Clinical Voices January 2022

Jan 06, 2022

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This month we feature reducing nonactionable alarms, solutions for socioeconomic disparities in women’s heart health, and cardiac radiotherapy for arrhythmia. Plus, read the new President’s Column and watch an informative video Q&A interview.

Solutions for Socioeconomic Disparities in Women’s Cardiovascular Health

Socioeconomic disparities need to be addressed individually and collectively.

Women, particularly those with minority or disadvantaged backgrounds, face increased cardiovascular risks associated with many socioeconomic disparities.

Socioeconomic Determinants of Health and Cardiovascular Outcomes in Women,” in JACC: Journal of the American College of Cardiology, reviews the conditions associated with cardiovascular disease in women, finding potential barriers such as poverty, racism, geography, education, and access to care and insurance. “These contributing factors are often overlapping and, importantly, are modifiable, with actionable solutions,” notes Kathryn Lindley, chair of the ACC Cardiovascular Disease in Women Committee.

Socioeconomic disparities, which can adversely affect women’s health, need to be addressed individually and collectively, the review adds. The barriers can potentially be overcome and, with lifestyle modifications, help decrease the estimated 80% of women’s cardiovascular cases.

“Suggested solutions include addressing bias, resolving issues based on racial discrimination, expanding Medicaid coverage, emphasizing value-based care, using technology to expand access to cardiology care, improving patient education and health literacy, providing access to interpreters, and involving more women and diverse populations in clinical trials.

“Lack of diversity among health care professionals may be even more responsible for disparities in health care access and outcomes than lack of health insurance,” add Lindley and colleagues in a related article in Healio.

Other issues for women in socioeconomically disadvantaged communities include lack of patient-centered care, community support and transportation, and insufficient access to healthy foods and exercise centers. “Resolving health care outcome disparities in women will require both investment in sex-specific science and health policy advocacy and incorporating awareness of the impact of these barriers into our health care delivery (on both personal and systemic levels),” Lindley notes.

Telemetry Strategies to Reduce Nonactionable Alarms

A nurse-led discontinuation protocol could remove certain patients from telemetry.

Using evidence-based guidelines and strategies to reduce telemetry for cardiac patients in non-critical care areas can decrease nonactionable alarms.

According to “Reducing Overuse of Telemetry,” in American Nurse, continuous cardiac monitoring (telemetry) frequently leads to false alarms in medical, surgical and intermediate care units. However, the American Heart Association (AHA) “has developed evidence-based guidelines for appropriate telemetry use,” adds a related article in Circulation.

The guidelines offer a rating system with three categories for cardiac monitoring:

  • “Class I: high indication for monitoring
  • Class II: may benefit, but not essential
  • Class III: no therapeutic benefit”

AHA recommends building the guidelines into ordering practices and calls for set times in the ordering process to stop and reevaluate a patient’s need to remain on telemetry, rather than using options such as “until discharged.”

“Revising the process for ordering telemetry and assessing clinical necessity, creating buy-in from key stakeholders, forming a task force to decrease telemetry use, and framing the AHA standards as evidence-based guidelines rather than protocol can ease tensions and resistance from providers,” adds the article in American Nurse.

A set of discontinuation criteria in 13 measurable categories can help develop “a nurse-led discontinuation protocol” to remove certain patients from telemetry. Using collaborative techniques, nurses can communicate possible reductions in telemetry to attending physicians when advocacy is needed.

AACN clinical resources on alarm reduction include a practice alert, “Managing Alarms in Acute Care Across the Life Span,” a nurse-led Clinical Scene Investigator project that offers a presentation and toolkit to help units achieve data-driven outcomes, and “Updated Practice Standards for ECG Monitoring: Impact at the Bedside,” an on-demand webinar.

Reducing alarm fatigue can also be accomplished through evidence-based interventions, such as a burn ICU’s quality improvement initiative and an ICU’s process-oriented intervention with a change of shift protocol.

Nurses May Be at Risk of Suicidal Ideation

Burnout among nurses may be a risk factor for suicidal ideation.

Nurses face a greater risk of suicidal ideation than workers in other professions, according to a 2017 survey, and the risk is higher among those reporting depression or burnout.

Original Research: Suicidal Ideation and Attitudes Toward Help Seeking in U.S. Nurses Relative to the General Working Population,” in AJN: American Journal of Nursing, notes the cross-sectional survey had an 8.5% response rate with more than 7,000 nurses participating, of whom 5.5% reported suicidal ideation within the past year, compared with 4.3% in the general population.

“Most nurses (84.2%) indicated willingness to seek professional help for a serious emotional problem. Yet nurses with suicidal ideation were less likely to report that they’d seek such help (72.6%) than nurses without suicidal ideation (85%),” the review adds.

“Systems- and practice-level interventions must be identified and implemented, both to address the higher prevalence of burnout and suicidal ideation in nurses and to mitigate the stigma about mental health problems and other barriers to seeking help.”

The review adds that 38.2% of nurse respondents reported symptoms of burnout and, based on their answers, 43.3% were considered positive for depression. Respondents were overwhelmingly white and female, with a median age of 51 and 20 years of nursing experience.

“Burnout has always been a big topic in healthcare, becoming more prevalent since the pandemic,” lead author Elizabeth Kelsey, Mayo Clinic, Rochester, Minnesota, notes in a related article in MedPage Today. “If anything, potentially these numbers could be even higher now.

“The hope is to ‘build a positive work culture ... balancing the job demands and the resources that can help promote this workplace culture of well-being,’” Kelsey adds.

If you or anyone you know may be experiencing suicidal thoughts or emotional distress, the National Suicide Prevention Lifeline (800-273-8255) is available 24/7. The lifeline provides “free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States,” the website notes.

Cardiac Radiotherapy Effective Against Arrhythmia

Understanding how this process works can improve treatment and be applied to other diseases.

For patients with heart failure, cardiac radiotherapy (RT) can be an effective and noninvasive way to manage refractory ventricular tachycardia (VT).

Cardiac Radiotherapy Induces Electrical Conduction Reprogramming in the Absence of Transmural Fibrosis,” in Nature Communications, finds that a single-fraction dose of 25 Gray ionizing radiation persistently restores electrical propagation in diseased hearts. The technique can replicate the therapeutic effects of catheter ablation but is far less invasive.

“The ability to noninvasively and functionally eliminate VT circuits, by modulating cardiac electrophysiology in a localized way and without tissue destruction, may allow for safer treatments and prevention of arrhythmias for individuals with myocardial scarring,” the study notes.

Conducted at Washington University School of Medicine in St. Louis, the study identifies Notch (the cardiomyocyte signaling pathway) as a potential mechanism for radiation-induced reprogramming. “Our results demonstrate that the functional and molecular effects of RT and Notch reactivation are persistent and expected to directly translate into long-term durability of therapy,” the study adds.

A related article in New Atlas notes that while the Notch pathway is normally inactive in adults, radiation seems to revert it to a healthier, “younger” state with beneficial effects that can last at least two years.

“Radiation does cause a type of injury, but it’s different from catheter ablation,” notes study co-author Julie Schwarz, Washington University School of Medicine, in the related article. “As part of the body’s response to that injury, cells in the injured portion of the heart appear to turn on some of these early developmental programs to repair themselves. It’s important to understand how this works because, with that knowledge, we can improve the way we’re treating these patients and then apply it to other diseases.”

Positive Safety Attitudes Result in Better Patient Outcomes

Teamwork and communication among nurses can lead to improved patient outcomes.

When nurses have positive attitudes about safety, hospital units report fewer adverse patient outcomes, including patient falls, medication errors, pressure injuries and healthcare-associated infections.

Systematic Review: Nurses’ Safety Attitudes and Their Impact on Patient Outcomes in Acute-Care Hospitals,” in NursingOpen, notes that the database searches identified 3,452 studies for consideration in the review, and after further screening, nine were eligible. Five studies were conducted in the U.S. with one each from Canada, Switzerland, South Korea and China.

“Studies were included if they were published in English, collected data from nurses working in acute-care hospitals and explored the impact of nurses’ safety attitudes on patient outcomes,” the review adds. “Studies that examined nurses’ safety attitudes as part of the interdisciplinary team were included if data from nurses could be extracted.”

Among the review’s key findings:

  • Nurses with positive safety attitudes report fewer adverse events.
  • Units and hospitals with a positive safety culture have improved patient outcomes.
  • Teamwork and communication among nurses lead to fewer adverse patient outcomes.
  • Nurse managers are essential to promote a positive safety culture that improves nurses’ safety attitudes and patient outcomes.

The review acknowledges that results are based on a comparatively small number of observational studies, most of which relied on self-reported data. Also, a variety of tools were used to assess nurses’ safety attitudes at different organizational levels.

While noting that these factors and others justify further research, the review contends that “the included studies provide important evidence about the influence of nurses’ safety attitudes on patient outcomes.”

Chest Pain: New Guidelines and Top 10 Takeaways

A joint report addresses evaluation of chest pain in adults.

Several cardiovascular care organizations released a joint report with clinical practice guidelines that provide recommendations and algorithms to evaluate, assess and diagnose chest pain in adults.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,” in JACC: Journal of the American College of Cardiology, was developed using scientific evidence gathered from November 2017 to May 2020, encompassing many clinical trials, observational studies, registries and other sources.

The guidelines include sections on initial evaluation, cardiac testing, choosing the right pathway with patient-centric algorithms for acute chest pain, and evaluating patients with stable chest pain. The report also features 10 take-home messages to evaluate and diagnose chest pain:

  1. Chest pain is more than pain in the chest. Also consider pressure, tightness or discomfort in the shoulders, arms, neck or jaw.
  2. High-sensitivity cardiac troponins are the preferred standard to establish a biomarker diagnosis of acute myocardial infarction.
  3. Immediate medical care, including calling 911, is recommended for acute chest pain or equivalent symptoms.
  4. Involve clinically stable patients in discussing treatment options and making decisions.
  5. For low-risk chest pain, urgent diagnostic testing is not routinely needed.
  6. Clinical decision pathways should be used routinely for chest pain in the emergency department and outpatient settings.
  7. Women are more likely than men to present with accompanying symptoms, such as nausea or shortness of breath.
  8. Cardiac imaging is most beneficial for patients at intermediate to high risk of obstructive coronary artery disease.
  9. The term “noncardiac” should be used when heart disease is not suspected, because the term “atypical” can be misleading.
  10. Evidence-based diagnostic protocols can help assess risk of coronary artery disease.

President’s Column: The Future of Nursing Starts Now

The new year offers us a time to reflect back and look forward. In her new column, Beth Wathen examines how, pre-pandemic, nurses reported struggles with burnout, moral distress and compassion fatigue. The COVID crisis has accelerated and amplified these trends. So, what does the future hold for nursing?

Read Now

Expectations for Implementing Medication Titration Orders

In 2021, The Joint Commission clarified its requirements for administration and documentation of rapidly titrated medications. AACN worked with them to clarify its medication management standard, which delineates required hospital policies for medication orders, including titrated medications.

Read Now

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