Clinical Voices August 2022

Aug 24, 2022

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This month we feature articles on the link between RN hours and reduced sepsis mortality, disinfecting cellphones in the ICU, how gratitude writing helps reduce stress, and more. Plus, read the new President’s Column and Q&A on empowering new nurses.

More Nurse Hours Linked to Reduced Sepsis Mortality for Medicare Patients

If all hospitals in the study had nine RN HPPD, 6,360 patient deaths could be avoided.

For older adults hospitalized with sepsis, each additional hour of RN care per patient decreases the risk of 60-day mortality by 3%, a statistically significant finding.

In addition to reducing deaths, “Association of Registered Nurse Staffing With Mortality Risk of Medicare Beneficiaries Hospitalized With Sepsis,” in JAMA Health Forum, suggests that adding more RN hours per patient day (HPPD) could help hospitals improve Severe Sepsis and Septic Shock Management Bundle (SEP-1) compliance.

Using 2018 data, the study analyzed SEP-1 scores and nurse staffing records from 1,958 acute care hospitals treating Medicare beneficiaries with sepsis. Hospitals in the study provided a mean of 6.2 RN HPPD.

Overall, 182,346 patients died during the study period, but if all hospitals in the study were staffed at a minimum of six RN HPPD, there could be 1,266 fewer deaths. At nine RN HPPD, 6,360 patient deaths could be avoided, the study adds.

While the study was conducted pre-pandemic, co-author Jeannie Cimiotti, of Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, notes the “exodus of nurses from acute care” makes the findings even more relevant today, according to a related article in MedPage Today.

“At the end of the day, acute care hospitals nationwide have to make it a priority that their units are adequately staffed with adequately trained RNs, and they have to be compensated in a way ... that will not only attract nurses but retain them,” Cimiotti adds. “Otherwise every patient is at risk – even those without sepsis.”

To help identify nurse staffing strategies, the American Association of Critical-Care Nurses (AACN) has convened Partners for Nurse Staffing, which launched a think tank and task force on the issue. Access the AACN webpage to read about successful staffing strategies from your nursing colleagues.

Cellphone Disinfection in ICUs May Reduce Disease Transmission

The method in this study may have implications for use in acute care settings.

Disinfecting nurses’ personal phones as well as shared phones in an ICU showed significantly reduced surface bioburden, which could improve patient safety.

Efficacy of a Bioburden Reduction Intervention on Mobile Phones of Critical Care Nurses,” in AJIC: American Journal of Infection Control, notes that the single-site study used a luminometer to determine that disinfection decreased residual organic matter on the devices, adding that “no recommended practice yet exists for disinfection of mobile phones in the acute care setting.”

At the 20-bed cardiovascular ICU, staff nurses developed a protocol to disinfect the unit’s shared phones with sanitizing wipes every 12 hours and encourage disinfection of personal phones. The bioburden on the shared phones decreased from 417 relative light units (RLUs) at baseline to 46 at 12 months, and personal phones decreased from 497 RLUs to 63 at 12 months.

“The disinfection method and routine used in this study may have implications for use in acute care settings to reduce opportunities for infectious disease transmission,” the study adds.

“Opportunities for the spread of infectious disease can hide in plain sight,” notes lead study author and RN Jennifer Kopp in a related article in Medscape. “I identified this as an opportunity to engage our staff nurses in playing an active role to reduce the spread of infectious disease,” she adds. Kopp is a graduate student at Baylor College of Medicine in Houston.

The study included bioluminescence data from 300 swab samples from 30 shared phones and 30 personal phones. Education for personal phone cleaning included reminders and strategically placed supplies, while shared phones underwent a cleaning process with disinfecting wipes before each shift, the article adds.

“This study objectively demonstrated something I think we all may suspect: Our cellphones can be quite contaminated,” Kopp notes in the article. “This is a population that arguably has more frequent interaction with microbes than an average cellphone user.”

Gratitude Writing May Help Reduce Stress

The regular practice of gratitude may lead to a positive cognitive style.

A gratitude writing intervention helped people manage stressful events during the pandemic.

A Brief Gratitude Writing Intervention Decreased Stress and Negative Affect During the COVID-19 Pandemic,” in Journal of Happiness Studies, notes that online interventions and assessments during stay-at-home periods during the pandemic indicated advantages to gratitude writing not found in groups assigned to other expressive writing or no writing.

“Our results add to the growing body of evidence suggesting gratitude is a beneficial tool that reduces psychological distress associated with the experience of traumatic events such as natural disasters, terrorist attacks, war … and global pandemics,” the study notes.

The study’s final sample size was 79 participants; 19 were assigned to gratitude writing, 25 to expressive writing and 35 were in the control group. The participants were 94% white, 86% female and 85% college graduates or higher, with an average age of 40.8.

At one month post-intervention, the gratitude writers reported a decrease in stress and negative affect and maintained gratitude level, while the expressive writers reported decreased gratitude but no change in stress or negative affect. The control group decreased in gratitude and negative affect but had no changes in stress.

“The regular practice of gratitude, such as writing about things one is grateful for daily, may allow for a shift toward a positive cognitive style … Gratitude writing may be a better resource for dealing with stress and negative affect than traditional expressive writing methods under extremely stressful situations with uncertain trajectories.”

“This study was limited due to the small sample size and substantial loss of follow-up, which may impair generalizability of the results,” adds a related article in 2 Minute Medicine.

Early Parenteral Nutrition Optimal After Major Abdominal Surgery

A study associates early supplemental parenteral nutrition with fewer nosocomial infections.

For patients at risk of malnutrition after major abdominal surgery, starting supplemental parenteral nutrition (SPN) earlier rather than later is associated with reduced nosocomial infections and fewer days of antibiotic therapy.

Effect of Early vs Late Supplemental Parenteral Nutrition in Patients Undergoing Abdominal Surgery: A Randomized Clinical Trial,” in JAMA Surgery, seeks to determine the optimal timing to initiate SPN for postoperative patients whose energy targets can’t be met by enteral nutrition (EN) alone.

Conducted at 11 hospitals in China in 2017-2018, the study involved 230 adults (mean age 60.1) who underwent elective gastric, colorectal, hepatic or pancreatic resections, and were at risk of malnutrition defined as a Nutritional Risk Screening 2002 score of three or higher. Patients were randomly assigned to receive early SPN (E-SPN) at three days after surgery or late SPN (L-SPN), beginning eight days postoperatively.

The study reveals that 8.7% of patients in the E-SPN group developed nosocomial infections, significantly fewer than the 18.4% of L-SPN patients. The E-SPN patients also required a mean of six days of antibiotic therapy compared with seven days for L-SPN patients. No significant differences in noninfectious complications were noted between the groups.

“Logically, the total energy and protein intakes were significantly higher during the intervention period (days 3-7) after surgery in the E-SPN group,” the study notes, adding that E-SPN improved serum prealbumin and albumin levels before hospital discharge, suggesting improvement in nutritional risk.

“Therefore, E-SPN seems to be a favorable strategy to reduce nosocomial infections among patients with high nutritional risk and poor tolerance to EN after major abdominal surgery.”

The study lists some limitations, including that indirect calorimetry, the preferred method to measure resting energy expenditure in surgical patients, was not available at all participating hospitals. A recommended formula was used instead.

An AACN webinar, “Critical Factors in Meeting the Nutrition Needs of Patients,” describes ways that nurses can advocate for adequate nutrition in their patients.

Clinical Statements Focus on Long COVID-19

A collaborative is publishing long COVID-19 guidance on a continuing basis.

With millions of Americans dealing with post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID-19, a collaborative offers guidance to help clinicians diagnose and treat patients with health conditions linked to the virus.

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) is publishing a series of statements on its PASC guidance webpage about these issues:

  • Cardiovascular complications: myocardial infarction, heart failure, stroke, dysrhythmia, thromboembolic disease, etc.
  • Breathing discomfort: shortness of breath, impaired exercise tolerance, cough, chest pain
  • Fatigue: severe exhaustion after minimal physical or mental exertion, tiredness, lack of energy, feelings of “crashing” after a “good day”
  • Cognitive symptoms: deficits in reasoning, problem solving, memory or attention, difficulty in word retrieval, etc.

In March 2021, AAPM&R launched the PASC Collaborative to develop and release guidance statements on a rolling basis. The multidisciplinary collaborative of physicians, clinicians and patient advocates seeks to foster engagement and share experiences that propel the health system toward defining standards of care for people with long COVID-19.

A related article in MedPage Today addresses the cardiovascular complications statement released in June 2022, noting that 5% to 29% of COVID-19 survivors have symptoms such as chest pain, dyspnea or palpitations after recovering from acute infection. These symptoms, which range from mild to incapacitating, can develop weeks or months after the initial infection.

“Unfortunately, many people could have chronic cardiovascular conditions due to COVID-19 infection – even patients without previous cardiovascular disease, comorbidities, and otherwise low risk of cardiovascular disease,” adds lead author Jonathan Whiteson, NYU Langone Health, in the related article. “Because of the chronic nature of cardiovascular conditions, there will likely be long-lasting consequences for patients and health systems worldwide.”

Whiteson’s team outlined several best practices, including taking a full history with details about the patient’s previous COVID-19 infections, noting any common or worsening cardiac complaints and recommending all relevant cardiac testing, notes the related article.

PASC (Long COVID-19) – Emerging Evidence and Management,” an AACN blog, reviews the symptoms, management guidelines, research priorities and other questions on long COVID-19.

Outcomes Similar Despite Fluid Restrictions for Septic Shock

Mortality rates were 42.1% in the standard group and 42.3% in the restricted group.

Restricting IV fluids for adult ICU patients with septic shock produced minimal differences in mortality at 90 days or other severe adverse events compared with standard therapy.

Restriction of Intravenous Fluid in ICU Patients With Septic Shock,” in The New England Journal of Medicine (NEJM), notes the international CLASSIC trial did not indicate reduced harm from lower fluid volumes, as predicted, with a less-than-anticipated difference between the volumes in the two groups possibly affecting outcomes. In addition to 90-day survival rates, there were similarities in total days alive, days alive without life support, and days out of the hospital.

The randomized trial included primary data for 1,545 patients in 31 ICUs across eight countries for one group with standard IV fluid care and another group with a restriction to allow daily intake of 1 liter plus 250 mL to 500 mL under certain conditions. The standard care group averaged 3,811 mL, compared with 1,798 mL in the restricted group.

A related article in MedPage Today notes that the standard care group received much less fluid than had been anticipated when using the Surviving Sepsis Campaign guidelines.

According to an accompanying editorial in NEJM, “The results of work completed previously by the authors that suggested benefit from a more restrictive fluid-management strategy might have changed clinical practice in northern Europe sufficiently that this trial was unable to answer the question it set out to address.”

Mortality rates were 42.1% in the standard group and 42.3% in the restricted group, with serious adverse events in 30.8% of patients in the standard group and 29.4% in the restricted group. “These findings show that a highly restrictive fluid-management strategy is safe and raise important new questions that challenge conventional wisdom regarding the management of shock,” the editorial adds.

President’s Column: The Staffing Crisis — An Evidence-to-Practice Gap

Appropriate staffing is not a new problem. But solving it will take new ideas. AACN President Amanda Bettencourt discusses she works to make it easier for clinicians to use high-quality evidence in care, and how AACN has made it a priority to help activate the staffing improvements nurses need now.

Read Her Column

Nurse Story: Empowering New Nurses

Using her experiences and the coping methods she developed herself, Lacey Magen Naematullah breezed through nursing school and new nurse orientation. It disheartened Lacey to see other new nurses struggling, so she founded The Empowered Nurse Mentorship Program to help new-to-practice nurses become more confident and resilient.

Learn More