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Clinical Rounds

doi: 10.1097/01.NURSE.0000604744.85372.10
Department: CLINICAL ROUNDS
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INFLUENZA PROTECTION

Medical masks work as well as N95 respirators

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Many healthcare professionals wear a surgical or medical mask to protect themselves from influenza and other contagious viral diseases, but are masks as effective as N95 respirators? A new study says they are.

During the 2009 H1N1 flu pandemic, the CDC advised healthcare workers to protect themselves by wearing N95 respirators, which fit the face more tightly than surgical masks and filter at least 95% of airborne particles. But many workers find these respirators to be less comfortable than masks. In addition, some facilities have trouble replenishing their supply of respirators, which are about 10 times more expensive than masks.

To compare their effectiveness for preventing transmission of influenza and other viral respiratory infections in healthcare workers, researchers conducted a cluster randomized pragmatic effectiveness study at 137 outpatient study sites at 7 US medical centers between September 2011 and May 2015, with final follow-up in June 2016. Participants in 189 clusters were randomly assigned to wear N95 respirators and participants in 191 clusters were randomly assigned to wear medical masks when near patients with respiratory illness. Over 2,370 participants completed the study. The primary outcome was the incidence of laboratory-confirmed influenza.

Two hundred seven laboratory-confirmed influenza infections were found in the N95 groups versus 193 in the mask group. Researchers concluded that their findings revealed no significant difference in the incidence of laboratory-confirmed influenza between the two groups of outpatient healthcare workers.

This was “a huge and important study—the largest ever done on this issue in North America,” said coauthor Trish M. Perl, MD. “The takeaway is that ... one type of protective equipment is not superior to the other. Facilities have several options to provide protection to their staff—which include surgical masks—and can feel that staff are protected from seasonal influenza.”

Sources: Radonovich LJ Jr, Simberkoff MS, Bessesen MT, et al. N95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial. JAMA. 2019;322(9):824-833. UT Southwestern Medical Center. Surgical masks as good as respirators for flu and respiratory virus protection. ScienceDaily. Sept. 3, 2019.

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INFECTION CONTROL

FDA urges transition to safer duodenoscopes

According to the FDA, duodenoscopes are used in more than 500,000 endoscopic retrograde cholangiopancreatography procedures each year in the US. These devices have complex designs and reusable components that are hard to clean. Failure to adequately reprocess a duodenoscope can result in tissue or fluid from one patient remaining in the device when it is used on a subsequent patient, increasing the risk of patient-to-patient disease transmission. To reduce this risk, the FDA recommends that hospitals and endoscopy facilities:

  • transition away from fixed-endcap duodenoscopes to those with newer design features that facilitate or eliminate the need for reprocessing.
  • consider using duodenoscopes with disposable components, if available.
  • ensure staff are meticulously following reprocessing instructions.
  • consider reprocessing with supplemental measures such as sterilization or use of a liquid chemical sterilant processing system.
  • institute a quality control program that includes monitoring methods, such as sampling and microbiological culturing.
  • monitor reprocessing procedures and develop schedules for routine inspection and periodic maintenance in accordance with the duodenoscope manufacturer's instructions.

The FDA also recommends informing patients that the risk of infection from inadequate reprocessing is relatively low, and that they should not cancel or delay any planned procedure without first discussing the benefits and risks with their healthcare provider.

Source: US Food and Drug Administration. The FDA is recommending transition to duodenoscopes with innovative designs to enhance Safety. FDA Safety Communication. August 29, 2019.

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PAIN MANAGEMENT

Getting real results with virtual reality

Therapeutic virtual reality (VR) is emerging as a drug-free alternative for pain management, but little research has been conducted on its effectiveness for hospitalized patients. A prospective randomized trial was performed in hospitalized patients with an average pain score of 3 or more out of 10 points. Patients in the experimental group (n = 61) received a library of 21 VR experiences; control patients (n = 59) viewed specialized TV programming to promote health and wellness. Clinical staff provided usual care to all patients. The primary outcome was patient-reported pain on a numeric rating scale, documented by nurses during usual care. Pre- and postintervention pain scores were compared immediately after initial treatment and after 48 and 72 hours.

The study showed that VR significantly reduced pain in these hospitalized patients, and that it was most effective for managing severe pain. “Future trials should evaluate standardized order sets that interpose VR as an early non-drug option for analgesia,” the authors concluded.

Source: Spiegel B, Fuller G, Lopez M, et al. Virtual reality for management of pain in hospitalized patients: a randomized comparative effectiveness trial. PLoS One. 2019;14(8):e0219115.

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CRITICAL CARE

41% of pressure injuries may be unavoidable

Despite preventive efforts, hospital-acquired pressure injuries (HAPIs) continue to occur, especially in ICUs. Based on results of a new study, nurse researchers concluded that about 41% of pressure injuries in critical and progressive care units are not preventable. They also explored risk factors that differentiate avoidable from unavoidable HAPIs.

This descriptive retrospective study involved 165 patients (mean age, 60). Data collected included demographic information, Braden Scale scores, clinical risk factors, and preventive interventions. Most of the HAPIs were deep tissue pressure injuries (63%), followed by Stage 2 (21%) and Unstageable (15%).

The Pressure Ulcer Prevention Inventory was used to categorize HAPIs as avoidable or unavoidable. Unavoidable HAPIs were defined as those that developed despite consistent documentation of evidence-based preventive interventions.

Results showed that factors associated with unavoidable pressure injuries included the presence of bowel management devices and prolonged length of stay: For each 1-day increase in stay, the odds of developing an unavoidable pressure injury increased by 4%. In addition, patients who had previously experienced a pressure injury were five times more likely to have an unavoidable HAPI.

The authors identified some HAPI risk factors, such as heart failure and systolic BP below 90 mm Hg, that they believe may be related to nurses' perceptions of patients' hemodynamic instability and ability to tolerate repositioning. The authors note that “the complexity and instability of the patient's condition often limit repositioning by the nurse. However, best practice continues to suggest that slow, gradual turning allows sufficient time for stabilization of blood pressure and oxygen saturation and should be considered.”

Source: Pittman J, Beeson T, Dillon J, Yang Z, Cuddigan J. Hospital-acquired pressure injuries in critical and progressive care: avoidable versus unavoidable. Am J Crit Care. 2019;28(5):338-350.

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In December, celebrate

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WORKPLACE DISTRACTIONS

Social media intrudes on nurses' performance

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Using an online survey involving nurses from 53 countries, researchers investigated the relationship of social networking site (SNS) addiction and nurses' performance on the job. After a web-based questionnaire was distributed among relevant Facebook groups worldwide, 461 nurses from 19 Facebook groups participated. Examples of SNSs are Facebook, Twitter, and Instagram. SNS addiction and employee performance were measured on standardized scales. The average age of participants was approximately 30, and the average length of time in nursing was about 4 years. The survey remained active for a 3-month period.

Researchers found that SNS addiction lowers nursing performance and contributes to task distraction. However, this negative effect on performance is mitigated by self-management. By definition, a self-managed person makes plans, works toward goals, and resists distractions.

The authors say their study has important implications for nurses, physicians, and hospital administrators. For example, they recommend that hospitals limit employees' use of SNSs on the job, offer self-management training, and establish a workplace environment free from the distracting sounds of cell phone ringtones and social media notifications.

Source: Javed A, Yasir M, Majid A, et al. Evaluating the effects of social networking sites addiction, task distraction, and self-management on nurses' performance. J Adv Nurs. [e-pub ahead of print August 5, 2019]

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MATERNAL SLEEP POSITION

Pregnant women can sleep on it

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Traditionally, pregnant women are advised to sleep on their left side to reduce the risk of stillbirth, but the evidence supporting this recommendation is weak. Results of a recent prospective study involving 8,706 pregnant women found that sleeping supine or on the right side instead did not increase the risk of stillbirth or other adverse outcomes through the first 30 weeks of gestation.

The study involved nulliparous women with singleton gestations who were enrolled between October 2010 and May 2014. Participants completed in-depth sleep questionnaires in early and middle pregnancy. The primary outcome was a composite of adverse pregnancy outcomes such as stillbirth, a small-for-gestational-age newborn, and gestational hypertensive disorders. Through 30 weeks of gestation, no significant differences in composite adverse outcomes were associated with left-lateral, right-lateral, or supine sleep positioning. The study did not address sleep positioning after 30 weeks of gestation.

In an accompanying editorial published in Obstetrics & Gynecology, the authors say that the prospective methodology of this research makes the evidence superior to previous case-control studies that seemed to favor left-lateral positioning. They recommend that practitioners tell patients that because the best evidence does not show an association between sleep positions and adverse pregnancy outcomes, “they should feel comfortable sleeping in any position that works for them.”

Sources: Silver RM, Hunter S, Reddy UM, et al. Prospective evaluation of maternal sleep position through 30 weeks of gestation and adverse pregnancy outcomes. Obstet Gynecol. 2019;134(4):667-676. Fox NS, Oster EF. The advice we give to pregnant women: sleep on it. Obstet Gynecol. 2019;134(4):665-666.

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