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Clinical Rounds

doi: 10.1097/01.NURSE.0000569828.26948.a5
Department: CLINICAL ROUNDS
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World Health Organization recognizes burnout as an “occupational phenomenon”...inappropriate use of peripherally inserted central catheters is common in patients with advanced chronic kidney disease...robotic surgery is not superior to radiation therapy for treating oropharyngeal cancer...and more

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WORLD HEALTH ORGANIZATION

Burnout defined as an “occupational phenomenon”

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The World Health Organization (WHO) includes burnout in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon (not a medical condition). It is listed in a chapter describing “factors influencing health status or contact with health services,” which includes reasons for which people contact health services that are not classed as illnesses or health conditions.

The ICD-11 describes burnout as a syndrome “resulting from chronic workplace stress that has not been successfully managed.” It is characterized by

  • feelings of energy depletion or exhaustion.
  • increased mental distance from one's job, or feelings of negativism or cynicism related to one's job.
  • reduced professional efficacy.

The WHO states that burnout “refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life,” and is initiating development of evidence-based guidelines on mental health in the workplace.

Source: World Health Organization. Burn-out an “occupational phenomenon:” International Classification of Diseases. News release. May 28, 2019.

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CHRONIC KIDNEY DISEASE

Inappropriate use of PICCs is common

Current practice guidelines, including Choosing Wisely recommendations, advise against placing peripherally inserted central catheters (PICCs) in patients with advanced chronic kidney disease (CKD) to preserve veins for arteriovenous fistula placement. A prospective cohort study was performed to evaluate PICC use in hospitalized patients with stage 3b or greater CKD (glomerular filtration rate [GFR] <45 mL/min/1.73 m2). The study involved hospitalized medical patients who received a PICC between November 2013 and September 2016 in 52 Michigan hospitals. Of 20,545 patients who had PICCs placed, 4,743 (23%) had an estimated GFR (eGFR) less than 45 mL/min/1.73 m2 and 699 (3.4%) were receiving hemodialysis. In the ICU, about 31% of patients receiving PICCs had an eGFR less than 45 mL/min/1.73 m2; the corresponding percentage in medical/surgical units was 19%. Among patients with an eGFR less than 45 mL/min/1.73 m2, multilumen PICCs were placed more frequently than single-lumen PICCs. The authors concluded, “In this sample of hospitalized patients who received PICCs, placement in those with CKD was common and not concordant with clinical guidelines.”

Source: Paje D, Rogers MAM, Conlon A, Flanders SA, Bernstein SJ, Chopra V. Use of peripherally inserted central catheters in patients with advanced chronic kidney disease: a prospective cohort study. Ann Intern Med. [e-pub June 4, 2019].

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OROPHARYNGEAL CANCER

Robotic surgery not superior to radiation therapy

In 2012, researchers launched a 7-year study to compare robotic surgery to radiation therapy for the treatment of oropharyngeal cancer. Recently announced, the team's findings challenge beliefs that surgery leads to better swallowing outcomes. The study involved 68 participants from six facilities in Canada and Australia. Participants were randomized to receive either precision radiation therapy, often combined with chemotherapy, or transoral robotic surgery (TORS), which uses a small 3D camera and miniature robotic instruments to remove tumors. Early research suggested that TORS might reduce the risk of swallowing difficulties often associated with radiation therapy, but no clinical trials had previously been conducted to confirm this assumption.

The researchers were surprised to find that participants in the radiation group experienced better swallowing outcomes than those in the TORS group. All participants could eat a full diet after treatment but 16% from the surgery group required specially prepared food. No differences in survival were found, but patients in the surgery group were more likely to experience such adverse events as bleeding, persistent pain, and shoulder impairment. One year after treatment, 45% of patients in the TORS group were using pain medication, compared with 15% in the radiation group.

Patients in the radiation group were more likely to experience short-term constipation and a temporary drop in blood counts. Those who also received chemotherapy had an increased risk of tinnitus and high-frequency hearing loss.

The researchers say these findings suggest that TORS is not superior to modern radiation, pointing out that advances in radiation therapy have likely mitigated swallowing risks that were more common in the past. They recently launched a new trial to further compare the two treatment options. The study was presented at the American Society of Clinical Oncology's annual meeting.

Source: Lawson Health Research Institute. Robotic surgery for throat cancer not superior to radiation therapy, study finds. News release. June 6, 2019.

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NURSING EDUCATION

Interactive program to teach geriatric nursing

Nurses are increasingly challenged to provide age-appropriate nursing care to a burgeoning geriatric patient population: By 2030, an estimated one in five adults will be age 65 or older. Barriers to educating nursing students about geriatric care include a shortage of nursing instructors with geriatric expertise and a general lack of interest in long-term-care (LTC) nursing. Educators at one school of nursing addressed these challenges by designing an innovative curriculum comprised of six learning assignments to teach care of older adults in clinical practice.

The program involved 124 senior-level baccalaureate nursing students who participated in an intensive 7-week geriatric immersion with their clinical preceptors. Three of the six assignments were interactive and based on competencies involving interviewing, performance-based assessment, clinical decision-making, and problem-based learning. A mandatory 8-hour workshop devoted to an evolving case scenario covered rules for Medicare and Medicaid beneficiaries, state-funded programs and services, and access to senior services. Interactive assignments were conducted in LTC facilities or assisted-living units located within LTC facilities and at the school of nursing simulation lab.

At the conclusion of the program, the educators surveyed the students about their perceptions. Of all the learning assignments, the students gave those deemed interactive, such as obtaining patient histories related to the new onset of a geriatric syndrome, the highest average scores compared with assignments that were noninteractive. The 8-hour workshop, described as “dry” by some students, received the lowest overall rating.

The educators say the program was well received by students and believe it offers students “the content and skills necessary to provide safe, competent, and compassionate care to the geriatric patient population.”

Sources: Gray-Miceli D, Morse C. Curricular innovations for teaching undergraduate nursing students care of older adults. Nurse Educ. 2019;44(3):E7-E10. Florida Atlantic University. If you teach them, they will care. News release. June 6, 2019.

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DIABETES

Dysglycemia drives MI and severe peridontitis

A large case-controlled study has found that previously undiagnosed dysglycemia (diabetes and prediabetes) is independently associated with both myocardial infarction (MI) and severe peridontitis. The research included 805 patients with a first MI and 805 matched control subjects. An oral glucose tolerance test was conducted on participants without a diabetes diagnosis (91%). Dental X-rays were used to establish periodontal status. Adjustments were made for age, gender, smoking, education, and marital status.

Results revealed that undetected dysglycemia was twice as likely in patients with MI compared with healthy control subjects. Similarly, undetected diabetes was more common in patients with severe periodontitis. Based on an analysis of the data, the researchers estimate that undetected dysglycemia doubles the risk of a first MI and severe periodontitis. They say that their findings support the hypothesis that dysglycemia drives both MI and periodontitis.

Source: Norhammer A, Kjellstrom B, Habib N, et al. Undetected dysglycemia an important risk factor for two common diseases myocardial infarction and periodontitis: a report from the PAROKRANK study. Diabetes Care. [e-pub ahead of print June 10, 2019].

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In August, celebrate

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END-OF-LIFE CARE

Document advance care planning to prevent unwanted treatments

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A primary goal of hospice care is to avoid hospitalization and unnecessary medical procedures at the end of life. Analyzing the health records of 1,185 patients diagnosed with cancer who had been referred to hospice, researchers found that a verified do-not-resuscitate order issued within the last 30 days of a patient's life reduced the risk of hospitalization. A prominent note in the electronic health record (EHR) indicating advance care planning also reduced the risk of hospitalization, especially if written at least 6 months before death. Examples of advance care planning included discussions with providers on legal directives, a living will, or a healthcare power of attorney. The researchers note that, based on previous studies, only 13% to 44% of terminally ill patients have documentation of advance care planning placed in their EHR and that the ease of finding that documentation is inconsistent.

“I think everyone in medicine is aware that we need to do a better job documenting end-of-life wishes, but as a nation we haven't figured out how best to do that,” said lead author Laura Prater in an interview. She hopes this research will encourage healthcare professionals and facilities to find ways to incorporate advance care planning into their processes “to make sure that these conversations are happening consistently, early and often, even though they are complex and difficult conversations to have.”

Sources: Prater LC, Wickizer T, Bower JK, Bose-Brill S. The impact of advance care planning on end-of-life care: do the type and timing make a difference for patients with advanced cancer referred to hospice? Am J Hosp Palliat Care. [e-pub May 14, 2019]. Ohio State University. For dying patients, early plans can improve quality of life. News release. June 6, 2019.

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ZIKA VIRUS INFECTION

FDA authorizes new diagnostic test

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The ZIKV Detect 2.0 IgM Capture ELISA, which detects Zika virus immunoglobulin (IgM) antibodies in human blood, is the first Zika diagnostic test authorized by the FDA for marketing in the US. It is indicated for use only in patients with clinical signs and symptoms consistent with Zika virus infection or those who meet the CDC's Zika virus epidemiologic criteria, such as history of travel to a region where Zika is endemic. It is not authorized for testing blood or plasma donors. The test should be used in conjunction with clinical observations, patient history, epidemiologic information, and other lab evidence. Because of the potential for false negative findings, a negative test result does not eliminate the possibility of Zika infection.

Zika virus is transmitted by the bite of an infected Aedes species mosquito and has been linked to neurologic complications such as Guillain-Barré syndrome and microcephaly and other poor outcomes in infants exposed to Zika virus during the mother's pregnancy. Most cases that have been reported in the continental US were contracted in endemic areas; the CDC has reported no local mosquito-borne Zika virus transmissions in the continental US for 2018 and 2019 to date.

Source: US Food and Drug Administration. FDA authorizes marketing of first diagnostic test for detecting Zika virus antibodies. News release. May 23, 2019.

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