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Clinical Rounds

doi: 10.1097/01.NURSE.0000559931.04760.07
Department: CLINICAL ROUNDS
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BYSTANDER CPR

Compression-only CPR helps save lives

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Performing CPR is the most important initial intervention for a witnessed out-of-hospital cardiac arrest, yet many bystanders are reluctant to perform CPR because they do not feel competent to do so or because they do not want to engage in rescue breathing. Compression-only CPR (CO-CPR) is easier for an untrained person to learn and perform and does not require rescue breathing. Consequently, since 2010, CPR guidelines recommend CO-CPR as an alternative to standard CPR (S-CPR) for both trained and untrained bystanders unwilling to administer rescue breaths. But does this approach save lives?

Researchers studied data on all bystander-witnessed out-of-hospital cardiac arrests reported to a Swedish registry from 2000 to 2017—in all, 30,445 patients. The study encompassed three periods of different CPR guidelines. Patients were categorized as receivers of no CPR (NO-CPR), S-CPR, or CO-CPR before emergency medical service (EMS) arrival. The primary outcome was 30-day survival.

During the three periods of different CPR guidelines, researchers found “an almost 2-fold higher rate of CPR before EMS arrival and a concomitant 6-fold higher rate of CO-CPR over time. Any type of CPR was associated with doubled survival rates in comparison with NO-CPR.” They say these findings support the continued endorsement of CO-CPR as an option in CPR guidelines.

Sources: Riva G, Ringh M, Jonsson M, et al. Survival in out-of-hospital cardiac arrest after standard cardiopulmonary resuscitation or chest compressions only before arrival of emergency medical services: nationwide study during three guideline periods. Circulation. [e-pub April 1, 2019]. Crawford TC. Survival after cardiac arrest with chest compressions only. American College of Cardiology. April 8, 2019.

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CANCER CHEMOTHERAPY

Ice chips reduce a common adverse reaction

Oxaliplatin, a chemotherapy drug commonly prescribed to treat gastrointestinal cancers, is known to cause oral thermal hyperalgesia (OTH), a form of acute neuropathy associated with hyperexcitability of cold-sensing sensory nerves. Patients with OTH cannot tolerate cold food or drink, undermining their appetite, nutritional intake, and quality of life. A new study suggests keeping ice chips in the mouth for the duration of the chemotherapy infusion can significantly reduce signs and symptoms of OTH.

Researchers randomized 50 patients receiving oxaliplatin into two groups. Those in the treatment group were given ice chips and encouraged to keep them in their mouths for the duration of the infusion. Those in the control group did not receive ice chips and were asked not to ingest anything cold during the infusion. At baseline, no patients in either group had any ongoing oral symptoms.

The primary outcome was oral symptoms, defined as prickling, burning, tingling, or pins and needles, after the first treatment cycle. Oral symptoms were scored on a scale of one (no oral symptoms) to five (maximal symptoms).

Patients in the treatment group reported less trouble with eating and drinking cold things, less trouble eating and drinking overall, fewer negative effects on quality of life due to oral symptoms, and a shorter duration for oral symptoms. These patients also reported a reduction in peripheral neuropathy (PN) symptoms, but researchers could not say whether this was due to a lowering of core body temperature from the ice or the placebo effect.

The researchers hypothesize that cooling the mouth with ice chips constricts blood vessels in oral mucous membranes, reducing the amount of chemotherapy delivered directly to the mouth and throat. They say this simple noninvasive intervention “has the potential to reduce OTH and PN symptoms caused by this chemotherapy, at least during early cycles of treatment.” Additional research is needed to explore whether the intervention's benefits persist throughout later cycles.

Sources: Bauman B, Mick R, Martinez E, et al. Efficacy of oral cryotherapy during oxaliplatin infusion in preventing oral thermal hyperalgesia: a randomized trial. J Natl Compr Canc Netw. 2019;17(4):358-364. National Comprehensive Cancer Network. New research in JNCCN touts ice chips as a simple, inexpensive way to reduce a common chemotherapy side effect. News release. April 15, 2019.

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In July, celebrate

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TOURETTE SYNDROME

New guideline stresses watchful waiting

The American Academy of Neurology (AAN) has issued a practice guideline for clinicians treating patients with Tourette syndrome, a neurologic disorder characterized by motor and vocal tics (involuntary, repetitive movements and vocalizations). According to the AAN, the characteristic tics develop in childhood and wax and wane as the child ages. Symptoms often abate with time and many children improve significantly in their teens.

Because no evidence indicates that treatment is more effective the earlier it is started, the AAN says that watchful waiting is “an acceptable approach” for children who are not functionally impaired by their symptoms. For those who experience physical or psychosocial impairment from their symptoms, the AAN recommends Comprehensive Behavioral Intervention for Tics (CBIT), if available, rather than medication as the first line of treatment. CBIT consists of habit-reversal and relaxation training and a functional intervention to address situations that sustain or worsen tics. If indicated, medications such as alpha-2 adrenergic agonists and antipsychotic drugs are individualized based on the patient's symptoms and may eventually be discontinued in patients whose symptoms improve with time. Deep brain stimulation is an option for patients who do not respond adequately to CBIT or medication. Read the entire guideline at www.aan.com/Guidelines/Home/GetGuidelineContent/960.

Source: American Academy of Neurology. Practice guideline: the treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology. [e-pub May 6, 2019].

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INFECTION CONTROL

PPE doffing errors spread MDROs

To study the impact of personal protective equipment (PPE) doffing errors on the contamination of healthcare workers (HCWs) with multidrug-resistant organisms (MDROs), researchers enrolled 125 HCWs caring for 95 patients on contact precautions for methicillin-resistant Staphylococcus aureus and other MDROs. Most of the HCWs were nurses (66%) or physicians (19%). Samples were collected from standardized areas of patients' bodies, garb sites, and high-touch surfaces in patient rooms. Before and after patient interactions, HCWs' hands, PPE, and equipment were sampled. Research personnel observed PPE doffing and coded errors based on CDC guidelines. Findings included the following:

  • Among 5,093 cultured sites, nearly 15% were contaminated with the target MDRO.
  • 35% of HCWs were contaminated with the target MDRO after patient interactions.
  • 39% of HCWs made multiple PPE doffing errors and were more likely to have contaminated clothes following patient interactions.
  • Four HCWs had contaminated hands, and all made doffing errors.
  • The risk of hand contamination was higher when gloves were removed before gowns.

The authors conclude, “An intervention as simple as reinforcing the preferred order of doffing may reduce HCW contamination with MDROs.”

Source: Okamoto K, Rhee Y, Schoeny M, et al. Impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions. Infect Control Hosp Epidemiol. [e-pub Mar. 20, 2019].

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INFORMED CONSENT

Comics: Not just for kids

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Barriers to informed consent include patient anxiety, low literacy levels, and differences in clinicians' communication skills. Medical graphics, or “comics,” can help clinicians communicate complex medical information more clearly, according to a recent study involving 121 patients scheduled for cardiac catheterization. To enhance the informed-consent process, researchers created a 15-page comic-style booklet explaining cardiac catheterization in simple words and illustrations. The patients then underwent either the standard informed-consent process or the standard informed-consent process supplemented with the comic booklet. The researchers then assessed the patients' levels of comprehension, anxiety, and satisfaction with the consent process using questionnaires administered both before and after the informed-consent process. Findings included the following:

  • Questioned about procedural details, risks, and postoperative advice, patients who received the comic booklet answered 12 out of 13 questions correctly on average, compared with an average of 9 correct answers from patients in the standard consent group.
  • Compared with patients in the standard group, those in the test group reported feeling less anxious after the informed-consent process.
  • About 72% of patients in the test group were satisfied with the informed-consent process and reported feeling well prepared for cardiac catheterization, compared with only 41% of participants in the standard group.

“For the first time, our study showed that comic-based medical information can be a highly effective addition to the medical consenting process,” said lead investigator Dr. Anna Brand. “We want to use future research to test whether similar positive effects can be achieved in patients undergoing other medical procedures.”

Sources: Brand A, Gao L, Hamann A. Medical graphic narratives to improve patient comprehension and periprocedural anxiety before coronary angiography and percutaneous coronary intervention: a randomized trial. Ann Intern Med. 2019;170(8):579-581. Charité – Universitätsmedizin Berlin. Why comic-style information is better at preparing patients for cardiac catheterization. News release. April 16, 2019.

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AAN POLICY STATEMENT

Stop punishing women with SUD

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The American Academy of Nursing (AAN) has released a policy and action statement calling for an end to criminal prosecution and punitive civil actions against pregnant and parenting women based solely on their substance use or substance use disorder (SUD). Punitive responses resulting in criminal charges, incarceration, and other penalties have created a significant barrier to essential health services, including early maternity care, for these women. In a statement, the AAN states that “recovery-oriented public health responses are urgently needed to shift the culture of punishment to one of enduring therapeutic intent for women as well as their infants, children, and families affected by SUDs.” AAN recommends increased funding for substance abuse education and services at the federal and state level and offers strategies for nursing leadership to safeguard comprehensive clinical assessment and provider practice consistent with a therapeutic health justice approach. AAN also calls on the CDC to collect comprehensive data on maternal deaths related to SUD.

Sources: Jessup MA, Oerther SE, Gance-Cleveland B, et al. Pregnant and parenting women with a substance use disorder: actions and policy for enduring therapeutic practice. Nurs Outlook. 2019;67(2):199-204. American Academy of Nursing. American Academy of Nursing releases policy brief on pregnant and parenting women with a substance use disorder. News release. April 15, 2019.

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