Clinical Voices July 2022

Jul 25, 2022

Added to Collection

This month we feature articles on a protocol for administering enteral medication, an updated heart failure guideline, tools to assess chest pain, and more. Plus, watch the new President’s Video and read a Q&A on integrating travel nurses on the unit.

Protocol for Enteral Medication Administration

Every patient had a large decrease in total fluid administered through medication diluents and tube flushes.

A quality improvement (QI) project led by nurses and pharmacists established a protocol for enteral medication administration that reduced excess fluid volumes without increases in medication intolerance or abdominal discomfort.

A Standardized Approach to Enteral Medication Administration,” in Nursing2022, notes that an interdisciplinary team at a university medical center reduced the effects of residual fluid volumes in patients who required feeding and medication through an enteral tube, and established new evidence-based practices. “The organization is currently using the new process and has not reported increases in medication intolerance or abdominal discomfort identified to date,” the article adds.

Every patient in the study had a large decrease in total fluid administered through medication diluents and tube flushes, ranging from a drop from 315 mL to 145 mL when patients required three medications to a drop from 1,565 mL to 624 mL when they required 10 medications. “The new protocol reduces fluid volume overload and decreased gastric residual volumes while maintaining feeding tube patency, nutrition, and needed medications,” the article adds.

In consultation with pharmacists, the nursing team determined that flushing the enteral tube with sterile water between each medication was not necessary to mitigate the risk of drug-drug interactions and that crushed pills could be diluted in just 5 mL of water. “This QI project shows that standardization of the nursing process and a cultural change concerning enteral tubes and medications are needed.”

After twice-daily medication administrations, patients were surveyed about possible gastrointestinal pain or discomfort, and they “reported no feelings of fullness, bloating, or distension pain.” Nurses also completed questionnaires indicating they did not withhold any scheduled feedings due to high residual volumes, and there were no clogged tubes reported or signs of edema or aspiration.

Updated Heart Failure Guideline Focuses on Early Prevention

A primary goal was using newly published data to update the recommendations.

A new guideline for preventing heart failure (HF) includes an emphasis on detection and treatment strategies for patients with early signs of disease and recommendations for managing patients at all four stages.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,” in Circulation, notes the committee developed 10 take-home messages and presents evidence-based guidance to implement the strategies. “One primary goal with the new guideline was to use recently published data to update our recommendations for the evaluation and management of heart failure,” committee chair Paul Heidenreich adds in a related American Heart Association news release.

The take-home messages include step-by-step flowcharts, estimations of the strength of the recommendations and measurements of the quality of the medical evidence. Some treatments also have value statements assessing cost-effectiveness studies related to the interventions.

The new guideline redefines stage A as “at risk for HF,” with early identification of risk factors for patients without symptoms, and stage B as “pre-HF” with treatments for preventing decreased heart function or structural changes in patients with early evidence of disease. “One focus was prevention of heart failure through optimizing blood pressure control and adherence to a healthy lifestyle,” Heidenreich adds in the release.

Patients at stage C, “symptomatic HF,” should be evaluated using refined classifications based on left ventricular ejection fraction and new terminology, and four medication classes are included in the recommendations. “This is a major step forward in reducing mortality rates in this vulnerable population,” vice-chair Biykem Bozkurt notes in the release.

For stage D, “advanced HF,” the guideline offers recommendations on implantable devices and therapy as well as palliative care and cardio-oncology. Other areas addressed include cardiac amyloidosis, atrial fibrillation and valvular heart disease.

Tools to Assess Chest Pain

The guideline includes a graphic and a memory aid to evaluate and diagnose clinical stability.

A revised clinical practice guideline to evaluate and diagnose chest pain helps assess risk and determine appropriate workups with the goal of identifying potential ischemic causes.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,” in Circulation, aims to help clinicians in a variety of clinical settings with mnemonic aids and commonly used descriptive terms. “Distinguishing between serious and benign causes of chest pain is imperative,” the report notes.

The guideline incorporates a graphic and a memory aid for evaluation and diagnosis of adult patients’ clinical stability and whether they need hospitalization, using the letters C-H-E-S-T-P-A-I-N-S. The top 10 take-home messages:

  • Chest pain means more than pain in the chest
  • High-sensitivity troponins preferred
  • Early care for acute symptoms
  • Share the decision-making
  • Testing not needed routinely for low-risk patients
  • Pathways for clinical decisions
  • Accompanying symptoms
  • Identify patients most likely to benefit from further testing
  • Noncardiac is in, atypical is out
  • Structured risk assessment

Recommendations for definitions categorize the words most commonly used by patients to describe their chest pain into groups that indicate a high or low probability of ischemia. Higher probability words include central, pressure, squeezing and left-sided; lower probability words include right-sided, tearing, sharp and fleeting.

The guideline identifies chest pain as the second-leading cause of adults presenting at emergency departments, but “only 5.1% will have an acute coronary syndrome (ACS) and more than half will ultimately be found to have a noncardiac cause.” Women experience chest pain more than men, and the guideline includes a focus on the uniqueness for women, older patients and diverse populations.

Lifestyle Coaching and Controlling BP Among Black Adults

At 24 and 48 months, LC participants achieved the highest BP control rates.

For Black adults with persistent hypertension, a telephone-based lifestyle coaching (LC) program based on a dietary approach is more successful than usual care (UC) or enhanced pharmacotherapy (EP) for improving long-term blood pressure (BP) control.

Effect of Lifestyle Coaching or Enhanced Pharmacotherapy on Blood Pressure Control Among Black Adults With Persistent Uncontrolled Hypertension: A Cluster Randomized Clinical Trial,” in JAMA Network Open, involved 1,761 participants (mean age 61, 68.9% women) with a BP of at least 140/90 mm Hg. Participants were assigned to 12-month interventions in one of three groups: UC, EP, or diet and LC.

Usual care involved free BP checks and reviews of current medications, while EP consisted of contact with a research nurse or pharmacist to discuss drug therapies and barriers to BP control. Lifestyle group participants received as many as 16 telephone coaching sessions with a registered dietician to help maintain a low-salt Dietary Approaches to Stop Hypertension (DASH) diet.

After 12 months, there were no significant differences in BP control rates among the three study groups. However, at 24 and 48 months, LC participants achieved the highest BP control rates:

  • 24 months: LC 72.4%, EP 67.6%, UC 61.2%
  • 48 months: LC 73.1%, EP 66.5%, UC 64.5%

“The LC intervention was feasible to implement in this high-risk population and was effective in helping these adults manage their chronic condition even 3 years after the intervention ended,” the study adds.

Conducted from June 2013 to June 2018, the study lists some limitations, including that all participants were members of an integrated healthcare delivery system (Kaiser Permanente Northern California) with pharmacy benefits and access to care. “Future research efforts should explore the implementation of this successful intervention in different clinical settings and populations,” the study notes.

Fluvoxamine Could Be New Tool Against COVID-19

Fluvoxamine would likely have to be effective against omicron to receive FDA approval.

Fluvoxamine shows a “high probability” for reducing hospitalizations among people with COVID-19.

Fluvoxamine for Outpatient Management of COVID-19 to Prevent Hospitalization: A Systematic Review and Meta-analysis,” in JAMA Network Open, examines data from three clinical trials involving 2,196 unvaccinated, symptomatic adults within six to seven days of infection. Each trial compared fluvoxamine, a selective serotonin reuptake inhibitor, with a placebo for efficacy against the virus.

“Under a variety of assumptions, we found the probability that fluvoxamine was associated with reduced hospitalization ranged from 94.1% to 98.6%, and the probability of moderate association ranged from 81.6% to 91.8%,” the study notes. Ongoing randomized trials will be important to evaluate fluvoxamine dosing levels and explore its effectiveness for vaccinated patients.

“Based on our analysis, and coupled with worldwide accessibility, decades of safety data, and a current price of approximately $1 per day, fluvoxamine may be a reasonable option for high-risk outpatients who do not have access to SARS-CoV-2 monoclonal antibodies, direct antivirals, or clinical trials,” the study adds. The medication also might be an outpatient treatment option, particularly in resource-limited settings.

A related article in Healthline points to the need for further investigation, noting that the clinical trials used in the meta-analysis took place before the rise of the omicron variant. Fluvoxamine would likely have to show effectiveness against omicron to receive FDA approval, the article suggests.

“This small benefit (from this study) may have seemed like especially good news before newer, highly effective therapies became available,” David Cutler, a physician at Providence Saint John’s Health Center in California, says in the article. “While fluvoxamine has an advantage of being inexpensive and a long safety record, it cannot deliver anywhere near the proven benefit of Paxlovid and the monoclonal antibodies.”

Teens and Fentanyls: Deadly Combination

Pills and powders have a very high risk of contamination.

Although teenage drug use is declining, overdose deaths have increased in recent years, which appears to be linked to illicit fentanyls and other synthetic opioid and benzodiazepine analogues.

Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021,” in JAMA: The Journal of the American Medical Association, notes that overdose deaths among youths ages 14 to 18 nearly doubled from 492 in 2019 to 954 in 2020. In 2021, overdose deaths increased another 20% to 1,146, with American Indian, Alaska Native, Latinx and white youths experiencing the highest rates.

According to the study, these deaths occurred despite a decline in overall adolescent drug use in 2021, when 18.7% of 10th graders reported using illicit drugs in the past 12 months. That figure was about 30% in both 2010 and 2020.

“In the context of decreasing adolescent drug use rates nationally, these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency,” the study notes, adding that fentanyls are often added to counterfeit pills that resemble prescription opioids.

Study data shows how fentanyl-involved fatalities have increased among U.S. adolescents:

  • 2010 – 38 deaths
  • 2019 – 253 deaths
  • 2020 – 680 deaths
  • 2021 – 884 deaths, or 77.14% of all adolescent overdose deaths

The trend highlights a need for “accurate harm-reduction education for adolescents and greater access to naloxone and services for mental health and substance use behaviors,” the study adds.

In a related article in NPR, lead study author Joe Friedman, University of California, Los Angeles, emphasizes the need to educate teens that some drugs are more dangerous than others.

“Alcohol and cannabis are not risk free, of course,” Friedman adds in the article. “But we know that those drugs have never been found to be contaminated with fentanyls, whereas pills and powders are at a very high risk of being contaminated.” Safety First: Real Drug Education for Teens is a “harm reduction-based drug education curriculum for high school students,” the article notes.

President’s Video: Starting Now: Renewed Hope

In the first video of her term, new AACN President Amanda Bettencourt introduces the new AACN theme, shares a powerful personal story, and encourages nurses to tell others their own stories.


Nurse Story: Integrating Travel Nurses on the Unit

As demand for travel nurses increases, both challenges and opportunities arise. Nurse leaders from a California medical center share their keys to orient and support travelers, and tips to set up units for a culture of teamwork and inclusion.