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Clinical Rounds

doi: 10.1097/01.NURSE.0000554621.20594.49
Department: CLINICAL ROUNDS
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CARDIAC REHAB

Nurse navigators improve outcomes

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In 2017, Sanger Heart & Vascular Institute in Charlotte, N.C., established its Heart Care Navigation Team to reduce readmissions and mortality, promote self-management, and improve patients' experience. Each patient in the program was assigned a health advocate and a nurse navigator, who met the patient during hospitalization, then called the patient within 24 to 48 hours of discharge and again every 2 to 4 weeks for 90 days to facilitate follow-up care and address patients' questions or concerns.

To evaluate the program's effectiveness, researchers compared data from 560 patients treated for myocardial infarction between July 2016 and June 2017, before the program began, with data from 421 patients treated in the year after program implementation (July 2017 to June 2018). Results showed that:

  • the 30-day readmission rate after program implementation was 3.7%, compared with 6.3% before implementation.
  • 30-day mortality dropped from 5.75% to 4.57% after program implementation.
  • patients' follow-up appointments increased from 78% to 96% after program implementation.

The study also found small increases in guideline-based care and cardiac rehab referrals associated with program implementation.

According to performance improvement coordinator Amber Furr, BSN, RN, CPHQ, “This study shows that nurse navigators are an integral part of reducing heart attack readmission and mortality. We're not where we want to be yet with cardiac rehab referrals or guideline-driven care, but we have seen an improvement.”

The study was presented at the American College of Cardiology's Cardiovascular Summit in February.

Source: American College of Cardiology. Patient navigator team successful in improving patient outcomes, reducing readmissions. News release. February 14, 2019.

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WORKPLACE VIOLENCE

Handoff huddle heads off trouble

In a 2-year period, staff at a large academic hospital experienced two patient safety incidents in which a patient became violent at the time of admission from the ED to the medical unit. To address the risk of violent patient events, a multidisciplinary quality improvement team was formed to design and test a huddle handoff communication tool called the Potentially Aggressive/Violent Huddle. The tool was tested in two Plan-Do-Study-Act (PDSA) cycles. An ED nurse initiated the huddle process by informing the admitting unit that a potentially violent patient was being admitted. The admitting care team would then call the ED team so that both teams participated in the handoff call together. The huddle process was used in 21 transfers in the first PDSA cycle and 18 transfers in the second.

Findings showed that nurses from the ED and six medical units reported feeling safe during the transfer process 100% of the time during both PDSA cycles, versus 55% at baseline. From the first to the second PDSA cycle, satisfaction with the process improved from 53% to 75%. The authors concluded, “The huddle handoff communication tool and other methods to facilitate the transfer of potentially violent patients have the potential to decrease the number and severity of violent incidents in the health care workplace.”

Sources: Larson LA, Finley JL, Gross TL, et al. Using a Potentially Aggressive/Violent Patient Huddle to improve health care safety. Jt Comm J Qual Patient Saf. 2019;45(2):74-80. Lyons M. Huddle handoff communication tool improves process of addressing workplace violence in health care. The Joint Commission. News release. March 4, 2019.

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PATIENT ASSESSMENT

Few patients disclose complementary therapies

Based on a systematic meta-analysis of 14 observational studies published between 2003 and 2016, researchers concluded that only one-third of patients tell healthcare professionals about their use of biologic-based complementary medicine (CM), such as herbal, vitamin, mineral, and nutritional supplements. Reasons for nondisclosure included lack of inquiry from healthcare providers, belief that providers lack knowledge of CM, lack of time, and belief that CM is safe. Reasons for disclosure included inquiry about CM by providers, belief providers would support CM use, belief disclosure is important for safety, and belief providers would give advice about CM.

The authors say that disclosure may be influenced by the nature of patient-provider communication, but that an accurate analysis was hindered by inconsistent definitions of CM and lack of a standard measure for disclosure. The authors write that healthcare professionals must take this issue seriously: “It is central to wider patient management and care in contemporary clinical settings, particularly for primary care providers acting as gatekeeper in their patients' care.”

Sources: Foley H, Steel A, Cramer H, Wardle J, Adams J. Disclosure of complementary medicine use to medical providers: a systematic review and meta-analysis. Sci Rep. 2019;9(1):1573. Most patients do not disclose complementary medicine use. HealthDay News. February 22, 2019.

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INFECTION CONTROL

Dangerous microbes lurk in sinks near toilets

Using two swab types, researchers collected specimens from each sink drain in rooms in a medical ICU, one sink next to the toilet and one next to the door. The ICU had no known history of Klebsiella pneumoniae carbapenemase (KPC)-producing organisms in the past year. A direct polymerase chain reaction (PCR) assay was performed on the swabs within 4 hours of specimen collection. Cultures from some specimens were also obtained.

Even though the ICU had no recent history of KPC, the researchers found a high prevalence (54%) of KPC in sink drains via PCR testing; in addition, 9% of sink drains were culture-positive. Sinks near toilets were four times more likely to be positive (87%) than sinks near the doors (22%).

“This study, if validated, could have major implications for infection control,” said lead researcher Blake W. Buchan in a statement. “If sinks next to toilets are indeed a reservoir for KPC, additional interventions—such as modified hand hygiene practices and sink disinfection protocols—may be needed to stem the risk of transmission among healthcare providers and patients alike.”

Sources: Buchan BW, Graham MB, Lindmair-Snell J, et al. The relevance of sink proximity to toilets on the detection of Klebsiella pneumoniae carbapenemase inside sink drains. Am J Infect Control. 2019;47(1):98-100. Sinks by toilets in ICU patient rooms harbor harmful bacteria. HealthDay News. February 13, 2019.

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MAMMOGRAMS

Thermography is not an acceptable alternative

The FDA is warning healthcare practitioners and the public against the use of thermography as an alternative to mammography for breast cancer screening. According to the FDA, thermography is being offered by some health spas, homeopathic clinics, mobile health units, and other healthcare facilities as a standalone tool for breast cancer screening or diagnosis. Contrary to false or misleading claims made by some facilities, no research has shown that thermography is effective for breast cancer screening. The evidence shows that mammography is the most safe and effective tool for breast cancer screening and diagnosis, and it is the only method proven to increase the chance of survival through earlier detection.

The FDA recommends that healthcare professionals:

  • educate patients about the limitations of thermography. For example, the high false-negative and false-positive rates for thermography can provide misleading information, resulting in a delayed diagnosis or unnecessary medical follow-up.
  • discourage patients from relying on thermography to diagnose or screen for breast cancer.
  • talk to patients or caregivers about safe and effective alternatives for breast cancer screening.

Read the FDA's warning at www.fda.gov; search for 2019 Safety Communications.

Source: US Food & Drug Administration. FDA warns thermography should not be used in place of mammography to detect, diagnose, or screen for breast cancer: FDA Safety Communication. February 25, 2019.

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In May, celebrate

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PEDIATRICS

New tonsillectomy guidelines issued

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The American Academy of Otolaryngology--Head and Neck Surgery Foundation has released a revised clinical practice guideline for children ages 1 to 18 years under consideration for tonsillectomy. Key points include the following:

  • Watchful waiting is recommended for recurrent throat infection of less than seven episodes in the previous year, less than five episodes per year in the previous 2 years, and less than three episodes per year in the previous 3 years.
  • A single intraoperative dose of I.V. dexamethasone is recommended during tonsillectomy.
  • After tonsillectomy, ibuprofen, acetaminophen, or both are recommended for pain control.
  • Administering or prescribing perioperative antibiotics to children undergoing tonsillectomy is strongly discouraged, as is administering or prescribing codeine or medications containing codeine after tonsillectomy in children younger than 12 years.

About 289,000 ambulatory tonsillectomies are performed annually in children under age 15. The guideline authors say that updated evidence-based recommendations are warranted due to the frequency of the procedure, the associated morbidity, and the availability of new randomized clinical trials.

Source: Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg. 2019;160(1_suppl):S1-S42.

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GERIATRICS

Do not delay antibiotics to treat UTI in older adults

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A study was conducted to evaluate the association between antibiotic treatment for urinary tract infection (UTI) and serious adverse outcomes in older adults in primary care. Running from November 2007 to May 2015, the study involved over 157,200 adults age 65 or older presenting to a general practition-er with at least one diagnosis of suspected or confirmed lower UTI. The main outcome measures were bloodstream infection, hospital admission, and all-cause mortality within 60 days after the index UTI diagnosis.

Among 312,896 UTI episodes, researchers found no record of an antibiotic prescription in 7.2% of cases, and delayed antibiotic prescriptions in 6.2% of cases. Within 60 days after the initial UTI diagnosis, 1,539 episodes of bloodstream infection were recorded. Compared with patients who were immediately treated with antibiotics, those in the delayed and/or no antibiotics groups were:

  • significantly more likely to experience a bloodstream infection.
  • about twice as likely to be admitted to a hospital.
  • at significantly higher risk of all-cause mortality during the 60-day follow-up period.

Men over age 85 were especially vulnerable to poor outcomes when antibiotics were delayed or not prescribed. The authors recommend early initiation of therapy with first-line antibiotics for all older adults with UTI.

Source: Gharbi M, Drysdale JH, Lishman H, et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study. BMJ. 2019;364:1525.

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