Clinical Voices December 2022

Dec 07, 2022

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This issue features articles on steps to improve mass shooting response, reviews of hand hygiene studies, creating ICU follow-up clinics, shared governance for night-shift nurses, and more. Plus, read a new nurse story Q&A.

Steps to Improve Mass Shooting Response

Eight consensus items were developed to help improve care.

New recommendations are meant to help communities and hospitals better manage responses to mass shootings and save lives, reports an article in JAMA: The Journal of the American Medical Association.

Published in JACS: Journal of the American College of Surgeons, the guidance focuses on improving system-wide response and communication, including better patient triage and tracking to avoid overwhelming trauma centers. The participants (emergency medical services [EMS] professionals, emergency physicians and surgeons) responded to one of six mass shootings in the United States from 2016 to 2019 that resulted in at least 15 deaths or injuries. They agreed on eight consensus items to improve care:

  • Conduct regular interdisciplinary training for mass shootings, including hospitals, EMS, law enforcement, fire departments and 911 dispatch.
  • Provide real-time direction from mobile phone apps to transport patients to the appropriate hospitals.
  • Set up triage at the scene and at hospitals to prioritize patients for operating rooms.
  • Establish effective communication between on-scene personnel and hospitals.
  • Develop systems to track patients from point of injury and throughout their care.
  • Establish alternative methods to document and input patient details.
  • Rapidly establish well-communicated family reunification sites.
  • Have mental health services available for all responders.

The recommendations are an “attempt to establish best practices based on real-life experience of EMS personnel, ER physicians and trauma surgeons who were on duty and responded to mass shootings,” co-author Deborah Kuhls, a surgeon at University Medical Center of Southern Nevada, says in the article in JAMA.

In September, JAMA published a series of viewpoints on firearm violence, which led to 48,000 U.S. deaths in 2021. In a related podcast, several writers share insights on various topics, including state-level response to firearm-related harms, lack of data on firearm violence and the health effects on neighborhoods.

Hand Hygiene: Several Studies Reviewed

Developing simpler and faster methods could increase compliance.

A review of several hand hygiene (HH) studies finds that the World Health Organization’s (WHO’s) technique is effective, but more research is needed to determine if it’s the best method to remove bacteria from hands.

Comparing the Effectiveness of Hand Hygiene Techniques in Reducing the Microbial Load and Covering Hand Surfaces in Healthcare Workers: Updated Systematic Review,” in American Journal of Infection Control, also finds that HH application is not optimal and developing new methods that are effective, yet simpler and faster, could increase compliance.

The six-step WHO technique, which involves cleaning hands with alcohol-based rub or soap, takes 20 to 30 seconds and is considered the global standard. The technique successfully reduces microbial load on hands, but the results are inconclusive on whether it’s more effective than the Centers for Disease Control and Prevention’s three-step method, the review adds. Other differences were noted when comparing modified or adapted methods of the two techniques.

Future research should focus on standardization, taking into account the various HH techniques, different sampling methods, types of products used, application time and other factors. “HH research must continue to evolve to inform global action to prevent and control healthcare-associated infections and contain antimicrobial resistance,” the review adds.

A related article in Infection Control Today (ICT) notes that most study participants — physicians, nurses, nursing assistants and others — were observed while performing HH. Their performance in everyday clinical practice may be different due to workload pressures, suggests Sharon Ward-Fore, an infection prevention consultant and a member of the ICT editorial advisory board.

“The WHO 6-step method for HH is the gold standard; however, most health care personnel do not take, or have the time to do it correctly,” Ward-Fore says in the article. “Most clean hand surfaces but neglect the fingertips. A method that reduces bioburden and is quick is needed.”

Identifying Autonomic Dysreflexia in Patients With Paraplegia

A clinician’s quick identification of the symptoms can avert life-threatening complications.

Recognizing the symptoms of autonomic dysreflexia in patients with spinal cord injuries can help clinicians improve outcomes quickly by identifying and removing the noxious stimulus.

Recognizing Autonomic Dysreflexia,” in American Nurse, presents the case study of a patient with paraplegia who had severe symptoms requiring a quick diagnosis. Because the patient had increasingly high blood pressure with profuse sweating, understanding her potential condition and identifying the triggering cause could prevent a stroke, the article notes.

The nurse in the case study understood that the patient had difficulty self-catheterizing before the onset of symptoms and determined a distended bladder (the noxious stimulus in this case) caused the reaction. A patient with a spinal cord injury at or above T6 is at risk of a sensory message triggering the body’s sympathetic nervous system; in this case causing a severe headache, nausea and spasms in her legs.

Within minutes after the nurse drained the patient’s bladder, the patient’s blood pressure began to normalize, and the other symptoms lessened. “Other triggers include cutaneous pressure, lack of mobility, pressure injuries, and bowel or bladder stimulation used in patients with paraplegia,” the article adds.

Susceptible patients and their caregivers may need education on ways to recognize triggers of autonomic dysreflexia at home to prevent the onset of severe reactions. “Other signs and symptoms include nasal congestion, blurred vision, chills without fever, bradycardia, nausea, and unusually frequent spasms of the abdomen or lower extremities.”

A clinician’s quick identification of the symptoms can avert life-threatening complications, and a close call can be an opportunity to help these patients avoid future episodes, the article adds.

Opening ICU Follow-Up Clinics

Follow-up clinics can prevent readmissions, improve safety and target the goals of care.

Healthcare organizations seeking to create follow-up clinics for patients with post-intensive care syndrome may face challenges in securing sufficient space, necessary staff and appropriate resources.

Meeting the Challenges of Establishing Intensive Care Unit Follow-up Clinics,” in American Journal of Critical Care, explains that the main issues for setting up these clinics are space, staff and stuff. “These multidisciplinary post-acute care clinics, initially developed for survivors of critical illness, are also well suited to the needs of those with ‘long’ COVID-19, which shares many features with post-intensive care syndrome,” the article notes.

Addressing space concerns includes determining the services that can be offered in a potentially small location, as well as considering telemedicine alternatives. Establishing a clinic with the staff needed for a multidisciplinary team may require partnering with hospital administrators and researchers to obtain the necessary buy-in, the article adds.

The “stuff” required to provide for patients’ “physical, cognitive, psychiatric, and social rehabilitation” also includes physical equipment, although telemedicine can reduce that burden. There is no uniform approach to screening patients for clinic eligibility, so selection criteria that could include ICU length of stay needs to be determined, as well as identifying the patients who are most likely to benefit.

Although follow-up clinics generate little revenue, they can produce long-term cost savings by preventing readmissions, improving safety and targeting the goals of care. “Enhancing patient and family satisfaction, increasing downstream referrals to other clinicians in your health care system, and decreasing burnout among physicians and other members of the health care team are other potential but as yet unproven benefits,” the article adds.

Shared Governance for Night-Shift Nurses

Outcomes include better provider communication, an IV resource team and a journal club.

A New Jersey hospital created a specific shared governance council for night-shift nurses to identify their needs, address concerns and enhance professional development.

Night Councils,” in American Nurse, describes a program at Morristown Medical Center that started in 2020 after several years of assessing the need for greater shared governance, noting that “most system-wide and unit-based council meetings take place during the day,” so night-shift nurses are not included in decisions.

“The Night Council Coordinating Body has deployed several strategies — monthly meetings to discuss current issues, yearly surveys, and steps for improving attendance from other disciplines — to ensure it remains productive and engages all staff,” the article adds.

The council initially defined its purpose as a structure for providing leadership and practice guidance. It created bylaws and built its membership with nurses from medical-surgical, pediatric, critical care and cardiac units, as well as managers and clinicians from various departments. The council “promotes and empowers nurses to be engaged leaders within their own practice, fosters collaboration among different units and interprofessional partners, and identifies areas for improvement and solutions.”

The night council reports to an executive council, participates in retreats and shares successes at system-wide meetings to encourage similar programs at other sites. It also provides “clinical recommendations to improve care quality and integrate the scope of practice and standards of care within specialty clinical areas.”

Successful outcomes include improved provider communication, a dedicated resource team for IV insertion, and a journal club to build professional development by analyzing the literature. “Night-shift team member participation in identifying challenges and problem solving gives them a voice in improving the care they provide,” the article adds.

Polypill Strategy Improves Outcomes After Myocardial Infarction

The treatment resulted in a significantly lower risk of major adverse cardiovascular events than usual care.

Patients post-myocardial infraction (MI) taking a polypill, which has three medications in one, had lower death rates, lower secondary complications and increased adherence.

Polypill Strategy in Secondary Cardiovascular Prevention,” in The New England Journal of Medicine, describes a randomized, controlled trial that found patients with MI in the previous six months fared better in primary and secondary outcomes when taking the polypill, with adverse events that were similar to multiple medications.

“Treatment with a polypill containing aspirin, ramipril, and atorvastatin within 6 months after myocardial infarction resulted in a significantly lower risk of major adverse cardiovascular events than usual care,” the study notes.

The trial in 113 European locations included 2,499 patients who underwent randomization to receive either the polypill or usual care. The polypill contained 100 mg of aspirin; 2.5, 5 or 10 mg of ramipril; and 20 or 40 mg of atorvastatin.

Primary outcomes (“cardiovascular death, nonfatal type 1 myocardial infarction, nonfatal ischemic stroke, or urgent revascularization”) occurred in 9.5% of patients taking a polypill within a median of 36 months compared with 12.7% in the usual care group. Key secondary outcomes (“composite of cardiovascular death, nonfatal type 1 myocardial infarction, or nonfatal ischemic stroke”) occurred in 8.2% of patients taking a polypill, compared with 11.7% in the usual care group.

According to a related article in 2 Minute Medicine, patients receiving a polypill reported adherence of 70.6%, compared with 62.7% in the usual care group. The study did not account for patients unable to complete trial visits due to COVID-19 and was “limited as no adjustment was made for multiple comparisons of secondary outcomes, and loss to follow-up may potentially bias comparisons between groups.”

Nurse Story: A Knack for Strength & Training

Antonio Meehan is a nurse with a passion for cardiovascular medicine. He’s also a champion powerlifter. Recently, he powered through and passed the PCCN, CMC and CSC certification exams in back-to-back months. “Nursing and powerlifting both take persistence, drive,” he says. “And there really is no ceiling when it comes to knowledge.”

Read His Story