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Clinical Rounds

doi: 10.1097/01.NURSE.0000554279.69751.f2
Department: CLINICAL ROUNDS
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SLEEP DEPRIVATION

Nurses champion a “siesta” for patients

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An intervention called Sleep for Inpatients: Empowering Staff to Act (SIESTA) has been shown to reduce sleep-disrupting activities at night and improve patient experiences. A prospective study involved two 18-room general medicine units in an urban hospital. In the SIESTA-enhanced unit, nurses and physicians were educated about and empowered to employ sleep-enhancing strategies. Electronic “nudges” in the electronic health record (EHR) reminded nurses not to perform unnecessary nocturnal care, such as taking routine vital signs. Because the same physicians cared for patients in both units, the control unit received all interventions except the nursing interventions.

To develop SIESTA's sleep-enhancing strategies, researchers conducted focus groups and surveys of staff to identify barriers to a good night's sleep. Overnight vital signs, medication administration, and phlebotomy were identified as major barriers. For example, the researchers learned that physicians did not know how to change the “every 4 hours” default vital signs order. Consequently, nurses were waking patients at 0100 to obtain vital signs and administer subcutaneous heparin. Improvements to the EHR and staff education about sleep-enhancing strategies were built into the SIESTA program.

The results: nighttime room entries dropped by 44% in the SIESTA-enhanced unit. In addition, patients were more likely to report no disruptions for nighttime vital signs or medications. These indicators were unchanged in the control unit. The authors concluded that nursing interventions drove these positive results, writing that “even when sleep-friendly orders are present, creating a sleep-friendly environment likely depends on the unit-based nurses championing the cause.”

Source: Arora VM, Machado N, Anderson SL, et al. Effectiveness of SIESTA on objective and subjective metrics of nighttime hospital sleep disruptors. J Hosp Med. 2019;14(1):38-41.

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I.V. THERAPY

Why so many dislodged catheters?

Accidental dislodgment of an I.V. device interrupts treatment, increases the risk of complications, and raises costs associated with I.V. therapy. Based on past estimates, from 1.8% to 24.5% of all I.V. devices become dislodged per year. To study clinicians' perceptions of frequency, impact, contributing factors, and safety issues surrounding accidental dislodgment of I.V. devices, a nurse researcher conducted a cross-sectional descriptive online web-based survey targeting clinicians currently working in a clinical healthcare setting. Of 1,561 respondents, 68% reported dislodgments occurring “often, daily, or multiple times daily.” Overwhelmingly, most respondents identified peripheral I.V. catheters as the most commonly dislodged device. The top three contributing factors were confused patient (80%), patient physically removes catheter (74%), and I.V. catheter tape or securement loose (65%).

Nearly all respondents said the added risk of patient complications associated with catheter replacement makes catheter dislodgment a safety issue. The author says that this study uncovers how inconsistencies in the use, application, and management of I.V. catheter securement devices and dressings affect catheter viability.

Source: Moureau N. Impact and safety associated with accidental dislodgement of vascular access devices: a survey of professions, settings, and devices. J Ass Vasc Access. 2018;23(4):203-215.

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EVIDENCE-BASED CARE

ECRI Institute offers free access to clinical guidelines

The ECRI Guidelines Trust has been launched to give clinicians free access to evidence-based clinical practice guidelines that were previously available through the National Guideline Clearinghouse (NGC) at the Agency for Healthcare Research and Quality. This resource was discontinued last year due to cuts in federal funding.

An independent, nonprofit patient safety organization, ECRI Institute had developed and maintained the NGC website for 20 years. When the NGC site was shut down, its records became inaccessible. ECRI Institute staff who had previously worked on the NGC website has been rebuilding this resource based on new summaries of evidence-based guidelines from participating guideline developers, medical specialty societies, and other healthcare organizations. A scorecard feature rates each guideline for rigor and transparency. New content will be added continuously as it becomes available.

Visit the ERCI Guidelines Trust at https://guidelines.ecri.org.

Source: ECRI Institute. ECRI opens access to clinical practice guidelines. News release. November 19, 2018.

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SEXUAL/GENDER IDENTITY

Sexual minority patients prefer to put it in writing

Although collecting information about sexual orientation and gender identity (SOGI) is routine in clinical settings, little research has been conducted into the preferences of sexual and gender minority (SGM) patients. To explore the issue, a matched cohort study was conducted in four EDs in the US. Between February 2016 and March 2017, researchers sequentially tested two different SOGI collection approaches: nurse verbal collection during the clinical encounter, and nonverbal collection by a registrar during patient registration. For the nonverbal arm of the study, registrars asked patients to confidentially complete a demographics information form that included SOGI information, administered either via iPad or on paper.

Before and during the intervention period, ED physicians, physician assistants, nurses, and registrars received education on SGM health disparities and terminology. Main outcome and measures were a detailed survey that included a modified Communication Climate Assessment Toolkit score and additional patient satisfaction measures.

Responses were analyzed from 540 enrolled patients (mean age 36.4; 66.5% identified themselves as female). After adjusting for age, race, illness severity, and site, researchers found that SGM patients had 2.57 increased odds of a better Communication Climate Assessment Toolkit score category during form collection compared with verbal collection by a nurse. No differences were found among non-SGM patients.

Noting that SGM patients were more comfortable with the confidential nonverbal method, the researchers concluded that “registrar form collection was the optimal patient-centered method for collecting SOGI information in the ED.”

Source: Haider A, Adler RR, Schneider E, et al. Assessment of patient-centered approaches to collect sexual orientation and gender identity information in the emergency department: the EQUALITY study. JAMA Netw Open. 2018;1(8):e186506.

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COMPENSATION

Many female healthcare workers live in poverty

Using the 2017 Annual Social and Economic Supplement to the Current Population Survey, researchers compared earnings, insurance coverage, public benefits usage, and occupational distribution of male and female healthcare workers of different races/ethnicities. They found that many US female healthcare workers, particularly women of color, live in poverty and lack health insurance. Among the findings:

  • nearly 40% of all female healthcare workers earn less than $15 per hour.
  • nearly half of Black and Latina female healthcare workers earn less than $15 per hour, and more than 10% lack health insurance.
  • a total of 1.7 million female healthcare workers and their children live in poverty.
  • raising the minimum wage to $15 per hour would reduce poverty rates among female healthcare workers by 27.1% to 50.3%.

Based on these findings, the authors conclude, “Achieving economic, gender, and racial/ethnic justice will require significant changes to the compensation structure of healthcare.”

Source: Himmelstein KEW, Venkataramani AS. Economic vulnerability among US female health care workers: potential impact of a $15-per-hour minimum wage. Am J Public Health. 2019;109(2):198-205.

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NURSING EDUCATION

For-profit programs come up short

In recent years, the availability of for-profit nursing programs has expanded dramatically, but how well do they prepare students for nursing practice? To find out, researchers investigated trends in the growth of nursing programs and compared their outcomes, as measured in first-time NCLEX pass rates, by ownership type and by degree (bachelor of science in nursing, associate degree in nursing, and practical nurse). The study was based on 10 years of data from the Integrated Postsecondary Education Data System and 5 years of data from state boards of nursing on first-time NCLEX pass rates by degree.

The researchers found that from 2007 to 2016, the number of for-profit nursing programs increased fivefold. In addition, the share of total graduates from for-profit programs grew from 1.7% to 14.2% while the percentage of public nursing program graduates declined. Analysis of the data showed that for-profit ownership was a significant predictor of lower NCLEX pass rates for all three degree programs.

An NCLEX pass rate of at least 80% is generally accepted as a minimum quality standard for nursing programs. In a statement, lead study author Patricia Pittman, PhD, said, “Our study found that for-profit nursing programs were nearly twice as likely to have failed to meet that 80% threshold as compared to public programs.” The reasons for these study findings require further research.

Sources: Pittman P, Bass E, Han X, Kurtzman E. The growth and performance of nursing programs by ownership status. J Nurs Regul. 2019;9(4):5-21. For-profit nursing program grads perform worse on licensure test. HealthDay News. January 22, 2019.

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In April, celebrate

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PANCREATIC CANCER

Routine screening still not recommended

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In a draft recommendation issued in February, the U.S. Preventive Services Task Force (USPSTF) recommends against screening for pancreatic cancer in asymptomatic adults. USPSTF bases this update on data from 13 unique prospective cohort screening studies reporting results for 1,317 people. Researchers found no evidence supporting the accuracy of imaging-based screening tests or endoscopic ultrasonography for detecting pancreatic cancer. In addition, they found no evidence that pancreatic cancer screening improved disease-specific or all-cause morbidity or mortality. Based on “the low incidence of pancreatic cancer in the general population, the uncertain accuracy of current candidate screening tests, and the poor prognosis for pancreatic cancer even when treated at an early stage,” the USPSTF reaffirmed its previous recommendation against routine screening for pancreatic cancer.

Source: U.S. Preventive Services Task Force. Draft recommendation statement. Pancreatic cancer: screening. 2019. www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement/pancreatic-cancer-screening1.

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HEADACHE DISORDERS

New tool for migraine sufferers

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The Patient Advocate Foundation has launched an interactive widget, Migraine Matters, to educate and empower patients with migraine and headache disorders. This user-friendly tool offers an ever-expanding collection of articles, videos, webinars, infographics, and other resources from top nonprofits and clinical experts in the field of migraine treatment and research. Access it at https://migrainematters.patientadvocate.org.

Source: New online resource tool available for persons with migraine disease to help address healthcare challenges. Patient Advocate Foundation. News release. January 7, 2019.

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