Clinical Voices April 2024

Apr 08, 2024

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In this issue, read articles on an expert panel’s guidelines for recognizing and responding to non-ICU clinical deterioration, new pediatric criteria in the Phoenix Sepsis Score, the importance of faster trauma transfusions, and more. Plus, read a new nurse Q&A and spring President's Column.

New Phoenix Score Identifies Pediatric Sepsis and Septic Shock

Convened by SCCM, a task force of 35 pediatric experts developed the Phoenix criteria.

The novel Phoenix Sepsis Score provides new criteria for identifying sepsis and septic shock in children 18 and younger, creating the potential to improve clinical care, epidemiological assessment and research in pediatric sepsis worldwide.

International Consensus Criteria for Pediatric Sepsis and Septic Shock,” in JAMA: The Journal of the American Medical Association, reveals that for children with suspected infection, sepsis is identified by a Phoenix score of at least two points, indicating potentially life-threatening dysfunction in four organ systems — respiratory, cardiovascular, coagulation and/or neurological. Septic shock is defined as sepsis and cardiovascular dysfunction, indicated by one or more cardiovascular points.

Convened by the Society of Critical Care Medicine (SCCM), a task force of 35 pediatric experts developed the Phoenix criteria using an international survey, systematic review and meta-analysis, and more than 3 million pediatric encounters. Previous pediatric-specific sepsis criteria — based on expert opinion — were published in 2005 by the International Pediatric Sepsis Consensus Conference (IPSCC), which characterized sepsis as suspected or confirmed infection with systemic inflammatory response syndrome.

According to the recent study, children with a Phoenix Sepsis Score of at least two points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than eight times that of children not meeting these criteria. Mortality was highest among patients with dysfunction in at least one of the four organ systems.

In addition, the Phoenix threshold resulted in higher positive predictive value and higher or comparable sensitivity for in-hospital mortality compared with the IPSCC definition of sepsis, the study reports.

Commenting in a related article in MedPage Today, task force members say the “new pediatric sepsis criteria should maximize identification of true-positive cases so that infected children with life-threatening organ dysfunction receive best-practice sepsis care, are appropriately enrolled in clinical studies, and are correctly represented in epidemiological surveillance.”

Guidelines Address Non-ICU Clinical Deterioration

The one strong recommendation is hospital-wide use of rapid response systems.

An expert panel developed a set of 10 recommendations for recognizing and responding to clinical deterioration in patients hospitalized outside ICUs, for early identification of potential risks.

In “Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023,” in Critical Care Medicine, the only strong recommendation on the evidence-based list calls for hospital-wide deployment of rapid response systems that include explicit activation criteria.

“When the onset of critical illness occurs outside of the ICU, early identification and prompt response to deterioration confer the greatest chance of success, yet may be hampered by an environment where the staffing ratios and resource base are configured for lower levels of acuity,” the article notes.

The guidelines to recognize deterioration include obtaining complete and accurate vital signs and escalating issues urgently, but there are no recommendation about continuous vital sign monitoring. They also recommend educating non-ICU clinicians on how to recognize deterioration, empowering patients and families to alert personnel based on their observations, and incorporating their concerns into early warning systems.

Guidelines for responding to deterioration don’t include a recommendation on who should lead a rapid response team (RRT) or whether palliative care-trained personnel should be part of the teams. They do recommend clinician expertise in learning patients’ goals of care and including those wishes in treatment plans, and the guidelines identify a quality improvement process in RRTs as a good practice.

Areas identified for additional research include determining physiologic parameters to help recognize signs of deterioration, whether the professional composition of the RRT impacts outcomes, and whether certain interventions and resuscitation goals must be met in defined timeframes to improve outcomes.

“Various schemes for patient screening and clinician response — typified by rapid response systems (RRSs) — have been used, yet there is uncertainty over which components of such interventions provide measurable benefits to patients.”

Trauma and Transfusions: Every Minute Counts

Survival benefits were associated with time to first WB transfusion but should not be considered a direct cause.

Survival chances for injured patients with significant bleeding improve the faster they receive a whole blood (WB) transfusion within 24 hours of emergency department (ED) arrival.

Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients,” a study in JAMA Surgery, finds that mortality risk increases every minute a transfusion is delayed, with the most prominent point of reduced survival occurring just 14 minutes after arriving at the hospital.

The study analyzed data from 1,394 patients (median age 39) who received WB as part of a massive transfusion protocol (MTP) at U.S. and Canadian trauma centers in 2019 and 2020. The median time to first WB transfusion was 30 minutes, and the study’s primary outcomes were survival at 24 hours and 30 days.

“A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion,” the study reveals, adding that early transfusion led to improved survival “at each time point” within both 24 hours and 30 days compared with patients receiving delayed transfusions.

“These findings may lead clinicians and hospital systems to consider whole blood as a standard emergency transfusion product incorporated into the massive transfusion protocol,” study co-author Crisanto Torres, Boston University School of Medicine, says in a related article in Medical Xpress. “There may be a similar benefit for using whole blood transfusion at the scene of injury or during transport.”

In listing limitations, the study notes that while survival benefits were associated with the time to first WB transfusion, they should not be interpreted as a direct cause. Also, the study’s lack of randomization raises an inherent risk of confounding factors.

“Further prospective studies are warranted to complement our results to incorporate these findings into MTPs and further understand best WB transfusion practices,” the study adds.

Bundle Care for Better ICU Outcomes

The ABCDEF bundle reduced ICU length of stay, MV duration and medical costs.

Hospitals that implement the ICU Liberation Bundle can reduce the time critically ill patients are on mechanical ventilation (MV) and help prevent prolonged ICU stays.

Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System,” an observational study in Critical Care Explorations, suggests that evidence-based implementation strategies, strong leadership support and other factors can facilitate bundle adoption and sustainability.

“Because 80% of adult ICU beds in the United States reside in community hospitals, we believe these findings are generalizable to ICUs in community hospitals nationwide,” the study notes. “These results are particularly important considering that worldwide bundle compliance has decreased significantly in the wake of the COVID-19 pandemic.”

Conducted at six Dignity Health System hospitals in California, the study enrolled 1,914 adult ICU patients receiving MV and 3,019 non-MV patients to assess bundle baseline and performance. A comparison of 12-month periods — before and after implementation — reveals that bundle use reduced ICU length of stay by 0.5 day, MV duration by 0.6 day, and ICU stays of seven or more days by 18.1%.

The study also assessed compliance, finding considerable inconsistencies in the use of the A-F bundle elements:

  • A: Assess and manage pain
  • B: Conduct daily spontaneous awakening and breathing trials
  • C: Choose sedation strategies
  • D: Assess and manage delirium
  • E: Encourage early mobility
  • F: Facilitate family engagement

Even partial bundle performance can significantly improve patient outcomes and reduce medical costs, says lead study author Juliana Barr, VA Palo Alto Health Care System, in a related article in Healio.

“Yet many hospitals and health care systems have yet to fully implement the A through F bundle, citing staffing shortages, EHR limitations and costs,” Barr adds in the article. “ICU providers and leaders must partner with hospital and health care system executives to make the business case for ICU liberation.”

AACN offers many resources, including a CSI Academy project and a CE article, plus “ABCDEF Bundle,” in American Journal of Critical Care, with tips to implement the bundle.

Nursing Education Focus Turns to Competency, Clinical Judgment

A revised education framework emphasizes preparedness using critical thinking.

Nursing education programs should shift their focus to promote competency and clinical judgment to prepare for the revised licensing exam and support a smoother transition to clinical practice.

In “Competency-Education and the Revised AACN Essentials,” in Nurse Leader, a revised education framework developed by the American Association of Colleges of Nursing emphasizes preparedness using critical thinking and decisions that lead to better patient outcomes. “The operational definition of nursing clinical judgment refers to a decision-making process where the nurse observes and assesses situations, identifies and prioritizes a concern, and generates the best possible evidence-based solution to deliver safe client care,” the report notes.

The revised Essentials framework aims to prepare graduates for the restructured licensing exam through competency attainment assessments and incorporates the spheres of wellness and disease prevention, chronic disease management, regenerative and restorative care, and hospice/palliative care. “Well-constructed program learning outcomes should point students to the knowledge, skills, and abilities they must demonstrate as they progress through the curriculum and graduate,” the report adds.

Suggested ways to support nurses during orientation include providing preceptor training to assess and evaluate competency, building and scaffolding desired competencies over time, using an individualized approach, and focusing on context learning and case studies rather than skill attainment. The report also emphasizes collaboration between clinical partners and nursing schools to identify common ability gaps and build on shared goals.

To aid nurses in their transition to effective practice, the American Association of Critical-Care Nurses (AACN) offers the AACN Knowledge Assessment Tool to identify educational gaps for nurses new to the unit or ICU/PCU care and build customized plans to address personal learning needs.

To build competence to guide new nurses from orientation to full assessment of their ability to apply their education at the bedside, AACN’s Competence Framework for Progressive and Critical Care and accompanying toolkit give managers and preceptors effective evaluation and documentation tools.

Glycemic Control Guidelines: Evidence-Based Updates

The updates are composed of seven statements for adults and seven for children.

Updated guidelines for glycemic management in adults and children offer some new recommendations based on reviews of recent clinical trials as well as areas for additional research.

Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024,” in Critical Care Medicine, discusses updates to the 2012 guidelines that are composed of seven statements for adults and seven for children across the categories, with different levels of strength. “The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels.”

The one strong recommendation involves care of pediatric patients, stating that moderate evidence goes against intensive (INT) blood glucose control compared with conventional control: “The panel judged the undesirable effects of INT, namely risk of severe hypoglycemia, to be moderate and considered that such events may lead to long-term developmental and neurocognitive problems, although evidence for the latter is limited.”

Proposed research covers a range of topics, including the accuracy of wearable sensors for glucose monitoring. In regard to monitoring devices, “the panel is unable to provide a specific statement due to inconsistent methodologies and reporting among comparative studies, but we recognize the need for timely results in a clinical setting.”

An Environment of Growth and Renewal

Spring is here and many nurses are beginning their nursing careers. AACN President Terry Davis maps out some ways AACN helps create healthy work environments, where new and experienced nurses feel valued and recognized as part of a collaborative, respectful practice.

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I’m Certified: The Path to Nursing Excellence

For a director of acute care nursing, getting certified and encouraging others to obtain certification is a path to continually improving skills and knowledge. “Certification reignited my passion for nursing.”

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