Clinical Voices February 2021

Feb 02, 2021

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AANP Addresses NP Restrictions in Open Letter

Remove restrictions on scope of practice, so NPs can deliver high-quality care.

A letter to the American Medical Association (AMA) addresses restrictions on scope of practice for nurse practitioners (NPs).

In "Open Letter to the American Medical Association," Sophia L. Thomas, president of the American Association of Nurse Practitioners (AANP), defends the NP profession against public criticism from the AMA, raising study-based arguments to assert that NPs can deliver high-quality patient care.

"NPs consistently deliver the high-quality, compassionate care they are educated, clinically trained and nationally certified to provide - health care services authorized by state law," Thomas writes.

The letter notes that patient outcomes can be improved by removing the practice barriers that NPs face in many states and U.S. territories. "Patients receiving NP care have high satisfaction rates, shorter hospital stays, fewer avoidable emergency room visits and hospital readmissions, and lower medication costs — not to mention significantly lower malpractice rates than their physician counterparts."

Thomas references more than 200 studies noting that "more than 56% of patients report that NPs spend more time listening to them and addressing their concerns than other providers." In addition, she addresses the urgent need to expand care opportunities during the COVID-19 pandemic.

AANP also seeks to expand the ability of NPs to serve the 80 million patients in underserved rural areas. "This outdated regulation needlessly creates geographic maldistribution of health care access, delays care and decreases the productivity of both NPs and physicians," the letter adds.

Well-Being Initiative Offers Free Resources

Amid the continuing uncertainty of the pandemic, nurses have resources for self-care.

AACN offers free resources and tools to support nurses' mental health and wellness through the Well-Being Initiative, including a digital toolkit, expert knowledge and a virtual support system.

Working in partnership with several other nursing organizations, including the American Nurses Association, AACN recognizes the uncertainty, mental and emotional stress, and anxiety the community faces while providing critical care during a pandemic. Two webpages, "Well-Being in Uncertain Times" and "Well-Being Initiative," include links to resources, inspiring stories, activities and articles to help nurses navigate their challenges.

Elements of the digital toolkit and support network include the following:

  • Moodfit app for setting wellness goals, mindfulness meditation, and tracking sleep, nutrition and exercise
  • Happy app for managing stress, anxiety, fear and isolation
  • Confidential calls with compassionate listeners, 24/7
  • Narrative expressive writing
  • Guide to better sleep and restoring energy
  • Podcast series on coping mechanisms with practical ideas
  • Self-assessment of stress
  • Mental health support services, including grief management, suicide prevention and family support
  • Downloadable and printable fact sheets and checklists
  • Peer Support Community online discussion group

AACN's well-being content also offers resources for self-care while managing challenging patient care. The focus of the topics includes mindfulness, resilience, work environments, being gritty and searching for inner peace.

Readers can find inspiration through nurse stories on well-being, expert knowledge, evidence-based resources and opportunities for advocacy. Links to address financial hardship are included, as well as how to make donations to help those in need.

Ultrasound May Be Better Option for Lung Diagnoses

Point-of-care ultrasound, which may provide better information than a stethoscope, has been invaluable during the pandemic.

For diagnosing adult respiratory diseases, lung auscultation has low sensitivity and only acceptable specificity, according to a meta-analysis suggesting that more accurate modalities such as ultrasound should be used when available.

"The Diagnostic Accuracy of Lung Auscultation in Adult Patients With Acute Pulmonary Pathologies: A Meta-Analysis," in Scientific Reports, finds that in most circumstances, auscultation is not clinically useful in making an accurate diagnosis. Its value depends on the prevalence of the disease, the clinical setting and the physician's ability.

"Now 200 years after the invention of the stethoscope, better diagnostic options are available such as lung ultrasound," the meta-analysis adds.

Data review included 34 studies and 14,814 adults examined for cardiopulmonary edema, (hemato)pneumothorax, pneumonia and obstructive lung diseases. Overall, sensitivity for lung auscultation was "low" at 37%, and specificity was "acceptable" at 89%.

"The results underline that auscultation only marginally alters the provisional diagnosis, although results are limited by a high risk of bias and heterogeneity of included studies."

A related editorial in Stat suggests that point-of-care ultrasound provides "more and better information" than a stethoscope and has proven invaluable during the pandemic. Ultrasound enables clinicians to "digitally peel back the skin and observe the ecosystem of internal organs functioning in real time," writes Larry Istrail, a hospitalist physician certified in point-of-care ultrasound.

"I believe that given the remarkable diagnostic accuracy of point-of-care ultrasound, every patient presenting to a clinic or hospital should have a focused ultrasound to augment their clinician's physical exam findings," Istrail adds.

Benefits of Animal-Assisted Interventions

AAI programs should include infection prevention and possible partnerships with therapy animal organizations.

Therapy animals can improve patient outcomes, including enhanced benefits for patients with COVID-19 and possibly detecting positive cases.

According to "Animal-Assisted Interventions," in Nursing Management, case studies and descriptive literature show that therapy animals can "accomplish global goals, such as improving well-being, providing comfort and joy, reducing anxiety, and improving patient satisfaction." Improvements have been achieved in pain reduction, physical functioning, socialization and psychological outcomes, adds author Julie Miller, AACN clinical practice specialist.

Nurse managers planning to implement animal-assistance interventions (AAIs) need to develop policies and procedures that include infection prevention and consider partnerships with therapy animal organizations, she adds. Clinical trials should also be expanded to address the evidence of therapeutic benefits.

In a related AACN blog, "Therapy Animals: Infection Prevention, Safety and Impact on Patients and Staff," Miller discusses her work as a critical care nurse and therapy animal volunteer, and how to employ best practices when launching an AAI program. Therapy animals can be used during COVID-19, Miller writes, including visits to intensive care patients who do not have COVID-19 symptoms, as well as virtual visits.

During the pandemic, when pediatric patients may have restricted access to interventions that improve hospital stays, AAI remains a useful approach, according to a related article in The New York Times. Deemed essential workers at a children's hospital in Atlanta, therapy dogs help "normalize the hospital environment and help kids feel like kids," the article notes.

Dogs who are trained to detect smells also might provide a valuable service in sensing COVID-19 positivity. In a proof-of-concept study using sweat samples, six dogs had success rates from 76% to 100% in identifying positive samples. In another study using saliva or throat swabs, eight dogs performed at a 94% success rate.

Older Patients With COVID-19 Presenting With Delirium

Delirium should be considered an important marker for increased risk of poor outcomes.

Among older patients with COVID-19, delirium is a common presenting symptom in the emergency department (ED) and should be considered an important marker for increased risk of poor outcomes.

"Delirium in Older Patients With COVID-19 Presenting to the Emergency Department," in JAMA Network Open, finds that 28% of patients over age 65 had delirium at ED presentation. Of those patients, 37% showed no typical COVID-19 symptoms, such as fever or shortness of breath.

The study involved 817 patients (mean age 77.7) diagnosed with COVID-19 at seven U.S. EDs on or after March 13, 2020. Delirium was the sixth most common symptom for this age group and was significantly associated with poor outcomes, including ICU stay, discharge to a rehab facility and death.

The study suggests that delirium should be included on clinical checklists of COVID-19 signs and symptoms. "Adding delirium as a common presenting symptom of COVID-19 will keep important cases from being missed and allow earlier identification and management of vulnerable patients at high risk for poor outcomes," the study notes.

In a related post in Doctors Lounge, Claire Steves, deputy director of London-based TwinsUK, a registry that studies complex diseases, says the U.S. findings align with a study her team conducted in the United Kingdom that revealed over one-quarter of hospitalized older adults with COVID-19 initially presented with delirium.

"It's critical for health care workers and those who are caretakers of older people to be aware that delirium can be a sign of COVID-19, so that infection controls and treatments can be started," Steves adds in the article.

Societal Factors vs. Ancestry in Heart Risk for Blacks

These findings note the greater importance of nonbiological risk factors.

Societal risk factors rather than genetics and ancestry may be the major drivers resulting in well-established racial disparity in cardiovascular health associated with hypertension, suggests a study involving 2,466 Black adults.

"Association of Genetic West African Ancestry, Blood Pressure Response to Therapy, and Cardiovascular Risk Among Self-Reported Black Individuals in the Systolic Blood Pressure Reduction Intervention Trial (SPRINT)," in JAMA Cardiology, finds that West African ancestry proportion is not significantly associated with adverse cardiac risk.

The study divided Black adults enrolled in SPRINT into tertiles by proportion of West African ancestry based on genetic markers. Upon follow-up (mean 3.2 years), there were no significant differences in trajectories of blood pressure, kidney function and left ventricular mass across the tertiles. There was a moderate decrease in the risk of a composite cardiovascular event with each 5% increase in the proportion of West African ancestry.

"These findings highlight the greater importance of nonbiological risk factors — including socioeconomic status, environmental factors, educational attainment, behavioral characteristics, structural racism, and access to health care — in existing disparities in hypertension control and downstream adverse cardiovascular risk," the study concludes.

In an accompanying editorial, Tiffany Powell-Wiley of the National Heart, Lung, and Blood Institute of the National Institutes of Health, in Bethesda, Maryland, comments that the medical community is beginning to see race as "what it has always been: a social construct."

She adds, "It is clear that systemic racism, or structural inequity defined by race, limits access to economic stability, quality healthcare, and safe, well-resourced environments, which are reflected in the social determinants of health for Black people in the U.S."

President's Column: Making Things Different

In her February column, President Elizabeth Bridges asks, "How do you want to be remembered on your 100th birthday?" Amid all of this uncertainty, now is the time to think in another way about making a meaningful difference for ourselves and others.

Read Now

Nurse Story: Taking the Scenic Route — A First Person Account by Sandra Lee

A pediatric ICU nurse shares a firsthand account about how her own health challenges led to a career in nursing and how reflecting on that journey during a pandemic gives her work more meaning.

Read Her Story

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