Clinical Voices April 2021

Apr 01, 2021

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Sponsored by Masimo

Multimodal Pain Regimen Trial Reduced Opioid Use, Prescriptions

The clinical trial included 1,561 adult trauma patients at an urban hospital.

A multimodal pain regimen (MMPR) to reduce opioid exposure achieved similar pain outcomes, lower opioid use and fewer opioid prescriptions compared with a standard MMPR in a single-site trial.

"Multi-Modal Analgesic Strategy for Trauma: A Pragmatic Randomized Clinical Trial," in JACS: Journal of the American College of Surgeons, notes that a trial testing a Multi-Modal Analgesic Strategies for Trauma (MAST) MMPR alternative may support a cost-conscious and widely available generic treatment option that also might help deter opioid abuse. "These findings underscore the efficacy of opioid-minimizing strategies after trauma, and the MAST MMPR has become usual practice for injured patients admitted to our trauma center."

The trial included 1,561 adult trauma patients at a Houston hospital trauma ward, intermediate care unit or ICU. Half were randomly assigned the center's original MMPR (IV, then oral acetaminophen, 48 hours of celecoxib and pregabalin, followed by naproxen and gabapentin, scheduled tramadol, with oxycodone available for breakthrough pain), and half were assigned the MAST option (oral acetaminophen, naproxen, gabapentin and lidocaine patches, with opioids as needed).

The MAST group averaged 34 oral morphine milligram equivalents (MMEs) per day, compared with 48 for the standard MMPR group, and lower total MMEs over the hospital stay (164 vs. 218), but patients in the intermediate care unit and ICU had a 12% and 8% higher total of MMEs in the MAST group. The MAST group had a lower rate of opioid prescriptions at discharge (62% vs. 67%), with a 27% reduction for ICU patients.

Limiting COVID-19 Effects on Brain

Lighter sedation, frequent awakening and breathing trials, mobilization and safe visitation are key.

Heavy sedation and patient isolation from family can be modified to reduce the risks of coma and delirium for critically ill patients with COVID-19.

"Prevalence and Risk Factors for Delirium in Critically Ill Patients With COVID-19 (COVID-D): A Multicentre Cohort Study," in The Lancet Respiratory Medicine, finds that prolonged benzodiazepine infusions are associated with a 59% higher risk of delirium for mechanically ventilated adults with COVID-19. Additionally, when family members visit, a patient's risk of developing delirium the following day declines 27%.

The study, which involved 69 ICUs in 14 countries in early 2020, included 2,088 adults with COVID-19 and acute respiratory distress syndrome. Two-thirds were sedated with benzodiazepines or propofol for a median of seven days.

Findings revealed that 1,704 patients (81.6%) were comatose for a median of 10 days, and 1,147 (54.9%) were delirious for a median of three days.

"The overuse of benzodiazepine sedative infusions and lack of family visitation (either in person or virtual) were associated with more delirium and thus, strategies to modify these approaches might mitigate delirium and any associated sequalae [sic]," the study adds.

That conclusion is reinforced in a related article in Medical News Today, which notes that during the pandemic, many healthcare providers have reverted to older sedation practices rather than following newer protocols to combat acute brain dysfunction.

"These prolonged periods of acute brain dysfunction are largely avoidable," senior study author Pratik Pandharipande, Vanderbilt University Medical Center, Nashville, Tennessee, adds in the article. "Our study sounds an alarm: As we enter the second and third waves of COVID-19, ICU teams need, above all, to return to lighter levels of sedation for these patients, frequent awakening and breathing trials, mobilization, and safe in-person or virtual visitation."

Turbulence Distracts From Patient Care

Additional research will lead to a better understanding of turbulence and its impact.

Nursing turbulence, or everyday interruptions that distract a nurse's attention, is strongly associated with risks to patient safety, yet it is not well defined as a measure of workload.

"Nursing Turbulence in Critical Care: Relationships With Nursing Workload and Patient Safety," in American Journal of Critical Care, suggests that workload and turbulence should be considered separately when assessing work demands. Turbulence examples include time spent searching for equipment or medication, or retrieving lost data.

"Because staffing and resource availability are often designed around workload measures alone, recognizing turbulence helps advance the science and improve the measurement of nursing work," the study explains.

A survey distributed by AACN asked nurses if any of 15 turbulence activities affected the work on their units. An analysis of the 296 responses reveals that risk to patient safety is much stronger due to turbulence than it is due to workload.

The study defines turbulence as the degree a nurse's attention is redirected due to four processes — thought diversions, inadequate resources, communication breakdowns and interpersonal relationships. Technology is a fifth possible factor. To measure the level of turbulence in a workplace, the study proposes a scale listing 12 types of turbulence within the four processes.

In a related blog on, study co-author Jennifer Browne, University of the Incarnate Word, San Antonio, Texas, says the study confirms "there are elements of nursing activities not identified in workload that might have a profound influence on patient care." She adds, however, that more research is needed to better understand turbulence and its impact.

"Further research is also needed because the majority of our study respondents were expert ICU nurses," Browne adds. "Turbulence might have different characteristics with nurses who have less experience or who work in other areas of acute care."

Nurse-Driven Antibiotic Stewardship Intervention

A pilot study combining nurse education with an algorithm reduced total and inappropriate urine cultures.

A nurse-driven antibiotic stewardship intervention reduced total urine cultures (UrCxs) and the rate of inappropriate UrCxs to improve patient outcomes through nurse education.

According to "A Pilot Study to Evaluate the Impact of a Nurse-Driven Urine Culture Diagnostic Stewardship Intervention on Urine Cultures in the Acute Care Setting," in The Joint Commission Journal on Quality and Patient Safety, a nurse education program and use of an algorithm can trigger discussions with hospitalists that lead to cost-saving benefits and reduce antibiotic resistance. "Working with nurses to reduce unnecessary UrCxs may improve the diagnosis of urinary tract infections (UTIs) and, indirectly, antibiotic use," adds a related news release.

Conducted at an adult medicine unit at Johns Hopkins Hospital, Baltimore, the study involved 37 nurses and included diagnostic stewardship education, identifying a nurse champion as a liaison and implementing a discussion guide algorithm. The intervention lowered the mean UrCx rate per 100 patient-days from 2.30 to 1.52 and the rate of inappropriate UrCx from 0.83 to 0.71. In a control unit without intervention the UrCx rate increased from 2.17 to 3.10.

As noted in the news release, a related editorial adds that the study "demonstrated the impact of a multifaceted method to engage nursing staff in antibiotic and testing stewardship."

"In addition, the algorithm supported nursing decision making, and the SBAR tool helped nurses to overcome reservations about discussing provider orders and addressing provider resistance, both of which are potential barriers to nursing success" in antibiotic stewardship.

Midline Catheters Prove Favorable in Blood Collection Study

Additional research will help determine best practices for blood sampling.

A first-time study to evaluate outcomes on blood collection from midline catheters (MCs) resulted in low rates of hemolysis, an increase in dwell time and completed therapy.

According to "Evaluation of Processes, Outcomes, and Use of Midline Peripheral Catheters for the Purpose of Blood Collection," in The Journal of the Association for Vascular Access, the study's initial favorability using one type of MC may lead to further research on outcomes and the development of clinical guidelines. "More studies are needed to determine best practices for blood sampling through various types of MCs and outcomes," adds the CE article.

The study involved two medical and two surgical units at a single-site hospital and included data on 397 MC uses on 378 patients over a three-month period. The hemolysis rate was 0.69% in 1,021 tests, and the mean dwell time (time the catheter is in place) when an MC was used for withdrawal was 44% higher (127.19 hours vs. 88.34 hours).

Evaluation included focus group sessions with nurses to assess practices, which "demonstrated wide variation," and "most learned techniques from their preceptors, other nurses, or patients."

According to a related news release, Infusion Nurses Society standards include "guidance for blood collection from central venous and short peripheral catheters (SPCs), but no formal guidance regarding midline catheters, as there have previously been no study data upon which to base a recommendation."

Lead author and principal investigator Daleen Penoyer, Orlando (Florida) Regional Medical Center, notes the potential to reduce needlesticks and improve patient satisfaction. "While recognizing that this was a single site study, this data may further support the use of midlines for the purpose of blood sampling and could potentially reduce unnecessary repeated venipunctures," he adds in the release.

Women More Prone to Heart Failure Hospitalization After AMI

The difference in outcomes begins within two weeks of discharge after AMI.

Women who survive acute myocardial infarction (AMI) are more likely to be admitted for heart failure within six months than men, finds a retrospective analysis, and the risk emerges early after discharge.

"Sex Differences in Heart Failure Hospitalisation Risk Following Acute Myocardial Infarction," in Heart, notes women have an overall 19% higher risk of readmission for heart failure, and the risk for women is consistent across multiple subgroups. "So, there are certain differences which may exist both in the pathophysiology, in how we provide care to our patients, in how patients perceive their disease processes, and maybe in how outpatient follow-up might be happening that [could be] causing these differences in outcomes," lead author Srikanth Yandrapalli, Westchester Medical Center and New York Medical College, Valhalla, New York, adds in a related article in TCTMD.

Potential explanations, Yandrapalli adds in the article, could include lower medication compliance for women or lower disease and symptom awareness, which could be solved with increased telehealth or calls after discharge. "There are simple things that we can solve over the phone, and this can probably be done in the first week, because this is the highest-risk period."

The analysis reviewed the records of adults in the U.S. Nationwide Readmissions Database from January to June 2014, with 237,549 survivors of AMI included. Hospitalization within six months occurred in 6.8% of women and 4.6% of men, with a separation of the specific curves within the first two weeks.

Female patients were older on average with more comorbidities, although they were less likely to have high cholesterol, smoke or have a prior MI. Women were also less likely to receive angioplasty or coronary artery bypass graft surgery than men (49% to 69%).

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