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Clinical Rounds

doi: 10.1097/
Department: Clinical Rounds
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Nurses concerned about patient safety



Lead by prominent nursing researcher Linda Aiken, PhD, RN, investigators surveyed 535 hospitals in four large states at two points in time between 2005 and 2016 to determine the extent to which work environments and patient safety have improved in recent years. The data included reports from 53,644 RNs and 805,881 patients who practiced or received care at these hospitals.

In 2015-2016, about 30% of hospital nurses gave their hospitals low grades on patient safety, and 55% would not definitely recommend their hospital to a family member or friend who needed care. Also expressing concern about quality and safety, 30% of patients said that they would not definitely recommend their hospital to others. Nearly 40% said that they did not always receive help quickly from hospital staff and reported that medications were not always explained before given.

Among other study findings:

  • over 80% of nurses rated the clinical work environments in their hospitals as less than excellent.
  • nearly 30% of nurses gave their hospitals an unfavorable grade on infection prevention.
  • over 30% of hospital nurses scored in the high burnout range on standardized tests.
  • only 21% of hospitals significantly improved their clinical work environments over the past decade; most made no improvements and 7% experienced deteriorating work environments.

Hospitals that had significantly improved their care environments experienced much greater improvements in patient safety indicators than hospitals that did not improve clinical care environments, as recommended by the National Academy of Medicine in its landmark 1999 publication To Err Is Human. In hospitals in which the work environment worsened, the percentage of nurses saying that patient safety is a top priority for management decreased by 25%.

“Patients' and nurses' appraisals show patient safety in hospitals remains a concern almost 20 years after the [National Academy of Medicine] originally called for national action to reduce patient harm,” said Aiken. “Our findings show that clinicians continue to face challenging but modifiable work environments that interfere with their ability to implement safety interventions consistently. Improving work environments through organization and culture change is a comparatively low-cost intervention to improve quality of care and patient safety.”

Sources: Aiken LH, Sloane DM, Barnes H, Cimiotti JP, Jarrin OF, McHugh MD. Nurses' and patients' appraisals show patient safety in hospitals remains a concern. Health Affairs. 2018; 37(11): 1744-1751. Patient safety in hospitals still a concern. University of Pennsylvania School of Nursing. News release. November 5, 2018.

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AHA releases focused CPR/ECC update



As part of its commitment to update guidelines more frequently based on current evidence, the American Heart Association (AHA) recently released a Focused Update for CPR and emergency cardiovascular care (ECC). Before 2017, the official AHA guidelines for CPR and ECC were updated every 5 years.

This update focuses on the use of antiarrhythmic medications commonly administered during and immediately after a ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) cardiac arrest. New guidelines include the following:

  • Amiodarone or lidocaine may be considered for VF/pVT that is refractory to defibrillation.
  • Lidocaine has been added to the Advanced Cardiovascular Life Support (ACLS) Cardiac Arrest Algorithm and the ACLS Cardiac Arrest Circular Algorithm for treatment of shock-refractory VF/pVT.
  • The routine use of magnesium for cardiac arrest is not recommended in adults.
  • Evidence is insufficient to support or refute the routine use of a beta-blocker within the first hour after return of spontaneous circulation (ROSC).
  • Evidence is insufficient to support or refute the routine use of lidocaine in the first hour after ROSC.

For more details, visit the AHA's CPR/ECC Guidelines website at

Source: Panachal AR, Ber KM, Kudenchuk PJ, et al. 2018 American Heart Association Focused Update on advanced cardiovascular life support use of antiarrhythmic drugs during and immediately after cardiac arrest: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. [e-pub November 5, 2018].

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Who benefits from a rapid, aggressive response?

The rapid response system (RRS) is designed to identify and respond to seriously ill patients in acute care hospitals. A retrospective cohort study of 733 adult inpatients was conducted using data for the period 3 months before and after their last placed RRS call. The purpose was to evaluate whether treatment is beneficial for patients at end of life for whom an RRS call was made, describe interventions, and measure the cost of hospitalization. The study was conducted in a large Australian teaching hospital.

The results revealed that 8.9% of patients had a preexisting not-for-resuscitation (NFR) or not-for-RRS order, and none of these patients survived to 3 months. In contrast, patients without an NFR or not-for-RRS order had a 3-month survival probability of 71%.

Compared with survivors, RRS recipients who died were more likely to be older, to be admitted to a medical unit, and to have experienced more admissions before the RRS.

The most common responses to critical deterioration were oxygen therapy, continued ECG monitoring, blood tests, I.V. medications, and I.V. fluids. The average cost of hospitalization for patients age 80 and older transferred to the ICU was higher than for those not requiring treatment in the ICU.

“The findings of this study suggest that younger patients [under age 80] without a history of previous hospitalization or limitations of treatments such as NFR or not-for-RRS orders, potentially benefit from aggressive RRS treatments,” the authors write. “Our findings also indicate...a failure to recognize patients nEOL [near end of life] in acute hospitals in concert with a failure to limit life-sustaining treatments.”

Patients age 80 or older with multiple hospital admissions in the previous 3 months were the subject of one or more RRS calls within a week of their death, many despite having an NFR order. Half died within 2 days of the RRS call, and the deceased were twice as likely to be transferred to the ICU. “Enhanced awareness of the imminent risk and poor prognosis of those fitting an nEOL profile may guide clinicians before activating the RRS or before recommending aggressive management at the time of an RRS,” the authors conclude.

Sources: Cardona M, Turner RM, Chapman A, et al. Who benefits from aggressive rapid response system treatments near the end of life? A retrospective cohort study. Jt Comm J Qual Patient Saf. 2018;44(9):505-513. Bronk KL. New study on intensive rapid response system treatment in end-of-life care. The Joint Commission. News release. August 29, 2018.

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C. difficile spores survive laundering

Researchers designed a study to quantify the survival of Clostridium difficile spores on hospital bed sheets after laundering by the United Kingdom National Health System healthcare laundry process and by a commercial laundry. C. difficile spores were inoculated onto cotton sheets and laundered through a simulated washer extractor cycle using an industrial bleach detergent. In addition, sheets naturally contaminated with C. difficile by patients diagnosed with C. difficile infection were assessed after processing with a washer extractor plus drying and finishing cycles at a commercial laundry. Both laundering processes failed the microbiologic standards of no pathogenic bacteria remaining.

Based on their findings, the researchers speculate that spores surviving the laundry process may contribute to sporadic outbreaks of C. difficile infection. They write, “Further research to establish exposure of laundry workers, patients, and the hospital environment to C. difficile spores from bed sheets is needed.”

Source: Tarrant J, Jenkins RO, Laird KT. From ward to washer: the survival of Clostridium difficile spores on hospital bed sheets through a commercial UK NHS healthcare laundry process. Infect Control Hosp Epidemiol. [e-pub October 16, 2018].

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Nurse-led care both effective and economical



In the United Kingdom, only 40% of patients with gout receive urate-lowering therapy. Because nurses successfully manage many other diseases in primary care, researchers designed a study to compare nurse-led gout care with usual care led by general practitioners (GPs). The study involved 517 community-dwelling adults who had experienced a gout flare in the previous 12 months. They were randomly assigned 1:1 to receive nurse-led care or continue with GP-led usual care. Nurses were educated about best practice management of gout, including providing individualized information and engaging patients in shared decision-making.

Patients were assessed at baseline and after 1 and 2 years. The primary outcome was the percentage of participants who achieved serum urate concentrations less than 360 μmol/L (6 mg/dL) at 2 years. Secondary outcomes were flare frequency in year 2, presence of tophi, quality of life, and cost per quality-adjusted life-year (QALY) gained.

The results: Nurse-led care was associated with high uptake of and adherence to urate-lowering therapy. Among patients receiving nurse-led care, 95% had serum urate concentrations below 360 μmol/L at 2 years, compared with only 30% of patients receiving usual care. In addition, all secondary outcomes, including cost per QALY, favored nurse-led care at 2 years.

The authors concluded that nurse-led care was both efficacious and cost effective. “Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centered outcomes.”

Source: Doherty M, Jenkins W, Richardson H, et al. Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. Lancet. 2018;392(10156):1403-1412.

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Screen women for intimate partner violence



A US Preventive Services Task Force (USPSTF) Final Recommendation Statement urges clinicians to screen for intimate partner violence in women of reproductive age, and to provide or refer women who screen positive to ongoing support services. The authors emphasize the need for continuing support: “The evidence does not support the effectiveness of brief interventions or the provision of information about referral options in the absence of ongoing supportive intervention components.”

The authors also examined the risks and benefits of screening for abuse and neglect in all older or vulnerable adults and concluded that the current evidence is insufficient to make a recommendation for these populations.

The USPSTF statement is based on a systematic literature review involving 30 studies and 14,959 participants.

Source: US Preventive Services Task Force. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force Final Recommendation Statement. JAMA. 2018;320(16):1678-1687.

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