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Department: CLINICAL ROUNDS

Clinical Rounds

doi: 10.1097/01.NURSE.0000615120.08587.03
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WORKPLACE STRESS

A “bold vision” for preventing burnout

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In a detailed consensus report issued by the National Academies of Sciences, Engineering, and Medicine, an expert committee offers a “bold vision” for redesigning clinical systems to prevent clinician burnout. Among the report's goals and recommendations are to:

  • create positive work environments that foster professional well-being and support quality patient care.
  • create positive learning environments for clinicians and clinicians in training.
  • ease the administrative burden on clinicians that results from laws, regulations, policies, and standards.
  • reduce the stigma associated with obtaining support and services necessary to prevent burnout.
  • invest in research dedicated to clinician professional well-being.

According to the report, between 35% and 54% of US nurses and physicians have “substantial symptoms of burnout,” defined as high emotional exhaustion, high depersonalization, and low sense of personal accomplishment. “Burnout is the result of chronic workplace stress,” said committee member Lotte Dyrbye, MD, in a statement. “Solutions lie within the work environment.” Read the report at www.nap.edu/read/25521/chapter/1#xx.

Sources: The National Academies of Sciences, Engineering, and Medicine. Taking Action against Clinician Burnout: A Systems Approach to Professional Well-being. Washington, DC: The National Academies Press; 2019. Recommendations developed to address clinician burnout. HealthDay News. November 1, 2019.

CRITICAL CARE NURSING

Nurses feel unprepared to give palliative care

In a quantitative, descriptive study, researchers analyzed survey questionnaires from 167 critical care nurses in seven ICUs. The questionnaires were designed to explore nurses' perceptions of palliative care and moral distress in their practice settings. Findings showed that less than 40% of respondents felt highly competent in any palliative care domain. Most respondents said they had had little palliative care education and 38% said they had had no palliative care education in the previous 2 years. In addition, most respondents reported feeling moral distress during the study period, with higher levels of moral distress tending to correlate with the perception of less frequent use of palliative care.

The authors concluded that “health system leaders should prioritize palliative care training for critical care nurses and their colleagues and empower them to reduce barriers to palliative care.”

Source: Wolf AT, White KR, Epstein EG, Enfield KB. Palliative care and moral distress: an institutional survey of critical care nurses. Crit Care Nurs. 2019;39(5):38-49.

COPD

Disinfectant exposure puts nurses at risk

Recent research showed that occupational exposure to cleaning products and disinfectants was associated with a significantly increased risk of developing chronic obstructive pulmonary disease (COPD) independent of asthma and smoking. The cohort study included data on 73,262 female nurses participating in the Nurses' Health Study II who were followed up from 2009 to 2015. Participants were still in a nursing job and had no history of COPD in 2009. Occupational exposure to disinfectants was evaluated by questionnaire and a job-task-exposure matrix (JTEM). Main outcomes and measures were incident physician-diagnosed COPD evaluated by questionnaire.

Researchers found that “self-reported cleaning/disinfection tasks and exposure to several specific disinfectants evaluated by a JTEM, including glutaraldehyde, bleach, hydrogen peroxide, and alcohol and quaternary ammonium compounds, were associated with a 25% to 38% increased risk of COPD incidence.” Although all of these chemicals are known airway irritants, the study did not establish a causal relationship between disinfectant exposure and COPD. However, the authors write that their findings underscore the need to develop exposure-reduction strategies compatible with infection control standards. Potentially safer alternatives to consider include nonchemical technologies for disinfection, such as steam or UV light, and “green cleaning” with less toxic substances.

Sources: Dumas O, Varraso R, Boggs KM, et al. Association of occupational exposure to disinfectants with incidence of chronic obstructive pulmonary disease among US female nurses. JAMA Netw Open. 2019;2(10):e1913563. Quinn MM, Henneberger PK, Braun B, et al. Cleaning and disinfecting environmental surfaces in health care: toward an integrated framework for infection and occupational illness prevention. Am J Infect Control. 2015;43(5):424-434.

SAFETY ADVISORY

On alert for hemorrhage in pregnancy

The Joint Commission has issued a Quick Safety advisory reviewing two new standards that address complications in maternal hemorrhage and severe hypertension/preeclampsia. The advisory also suggests strategies to prevent complications from postpartum hemorrhage, including implementation of standardized, evidence-based obstetric safety bundles. Organized into four safety domains, obstetric safety bundles include these action items:

  • having a standardized, secured, and dedicated hemorrhage supply kit that is stocked according to the facility's defined process.
  • assessing hemorrhage risk prenatally, on admission, and at other appropriate times.
  • establishing a standardized, obstetric hemorrhage emergency management plan.
  • establishing a culture of huddles for high-risk patients and postevent debriefs to identify success and opportunities for improvement.

In the US, the most frequent cause of severe maternal morbidity and preventable maternal mortality is obstetric hemorrhage. The Joint Commission notes that while many risk factors are known, 20% of hemorrhages occur in women with no risk factors. Consequently, “all members of the obstetrical care team must maintain a constant readiness for this often-unpredictable emergency.” Read the advisory at www.jointcommission.org/assets/1/23/QS_51_Maternal_hemorrhage_10_25_19_FINAL2.PDF.

Source: The Joint Commission. Proactive prevention of maternal death from maternal hemorrhage. Quick Safety. Issue 51, October 2019.

PREDIABETES

Many PCPs are uninformed about diabetes prevention

A national survey of US primary care physicians (PCPs) was conducted to assess PCPs' knowledge and practice regarding management of prediabetes. Based on responses from 298 eligible respondents, researchers found PCPs had “limited knowledge of risk factors for prediabetes screening, laboratory diagnostic criteria for prediabetes, and management recommendations for patients with prediabetes.” Specifically:

  • only 36% of PCPs refer patients to a diabetes prevention lifestyle change program as their initial management approach.
  • 43% discuss starting metformin for prediabetes.
  • PCPs identified barriers to type 2 diabetes prevention at both the individual level (such as patients' lack of motivation) and the system level (such as lack of weight loss resources).

The researchers concluded that “gaps in PCP knowledge contribute to the inadequate diagnosis of prediabetes and referral to diabetes prevention interventions.” To support type 2 diabetes prevention in the primary care setting, they call for addressing gaps in PCP knowledge as well as system-level changes to improve the identification and care of patients with prediabetes.

Source: Tseng E, Greer RC, O'Rourke P, et al. National survey of primary care physicians' knowledge, practices, and perceptions of prediabetes. J Gen Intern Med. [e-pub ahead of print September 9, 2019]

In January, celebrate

CANCER THERAPY

Unmarried patients may face treatment bias

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Provocative new research suggests that healthcare providers are less likely to prescribe aggressive cancer therapies to unmarried patients compared with married patients primarily due to the unsupported assumption that unmarried patients do not have the social support needed to manage debilitating adverse reactions or multiple follow-up visits.

The author, herself an unmarried cancer survivor, examined 84 studies based on a massive National Cancer Institute database to show that patients with cancer are significantly less likely to receive surgery or radiation therapy if they are not currently married. Reasons proposed in the research include patient preferences or a weaker will to live among unmarried patients, but the author found no evidence to support these speculations. Rather, she found that cultural stereotypes create a bias against unmarried patients and disproportionately influence treatment plans.

According to the Census Bureau, 45% of US adults are unmarried. Although some patients, married or not, lack social support for aggressive treatment, “that generalization can't possibly apply to nearly half the adult population,” the author says. Although researchers in all 84 studies relied on marital status as a good indicator of social support, “their reliance on stereotypes about unmarried adults is misleading, especially when they misinterpret sociological and psychological studies that do not, in fact, support those stereotypes.” She hopes her research will raise awareness about this issue and spur more research.

Sources: DelFattore J. Death by stereotype? Cancer treatment in unmarried patients. N Engl J Med. 2019;381(10):982-985. University of Delaware. Bias against single people affects their cancer treatment. News release. September 9, 2019.

BLOOD TRANSFUSIONS

Should current guidelines be revisited?

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Recent research suggests that more restrictive policies that discourage blood transfusions for certain patient groups, such as those with stable BP, may improve patient safety as well as lowering costs. In a retrospective study, researchers from the Cleveland Clinic reviewed the medical records of 888 patients admitted to the medical intensive care unit (MICU) who required at least one transfusion of packed red blood cells (PRBC) from January 2015 to December 2015. During the study year, 3,140 units of PRBC were administered.

Current guidelines identify 60 specific indications for transfusion, categorized as acute blood loss (54%), chronic blood loss (37%), and acute hemolysis (9%). Evaluating the necessity and outcome of transfusions in the MICU during the study period, the researchers found that 13% of transfusions prescribed in accordance with transfusion guidelines could potentially have been avoided.

The Joint Commission has identified blood transfusions as an overused procedure, and the American Association of Blood Banks advises limiting transfusion to certain critically ill patients, such as those who are at risk for shock or cardiovascular failure. “We identified a specific group of patients for whom blood transfusion can be safely avoided,” says Divyajot Sadana, MD. “Closer inspection, greater scrutiny, and a vigorous investment in a restrictive transfusion practice could have significant implications on both financial and patient outcomes.”

Sources: American College of Chest Physicians. Further restricting blood transfusions guidelines could save lives and money. News release. October 14, 2019. CHEST: Blood transfusion practices should be revisited. HealthDay News. October 24, 2019.

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