Clinical Voices August 2021

Aug 01, 2021

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In August we spotlight VTE anticoagulation prophylactic dosage, hypotension prediction index technology, ambulatory ECMO for COVID-19-associated ARDS, and other topics. Plus: Beth Wathen’s new President’s Column and an enlightening Q&A with a nurse manager who shares the keys to creating mutual understanding in a multigenerational workforce.

Prophylactic-Dose VTE Anticoagulation May Be Optimal for Patients With COVID-19

Stronger evidence will help clinicians decide when to use either prophylactic- or therapeutic-dose anticoagulation.

A retrospective study of patients hospitalized with COVID-19 shows that prophylactic-dose and treatment-dose anticoagulation for venous thromboembolism (VTE) were both associated with lower in-hospital mortality (compared without anticoagulation), but prophylaxis had lower 60-day mortality.

According to “Trends in Venous Thromboembolism Anticoagulation in Patients Hospitalized With COVID-19,” in JAMA Network Open, patients who received treatment-dose anticoagulation were almost twice as likely to die within 60 days as those in the prophylactic-dose group (39.7% vs. 20.9%). “Given that only prophylactic anticoagulation was associated with lower 60-day mortality, prophylactic-dose VTE prophylaxis may be the optimal therapy for patients hospitalized with COVID-19,” the study adds.

The study reviewed the treatment of 1,351 patients with COVID-19 from March to June 2020 at 30 hospitals in Michigan, as evidence-based care increasingly included anticoagulation, with 1,127 (83.4%) receiving VTE prophylaxis during hospitalization. Over one-third of patients missed two or more days of prophylaxis, and patients in that group were much more likely (31.8%) to die within 60 days than those who did not have missed days (19.2%).

“Given what we know about coagulopathy in COVID-19 and growing evidence that anticoagulation may help hospitalized non-ICU patients the most, it is possible that even patients who seem low risk may benefit from anticoagulation,” the study adds. “We need better methods to risk stratify and diagnose patients with VTE and a stronger evidence-base on which to decide when to employ prophylactic vs therapeutic doses of anticoagulation for patients hospitalized with COVID-19.”

Hypotension Prediction Index Software Receives FDA Clearance

The technology is designed to help healthcare teams make informed decisions.

Edwards Lifesciences’ Acumen Hypotension Prediction Index (HPI) software with the Acumen IQ finger cuff has received 510(k) clearance from the Food and Drug Administration (FDA).

According to “Edwards Receives Clearance for Hypotension Prediction Index Software for Noninvasive Acumen IQ Cuff,” a company news release, this is the “first noninvasive solution that unlocks Acumen HPI software and uses machine learning to alert clinicians of the likelihood a patient is trending toward hypotension.” Previously, “Acumen HPI software has only been available for patients using an invasive arterial line.” The Acumen IQ cuff “provides access to automatically calculated, beat-to-beat hemodynamic parameters including mean arterial pressure and cardiac output.”

Kamal Maheshwari, an anesthesiologist with the Cleveland Clinic Foundation, suggests the importance of technologies focused on managing patients with hypotension: “Numerous studies, including our research, have demonstrated an association between intraoperative hypotension and increased risk of acute kidney injury, myocardial injury and even death. The noninvasive Acumen IQ cuff provides the opportunity to reduce hypotension in a broader range of patients,” he notes in the news release.

“This latest predictive technology demonstrates our commitment to patient care and providing clinicians with ‘smart’ monitoring tools that allow for better prediction and management,” Katie Szyman, Edwards’ corporate vice president, critical care, adds in the release.

Ambulatory ECMO May Help Patients With COVID-19-Associated ARDS

A case study indicates good outcomes, including potentially greater odds of survival.

Ambulatory ECMO for Respiratory Support in a Patient With COVID-19 Disease,” in CHEST, suggests early ambulatory venovenous extracorporeal membrane oxygenation (VV-ECMO), in addition to the ABCDEF bundle and lung protective ventilation, may “offer a survival advantage” for certain patients with COVID-19-associated acute respiratory distress syndrome (ARDS).

“Early extubation before ECMO decannulation can be performed in certain circumstances, facilitating patient mobilization and participation in physical therapy under strict precautions to minimize the risk of disease transmission,” the case study notes. It recommends early mobilization “when safe and feasible, in order to help improve recovery and maintain neuromuscular function” and suggests clinicians implement the ABCDEF bundle when caring for patients with COVID-19 who are receiving ECMO, in order to reduce post-intensive care syndrome (PICS) and delirium.

The case study examines a 52-year-old male patient with “hypertension, obstructive sleep apnea, and diabetes mellitus” who was diagnosed with COVID-19, admitted to the hospital and later intubated as his condition declined. The patient was considered for VV-ECMO based on a variety of factors, including his age and difficulty with oxygenation and ventilation.

“Upon ECMO initiation, the ventilator settings were reverted to ultra-lung protective P-CMV mode, FiO2 50%, PEEP 12, and PC 10. In ultra-lung protective settings, the tidal volume is further reduced from 6 mL/kg of Ideal Body Weight (as used in lung protective settings) to 2-3 mL/kg of Ideal Body Weight on the ventilator,” the study adds.

The patient was extubated and ambulated nine days after ECMO cannulation, continued on VV-ECMO for three more days, concluded ECMO support on day 12 and was discharged from the hospital on day 14.

Reducing Nonventilator Hospital-Acquired Pneumonia With Improved Oral Care

Further research will help determine the degree and frequency of effective oral care for acute care patients

Acute care patients are less likely to develop nonventilator hospital-acquired pneumonia (NV-HAP) if they receive daily oral care at a higher-than-usual frequency.

Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster Randomized Study,” in AJN: American Journal of Nursing, finds that strategies to enhance oral care can reduce NV-HAP rates up to 85% in some units.

“These findings add to the growing body of evidence that daily oral care as a means of primary source control may have a role in NV-HAP prevention,” the study notes.

The 12-month study involved 8,709 adults in two medical and two surgical units at an 800-bed tertiary medical center. Patients received usual oral care (control units) or a standardized, enhanced protocol (intervention units) approved by the American Dental Association.

Within the medical units, the study reveals that increasing daily oral care frequency from 0.95 times to 2.25 times led to a significant 85% reduction in NV-HAP incidence. Patients who received less care were 7.1 times more likely to develop the infection.

In the surgical units, boosting oral care from a mean of 1.8 to 2.02 times per day reduced the NV-HAP rate 56%, the study notes, adding that the odds of developing pneumonia were 1.6 times higher in the lower-frequency group.

Nurses and nursing assistants are “well positioned to have a strong impact” on improving oral care practices, because they are often the ones providing the care, the study adds. However, hospitals would need to make a sizeable initial investment to commit to higher-quality oral care products for use in NV-HAP prevention.

“In short, changing the clinical mindset will take time, sustained effort, ongoing involvement of nurses and nursing assistants, interdisciplinary collaboration, and buy-in from nursing and hospital leadership.”

Suicide and Self-Harm After ICU Discharge

Understanding the factors involved could lead to earlier intervention and help mitigate this health problem.

Patients who survive an ICU stay are at increased risk of suicide and self-harm, outcomes that are associated with preexisting mental illness and initiation of either invasive mechanical ventilation or renal replacement therapy.

Suicide and Self-Harm in Adult Survivors of Critical Illness: Population Based Cohort Study,” in BJM, also reveals that risk of suicide or self-harm tends to occur among younger patients and those from lower-income environments. Discharge directly to home instead of another healthcare facility is an additional factor.

Conducted within the Ontario, Canada, healthcare system, the study involved 423,060 adult ICU survivors (mean age 61.7) from January 2009 to December 2017. A comparison group consisted of more than 3 million non-ICU hospital survivors.

During the study period, 750 ICU survivors (0.2%) later died by suicide, compared with 2,427 (0.1%) non-ICU hospital survivors. Self-harm was reported among 5,662 (1.3%) of the ICU survivors vs. 24, 411 (0.8%) of non-ICU patients.

For ICU survivors specifically, 45 was the mean age of those who died by suicide or committed acts of self-harm, and 63.2% had a prior psychiatric diagnosis. The mean age of ICU survivors who did not commit acts of self-harm was 63.

“We found that previous mental health diagnoses had the strongest prognostic association with future suicide and self-harm, consistent with existing studies in a variety of populations,” the study notes.

For healthcare providers, having knowledge of a patient’s prior psychiatric diagnosis and other prognostic factors could lead to early interventions, the study suggests.

“Patient follow-up is of potential importance, and additional investigation into outpatient care of ICU survivors (particularly in relation to mental health and palliative care) after discharge represents an important avenue for future research.”

Discontinuing Statins May Increase Cardiovascular Risk Factors

In a follow-up, hospital admission rates were higher for the group that discontinued statins.

Older patients receiving polypharmacy who discontinued statins while maintaining other medications were linked to increased risks of fatal and nonfatal cardiovascular outcomes.

According to “Cardiovascular Outcomes and Mortality Associated With Discontinuing Statins in Older Patients Receiving Polypharmacy,” in JAMA Network Open, deprescribing statins for patients age 65 and older increases the risks of adverse outcomes. Specifically, there was a 12% increased risk for emergency admissions and up to a 24% increased risk for heart failure compared with patients who maintained statin use. “This occurred in younger and older patients, men and women, patients with mild or severe clinical profiles, and irrespective of whether statins were prescribed” for primary or secondary cardiovascular prevention, notes the retrospective study.

Based on National Health Service data from Italy’s Lombardy region, the study identified 5,819 older patients (from a cohort of 29,047) who discontinued statins while continuing other medications. From that group, 4,010 were matched to patients from the original cohort who remained on all medications. Outcomes of the matched pairs were then compared. Older patients with polypharmacy may have adverse reactions that led to deprescribing some medications.

In a follow-up approximately 20 months after discontinuation, hospital admission rates were higher for the discontinuing group than the control group for cerebrovascular disease (35.8 per 1,000 patient years vs. 31.2), heart failure (64.0 vs. 51.5) and ischemic heart disease (69.7 vs. 64.6). Emergency admissions were higher for any cause (506.2 vs. 449.8) and for neurologic disorders (53.4 vs. 50.4), as were deaths from any cause (77.5 vs. 67.4).

The study data leads to a “conclusion of unfavorable consequences of discontinuing lipid-lowering treatment,” even with some uncertainty about the reasons patients stopped taking it. The “observed increased risk of the considered clinical outcomes associated with discontinuing and/or deprescribing lipid-lowering medications might have been generated by factors accompanying but different from discontinuing and/or deprescribing.”

President’s Column: Cultivating Happiness

In her new column, AACN President Beth Wathen explores ways to help us move beyond the burdens of the pandemic and boost our emotional health. “One path toward well-being includes self-care practices that help cultivate happiness. Self-care is something we can each own individually.”

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