Clinical Voices April 2023

Apr 10, 2023

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In this issue, read about a proactive approach to reduce medication errors, a mother’s pediatric hospice story, fluid strategies for sepsis-induced hypotension and more. Plus, read a nurse story on the healing effects of an ancient tale.

Pediatric Hospice: One Woman’s Story

The open-access model of pediatric hospice care includes the family’s preferences.

Sharing her experience in The New England Journal of Medicine, a mother describes the option to place her child in hospice care.

In “Please Look at My Baby – When Clinicians Should Say the Word ‘Hospice,’” the author, Golda Grinberg, describes her 8-month-old’s genetic condition and how one of many ICU stays led to neurologic and respiratory complications that left him intubated, sedated and paralyzed.

“We were jarred by the idea of facing another surgery and recovery and then having to learn how to manage a tracheostomy,” she writes. “Trach care would push our son’s list of daily medications, G-tube feeds, and physical therapies onto a second page.”

Referral to pediatric palliative care was made in accordance with American Academy of Pediatrics guidelines when the genetic diagnosis was confirmed after birth. “But once we’d chosen to focus on life-sustaining interventions and intensive surgeries, we were never prompted to reconsider that decision.”

Placing a trach was the surgical ICU team’s “standard, safe, and familiar” recommendation, she adds, noting that an alternative wasn’t discussed until the family broached the idea of comfort care. “When we finally spoke those two words, the medical and surgical teams listened attentively and began devising possible avenues.”

Still, Grinberg acknowledges their change of heart felt like they were now withholding treatment at their child’s expense. “It would have been tremendously helpful if, from the beginning, we’d had an open conversation with our son’s medical team and discussed all the options,” she adds.

“The open-access model used for pediatric hospice care allows us to pursue as much care for our son as we like, including curative and disease-modifying treatments. Our main focus is electing care that maximizes quality of life, relieves symptoms, and enhances the time we do have together.

“In retrospect, we realized that the trach scare was just that – it was a nudge toward refining our goals for our son to give him the best life we can.”

Expectations for Medication Administration

To reduce medication errors, we must respond proactively with ways to support nurses.

Viewing nurses’ work as cyclical, chaotic and complex rather than linear provides deeper insight into the causes of medication errors and the organizational constraints that are often responsible.

In “Untenable Expectations: Nurses’ Work in the Context of Medication Administration, Error, and the Organization,” a study in Global Qualitative Nursing Research, interviews and observations demonstrate the complexity of a nurse’s workday and how interrelated factors — many beyond nurses’ control — make isolating medication administration from other tasks nearly impossible.

“These results deepen our understanding why present efforts targeting the reduction of medication errors may be ineffective and places administration accountable for the context in which medication errors occur,” the study notes.

Based on four months of engagement for all shifts and days at a single site in Utah with 28 staff nurses, the study reframes medication errors through the lens of expectations for nurses that conflict with reality. “To reduce medication errors and address the challenges inherent in nurses’ work, we must respond proactively with critical reflection on ways to buoy and brace our nurses when ‘storms’ hit.”

The studied nurses averaged 16 medication doses per patient per day and were expected to deliver them within 30 minutes of scheduled times. However, nurses often had to reorganize and shift their priorities, and “the inseparability of medication administration from other tasks became readily apparent” along with “the cascading nature of the work that cycles the day to chaos and back again.”

Management shares responsibility for errors, the study adds, by placing expectations for zero-harm goals “squarely on the shoulders of nurses,” while being “unable to effect change to assist nurses at the bedside.” Other factors leading to errors include national and corporate mandates, ineffective policies for flexible staffing, inconsistent safety practices and patient turnover.

Outcomes Between Fluid Strategies for Sepsis-Induced Hypotension

Patients were selected based on early evaluation of sepsis-induced hypotension in the ED.

The restrictive fluid strategy did not result in significantly lower or higher mortality before discharge home by day 90 than the liberal fluid strategy for patients with sepsis-induced hypotension.

Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension,” in The New England Journal of Medicine, tested the hypothesis that a restrictive strategy prioritizing vasopressors would reduce mortality compared with higher volumes of fluids before vasopressor use. “Despite separation between the two groups with respect to the volume of intravenous fluid administered and the use of vasopressors, we detected no significant difference in mortality before discharge home by day 90 (the primary outcome),” notes the randomized trial.

The trial conducted at 60 U.S. centers included 782 patients assigned to restrictive fluids and 781 assigned to liberal fluids, with death before discharge occurring in 109 (14.0%) of the former group and 116 (14.9%) of the latter. Reported serious adverse events were also similar between the two groups, with no significant differences in several measures of secondary outcomes such as ventilator-free days or days out of the ICU or hospital.

Among the trial’s limitations was an inability to differentiate among subgroups such as patients with coexisting conditions or clinical or biologic measurements who might benefit from one therapy over another. Although adherence to protocols was high, some patients received more (or less) fluid than intended, and the onset of vasopressor use may have varied from the guidelines.

Patients were selected based on early evaluation of sepsis-induced hypotension after arriving in the emergency department (ED), rather than those already receiving care or undergoing surgery. “These findings may not be generalizable to patients with delayed recognition of sepsis-induced hypotension or who are in the later phases of care,” the trial adds.

Protein for Critical Care Patients

The trial results will have an effect on clinical practice guidelines.

Administering high doses of protein to critically ill patients who are mechanically ventilated does not improve time to discharge and may be harmful for those with acute kidney injury and high organ failure.

The Effect of Higher Protein Dosing in Critically Ill Patients With High Nutritional Risk (EFFORT Protein): an International, Multicentre, Pragmatic, Registry-Based Randomised Trial,” in The Lancet, also finds that increased protein does not improve 60-day survival for this patient population.

From 2018 through 2021, the trial enrolled 1,301 nutritionally high-risk adults in 85 ICUs across 16 countries. Patients were randomly assigned to receive higher-dose protein (average 2.2 g/kg per day) or usual doses (1.2 g/kg per day) beginning 96 hours after admission and continuing up to 28 days.

After 60 days, 46.1% of patients in the higher-dose group were discharged compared with 50.2% in the standard protein group. Also, 60-day mortality was greater among the high-dose group (34.6% vs. 32.1%).

Despite an “overall null finding,” the trial notes the results will have an impact on clinical practice guidelines. “Our findings do not support the prevailing notion that mechanically ventilated patients who are older, obese, more severely ill, frail, malnourished, or sarcopenic benefit from a higher protein dose,” adds a related article in MedPage Today. “In contrast, higher protein dosing could be harmful in patients with greater severity of illness.”

The trial acknowledges that further research is warranted for important subgroups, such as trauma, surgical and burn patients. However, prescribing protein in levels consistent with American and European guidelines (1.2 g/kg per day and 1.3 g/kg per day, respectively) and “striving to achieve 80% of what was prescribed seems like a reasonable and safe approach for all critically ill patients,” adds the related article.

Improving Heart Failure Outcomes

Adjusting the pacemaker backup rate to approximate the resting heart rate improved outcomes.

For patients with heart failure with preserved ejection fraction (HFpEF), moderately raising their pacemaker backup rate leads to better health-related outcomes compared with the usual setting of 60 bpm.

Effect of Personalized Accelerated Pacing on Quality of Life, Physical Activity, and Atrial Fibrillation in Patients With Preclinical and Overt Heart Failure With Preserved Ejection Fraction: The myPACE Randomized Clinical Trial,” in JAMA Cardiology, suggests the benefit of tailoring the pacemaker backup rate to approximate an individual’s resting heart rate. “Heart rate modulation, delivered in a way that maintains or optimizes physiologic conduction may be a therapeutic target.”

In the trial, 50 patients with stages B and C HFpEF and a preexisting pacemaker were assigned to personalized pacing (median 75 bpm) calculated using a resting heart rate algorithm. Another 57 patients were assigned to the standard 60 bpm setting.

In the accelerated pacing group, median scores on the Minnesota Living with Heart Failure Questionnaire (MLHFQ), the primary endpoint, improved 11 points from baseline after one month and 17 points after one year. With usual care, median MLHFQ scores worsened by four points after a month and eight points in a year.

Personalized accelerated pacing also led to improved changes in N-terminal pro-brain natriuretic peptide levels, pacemaker-detected physical activity and atrial fibrillation. Adverse clinical events occurred in four patients in the accelerated group compared with 11 who had usual care.

In a related article in Medscape, senior author Markus Meyer, University of Minnesota College of Medicine, adds that some of the trial’s “quite substantial” benefit rivaled or surpassed available HFpEF drug therapies. Meyer adds that his group is confident the HR-modulation strategy will succeed in clinical trials and that “pacemakers, in the end, will become a treatment modality for HFpEF.”

Discontinuing DAPT After 9 Months

The study’s limitations include the small number of women.

The long-term risks of adverse events decrease when dual antiplatelet therapy (DAPT) is discontinued after nine months for certain patients, but early cessation could add risk.

In “Long‐Term Outcomes and Duration of Dual Antiplatelet Therapy After Coronary Intervention With Second‐Generation Drug‐Eluting Stents: The Veterans Affairs Extended DAPT Study,” in JAHA: Journal of the American Heart Association, patients removed from DAPT (aspirin and inhibitors) within six to nine months following percutaneous coronary intervention had lower risks of all-cause and cardiac death as well as ischemic or bleeding events.

“Our results support shorter-duration DAPT followed by single antiplatelet therapy in patients with second-generation drug-eluting stents regardless of a presentation of acute or stable coronary syndromes and without concerns of a late catch-up in the risk of MI,” notes the retrospective study. “More recent randomized trials support even shorter durations of DAPT with second-generation drug-eluting stents, particularly in patients at high bleeding risk and low ischemic risk.”

Using data from the Veterans Affairs system, the study tracked case histories from 2006 to 2016 for 40,882 qualifying patients (only 670 women) in groupings of DAPT duration of one to five, six to nine, 10 to 12, and 13 to 18 months. Patients who discontinued DAPT in the first two time periods (5.8% and 6.3%, respectively) had a higher risk of cardiovascular and non-cardiovascular death early in the time periods, “suggesting a lack of specificity for coronary events that would be expected if early discontinuation of DAPT caused death from stent thrombosis or MI.”

The study’s limitations include the small number of women and the likely adherence to treatment covered by veterans’ healthcare that may not occur in patients with different coverage.

Nurse Story: New Hope and Healing From an Ancient Tale

How can an ancient play help clinicians process trauma? Nurses from two AACN chapters participated in a Zoom performance of “The Nurse Antigone.” Featuring actors from “The Bold and the Beautiful,” “Orange Is the New Black” and “The Wire,” plus a chorus of direct care nurses, the teleplay helped frame powerful, guided discussions about the unique challenges nurses face. Learn the backstory.

Read Our Interview