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Clinical Rounds

doi: 10.1097/01.NURSE.0000585960.74029.6c
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Fewer RNs linked to higher patient mortality



Researchers examined the association of inpatient mortality with patients' cumulative exposure to shifts with low RN staffing, low nursing support staffing, and high patient turnover by analyzing data from a three-campus academic medical center from 2007 to 2012. Low staffing was defined as staffing below 75% of annual median unit staffing for each staff category and shift type. High patient turnover per day was defined as admissions, discharges, and transfers one standard deviation above unit annual daily averages.

The results showed that low RN and nursing support staffing were associated with increased mortality. No association was found between high patient turnover and mortality. The authors say their findings “should encourage hospital leadership to assure both adequate RN and nursing support staffing.”

Source: Needleman J, Liu J, Shang J, Larson EL, Stone PW. Association of registered nurse and nursing support staffing with inpatient hospital mortality. BMJ Qual Saf. [e-pub ahead of print Aug. 7, 2019]

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Most critical care nurses support sedation

Critical care nurses are “fundamental” to the implementation of sedation protocols for patients requiring mechanical ventilation, say the authors of a new study. To explore nurses' attitudes about sedation protocols for patients on mechanical ventilation, they invited members of the American Association of Critical-Care Nurses to complete the Nurse Sedation Practices Scale. Respondents (N = 177) were primarily clinical nurses (68%) with a BSN (63%). Comparing these responses to those on a similar 2005 survey, the study authors found that fewer nurses now believe that all patients receiving mechanical ventilation should be sedated. However, 66% of nurses still agreed that sedation is necessary for patients' comfort, and 34% agreed that limiting patients' recall was a desired outcome of sedation. Nurses with more experience or a critical care nursing credential had a less positive response to the effectiveness of sedation in minimizing distress.

The researchers write, “These results support previous findings that lack of support from nursing staff is a barrier to sedation protocol adherence and highlight the need to consider nurses' attitudes when seeking to change sedation practices.” Although the study did not examine why nurses' attitudes have shifted away from sedation over the last decade, they say the change “is most likely due to growing awareness of the potential negative consequences of routine administration of sedative medications to patients receiving mechanical ventilation.” Possible adverse reactions associated with sedation include delirium, increased duration of mechanical ventilation, and post-intensive care syndrome.

Source: Guttormson JL, Chlan L, Tracy MF, Hetland B, Mandrekar J. Nurses' attitudes and practices related to sedation: a national survey. Am J Crit Care. 2019;28(4):255-263.

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How to manage bleeding associated with DOACs

Responding to an increase in reported bleeding events related to direct oral anticoagulants (DOACs), The Joint Commission has issued a Sentinel Event Alert on the safe use of DOACs to all healthcare professionals and healthcare organization leaders. DOACs include apixaban, betrixaban, dabigatran, edoxaban, and rivaroxaban.

Compared with older anticoagulants such as warfarin and heparin, DOACs are more convenient for patients. However, unlike warfarin and heparin, some DOACs have no FDA-approved reversal agent, and those that are available are less well known and may not be available in every care setting. Consequently, bleeding complications such as intracranial hemorrhage can be difficult to manage and potentially devastating if patients are not assessed and treated promptly according to clinical guidelines. According to The Joint Commission, anticoagulants are one of the top two medications involved in error incidents causing death or serious harm.

The Sentinel Event Alert provides detailed guidelines for prescribing DOACs, monitoring patients during therapy, and treating complications. The Alert is accompanied with a graphic poster that highlights nine safety points for nurses and other healthcare professionals to observe when caring for patients taking DOACs. In addition, it lists patient education guidelines. The graphic can be posted in clinical areas for easy reference. Access it at

Source: The Joint Commission. Managing the risks of direct oral anticoagulants. Sentinel Event Alert. Issue 61. July 30, 2019.

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ED-based ICU improves outcomes

Having an ICU within the ED improves care and survival rates for the entire ED population, according to a cohort study of 349,310 patient encounters in the ED at a large academic medical center. Results showed that implementing an ICU within the ED was associated with a statistically significant reduction in risk-adjusted 30-day mortality among patients who visited the ED before and after implementation (2.13% versus 1.83%). Inpatient ICU admissions also decreased, from 3.2% before ICU implementation to 2.7% postimplementation.

“By applying cutting-edge critical care diagnostics and therapies to our sickest patients very early in their presentation to the emergency department, we were able to optimize their care in a way that improved outcomes and often reduced the need for an inpatient ICU admission,” says study coauthor Robert Neumar, MD. “In addition, this strategy increased the availability of inpatient critical care resources to other patients already in the hospital or awaiting a transfer to our hospital.”

Sources: Gunnerson KJ, Bassin BS, Havey RA, et al. Association of an emergency department-based intensive care unit with survival and inpatient intensive care unit admissions. JAMA Netw Open. 2019;2(7):e197584. Emergency department-based ICU improves patient survival rates. DG News: Internal Medicine. July 26, 2019.

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ICDs save lives, but are underused

Using data from the Swedish Heart Failure Registry (SwedeHF), investigators examined the association between use of implantable cardioverter defibrillators (ICDs) and short- and long-term mortality in a contemporary cohort of patients with heart failure with reduced ejection fraction (HFrEF). European Society of Cardiology criteria were used to determine eligibility for primary prevention ICDs. Of 16,702 eligible patients identified in the database, only 1,599 (10%) had an ICD.

For the study, the researchers assessed 1,305 ICD recipients and 1,305 nonrecipients for 1-year and 5-year all-cause and cardiovascular mortality. They found that ICD use was associated with a reduction in all-cause mortality risk within 1 year and 5 years. Results were consistent in all subgroups (patients with or without ischemic heart disease, males and females, patients older and younger than age 75, those with earlier or later enrollment in SwedeHF, and those who had or had not experienced cardiac resynchronization therapy).

The researchers write that although ICDs have proven effective for primary prevention of sudden cardiac death in patients with HFrEF, they are underused. “These results call for better implementation of ICD therapy.”

Source: Schrage B, Uijl A, Benson L, et al. Association between use of primary prevention implantable cardioverter-defibrillators and mortality in patients with heart failure: a prospective propensity-score matched analysis from the Swedish Heart Failure Registry. Circulation. [e-pub ahead of print Sept. 3, 2019]

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In November, celebrate

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Even without nicotine, vaping damages vasculature



Although e-cigarette use has been promoted as safer than cigarette smoking, evidence of its deleterious health effects is mounting. A recent study demonstrated that inhaling e-cigarette aerosols (vaping) causes acute systemic damage to the vascular system, even when the aerosol does not contain nicotine.

Magnetic resonance imaging was performed on 31 healthy, nonsmoking adults ranging in age from 18 to 35 before and after vaping an e-cigarette containing propylene glycol and glycerol with tobacco flavoring, but no nicotine. The supervised e-cigarette vaping consisted of 16 3-second inhalations. The researchers then analyzed three surrogate markers of vascular reactivity and tone: peripheral vascular reactivity to cuff-induced ischemia in the superficial femoral artery and vein, cerebrovascular reactivity in the superior sagittal sinus, and aortic arch pulse wave velocity. Their findings included the following:

  • 34% reduction in femoral artery dilation
  • 17.5% reduction in peak blood flow
  • 20% reduction in hemoglobin saturation in the superficial femoral vein
  • 25.8% reduction in reactive hyperemia after peripheral BP cuff release.

Lead study author Alessandra Caporale, PhD, noted that this “striking” evidence of endothelial damage occurred in healthy nonsmoking adults after just one vaping episode. “Many e-cigarette users are convinced that they are just inhaling water vapor,” Caporale said. “But the solvents, flavorings, and additives in the liquid base, after vaporization, expose users to multiple insults to the respiratory tract and blood vessels.” More research is needed to assess long-term adverse reactions.

Sources: Caporale A, Langham MC, Guo W, Johncola A, Chatterjee S, Wehrli FW. Acute effects of electronic cigarette aerosol inhalation on vascular function detected at quantitative MRI. Radiology. [e-pub ahead of print Aug. 20, 2019] Penn Medicine. Nicotine-free e-cigarettes can damage blood vessels. News release. August 20, 2019.

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New testing protocol streamlines diagnosis



Four previously FDA-approved diagnostic tests for Lyme disease are now approved for use in a new testing protocol that yields faster results. In the new protocol, two enzyme immunoassays (EIAs) are run concurrently or sequentially. Previously, testing required a two-step process in which a separate Western blot test is run after the initial EIA test. Called a modified two-tier test, the new approach relies entirely on EIA technology. According to the FDA, it is as accurate as the previous method for detecting antibodies to Borrelia burgdorferi, the causative Lyme disease pathogen.

Over 42,700 confirmed and probable cases of Lyme disease were reported to the CDC in 2017. If left untreated, the infection can have devastating health consequences. The new protocol is expected to improve the speed and accuracy of diagnostic testing so infected patients can begin treatment as soon as possible.

Source: US Food and Drug Administration. FDA clears new indications for existing Lyme disease tests that may help streamline diagnoses. News release. July 29, 2019.

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