Clinical Voices February 2022

Feb 15, 2022

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This month we feature articles on midline catheters for short-term antibiotic therapy, an app-based protocol to identify delirium, and high-flow oxygen therapy. Plus, watch a President’s Video and read a nurse staffing Q&A.

Study Compares Midline Catheters and PICCs

Using midlines for short-term antibiotic therapy rather than PICCs may improve patient safety.

For patients with difficult intravenous access, midline catheters for short-term antibiotic therapy lower risks of bloodstream infections and catheter occlusions compared with peripherally inserted central catheters (PICCs).

Safety and Outcomes of Midline Catheters vs Peripherally Inserted Central Catheters for Patients With Short-Term Indications: A Multicenter Study,” in JAMA Internal Medicine, notes that patients who receive PICCs are nearly twice as likely to develop a major complication, such as infection or occlusion, compared with those treated with midlines. However, results are unclear whether midlines are similar or better for reducing the risk of deep vein thrombosis (DVT).

The study involved 5,758 patients who received PICCs and 5,105 who received midlines from December 2017 through January 2020. Compared with the PICC group, patients with midlines experienced lower rates of occlusion (2.1% vs. 7.0%) and bloodstream infection (0.4% vs. 1.6%), with no significant differences in DVT risk.

“Judicious use of midlines over PICCs may improve patient safety,” the study notes, adding that randomized clinical trials are needed to compare the DVT risk for both devices.

A related article in 2 Minute Medicine notes that the study is strengthened by its large sample size but limited by its observational design, which can lead to confounding error and cannot suggest causative conclusions.

Optimal selection of a vascular access device involves recognizing that every device can cause patient harm, notes an article in Critical Care Nurse. And although midlines may have an important niche, their use should be evaluated carefully.

“Midline catheters should not be used as a catheter-associated bloodstream infection prevention strategy,” the article notes. They “should be inserted to administer peripherally compatible solutions, and should be considered for short-term continuous vesicant therapy only in emergent situations until more definitive vascular access can be achieved.”

Delirium Screening App Is Quick, Accurate

The protocol’s accuracy in identifying delirium in older adults was 89% for nurses.

An app-based protocol to help clinicians identify delirium in older adults was feasible, fast and nearly 90% accurate, according to study results.

Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants: A Cohort Study,” in Annals of Internal Medicine, finds that in real-world practice, the two-step, app-directed protocol compared favorably with the research reference standard delirium assessment (RSDA) screening tool.

Conducted at two hospitals — an academic medical center in Boston and a rural hospital in Pennsylvania — the study enrolled 527 general medicine inpatients (mean age 80), including 35% with preexisting dementia. Patients underwent RSDAs on two days, and delirium was diagnosed in 22% of them.

Alternatively, as a first step, certified nurse assistants administered a very brief, two-item screen (UB-2), which took an average of 62 seconds per patient. Subsequently, nurses and physicians performed the two-step protocol, consisting of the UB-2 followed by an app-based 3-Minute Diagnostic Assessment for the Confusion Assessment Method for patients who had a positive screen.

The app-directed protocol’s overall accuracy for identifying delirium was 89% among nurses and 87% among physicians, the study adds. Nurses completed the protocol in a mean of 104 seconds, while the physicians finished in a mean of 106 seconds.

A related article in HealthDay adds that for moderate to severe delirium, the protocol’s sensitivity was 78%. “Our protocol can substantially improve delirium identification with a low false-positive rate among vulnerable hospitalized adults,” note the study authors in the article.

High-Flow Oxygen Therapy May Improve COVID-19 Outcomes

Patients had shorter recovery times with high-flow oxygen therapy.

Using high-flow oxygen therapy through a nasal cannula reduced the likelihood of intubation and also decreased recovery time for patients with severe COVID-19.

In “Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19,”in JAMA: The Journal of the American Medical Association, the intubation rate for adult patients randomized to high-flow therapy was 34.3%, compared with 51.0% for those receiving conventional oxygen therapy. Median time to clinical recovery was 11 days in the high-flow oxygen therapy group, compared with 14 days in the conventional group.

The small open-label randomized clinical trial was conducted at three hospitals in Colombia, South America, from August 2020 to January 2021, plus a final follow-up in February 2021. Of the 220 patients, 109 were randomized to the high-flow oxygen therapy group and 111 to the conventional group, with a few less included in the final data.

Within 28 days, 77.8% of the high-flow oxygen therapy group had recovered, compared with 71% of the conventional group. The trial also found that 13.1% of patients in the high-flow oxygen therapy group contracted suspected bacterial pneumonia, compared with 17.0% in the conventional group.

The clinical trial excluded patients with certain chronic conditions that can be risk factors for severe COVID-19, including heart failure and severe chronic obstructive pulmonary disease. Patients were included if they had respiratory distress with a PaO2/FiO2 ratio less than 200.

Obesity Elevates Mortality Risk for ICU Patients With COVID-19

The study suggests including BMI in severity scoring for ICU patients with COVID-19.

Higher body mass index (BMI) is associated with a greater likelihood of death due to COVID-19 as well as longer length of stay (LOS) for survivors.

In “Impact of Obesity on Intensive Care Outcomes in Patients With COVID-19 in Sweden – A Cohort Study,” in PLOS One, ICU patients with COVID-19 and a BMI of 35 kg/m2 or more had double the mortality risk or extended LOS in intensive care compared with patients who had a healthy weight.

“Based on our findings, we advocate that BMI is included in the severity scoring for patients with COVID-19 admitted to intensive care, and suggest that individuals with obesity should be more closely monitored when hospitalized for COVID-19,” the study notes.

Using data from across Sweden from March to August 2020, the observational, registry-based study included 1,649 patients (74.4% male), of whom 343 were not overweight or obese (between 18-25 kg/m2), 641 were categorized as overweight (between 25-30), 404 were categorized as Obesity 1 (between 30-35), and 246 as Obesity 2 and 3 (above 35 kg/m2). The cohort contained an overrepresentation of men and overweight individuals compared with the general population.

Because overweight and obese patients were twice as likely to require LOS exceeding 14 days, the impact on ICU bed availability was significant. “Thus, a prolonged LOS is an important factor not only for the individual patient but also as an important factor for health care, putting excess strain on ICUs during the COVID-19 outbreak,” the study adds.

The strengths of the study include the large population-based cohort, nationwide coverage of regions and care facilities across Sweden as well as detailed and current BMI data. Limitations include lack of data on some risk factors such as tobacco use and socioeconomic factors, as well as data being restricted to the “first wave of the pandemic.”

Bougie vs. Stylet: Is Either Better for First-Attempt Success?

Successful intubation on the first attempt occurred in 80.4% of the bougie group and 83.0% of the stylet group.

A clinical trial on whether a bougie or an endotracheal tube with stylet is better to intubate critically ill patients finds no significant difference in achieving success on the first attempt.

Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial,” in JAMA: The Journal of the American Medical Association, also finds little difference in the incidence of severe hypoxemia between the two methods.

The trial involved 1,102 critically ill patients (median age 58) randomly assigned to intubation with either a bougie or a stylet at seven emergency departments and eight ICUs in the United States from April 2019 to February 2021.

“Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group,” the trial notes. In addition, “a total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia,” defined as peripheral oxygen saturation less than 80%, “compared with 46 patients (8.8%) in the stylet group.”

A related commentary in First10EM notes that while the clinical trial provides valuable information, limitations include a lack of detail about the experience levels of the clinicians performing intubations. Both groups performed relatively poorly, the commentary notes, adding that “an 80% first pass success rate is not good enough,” and “airway management is not about the device; it is about the approach and the training.

“Whichever option you choose as your primary technique, you need to ensure you have mastered it,” the commentary notes. “However, being facile with your backup option may be even more important,” so it’s critical to master both techniques.

‘RAPIDO’ Mnemonic Increases Stroke Awareness for Spanish-Speaking Americans

The tool was developed as an alternative to BE-FAST.

A nurse-led team developed RAPIDO, a mnemonic and infographic for Spanish-speaking Americans, to create stroke awareness, help detect early signs and encourage rapid response in seeking emergency care.

RAPIDO: Promoting Stroke Awareness Among Spanish Speakers,” in Nursing2021, emphasizes the limitations of providing effective health literacy for patients with limited English-speaking ability, particularly the Spanish-speaking population, which has a higher risk of strokes and related events. “We propose the creation of a mnemonic tool that standardizes stroke-specific messaging across the US Spanish-speaking population,” the article notes.

Developed as an alternative to BE-FAST (Balance, Eyes, Face, Arm, Speech, Time), the commonly used English mnemonic for stroke awareness, RAPIDO can be tested for effectiveness and used as a tool in education campaigns. The article explains the mnemonic translation as R for “rostro caido” (facial drooping), A for “alteración del equilibrio” (loss of balance), P for “perdida de fuerza en un brazo o pierna” (unilateral weakness), I for “impedimento visual” (visual impairment), D for “dificultad para hablar” (difficulty speaking or understanding speech), and O for “obtenga ayuda rapido, llame a emergencias!” (obtain help fast, call emergency services!).

Andrea Ancer Leal, a nurse at Ben Taub Hospital, Houston, said, “We are still in the first stages of this,” according to a related article. “She and her colleagues are working to get funding and gain greater validation for the mnemonic RAPIDO before rolling it out in health campaigns locally and then nationwide in neurology clinics and hospitals.”

The RAPIDO tool is intended for speakers from Central American and Mexican cultures based on those dialects, as Spanish around the world can vary in medical terminology and descriptions of health conditions. The tool “has the potential to increase the likelihood of stroke awareness and stroke sign and symptom recognition among US Hispanics by targeting Spanish speakers who do not benefit from the BE-FAST mnemonic,” adds the article in Nursing2021.

President’s Video: Co-Creating Our Path Forward

In a video message from AACN President Beth Wathen, she recognizes the physical, emotional and mental exhaustion nurses face and addresses the ongoing staffing crisis. She also invites you to participate in a series of AACN Town Hall Q&A sessions.

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Nurse Story: Dual-Role Staffing Solution

Even before the pandemic, a Michigan hospital was developing a strategy to address the growing nursing shortage and increasing cases of burnout among nurses. A nurse leader there explains how her team developed a dual-role employee initiative that improved nurses’ job satisfaction and enhanced the quality of patient care.

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