Clinical Voices December 2023

Dec 07, 2023

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In this issue, read articles on responsible use of AI, warning symptoms of sudden cardiac arrest, the benefits of whole-body sonography for critically ill patients, and more. Plus, read a Q&A with an advocate for nurses who speak out about their experiences as victims of workplace violence.

Nurses Are Key to Responsible Use of AI

Nurses can help design the future of healthcare, which includes AI.

Artificial intelligence (AI) offers exciting possibilities for healthcare, but some clinicians worry that their experience and insight could be devalued or that clinicians could face the unlikely possibility of being replaced.

Artificial Intelligence and Nursing: Promise and Precaution,” in American Journal of Nursing, covers the pros and cons of this rapidly evolving technology, emphasizing caution and highlighting the value of nurses’ influence on AI development.

Early uses of AI include applications for ambient documentation and predictive algorithms for conditions such as sepsis, cardiac arrest and hospital-acquired infections. At Mount Sinai Hospital in New York, machine learning was used to study over 170,000 electronic health records to detect high-risk patients for falls.

But translating research into patient care isn’t easy, and that’s where front-line nurses are needed. “It’s the nurses who use the system,” notes Jung In Park, assistant professor at University of California Irvine School of Nursing. “But currently not many nurses are involved in the implementation process, so that has led to poor implementation in terms of workflow.”

A related editorial in Critical Care Nurse notes that like other healthcare tools, AI has the potential for benefit and harm. Nurses must be informed and willing to challenge the foundation on which AI algorithms are developed.

“Through active participation in the creation and application of AI, nurses can help mold the future of health care, safeguarding its fairness and safety in the process,” the editorial adds.

Sudden Cardiac Arrest May Have Warning Symptoms

Smartphone- or wearable-based technology may be developed for patients at higher risk.

About half of people who experience sudden cardiac arrest had potential warning symptoms the day before, and men and women have specific differences.

Warning Symptoms Associated With Imminent Sudden Cardiac Arrest: a Population-based Case-Control Study With External Validation,” in The Lancet Digital Health, notes that men are most likely to experience chest pain and pressure 24 hours before out-of-hospital cardiac arrest, and women are most likely to experience shortness of breath.

“Potential future directions include combining symptoms with a patient’s clinical profile or dynamic alterations in clinical markers or biomarkers measured by wearables to identify stronger associations with imminent sudden cardiac arrest,” the study adds.

The study reviewed cases in two U.S. communities and compared them with people who required emergency care for similar symptoms but did not go into cardiac arrest. Other common potential warning symptoms include palpitations, seizure-like activity and flu-like symptoms.

None of the identified symptoms individually or in combination occurred frequently enough to be considered a definitive predictor, because they occurred at similar rates in the control group. “Although warning symptoms can potentially be harnessed, many people have these symptoms on a daily basis.”

One of the research goals is to help develop smartphone- or wearable-based technology for patients at higher risk. A device could potentially indicate whether seeking emergency care would be recommended based on a patient’s symptoms, biometrics and baseline risk factors.

“We think of sudden cardiac arrest as a person being perfectly fine and then collapsing, but there may be a way that we can identify these people earlier so that help can be alerted,” Raman Mitra, North Shore University Hospital, Manhasset, New York, says in a related article in HealthDay. He was not involved in this particular study.

Reports of Patients’ Awareness on Brink of Death

Consciousness may be present despite being clinically undetectable.

In a study, 39% of patients who survived in-hospital cardiac arrest reported being somewhat conscious during resuscitation and near-death experiences, and many had a wide range of brain activity.

In “AWAreness during REsuscitation - II: A Multi-Center Study of Consciousness and Awareness in Cardiac Arrest,” in Resuscitation, these survivors report emerging from comas, having dream-like experiences and recalling near-death events. “The recalled experience surrounding death now merits further genuine empirical investigation without prejudice,” the study adds.

Out of 567 patients studied at 25 hospitals in the United States and United Kingdom, only 53 (9.3%) survived to discharge, and 28 were interviewed about their experiences. The perceptions of 11 survivors who reported awareness or consciousness (39%) include separation from the body, heading toward a destination, evaluating their life and returning home. Of those, 21.4% lucidly remembered their experiences.

Researchers set up EEG recording devices on 85 patients to measure brain activity, with some spikes identified up to an hour into cardiopulmonary resuscitation, with 47% showing no activity. “Our data supports studies that indicate consciousness may be present despite clinically undetectable consciousness.”

With a small sample size of survivors, the study could not correlate brain activity with any patient who reported awareness, leading to some criticism of the study for implying specific evidence. “Absence of record doesn’t mean there’s an absence of consciousness,” says lead study author Sam Parnia, NYU Grossman School of Medicine, New York, in a related article in HealthDay. “These lucid experiences cannot be considered a trick of a disordered or dying brain, but rather a unique human experience that emerges on the brink of death,” he adds.

“Ultimately, what we’re saying is, ‘This is the great unknown. We’re in uncharted territory.’ And the key thing is that these are not hallucinations,” Parnia continues. “These are a real experience that emerges with death.”

POCUS: Unlocking the Power of Ultrasound

Whole-body ultrasonography helps improve the care of complex critically ill patients.

Advancing beyond a simple tool for vascular access and single-organ assessments, point-of-care ultrasound (POCUS) should be used in a comprehensive, whole-body approach for critically ill patients.

Multiorgan Point-of-Care Ultrasound Assessment in Critically Ill Adults,” in Journal of Intensive Care Medicine, explains that advanced POCUS applications and a growing understanding of physiology are helping clinicians make complex assessments. This assessment moves away from compartmentalized scanning and standard protocols in favor of a multiorgan method.

“In this approach, the clinician, understanding which parts of the examination will add value and which can be omitted, crafts a personalized POCUS protocol depending on the clinical circumstances.” Using common critical care scenarios, the article describes how to integrate POCUS into the workflow in a problem-based way to:

Using common critical care scenarios, the article describes how to integrate POCUS into the workflow in a problem-based way to:

  • Assess for shock – POCUS is a first-line tool to determine causes of undifferentiated hypotension, replacing more invasive techniques such as pulmonary arterial catheterization.
  • Differentiate causes of respiratory failure – Multiorgan POCUS, including cardiac, lung and vascular ultrasound for deep vein thrombosis is already standard. POCUS has impressive accuracy compared with chest x-ray for pneumonia, pneumothorax and syndromes.
  • Identify sources of bleeding – While computerized tomography (CT) is preferred for detecting hemorrhagic complications, POCUS is useful in some scenarios, especially if the patient is unstable and can’t be transported for CT.
  • Assess for sepsis – In one study, POCUS assessment of the lungs, abdomen, heart and soft tissues resulted in a 25% improvement in identifying the source of sepsis compared with clinical examination alone.
  • Evaluate renal failure – POCUS is valuable for evaluating post-renal causes of acute kidney injury, such as assessing the balloon placement of indwelling catheters and examining the kidneys to exclude hydronephrosis and the bladder for urinary retention.

“The beauty of POCUS lies in its scalability,” the article concludes. “And with an ever-expanding repertoire of techniques at our disposal, whole-body ultrasonography is more helpful than ever in the care of the complex critically ill patient.”

Moral Injury Associated With Well-being

The review includes data from the United States and seven other countries.

A review finds a direct link between moral injury and healthcare workers’ well-being, professionally and personally, as well as mental health outcomes, burnout, compassion fatigue and stress.

The Association of Moral Injury and Healthcare Clinicians’ Wellbeing: A Systematic Review,” in International Journal of Environmental Research and Public Health, builds a case for extensive research into causes, outcomes and solutions regarding a worldwide crisis in well-being. “This review begins to transition research from exploration and understanding to association and trends, in synthesizing the connection of moral injury to other wellbeing constructs in the field of healthcare.”

Drawing on 18 quantitative and qualitative studies that evaluated associations between moral injury (excluding similar terms such as moral distress) and well-being, the review includes data from the United States and seven other countries. It sought to examine healthcare workers’ experiences to understand the issues, including the roles of power imbalance and systems-level causes.

The review finds several differences between U.S. and international studies, including a reliance on physicians and nurses only in U.S. studies and an emphasis on psychosocial measures of well-being in international studies. “Specifically, the capitalistic frame of healthcare services in the US, the US policy implemented for public health crises, and the lack of respect for the healthcare workforce all contribute to wellbeing in uniquely distinct ways than in other countries.”

The review recommends future research on strategies to reduce moral injury and including other healthcare workers in addition to nurses and physicians. “In forefronting power dynamics in the study of moral injury, scholars can be more inclusive of who is represented in their study samples, recognizing that other healthcare staff (i.e., social workers, housekeeping staff, certified nursing assistants) are at risk for experiencing moral injury due to their lack of power within the healthcare system,” the review adds.

Sharing the Responsibility to Coach New Nurses

The blog offers questions nurses can ask new graduates to promote critical thinking.

Coaching new nurse graduates to become critical thinkers is crucial in the fast-paced hospital environment, but preceptors and nurse managers can’t do it alone — everyone who interacts with new nurses should be ready to coach them in patient care situations.

In “Coaching to Promote Critical Thinking,” a blog in Nurse Leader, author Rose O. Sherman, a professor, author and nurse leader, writes that evidence shows new nurses can be effectively coached to become critical thinkers, meaning they will have the skills to think systematically and logically when making clinical decisions. The blog offers a series of open-ended “coaching questions” nurses can ask new graduates to promote critical thinking.

In summary, these questions involve:

  • Organizing care – What are your first actions for patients in your care? What’s the goal for the each one, and who’s available as a backup?
  • Clarifying thinking – Can you explain the situation and actions you plan to take? Are there alternatives, and if you’re unsure, who will you ask?
  • Inspiring reflection – Why do you think you were successful or unsuccessful? Could you have used a different approach? What will you do next time?
  • Challenging assumptions – How do you know your assumptions are correct? Is there another way to view this problem?
  • Building accountability – Based on your experience, what do you suggest? What changes are in the patient’s best interest? How could you have managed the situation differently?
  • Developing a growth mindset – What would you do if you knew you couldn’t fail? How could this situation help you grow, and what have you learned about yourself as a professional?

If we ever needed nurse leaders to coach, it’s now, Sherman writes, adding that every nurse is part of a village that can help new nurses adjust to their practice settings. “Helping them with critical thinking is a good beginning point.”

Additional resources include AACN’s “AACN Competence Framework for Progressive and Critical Care: Initial Competency 2022,” which establishes the standard for ICU and PCU entry-level nurse competency.

Nurse Story: Silent No More

After a Dallas-area emergency department nurse supervisor was attacked by a patient at work, she was determined to advocate for others and share her story. “Asking for help is not a sign of weakness … You are not alone and your voice needs to be heard.”

Read the Q&A