Clinical Voices February 2023

Feb 06, 2023

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In this issue, we feature topics on how virtual nurses can benefit patient care, dropping VAP rates with bundle compliance, the lifesaving potential of a tiny, disposable ventilator, and more. Plus, read a down-to-earth nurse story.

Fill Knowledge Gap With Virtual Nurses

Virtual nurses may offer many benefits for patient care.

With RN turnover rising steadily, adding virtual nurses is one way hospitals can help new nurses practice safely and prevent some experienced nurses from leaving the profession.

Virtual nursing could fill the resulting “knowledge gap” if experienced nurses decide to remain in the profession or return in virtual roles, suggests “Can Virtual Nursing Save the Workforce?” in MedPage Today. And 67% of RNs surveyed plan to leave their current position within three years, adds a report in the October 2021 issue of Critical Care Nurse.

Virtual nurses provide three core benefits: coaching or precepting nurses, relieving bedside nurses of time-consuming tasks and providing surveillance, notes the article in MedPage. “Anything that a bedside nurse does that doesn’t require hands on a patient, we provide that using AV (audiovisual) technology,” adds Chief Nursing Officer Ashley VonNida, with staffing firm Equum Medical.

Many of the company’s employees are retired but miss the interaction with patients and want to provide care, VonNida adds in MedPage Today. She doesn’t see virtual nursing as a replacement for bedside nurses but rather a hybrid approach and a redistribution of the workforce. “So instead of having six bedside nurses on a unit, you have five bedside nurses on a unit and a virtual nurse,” she explains.

Recommendations and a framework to implement tele-critical care into practice are part of a 2022 consensus statement released by the American Association of Critical-Care Nurses (AACN) Tele-critical Care Task Force, which was co-chaired by Theresa Davis, AACN’s president-elect.

This statement “explores the many practice changes and keeps pace with expanding applications in this area of telemedicine, and supports the terminology shift to tele-critical care,” reports an AACN executive summary. “It identifies essential tele-critical care elements, reflects current evidence, and delivers a fresh perspective to this fast-growing area of healthcare.”

VAP Rates Fall With Bundle Compliance, Nurse Education

The study evaluated the impact of nursing education on pulmonology care for ventilated adult trauma patients.

Critical care units could reduce ventilator-associated pneumonia (VAP) rates for trauma patients by introducing an evidence-based prevention bundle and providing bedside education to help nurses complete the tasks.

VAP rates dropped from 20.8% to 12.2% after bundle implementation in the 14-bed ICU, notes “An In-Depth Look at Ventilator-Associated Pneumonia in Trauma Patients and Efforts to Increase Bundle Compliance, Education and Documentation in a Surgical Trauma Critical Care Unit,” in AJIC: American Journal of Infection Control. The single-center retrospective study from 2017 to 2020 evaluated the impact of nursing education on pulmonology care for ventilated adult trauma patients.

Evaluators observed nurses performing bedside care and scored them on VAP bundle procedures, including proper hand hygiene, oral care procedures, head-of-bed (HOB) elevation, endotracheal tube rotation, gastrointestinal prophylaxis and careful documentation. “Any deficits noted upon performance were immediately remediated with return demonstration by the nurse at bedside if applicable,” the study notes.

“With the successful education and demonstration to the nurses and achievement of an effective bundle compliance rate along with detailed documentation, we observed a statistically substantial reduction in VAP rates.” Bundle use led to other improvements for patients, including fewer ventilator days, decreased conversion to tracheostomy and shorter hospital stays.

Limitations include the various types and severity of patients’ traumatic injuries, which prevented nurses from consistently performing all VAP bundle tasks. For example, spine fractures or open abdominal wounds precluded HOB elevations for some patients, the study adds.

“Further research is warranted as studies have noted that patients requiring mechanical ventilation are at greater risk for VAP than other ICU patients due to the nature of their injuries and increased risk of prolonged mechanical ventilation ≥ 21 days.”

Outcomes Similar for PSV, T-Piece in High-Risk Population

Spontaneous-breathing trials with PSV or a T-piece had a similar number of ventilator-free days at day 28.

Study patients with a high risk of extubation failure had a similar number of ventilator-free days whether spontaneous-breathing trials were conducted with pressure-support ventilation (PSV) or a T-piece.

In “Spontaneous-Breathing Trials With Pressure-Support Ventilation or a T-Piece,” in The New England Journal of Medicine, patients in the PSV group had a slightly higher rate of extubation within 24 hours or within seven days and a slightly higher rate of reintubation. “Among patients who had a high risk of extubation failure, spontaneous-breathing trials performed with PSV did not result in significantly more ventilator-free days at day 28 than spontaneous-breathing trials performed with a T-piece,” the trial adds.

Conducted at 31 ICUs in France, the multicenter open-label trial included 484 patients in the PSV group and 485 in the T-piece group, with both groups having a median of 27 days ventilator-free as of day 28 after the spontaneous-breathing trial. The PSV group received extubation within 24 hours in 376 patients (77.7%) and within seven days in 473 patients (97.7%), compared with 350 (72.2%) and 458 (94.4%) respectively, in the T-piece group.

The trial notes that 72 patients in the PSV group (14.9%) required reintubation, compared with 65 in the T-piece group (13.6%), with cardiac or respiratory arrest associated with nine of the reintubations (three in PSV group, six in T-piece group). Limitations include a lack of information about the use of sedation, and it was not a double-blind trial.

Patients were selected to participate based on high-risk factors, including age over 65 years or an underlying chronic cardiac or respiratory disease. Patients were excluded if they had been admitted for traumatic brain injury, had a do-not-reintubate order or had a preexisting peripheral neuromuscular disease.

Alternative Defibrillation Strategies May Improve Outcomes

DSED was also associated with more patients having a good neurological outcome compared with the standard.

Patients with out-of-hospital cardiac arrest receiving double sequential external defibrillation (DSED) or vector-change (VC) defibrillation had higher rates of survival to hospital discharge than those receiving standard defibrillation in a cluster-randomized trial.

Defibrillation Strategies for Refractory Ventricular Fibrillation,” in The New England Journal of Medicine, notes that the trial was conducted in Canada from March 2018 to May 2022 with some interruption due to the COVID-19 pandemic, when protocol changes and reduced paramedic staff increased response times. The trial included 136 patients in the standard defibrillation group, 144 in the VC group and 125 in the DSED group.

“Termination of ventricular fibrillation, return of spontaneous circulation, and a good neurologic outcome at hospital discharge appeared to be more common with the DSED strategy, as did termination of ventricular fibrillation with the VC defibrillation strategy,” the trial adds.

The DSED group had the highest survival rate (30.4%), followed by VC (21.7%) and standard (13.3%). The DSED group also had the highest rate for termination of ventricular fibrillation (84.0%), followed by VC (79.9%) and standard (67.6%). Survival with good neurological outcomes occurred in 27.4% of the DSED group, 16.2% of VC and 11.2% of standard.

The trial notes that a small number of its patients could impact the outcome, and previous observational studies and reviews did not find the same level of benefit from DSED and VC. “However, these studies lacked a control group with standard care characterized by high-quality CPR, did not control for the timing of interventional shocks, did not describe a consistent technique for performing DSED or VC defibrillation, and did not measure or report the quality of CPR performed during DSED or VC defibrillation.”

Analyzing Links Between Methamphetamine Use, Heart Failure

Further research will help support effective treatment for MethHF.

A review of observational studies linking methamphetamine use to risk of heart failure shows an increase in prevalence, impacts on diverse demographic groups, and a higher risk for men.

Methamphetamine-Associated Heart Failure: a Systematic Review of Observational Studies,” in Heart, notes that methamphetamine-associated heart failure (MethHF) is associated with worse symptoms than heart failure from other causes, longer hospital stays and more readmissions. “The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well-designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF,” the review notes.

The review determined that abstinence from methamphetamine use, even inconsistently, and adherence to guideline-directed medical therapy were associated with improved outcomes for users. Significant differences in the quantity and history of use by patients in the 21 reviewed studies conducted from 1997 to 2020 prevented the researchers from making a precise analysis, leading to a recommendation for “rigorous prospective studies using uniform definitions” to understand the precise impact of methamphetamine-use disorder (MUD) as well as increasing the availability of effective treatments to reduce harm, both nonpharmacological and pharmacological.

“General healthcare’s successful experience with management of the opioid epidemic needs to be translated and expanded to treatment of MUD,” the review adds. “Further research is essential to supporting clinicians in providing effective patient-centered treatment to individuals with MethHF and improve outcomes.”

The review notes that studies may be underestimating the incidence of MethHF due to inconsistent diagnosis and coding, as well as lack of awareness by clinicians and patients. “The increasing prevalence of MethHF across racial/ethnic and socio-demographic groups in the setting of rising MU worldwide calls for increased awareness and availability of treatment for methamphetamine addiction.”

Tiny Ventilator Has Huge Lifesaving Potential

A miniature, disposable ventilator that fits in a pocket can provide lifesaving aid.

A miniature, disposable ventilator that fits in your pocket could provide lifesaving respiratory aid for patients in critical care and emergency situations.

Clinical Center Doctors Testing 3D-Printed Miniature Ventilator,” in NIH Director’s Blog, notes that physicians at the National Institutes of Health (NIH) are part of an international research team testing the 3D-printed plastic device, which is designed to be inexpensive and mass produced. The device has no moving parts and measures 7.4 centimeters (about 3 inches) long and 2.4 centimeters (about 1 inch) in diameter.

Development began amid the global shortage of hospital ventilators during the COVID-19 pandemic. The research team of physicians, engineers, respiratory therapists and others set out to create an easy-to-use resuscitation device that could be distributed quickly.

“It’s based on principles of fluidics to ventilate patients by automatically oscillating between forced inspiration and assisted expiration as airway pressure changes,” NIH Chief Executive Officer James K. Gilman writes in the blog. “It requires only a continuous supply of pressurized oxygen.”

Hoping to refine the miniature ventilator for in-human trials, NIH researchers tested three versions in domestic swine that corresponded with mild, moderate and severe injuries. The group reported its findings in Science Translational Medicine.

“The respirators provided adequate support for moderate and mild lung injuries, and the doctors recall how amazing it was initially to witness a 190-pound swine ventilated by this miniature ventilator,” Gilman adds in the related article, noting the ventilator could one day be used to treat casualties from battles or disasters.

“The doctors believe that the 3D-printed miniature ventilator is a potential ‘game changer’ from start to finish since it is lifesaving, small, simple to use, can be easily and inexpensively printed and stored, and does not require additional maintenance,” he adds.

Nurse Story: Beyond the Limits of the Sky

After 26 years as a flight attendant, Krista Spence landed in critical care nursing. “Part of my motivation was my children, to be an example that you're never too old to pursue your dreams.”

Read Her Story