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Clinical Rounds

doi: 10.1097/
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Nurse understaffing increases risk of HAIs



Past research on the relationship between nurse staffing and healthcare-associated infections (HAIs) has been inconclusive. For a new study of this issue, researchers analyzed cross-sectional data between 2007 and 2012 from a large urban hospital system. They used the CDC's National Healthcare Safety Network definitions to identify HAI diagnoses in the final sample, which included 100,264 patients with 448,826 patient days from 34 units.

After adjusting for individual risks, the researchers looked for an association between nurse staffing (2 days before HAI onset) and HAIs. They found the following:

  • One shift was understaffed on 15% of patient days. Understaffing was defined as staffing below 80% of the unit median for a shift.
  • Both day and night shifts were understaffed on 6.2% of patient days.
  • Patients on units in which both shifts were understaffed were significantly more likely to develop HAIs 2 days later.

The researchers say that while understaffing on one shift may be manageable as nurses can compensate over a short term, continuous understaffing throughout the day undermines nurses' well-being, causes job-related stress, and undermines patient care. They write, “Our findings of an association between unit nurse understaffing and HAI confirm the findings of previous studies but with better data and a stronger design.”

Source: Shang J, Needleman J, Liu J, Larson E, Stone PW. Nurse staffing and healthcare-associated infection, unit-level analysis. J Nurs Adm. 2019;49(5):260-265.

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Educate patients about sudden death risk

In a recent report, the authors warn that although sudden unexpected death in epilepsy (SUDEP) is most common in intractable epilepsy types, it can occur in the full spectrum of epilepsies. Reviewing all cases referred to the North American SUDEP Registry between October 2011 and June 2018, the authors identified 237 definite or probable cases of SUDEP. The prevalence among epilepsy types ranged from 1% in benign epilepsy with centrotemporal spikes to 11% in intractable epileptic encephalopathies. Other findings included the following:

  • The median age at death was 26.
  • 93% of SUDEPs were unwitnessed.
  • 70% of deaths occurred during apparent sleep.
  • 15% of patients were sleep deprived at the time of death. The authors note that because sleep deprivation is a seizure provocation factor, it may be a risk factor for SUDEP.
  • Only 37% of patients had taken their last antiseizure medication dose.

The authors say that healthcare professionals must educate all patients with epilepsy and their families about the rare but real possibility of sudden death and stress the importance of taking their medications on time and as prescribed.

Source: Verducci C, Hussain F, Donner E, et al. SUDEP in the North American SUDEP Registry: the full spectrum of epilepsies. Neurology. 2019;93(3):e227-e236.

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New guidelines for screening, PrEP

In two statements, the US Preventive Services Task Force (USPSTF) recommends preexposure prophylaxis (PrEP) for people at high risk for HIV infection and routine HIV screening for most adults and adolescents regardless of risk status. Based on available evidence, USPSTF researchers found “convincing evidence that PrEP is of substantial benefit for decreasing the risk of HIV infection in persons at high risk of HIV infection, either via sexual acquisition or through injection drug use.” The recommendation statement provides specific guidelines for identifying those at high risk for HIV infection.

In a separate statement, USPSTF found “convincing evidence” that HIV screening tests are reliable and that early treatment with antiretroviral therapy (ART) is beneficial for patients infected with HIV and reduces disease transmission. Consequently, USPSTF recommends routine screening for adults and adolescents ages 15 to 65 and all pregnant women. Younger patients and older adults at high risk for HIV infection should also be screened. The recommendations also state that the benefits of ART “substantially outweigh the potential risks of treatment in persons living with HIV.”

Sources: US Preventive Services Task Force. Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(22):2203-2213. US Preventive Services Task Force. Screening for HIV infection. US Preventive Services Task Force recommendation statement. JAMA. 2019;321(23):2326-2336.

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In September, celebrate

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ACIP votes to raise maximum age for males

The Advisory Committee on Immunization Practices (ACIP) will recommend that the maximum age for human papillomavirus (HPV) vaccination in males be raised from age 21 to 26 to make it consistent with the current recommendation for females. The CDC recommends that all children start receiving two doses of the HPV vaccine at age 11 or 12. Girls and young women who were not adequately vaccinated at a younger age have been advised to receive the vaccine through age 26, but the age limit for males was previously 21. The new guideline is intended to simplify vaccination protocols for providers.

Based on evidence that the vaccine is safe and effective for older patients, ACIP also proposed that adults ages 27 through 45 who are not adequately vaccinated against HPV make shared decisions with their healthcare providers about getting vaccinated. Vaccination is not indicated for adults over age 45 because the HPV vaccines are not currently approved for use in this age group.

The new guidelines won't become standard until formally adopted by the CDC, which nearly always accepts ACIP recommendations.

Sources: American College of Obstetricians and Gynecologists. ACOG statement on HPV vaccination. News release. June 26, 2019. ACIP: Men as old as 26 should get HPV vaccine. HealthDay News. June 27, 2019.

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Surgeons behaving badly impede recovery

Researchers conducted a study to determine whether patients of surgeons with a high number of coworker reports about unprofessional behaviors experience more post-op complications than patients whose surgeons generate fewer coworker reports. The retrospective cohort study involved 13,653 patients undergoing surgery performed by 202 surgeons in two geographically diverse academic medical centers from August 8, 2018 through April 9, 2019. The researchers examined documented coworker reports about unprofessional behavior by surgeons in the 36 months preceding the date of surgery. The main outcomes and measures were post-op surgical or medical complications within 30 days of the operation.

The findings showed that patients whose surgeons had more coworker reports were significantly more likely to experience any complication, any surgical complication, or any medical complication. Compared with rates for surgeons with no reports, the adjusted complication rate was 14.3% higher for patients whose surgeons had one to three reports and 11.9% higher for patients whose surgeons had four or more reports. The authors say their findings “suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.”

Source: Cooper WO, Spain DA, Guillamondegui O, et al. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surg. [e-pub ahead of print June 19, 2019].

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Practitioners unaware of breast density risks



Increased breast density raises the risk of breast cancer. Although many states have enacted breast density laws requiring that women be informed of their breast density status, nearly half of primary care providers (PCPs) and other practitioners responding to a recent survey were not aware of these laws and over 60% were unaware of their rationale. Using anonymous, self-administered surveys, researchers explored the knowledge, attitudes, and practices of PCPs, radiologists, and gynecologists at academic medical centers and community and private practices primarily in New York City. Based on 155 responses, they found that:

  • 48% were unaware of breast density laws.
  • 62% were unaware that breast density increases the risk of breast cancer.
  • 67% said they need more education about breast density and supplemental screening.

Over 40% of respondents were PCPs, 28% were radiologists, 17% were gynecologists, and 9% were “other.” Seventy-five percent of respondents were female. Compared with specialists, PCPs were less aware of their state's breast density laws and of the increased breast cancer risk for women with dense breasts. The researchers conclude that “breast density laws have not translated into greater knowledge of breast density and recommendations for supplemental screening among PCPs.”

Source: Brown J, Soukas C, Lin JJ, Margolies L, Santiago-Rivas M, Jandorf L. Physician knowledge, attitudes, and practices regarding breast density. J Womens Health (Larchmt). [e-pub ahead of print May 7, 2019.]

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Americans worry about clinician burnout



New survey data released by the American Society of Health-System Pharmacists (ASHP) show that 74% of Americans are concerned about burnout among healthcare professionals. Conducted by The Harris Poll on behalf of ASHP, the online survey included the opinions of more than 2,000 US adults who were highly aware that burnout among nurses, pharmacists, physicians, and other healthcare professionals can impair functioning and may lead to medical errors and other safety issues.

Most respondents (91%) said they wanted their physician, nurse, or other healthcare professional to do whatever is necessary to avoid burnout, and 77% said they worry about their safety when they see that their clinician is feeling burned out. Nearly half of respondents said they would avoid asking questions if they thought the clinician appeared burned out because they would not want to add to the stress.

The survey also suggests that healthcare professionals may be conveying signs of burnout without knowing it. More than half of respondents said they can tell clinicians feel burned out if they seem tired or rushed.

Source: American Society of Health-System Pharmacists. Three quarters of Americans concerned about burnout among healthcare professionals. News release. June 17, 2019.

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