Clinical Voices April 2022

Apr 26, 2022

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This month we feature articles on the use of opioids after cardiac surgery, apixaban safety vs. rivaroxaban, proposed nurse staffing legislation in Illinois, and more. Plus, watch the new President’s Video and read a special nurse story.

Opioids Not Always Needed After Cardiac Surgery

Consider hospitalized patients’ level of opioid use to guide prescribing at discharge.

Some patients handle pain well following cardiac surgery and may be safely discharged without an opioid prescription.

Predictors of Discharge Home Without Opioids After Cardiac Surgery: A Multicenter Analysis,” in The Annals of Thoracic Surgery, involved 1,924 patients – mean age 64 and 25% women – who received coronary artery bypass grafting and/or valve surgery through a sternotomy at 10 centers from January to December 2019. Patients were opioid naïve, meaning they were not taking an opioid when admitted.

Findings reveal that 547 patients, or 28%, left hospitals without an opioid prescription. And just 10 of those patients, or 1.8%, were subsequently prescribed an opioid before their 30-day follow-up.

“Increasing the number of patients discharged without an opioid prescription may be an area for quality improvement,” the study notes, adding that post-discharge opioid prescribing was monitored to assess patients’ tolerance.

Multivariate analysis reveals that older age, longer hospital stays and undergoing surgery during the study’s last three months were independent predictors of discharge without an opioid prescription. Conversely, depression, non-Black and non-white races, and taking more opioid pills the day before discharge were predictors of receiving a prescription.

In a related article in Healio News, study co-author Catherine Wagner, cardiothoracic surgery resident at the University of Michigan, adds, “We should continue to consider the level of opioid use during a patient’s time in the hospital to guide prescribing at discharge.”

Apixaban Comparatively Safer Than Rivaroxaban

Patients were followed for four years and observed for major ischemic and hemorrhagic events.

For adults ages 65 or older with atrial fibrillation, rivaroxaban presents a significantly higher risk of major ischemic or hemorrhagic events than apixaban.

Association of Rivaroxaban vs Apixaban With Major Ischemic or Hemorrhagic Events in Patients With Atrial Fibrillation,” in JAMA: The Journal of the American Medical Association, compares outcomes for 581,451 Medicare beneficiaries (mean age 77) who were treated with either standard or reduced doses of the “most frequently prescribed oral anticoagulants for ischemic stroke prevention in patients with atrial fibrillation.”

Between 2013 and 2018, a total of 227,572 patients received rivaroxaban, while 353,879 received apixaban. Patients were followed for four years and observed for major ischemic events (stroke/systemic embolism) and hemorrhagic events (intracerebral hemorrhage/other intracranial bleeding/fatal extracranial bleeding).

Overall, adjusted incidence of major ischemic/hemorrhagic events per 1,000 person-years was 16.1 among adults taking rivaroxaban versus 13.4 for those prescribed apixaban. Rivaroxaban’s increased risk for major events was noted in both the reduced dose and standard dose groups.

In addition, compared with patients receiving apixaban, those taking rivaroxaban had higher risk of secondary outcomes, including nonfatal extracranial bleeding, fatal ischemic/hemorrhagic events and total mortality.

A related article in 2 Minute Medicine notes that the study is limited in that a “substantial proportion of patients discontinued treatment for reasons unrelated to the safety profile of anticoagulants, resulting in potential confounding of the results.”

Younger Women at Higher Risk for Ischemic Stroke

The review suggests caution in interpreting the results without further research.

The results of a systematic review reveal that 44% more women ages 35 and younger had ischemic strokes than men.

Systematic Review of Sex Differences in Ischemic Strokes Among Young Adults: Are Young Women Disproportionately at Risk?” in Stroke, which reviewed 16 worldwide studies, could not determine whether men or women are at higher risk between ages 35 and 45.

“More research is needed to better define the etiological sex differences of ischemic stroke in young adults and the contributions that nontraditional risk factors, such as pregnancy, postpartum, and hormonal contraceptives, play in the overall burden of ischemic strokes in young women,” the review adds.

The reviewed studies included 33,775 women and 36,018 men, and the results note that some of the uncertainty about sex differences among different age groups could be due to small sample sizes, differences in how studies separate ischemic stroke from other types, and the use of broader age groups in some studies. “To compensate for small sample sizes, there has been a tendency to group stroke types together.”

The data could suggest the presence of “more important, yet poorly understood risk factors for ischemic stroke” in young women. One of the reviewed studies found that about 18% of strokes in women younger than 35 were related to maternity, but stroke types were not differentiated in that study.

The review also observes a high degree of heterogeneity across the studies and suggests caution in interpreting the results without additional focused research. “Sex differences among young adults with ischemic stroke is a problem that demands attention.”

Prone Position in Patients With ARDS May Improve Cardiac Output

A small study notes that prone positioning requires careful assessment of hemodynamic effects.

A small study to test the effects of prone positioning on blood flow and cardiac output for patients with acute respiratory distress syndrome (ARDS) finds that all patients experienced increased mean systemic pressure.

In “Effects of Prone Positioning on Venous Return in Patients With Acute Respiratory Distress Syndrome,” in Critical Care Medicine, the small single-center trial finds the “resulting change in cardiac index depended on the extent of increase in (mean systemic pressure – central venous pressure) gradient, of preload responsiveness, and of the increase in venous return resistance.” The study adds that the successful test of the hypothesis suggests valuable clinical implications for the findings.

Conducted with 22 patients in a medical ICU in France in 2018, the study measured cardiac output at multiple stages of transferring patients to a prone position to understand the consequences. Patients were first changed from semirecumbent to supine horizontal position, and then to prone position.

Within 15 minutes of transfer to prone positioning, there was a 55% mean increase in mean systemic pressure, a 22% increase in central venous pressure (CVP), and a 59% increase in the measured mean systemic pressure minus CVP gradient. Resistance to venous return increased 53% at that stage, and cardiac index increased 8%.

During supine horizontal positioning midway through the process, data on 15 of the patients showed a 30% decrease in intra-abdominal pressure and a 12% increase in mean systemic pressure. “In preload-responsive patients, trunk lowering increased [cardiac index], so that this simple postural maneuver might be the first urgent step in circulatory failure, mimicking the effects of volume expansion,” the study notes. In some patients, there is a risk for a decrease in cardiac index during prone positioning; careful monitoring is needed.

Nurse Staffing Ratios in Illinois

A quality standard for nurse staffing in hospitals is in the public interest.

Legislation that was previously proposed in Illinois would limit medical-surgical units to four patients per nurse, which could help avoid thousands of deaths annually, reduce lengths of stay and save hospitals millions of dollars.

Patient Outcomes and Cost Savings Associated With Hospital Safe Nurse Staffing Legislation: An Observational Study,” in BMJ Open, reveals that in 2020, patient-to-nurse ratios ranged from 4.2 to 7.6 on medical-surgical units in Illinois, for an average of 5.4 patients per nurse. Odds of 30-day mortality increased 16% with each additional patient in a nurse’s care, while the chance of staying in the hospital a day longer rose 5%.

Conducted by the Center for Health Outcomes and Policy Research at University of Pennsylvania School of Nursing, the study reviewed outcomes for 210,493 Medicare patients ages 65 and older treated in 87 Illinois acute care hospitals during 2020. A survey sent to registered nurses supplied staffing data.

“Half (51.2%) of nurses reported their patient assignment during their last shift was unsafe; and among nurses assigned four or fewer patients, only 17.3% found that staffing ratio to be unsafe,” the study adds.

The study estimates that the 4:1 patient-nurse ratio recommended by Illinois’s Safe Patient Limits Act could have avoided 1,595 deaths and reduced hospital stays more than 40,000 days. In addition, Illinois hospitals would have collectively saved over $117 million – which could finance safer nurse staffing ratios, the study suggests.

“This independent scientific study shows that setting a quality standard for nurse staffing in hospitals is in the public’s interest,” study co-author Linda H. Aiken, founding director of the research center and a University of Pennsylvania professor, says in a media release. “And there are plenty of nurses to take good jobs in hospitals with the nation’s nursing schools producing an all-time high of over 180,000 new nurses every year,” she adds.

Nurses’ Prescription Drug Misuse

A national survey of nurses’ substance use was sent during the pandemic.

Nurses misuse prescription drugs at nearly double the rate of the general population, a survey shows, with nurses younger than 45 or working in critical or emergency care most likely to use illicit drugs.

The Prevalence of Substance Use and Substance Use Problems in Registered Nurses: Estimates From the Nurse Worklife and Wellness Study,” in Journal of Nursing Regulation, notes the results of a national survey of RNs and advanced practice nurses that was sent during the pandemic. The results reveal that 18% of respondents screen as positive for substance use problems, and 6.6% screen positive for substance use disorders.

Based on the results of 1,170 usable surveys from randomly selected nurses in nine states, the study identifies 9.9% misusing prescription drugs, compared with 5.9% of the general population. Misuse of illicit drugs is 5.7% overall, but younger nurses (8.2%), critical care nurses (15%) and those in emergency or urgent care (10%) report much higher use.

Nurses working in hospitals (8.5%), ambulatory care (7.0%) or at multiple sites (6.7%) are most likely to have a substance use disorder. Staff nurses have the highest rate (8.5%), with charge nurses, coordinators and nurse managers at 7.5%, and other administrators at 6.1%.

“Given that 18.0% of nurses in our study meet substance use problem criteria overall, this issue bears continuing scrutiny from policy makers and other stakeholders,” adds a related article in MedPage Today.

President’s Video: Building Toward a Thriving Nursing Workforce

In her latest video, AACN President Beth Wathen explores the need to find sustainable, impactful solutions to address some of the most critical issues facing nurses today — inappropriate staffing, unhealthy work environments and pay disparities.

Watch Now

Nurse Story: A New Start in a New Country

Olena Svetlov grew up in the former Soviet Union, in what is now Ukraine. Granted political asylum in the U.S., she is now a clinical nurse specialist in California. Svetlov discusses the hardships she endured and how she is moved to act, now that her homeland is under siege.

Read Her Story