Journal Logo

Department: CLINICAL ROUNDS

Clinical Rounds

doi: 10.1097/01.NURSE.0000651656.32765.04
  • Free

ECRI INSTITUTE

Top 10 technology hazards for 2020

Figure
Figure

ECRI Institute, a leading healthcare safety organization, has issued its annual Top 10 Health Technology Hazards list to inform healthcare facilities about important safety issues involving the use of medical devices and other healthcare industry technologies. The list identifies potential sources of danger that ECRI believes warrant the greatest attention for the coming year. These are not necessarily the most frequently reported problems or the ones associated with the most severe consequences, but rather risks that healthcare facilities should prioritize now. All issues on the list represent problems that can be avoided or risks that can be minimized through the careful management of technologies, including:

  • misuse of surgical staplers.
  • unproven surgical robotic procedures.
  • alarm, alert, and notification overload.
  • medication errors from dose timing discrepancies in electronic health records.
  • loose nuts and bolts leading to catastrophic device failures and severe patient injury.

An Executive Summary is available at www.ecri.org. The full report is available to members of ECRI Institute programs through their membership web pages.

Source: ECRI Institute. Executive brief. Special report: top 10 health technology hazards for 2020. www.ecri.org.

SEPSIS

Digital alerts improve patient outcomes

A digital sepsis alert system introduced into a multisite hospital network was shown to improve patient outcomes in a recently reported study conducted in the United Kingdom. Sepsis alerts were either visible to clinicians caring for patients in the intervention group or running silently and not visible to clinicians caring for patients in the control group. Outcomes were in-hospital 30-day mortality (all inpatients), prolonged hospital stay (7 days or more), and timely antibiotics (within 60 minutes of the alert) for patients triggering an alert in the ED.

The study involved 21,732 patient encounters with at least one alert between October 2016 and May 2018. For patients in the test group, nurses were notified when a patient triggered the alert either through a pop-up warning on the electronic health record (EHR) in inpatient units or as a dashboard highlighting any patient with an active alert in the ED and inpatient units. Physicians were presented with a sepsis warning only when they opened the patient's EHR.

Findings showed that introduction of the alert was associated with lower risk of mortality and lower odds of prolonged hospital stay of at least 7 days. In addition, patients who required antibiotics had better odds of receiving them in a timely manner. The researchers could not determine if sepsis alerting was responsible for the improved outcomes or if the alerts acted as a driver for quality improvement initiatives. They concluded that these findings “strongly suggest that the introduction of a network-wide digital sepsis alert is associated with improvements in patient outcomes, demonstrating that digital based interventions can be successfully introduced and readily evaluated.”

Source: Honeyford K, Cooke GS, Kinderlerer A, et al. Evaluating a digital sepsis alert in a London multisite hospital network: a natural experiment using electronic health record data. J Am Med Informatics Ass. [e-pub ahead of print Nov. 20, 2019]

RN WORKFORCE

Survey hints at future nursing shortages

A survey of nearly 20,000 RNs from March 27 to May 1, 2019 reveals that more than one in five RNs holds a second job, and about 273,000 nurses have two full-time jobs. About 66% of RNs worry their job is affecting their health, and 44% say they often feel like quitting.

The percentage of nurses reporting worsening nursing shortages during the past 5 years increased from 37% in 2015 to 52% in 2019. Among baby boomer nurses responding to this survey, 86% plan to retire in the next 5 years.

Forty-one percent of RNs say they experience bullying, incivility, or other forms of workplace violence, according to this survey. However, on a more positive note, 81% are satisfied with career choice, and 75% are satisfied with the quality of care they provide. Proposed solutions to workplace challenges include more flexibility to improve work-life balance, more support for diversity in the workplace, enhanced professional development support, and greater emphasis on safety practices.

On average, survey respondents had 19 years of nursing experience. Most were female (89%) and White (72%), and 60% worked in a hospital setting. This survey is conducted annually by AMN Healthcare, a national healthcare workforce solutions provider.

Sources: AMN Healthcare. 2019 AMN Healthcare Survey of Registered Nurses: a challenging decade ahead. www.amnhealthcare.com/2019-survey-of-registered-nurses-a-challenging-decade-ahead. Survey of US registered nurses points to worsening shortage. HealthDay News. November 14, 2019.

PEDIATRIC ICU

Is holding intubated infants safe?

Although early mobility in the ICU is promoted to improve outcomes, this intervention has not been well studied in infants. To determine if a holding intervention is safe for infants endotracheally intubated for respiratory failure, researchers studied a holding intervention in 24 intubated, medically stabilized infants under age 6 months in a pediatric ICU (PICU). The holding intervention involved a caregiver holding the infants at least twice a day. Vital signs before and during holding were recorded to assess for physiologic tolerance. Rates of adverse events were compared with historical controls matched by age and Pediatric Index of Mortality 2 score.

A total of 158 holding interventions were studied (mean holding duration, 99 minutes). Twenty holding interventions were terminated early, usually due to agitation.

In the intervention group, vital signs before and during holding were similar. Comparing the intervention and control groups, no differences were found in duration of intubation, length of PICU stay, or length of hospital stay. The intervention group had no unplanned extubations, inadvertent central venous catheter removals, or urinary catheter removals. One arterial catheter removal occurred, but it was not associated with the holding intervention.

The authors concluded that holding infants who are endotracheally intubated for primary respiratory failure is safe and well tolerated. In addition, they write that “the intervention was well received by nurses and parents and led to an unexpected increase in holding for all infant populations in our PICU.”

Source: Ortmann L, Dey A. Early mobilization of infants intubated for acute respiratory failure. Crit Care Nurs. 2019; 39(6):47-52.

In February, celebrate

NURSE-LED PROGRAM

A successful NICHE for older adults

Figure
Figure

Based at the New York University School of Nursing, the Nurses Improving Care for Healthsystem Elders (NICHE) is a nurse-led education and consultation program designed to help healthcare organizations improve the quality of care for older adults. Currently, over 620 hospitals and healthcare facilities are NICHE program members in the US, Singapore, Canada, and Bermuda.

Researchers recently conducted an analysis of 27 years of research on NICHE programs involving 12,254 patients and over 50,000 nurses. The goals were to determine how the NICHE program influences patient outcomes through specialized care of older adults and to provide an overview of its impact on nurses and the work environment. Forty-three studies published between January 1992 and April 2019 were included in the analysis. Findings included the following:

  • The NICHE program helped member facilities improve the care of hospitalized older adults by addressing specific geriatric issues such as falls, potentially inappropriate medications, catheter-associated urinary tract infections, and dementia symptom management.
  • Participation in the NICHE program encouraged use of the geriatric resource nurse model in which nurses become unit-based leaders providing specialized care for older adults. Implementing the geriatric resource nurse model triggered significant workplace culture changes and improved nursing knowledge about specific health issues common in older adults, such as incontinence and sepsis.
  • The NICHE program improved nurses' perceptions of care quality, aging-sensitive care delivery, resource availability, institutional values, and capacity for collaboration.

The authors say their findings are “promising,” but call for more research on patient outcomes and the program's impact on healthcare professionals to help healthcare organizations meet their goals and further improve outcomes for older adults.

Sources: Squires A, Murali KP, Greenberg SA, Herrmann LL, D'amico CO. Scoping review of the evidence about the Nurses Improving Care for Healthsystem Elders (NICHE) program. Gerontologist. [e-pub ahead of print Nov. 4, 2019.] New York University. Studies find nurse-led program improves care of older adults. News release. November 4, 2019. Hartford Institute for Geriatric Nursing. NICHE program. https://hign.org/who-we-are/partners/niche-program.

COMMUNITY-ACQUIRED MRSA

Hand hygiene is still the best defense

Figure
Figure

Because methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection is a growing threat worldwide, a study was designed to investigate factors driving community-acquired MRSA infections. From 2012-2015, researchers recruited otherwise healthy pediatric patients with culture-confirmed, community-onset MRSA infections for the Household Observation of MRSA in the Environment (HOME) prospective cohort study. Subjects were drawn from hospitals and community practices in metropolitan St. Louis, Mo. Household contacts (individuals sleeping in the home 4 nights per week or more) and indoor dogs and cats were also enrolled. Children with healthcare-related risk factors were excluded.

Researchers conducted a baseline visit at each patient's primary home, followed by four quarterly visits over 12 months. At each visit, they conducted interviews and collected serial cultures to detect S. aureus from three anatomic sites on household members, two anatomic sites on dogs and cats, and 21 environmental surfaces. Molecular typing was performed to define distinct S. aureus strains within each household.

Findings revealed 1,267 strain acquisition events, driven equally by introductions of novel strains into households and transmissions within households. Each was associated with distinct factors associated with disease transmission, such as:

  • not owning the home.
  • sharing bedrooms with strain-colonized individuals.
  • living in homes with higher environmental S. aureus contamination burden.

Transmission sources were more likely to share bath towels. Pets were often transmission recipients but rarely the sole transmission source. Frequent hand washing decreased the likelihood of introducing a novel MRSA strain into the household.

The researchers concluded that “household environment plays a key role in transmission, a factor associated with skin and soft tissue infection.” To prevent MRSA transmission, they recommend interventions targeting household members and the environment, “focusing on straightforward changes in hand hygiene and household sharing behaviors.”

Source: Mork RL, Hogan PG, Muenks CE, et al. Longitudinal, strain-specific introduction and transmission events in households of children with community-associated methicillin-resistant skin and soft tissue infection: a prospective cohort study. Lancet Infect Dis. [e-pub ahead of print Nov. 26, 2019]

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.