorce or separation and substance abuse in the household.

Data were collected via a nationally representative telephone survey on health-related behaviors, health conditions, and use of preventive services conducted from January 1, 2011 through December 31, 2014. Of the 214,157 respondents, 51.51% were female. Over 60% of respondents had at least one ACE and nearly 25% reported three or more ACEs. Significantly more exposures were reported by respondents identifying with various subgroups, including Black, Hispanic, or multiracial; unemployed; low-income (less than $15,000/year); and less educated (less than a high school education).

The study authors note that ACEs are associated with leading causes of adult morbidity and mortality and affect a person's lifetime opportunities. “This report demonstrates the burden of ACEs among the US adult population using the largest and most diverse sample to date,” they write. “Although identifying and treating ACE exposure is important, prioritizing primary prevention of ACEs is critical to improve health and life outcomes throughout the lifespan and across generations.”

Source: Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 states. JAMA Pediatr. [e-pub September 17, 2018].

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Testing needed to stem alarming resurgence

Reaching a 20-year high, the congenital syphilis rate has doubled since 2013, the CDC reports. Syphilis is easily cured with appropriate antibiotics during pregnancy. Without treatment, however, a pregnant woman with syphilis has up to an 80% chance of transmitting the infection to the fetus. Potential complications include miscarriage, newborn death, and severe lifelong physical and mental health problems for surviving infants.

The CDC recommends that all pregnant women be tested for syphilis the first time they see a healthcare provider about their pregnancy. Women at high risk for syphilis and those who live in high-prevalence areas should be tested again early in the third trimester and a third time at delivery.

“To protect every baby, we have to start by protecting every mother,” said Gail Bolan, M.D., director of CDC's Division of Sexually Transmitted Disease Prevention. “Early testing and prompt treatment to cure any infections are critical first steps, but too many women are falling through the cracks of the system. If we're going to reverse the resurgence of congenital syphilis, that has to change.”

Source: Centers for Disease Control and Prevention. Newborn syphilis cases more than double in four years, reaching 20-year high. News release. September 25, 2018.

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NLN promotes civility, inclusivity in academics

With a newly published entry to its Vision Series, Creating Community to Build a Civil and Healthy Academic Work Environment, the National League for Nursing (NLN) calls for cultural transformation in schools of nursing. Educators and nursing students are urged to collaborate in creating and implementing strategies and interventions that promote civility and inclusivity. “Faculty, staff, and students must assume the power of taking responsibility for co-creating a civil environment, sharing a collective commitment, and cherishing the joy of establishing a healthful work environment, grounded in a vibrant and respectful community of colleagues,” commented NLN CEO Beverly Malone, PhD, RN, FAAN, in her annual CEO address. The NLN's revised and updated Healthful Work Environment Toolkit and other resources are available at

Source: National League for Nursing. New installment in NLN Vision Series: Creating Community to Build a Civil and Healthy Academic Work Environment. News release. August 28, 2018.

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Mortality is 33% in older adults

In a retrospective cohort study, researchers examined data involving adults age 65 and older intubated in the ED from 2008 to 2015 in 262 hospitals across the US. The primary outcome was age-specific in-hospital mortality. Secondary outcomes were age-specific odds of death after adjusting for race, comorbid conditions, admission diagnosis, hospital disposition, and geographic region. Over 35,000 intubation encounters were included in the final analysis.

Results showed that after emergency intubation, 33% of older adults died during the index hospitalization, and only 24% of survivors were discharged to home. Mortality increased markedly with patient age, reaching 50% in patients age 90 and over. Mortality was also especially high in patients with an admission diagnosis of stroke.

Noting that little research has been done on the prognosis for older adults after emergency intubation, the authors write that their findings can help inform healthcare providers, patients, and caregivers during a health crisis. “Individuals aged 65 and older and their surrogates can be informed that, after intubation, the overall chance of survival and discharge to home after the index hospitalization is 24%....Data presented graphically, combined with experienced clinicians' overall clinical assessment, will be informative during shared decision-making.”

Source: Ouchi K, Jambaulikar GD, Hohmann S, et al. Prognosis after emergency department intubation to inform shared decision-making. J Am Geriatr Soc. 2018;66(7):1377-1381.

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In December, celebrate

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Older adults benefit most from balance training



Although falling is a significant risk for older adults, few studies comparing the effectiveness of various preventive interventions have been performed. In this study, researchers compared the effectiveness of three interventions:

  • a therapeutically tailored tai ji quan intervention, Tai Ji Quan: Moving for Better Balance (TJQMBB), developed on the classic concept of tai ji (also known as tai chi). This intervention involved practicing a core of eight therapeutically modified exercise forms with built-in variations and a subroutine of integrated therapeutic movement exercises.
  • a multimodal exercise (MME) program integrating balance, aerobics, strength, and flexibility activities.
  • stretching exercises; this intervention also included deep abdominal breathing exercises.

The study subjects, 670 community-dwelling older adults who had fallen in the preceding year, were assigned to one of the three intervention groups and participated in two 60-minute classes weekly for 24 weeks. The results:152 falls (85 participants) in the TJQMBB group, 218 falls (112 participants) in the MME group, and 363 falls (127 participants) in the stretching exercise group. At 6 months, the incidence rate ratio was significantly lower in the TJQMBB and MME groups compared with the stretching group. Falls were reduced by 31% for the TJQMBB group compared with the MME group.

The authors say their findings are of “considerable practical importance because they suggest the utility of an equipment-free, low-cost, non–space-constrained exercise intervention in addressing the clinical problem of falls and balance deficits in the older population.”

Source: Li F, Harmer P, Fitzgerald K, et al. Effectiveness of a therapeutic Tai Ji Quan intervention vs. a multimodal exercise intervention to prevent falls among older adults at high risk of falling: a randomized clinical trial. JAMA Intern Med. [e-pub Sep. 10, 2018]

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Help refute the milk-mucus myth



Many parents prevent children with any respiratory illness, even a cold, from drinking milk based on the false belief that milk consumption increases pulmonary mucus production. In a review of the evidence, Ian M. Balfour-Lynn, M.D., examines the myth's origins in the 13th century, its propagation in recent times, and the abundant research refuting it. “While certainly the texture of milk can make some people feel their mucus and saliva is thicker and harder to swallow, there is no evidence (and indeed evidence to the contrary) that milk leads to excessive mucus secretion,” he writes. “The milk-mucus myth needs to be rebutted firmly by healthcare workers.”

Sources: Balfour-Lynn IM. Milk, mucus and myths. Arch Dis Child. [e-pub September 6, 2018]. No evidence for milk increasing mucus production from lungs. HealthDay News. September 17, 2018.

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