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Clinical Rounds

doi: 10.1097/01.NURSE.0000558089.15723.80
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Burnout among top safety concerns for 2019



ECRI Institute, a healthcare industry leader in safety issues, issues a Top 10 Patient Safety Concerns list annually to help organizations identify and respond to threats to patient safety. Areas of focus for 2019 include:

  • using electronic health records for diagnostic stewardship and test result management
  • promoting antimicrobial stewardship in physician practices and aging services
  • addressing burnout and its impact on patient safety
  • detecting changes in a patient's condition.

In an executive brief, ECRI discusses each safety issue in turn and offers expert recommendations to improve patient care. Read the report at

Source: ECRI Institute. 2019 Top 10 Patient Safety Concerns: Executive Brief. 2019.

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Common signs are unreliable in older adults

A new study suggests that widely recognized signs and symptoms may not be reliable indicators of low-intake dehydration in older adults. The study involved 188 consecutively recruited residents in 56 long-term-care facilities. The residents were age 65 and older without renal or cardiac failure, and not receiving palliative care. Sixty-six percent were female and the average age was 85.7.

Over 2 hours, the residents underwent double-blind assessment of 49 signs and symptoms of dehydration, such as skin turgor; mouth, skin, and axillary dryness; capillary refill; sunken eyes; BP on resting and after standing; temperature; pulse rate; and self-reported feelings of thirst and well-being. These assessment findings were compared with the residents' serum osmolality values. Dehydration was defined as more than 300 mOsm/kg, and impending dehydration as 295 mOsm/kg or more.

Serum osmolality values identified current low-intake dehydration in 20% of residents and impending dehydration in 22% of residents. However, none of the commonly used clinical indicators of dehydration met “even basic levels of diagnostic accuracy in older adults, implying that many who are dehydrated are not being identified,” the researchers write. To accurately identify dehydration in older adults, they recommend replacing traditional clinical assessment with “a two-stage screening process that includes serum osmolarity calculated from sodium, potassium, urea, and glucose levels ... followed by serum osmolality measurement for those identified as high risk (calculated serum osmolarity >295 mmol/L).”

Source: Bunn DK, Hooper L. Signs and symptoms of low-intake dehydration do not work in older care home residents—DRIE diagnostic accuracy study. J Am Med Dir Assoc. [e-pub Mar. 9, 2019].

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CHG bathing benefits patients with medical devices

Bathing patients with chlorhexidine (CHG) soap has been shown to reduce multidrug-resistant organisms and bacteremia in ICUs. The ABATE (Active Bathing to Eliminate) Infection trial was conducted to determine whether daily bathing with CHG soap instead of soap and water would produce similar results in non-ICUs.

The ABATE trial involved 53 hospitals and 194 non-ICUs in the HCA Healthcare system. Five hospitals withdrew, leaving 24 hospitals in each arm of the 21-month-long intervention. During that period, the 330,000 enrolled patients had 1.3 million days of hospital care.

The hospitals were randomized and their participating non-ICUs assigned to either routine care or daily CHG bathing for all patients, plus mupirocin via nasal spray for patients known to be carriers of methicillin-resistant Staphylococcus aureus (MRSA). No statistically significant difference between the two intervention groups was found with one exception: the subset of patients with medical devices such as central venous catheters and lumbar drains who received the CHG/mupirocin intervention. These patients experienced a 30% decrease in bloodstream infections and a nearly 40% decrease in antibiotic-resistant bacteria, including MRSA and vancomycin-resistant Enterococcus, compared with similar patients in the trial's standard bathing arm.

“The results of the ABATE Infection trial are already being incorporated into infection prevention efforts,” said Jonathan Perlin, MD, PhD, a coauthor of the study and chief medical officer of HCA Healthcare. “The HCA system is using this decolonization strategy as a best practice for patients with medical devices across our 179 affiliated hospitals.”

Sources: Huang SS, Septimus E, Kleinman K, et al. Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial. Lancet. [e-pub Mar. 5, 2019]. National Institutes of Health. Results of trial to stem hospital-acquired bacterial infections published. News release. March 5, 2019.

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Using blindfolds improves leadership skills

Because pediatric resuscitations are rare events, many clinicians rely on tools such as simulation training to keep their skills sharp. To assess the effectiveness of using blindfolds to improve leadership skills in pediatric simulation training, researchers studied 12 teams, each composed of a pediatric emergency fellow, a pediatric resident, and two pediatric emergency nurses. Participants were randomly assigned to the blindfold group (BG) or to the control group. All groups participated in one 4-hour session covering five simulation-based resuscitation scenarios.

In the BG, the leader was blindfolded with a conventional sleep mask for three scenarios. Three evaluators assessed leadership skills on two video-recorded scenarios, and participants used questionnaires to self-report changes in stress and satisfaction about skills.

The results showed that improvement in leadership skills doubled in the BG compared with the control group (11.4% versus 5.4%, P = .04), with no increase in stress or decrease in satisfaction. The authors suggest that blindfolding enhances leadership skills by improving communication among team members and reducing “incomplete communication loops.” For example, they found that team members in the BG were more likely to audibly confirm receipt of the leader's instruction and completion of the task. In addition, by eliminating visual distractions, blindfolding helps the leader focus on leadership responsibilities instead of participating in interventions delegated to others.

Source: Buyck M, Manzano S, Haddad K, et al. Effects of blindfold on leadership in pediatric resuscitation simulation: a randomized trial. Front Pediatr. 2019;7:10.

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Study highlights risks for hospitalized patients

About one-third of hospitalized patients are at risk for malnutrition and poor outcomes despite being allowed to eat, according to a recent study described by the authors as “the most robust estimate of malnutrition risk in US hospitalized patients to date.” The risk is even greater for patients in certain subgroups, such as oncology and long-term care.

Analyzing data from 9,959 adult patients from 601 hospital units, researchers determined malnutrition risk by mapping self-reported nutritionDay survey questions in the US data set (2009 to 2015) to the Malnutrition Screening Tool. The data were used to evaluate the impact of nutrition risk and food intake on patients' 30-day in-hospital mortality.

During nutritionDay, which occurs worldwide every year on a single day in November, participating healthcare facilities conduct simple screening tests for nutritional risk to monitor and benchmark nutrition care on an international level. Based on nutritionDay data used in this study, about 32% of patients ate a quarter of their meal or less on nutritionDay, and 51% ate only half or less. Overall, the risk of malnutrition in hospitalized patients was about 32%. Among long-term-care patients and those with infectious diseases, the risk was about 50%; among patients with cancer, the risk was over 40%.

Failure to eat or finish a meal had a significant impact on mortality. For patients eating a quarter of their meal, the hospital mortality hazard ratio was 3.24 compared with those who ate their entire meal. For patients eating nothing despite being allowed to eat, the mortality hazard ratio increased to 5.99.

The authors write that “patients who have diminished meal intake experience increased mortality risk. These results highlight the ongoing issue of malnutrition in the hospital setting.”

Sources: Sauer AC, Goates S, Malone A, et al. Prevalence of malnutrition risk and the impact of nutrition risk on hospital outcomes: results from nutritionDay in the U.S. JPEN J Parenter Enteral Nutr. [e-pub Jan. 22, 2019]. Poor food intake common in hospitalized patients. HealthDay News. February 25, 2019. nutritionDay Worldwide.

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Ditch hip precautions?



To minimize the risk of dislocation following total hip arthroplasty (THA) with a posterior approach, patients are routinely instructed to follow standard “hip precautions,” such as not flexing the hip past 90 degrees or internally rotating the hip more than 10 degrees, using a grabber to pick up objects on the ground, and sleeping on their backs for 6 weeks. (Hip precautions are generally not recommended for THA with an anterior approach.) A new study found that eliminating hip precautions following posterior THA in low-risk patients did not increase the risk of hip dislocation.

Researchers followed 1,311 patients undergoing a posterior primary uncemented THA from January 2014 to June 2016. Surgeons could choose to put patients on standard precautions or a less stringent “pose avoidance” protocol (for example, instructing patients to avoid maintaining a single pose or a flexed external rotation position). The researchers then compared these patients with a matched cohort of patients who had followed standard hip precautions. They found no statistical difference in the number of hip dislocations between groups within the first 6 post-op weeks.

The researchers say that following strict hip precautions can be uncomfortable and burdensome for patients. “If you minimize the hip precautions in an appropriate way, patients focus more on their mobility and recovery and less on the fear of how they turn their leg 10 degrees,” said lead study author Peter Sculco, MD. “Minimizing precautions and simplifying the postoperative recovery is part of the larger simplification of surgery where we are using more selected resources and interventions for people, instead of blanketing everyone with the same kind of protocols.” The research was presented at the annual meeting of the American Academy of Orthopaedic Surgeons in March.

Source: Hospital for Special Surgery. Study suggests hip replacement patients can skip hip precautions. News release. March 12, 2019.

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Going green to reduce heart disease



In a population-based sample of 249,405 Medicare beneficiaries (age 65 and older) residing in Miami-Dade County, Florida, from 2010 to 2011, researchers analyzed relationships between the “greenness” of a person's neighborhood environment as determined by satellite imagery and four heart disease diagnoses. They found that higher greenness values were associated with reducing the odds of acute myocardial infarction by 25%, ischemic heart disease by 20%, heart failure by 16%, and atrial fibrillation by 6%. The authors conclude that strategies to increase neighborhood greenness “may be a future means of reducing heart disease at the population level.”

Source: Wang K, Lombard J, Rundek T, et al. Relationship of neighborhood greenness to heart disease in 249 405 US Medicare beneficiaries. J Am Heart Assoc. 2019;8(6):e010258.

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In June, celebrate

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