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Department: CLINICAL ROUNDS

Clinical Rounds

doi: 10.1097/01.NURSE.0000743280.34376.9f
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In Brief

MENTAL HEALTH

Tranquil settings ease staff stress

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As recently reported by The Joint Commission, Montefiore Medical Center in New York City implemented various mental health services to mitigate psychological distress among staff during the height of the COVID-19 pandemic. Interventions included psychoeducational resources, telephone support lines, staff support centers (SSCs), team support systems, and clergy support. SSCs were the most-used resource; telephone support lines, individual treatments, and clergy support were among the least used.

The SSCs were a modification of previously existing caregiver support centers (CSCs) established to provide a comforting environment for families of hospitalized patients. When visitors were no longer allowed in the hospital, CSCs were converted to SSCs to provide staff support. Utilization of SSCs grew from 25 visits on the first day to more than 750 daily visits during the height of the pandemic.

Consisting of tranquil spaces with couches, massage chairs, and computers, the SSCs were promoted as safe places to nurture one's whole self. Meals and snacks were provided at all sites. Volunteers ensured a steady supply of food and assisted with cleaning and sanitation. From March to mid-June 2020, more than 32,000 visits were recorded, and many staff members requested that the service continue after the pandemic.

To learn more about SSCs and other popular staff support interventions initiated at this medical center, visit www.ncbi.nlm.nih.gov/pmc/articles/PMC7673209.

Sources: Bernstein CA, Bhattacharyya S, Adler S, Alpert JE. Staff emotional support at Montefiore Medical Center during the COVID-19 pandemic. Jt Comm J Qual Patient Saf. 2021;47(3):18-189. The Joint Commission. Mental health support for health care workers during COVID-19 pandemic. News release. February 23, 2021.

HEART FAILURE

Universal definition and classifications proposed

In a consensus statement, a new universal definition of heart failure (HF) has been proposed by an international panel of 38 experts. The purpose of the statement is to standardize terminology and facilitate appropriate treatment in keeping with current evidence and clinical advances.

The proposed definition is as follows: “HF is a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion.” This definition encompasses three elements common to the various HF definitions currently in use: evidence of structural heart disease, a history of symptoms commonly reported in HF, and objective signs commonly seen in HF.

The statement also includes revisions to HF staging and classification. Notably, stage B has been reframed as “pre-HF” for patients without current or prior signs or symptoms of HF. “Pre-cancer is a term widely understood and considered actionable and we wanted to tap into this successful messaging and embrace the pre-heart failure concept as something that is treatable and preventable,” says committee chair Biykem Bozkurt, MD, PhD. The consensus statement also seeks to standardize HF classifications across practice guidelines based on ejection fraction.

The recommendations were published simultaneously in the Journal of Cardiac Failure and the European Journal of Heart Failure in March.

Sources: Bozkurt B, Coats JS, Tsutsui H, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. J Card Fail. [e-pub March 1, 2021] Beck DL. Heart failure redefined with new classifications, staging. Medscape. March 8, 2021.

PROSTATE CANCER

Rates rising as PSA screening drops

According to a new study, reduced screening for prostate cancer using prostate-specific antigen (PSA) testing corresponds to recent increases in diagnoses of metastatic prostate cancer. The average percentage of men age 40 or older in the US who were screened for prostate cancer using PSA decreased from 61.8% in 2008 to 50.5% in 2016. At the same time, the average number of men diagnosed with metastatic prostate cancer (after age adjustment) increased from 6.4 to 9 per 100,000 men.

Statistical modeling demonstrated that reductions over time in PSA screening were associated with increased metastatic prostate cancer diagnoses and that states with larger reductions in PSA screening tended to have larger increases in metastatic prostate cancer diagnoses.

The US Preventive Services Task Force (USPSTF) did not recommend PSA screening regardless of age in its 2008 and 2012 guidelines. In 2018, USPSTF issued updated guidelines recommending that “men aged 55 to 69 years make an individual decision about whether to be screened after a conversation with their clinician about the potential benefits and harms.” USPSTF recommends against PSA screening for men over 70.

The study was presented at the 2021 American Society of Clinical Oncology Genitourinary Cancers Symposium.

Source: American Society of Clinical Oncology. Increase in U.S. metastatic prostate cancer diagnoses seen after reduction in PSA screening. News release. February 8, 2021.

PATIENT SAFETY

Guidelines to prevent wrong-site surgery

Wrong-site surgery is a broad term that encompasses all surgical procedures performed on the wrong patient, the wrong body part, or the wrong side of the body; it also covers wrong procedures performed at a correctly identified anatomic site. Events resulting from wrong-site surgery can be devastating for both patients and the healthcare professionals involved. ECRI, a leading federally certified patient safety organization, has issued detailed guidelines and an action plan to prevent wrong-site errors. Among the recommendations:

  • Identify and adopt best practices for prevention of wrong-site surgery.
  • Educate providers and staff about the organization's commitment to preventing all cases of wrong-site surgery. Ensure that providers understand that wrong-site surgery events are considered never events and encourage a safety culture that empowers staff to speak up if they perceive a problem.
  • Consider use of a role-based time-out procedure and investigate other approaches to minimizing the risk of wrong-site surgery.
  • Ensure that site marks remain visible when the patient is prepped and draped.
  • Take appropriate action in the event of a wrong-site event. This includes critical analysis to determine what happened, why it happened, and how to prevent such events from happening in the future. For most personnel involved in patient safety events, coaching—not discipline—is an appropriate response.

Source: ECRI. Health System Risk Management. Wrong-site surgery. December 14, 2020. www.ecri.org.

In May, celebrate

HOSPITALIZED PATIENTS

Pandemic shutdowns increased alcohol withdrawal rates

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Prior research indicates that alcohol withdrawal (AW) affects up to 8% of all hospitalized patients with alcohol use disorder. To explore whether AW rates increased during and after the widespread COVID-19 stay-at-home orders last year, researchers at a large tertiary care hospital system conducted a cohort study involving all patients hospitalized between January 1, 2018, and September 22, 2020. A revised Clinical Institute Withdrawal Assessment for Alcohol score of 8 or higher was used to identify AW in hospitalized patients. They found that the AW rate in hospitalized patients was “consistently higher in 2020 compared with both 2019 and the average of 2018 and 2019, although the difference was larger in the period after the stay-at-home order.” In addition, increased AW rates persisted during the reopening period.

The authors theorize that factors associated with higher rates of AW include pandemic-related stress, anxiety, disrupted treatment plans, and increased alcohol use. They urge increased vigilance to identify and treat AW in hospitalized patients, particularly if stay-at-home orders are reinstated.

Source: Sharma RA, Subedi K, Gbadebo BM, Wilson B, Jurkovitz C, Horton T. Alcohol withdrawal rates in hospitalized patients during the COVID-19 pandemic. JAMA Netw Open. 2021;4(3):e210422.

TRAUMATIC BRAIN INJURY

Diagnostic criteria proposed for clinical syndrome

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For the first time, expert consensus criteria have been developed for traumatic encephalopathy syndrome (TES), the clinical disorder associated with chronic traumatic encephalopathy (CTE). A degenerative brain disease, CTE is associated with a history of repetitive head impacts, such as those sustained in football and boxing. Currently, CTE can be diagnosed only after death, and no approach or clinical criteria for diagnosis of CTE or TES during life has been widely accepted.

The proposed diagnostic criteria for TES were developed by a multidisciplinary panel of 20 clinician-scientists and 7 observers from 11 academic institutions across the country. The criteria include:

  • substantial exposure to repetitive head impacts from contact sports, military service, or other causes.
  • a progressive course of cognitive impairment (specifically in episodic or “short-term” memory and/or executive functioning, such as planning, organization, judgment, and multitasking) and/or neurobehavioral dysregulation (including explosiveness, impulsivity, rage, violent outbursts, and emotional lability).
  • a lack of other neurologic, psychiatric, or medical conditions that could be fully responsible for these clinical problems (although other neurologic and psychiatric conditions may be diagnosed together with TES).

The primary goal of these guidelines is to facilitate CTE research. The panel stresses that the criteria for TES are not intended for clinicians to make a clinical diagnosis of CTE. The consensus guidelines were developed during a workshop and 8-month review process funded by the National Institutes of Health.

Sources: Katz DI, Bernick C, Dodick DW, et al. National Institute of Neurological Disorders and Stroke consensus diagnostic criteria for traumatic encephalopathy syndrome. Neurology. [e-pub March 15, 2021] Criteria published for diagnosing the clinical syndrome of CTE during life. Boston University School of Medicine. News release. March 15, 2021.

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