Clinical Voices June 2021

Jun 01, 2021

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This month we explore six clinical topics, including the ABCDEF bundle, early tracheostomy and pediatric TBI, plus the President’s Farewell Column and an enlightening Nurse Story.

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Low Bundle Use During Pandemic

The study suggests using specific evidence-based protocols to improve patient outcomes during a pandemic.

"ABCDEF Bundle and Supportive ICU Practices for Patients With Coronavirus Disease 2019 Infection: An International Point Prevalence Study," in Critical Care Explorations, notes that overall bundle delivery rates were lower than those in prevalence surveys conducted before the pandemic. To facilitate better care, the study suggests implementing specific evidence-based protocols. It also hypothesizes that admitting patients with COVID-19 to higher-capacity ICUs may provide benefits because of access to more experienced staff and structured protocols in caring for these patients.

Led by the Japanese Society of Intensive Care Medicine, the study involved 212 ICUs in 38 countries on June 3 and July 1, 2020. ABCDEF bundle implementation and other elements of care were assessed for 262 patients with COVID-19. “Clinicians in each participating ICU completed web-based online surveys,” the study adds.

Among the findings:

  • More patients received bundle elements A (regular pain assessment) and C (regular sedation assessment) in ICUs with protocols for pain and sedation management.
  • In ICUs with more beds assigned exclusively to patients with COVID-19, elements A (regular pain assessment) and D (regular delirium assessment) were less frequent, but element E (early mobility and exercise) and nutrition therapy were more frequent.
  • The relationship between nurse-to-patient ratio and bundle implementation was mixed, leading the study authors to suggest that distributing resources based on “clinical needs might be critical to the implementation of evidence-based supportive care in the ICU.”
  • ICU diaries were used for only 25% of patients.

“The findings of this study call for urgent efforts to incorporate the ABCDEF bundle into routine clinical practice, especially as many countries are dealing with a second wave of COVID-19 infections,” the study notes, adding that serious disabilities and symptoms that persist after infection raise concerns about the long-term outcomes of COVID-19-induced post-intensive care syndrome.

Early Tracheostomy Placement May Benefit Patients on Ventilators

The analysis shows lower VAP risk, fewer total ventilator days and fewer total ICU days.

Critically ill adults had improved outcomes when they received a tracheostomy placement within seven days of ventilator support.

According to "Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients," a meta-analysis of 17 clinical trials in JAMA Otolaryngology - Head & Neck Surgery, early tracheostomy placement was associated with lower rates of ventilator-associated pneumonia (VAP), fewer total ventilator days and fewer total ICU days. “These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation,” the analysis adds.

In the trials studied, which involved 3,145 critically ill adult patients, those with early tracheotomy had a 40% reduction in the risk of VAP, averaged 1.7 fewer ventilator days and averaged 6.3 fewer ICU days. No significant differences in patient mortality were noted.

Although no patients in the meta-analysis were COVID-19 positive, a related article in says more recent “studies have demonstrated that tracheotomy can be safely done in a negative pressure room, with proper personal protective equipment, sedation of the patient and frequent suctioning of the site.”

The related article adds that the timing of tracheostomy placement has yet to be studied for patients with COVID-19, but “different professional societies now state that COVID-19 patients should be considered like other patients.”

Children With TBI May Need Regular Functional Reassessment

Trajectories for recovering executive function may vary over time.

Children with traumatic brain injury (TBI) have different patterns of executive function (EF) recovery for three years post-injury, suggesting the need for multiple reassessments for possible interventions.

According to "Trajectories of Children’s Executive Function After Traumatic Brain Injury," in JAMA Network Open, functioning worsened at each evaluation point but most sharply from injury to 12 months and then again from 24 to 36 months for some subgroups. “In this longitudinal cohort study of children with TBI, trajectory analysis revealed that some children worsen after a recovery plateau, suggesting a need for longitudinal reassessment beyond 1 year postinjury,” the study notes.

Conducted from 2013 to 2015 at two U.S. children’s hospitals, the study included 559 children across a three-year follow-up period and compared outcomes of TBI patients with those of children who had orthopedic injuries. “Among children with severe TBI, trajectories accelerated fastest, indicating increased problems, from injury to 12 months” in the subscales measuring Emotional Control, Inhibit and Working Memory, the study finds, “with a secondary acceleration before 36 months for the Emotional Control and Working Memory subscales.”

Follow-up assessments using the Behavior Rating Inventory of Executive Function (BRIEF) or BRIEF-Preschool were conducted with parents at three, 12, 24 and 36 months to evaluate the trajectories. Children at all levels of severity and development were unlikely to recover fully to preinjury functioning. “Across the TBI severity spectrum, children’s development of EF should be monitored,” the study adds.

“Results further suggest that children with TBI may struggle over time as tasks become more complex, leading to a need for reassessment and different supports to improve participation in the school, home and community,” adds Heather Keenan, University of Utah, in a related article on

Job-Related Nurse Suicides: Time for Changes

The analysis suggests a significantly increased suicide risk for nurses.

Nurses who experience job loss due to substance abuse, mental health issues or chronic pain are at risk for suicide, notes an analysis that calls for improved measures to identify and help prevent work-related struggles.

The National Suicide Prevention, Lifeline, 800-273-8255, offers free and confidential support for you or someone else, and is available 24 hours a day, seven days a week.

"Job-Related Problems Prior to Nurse Suicide, 2003-2017: A Mixed Methods Analysis Using Natural Language Processing and Thematic Analysis," in Journal of Nursing Regulation, finds that most job issues prior to suicide involve loss of employment or license. However, the analysis of 203 nurse suicides also suggests “the events leading up to job loss are largely modifiable.”

Also, “alternative-to-discipline programs for nurses with substance use disorder need to be improved and standardized,” the analysis notes. “Earlier or more complete treatment for mental illness may help prevent suicide in this population.”

In a related article in MedPage Today, lead study author Judy Davidson, nurse scientist at University of California San Diego, says the key takeaway is that suicide prevention measures should be taken when nurses are laid off or terminated.

“We need to change the way we dismiss people from the workplace and even consider should they be dismissed or,” if there’s a health issue, “should they be treated before dismissal,” Davidson notes in the article. Suicide prevention, she adds, should be part of treatment for substance use disorders.

Female nurses in the United States are at particular risk, with a suicide rate about twice as high as that for other women, according to a study noted in Medical Express.

"Association of US Nurse and Physician Occupation With Risk of Suicide," in JAMA Psychiatry, compares suicide rates for people ages 30 or older using data from 2017-2018. For female nurses, the rate per 100,000 was 17.1 compared with 8.6 for women in the general population. Suicides rates for male nurses were nearly equal to other men at 31.1 (nurses) and 32.6 (general population).

App With Free Communication Tools for Healthcare Providers

An app offers free resources to enhance health communication.

COMFORT Communication, an app designed to improve communication in healthcare and palliative care, offers clinicians free training and resources.

The app and resources use the COMFORT model as the structure, with a module devoted to each letter in the acronym — Connect, Options, Making meaning, Family caregiver, Openings, Relating and Team — with a specific focus. A separate COVID-19 module provides tools for effective communication with patients and families, including self-care for clinicians.

Tools in the app modules provide communication examples using simple language and questions that healthcare professionals and students can use to elicit helpful answers. Modules also cover areas such as listening, nonverbal communication, patient education, palliative care and working with team members.

The COVID-19 module includes simple terminology for clinical phrasing, topics on patient- and family-centered care, addressing limited resources, telehealth and provider self-care. Cards within each topic offer essential areas of communication and possible responses to certain questions.

The resources also include guides for nursing faculty and professional organizations to incorporate the COMFORT model. A Family Caregiver Communication Typology offers unique strategies for communicating with different family caregiver types to determine the best interventions, primarily for patients with cancer.

DOACs May Benefit Patients With Valvular AF

New users of DOACs had lower risks for ischemic stroke or systemic embolism.

A retrospective study finds that patients with valvular atrial fibrillation (AF) who are new users of direct oral anticoagulants (DOACs) were less likely to experience stroke, systemic embolism or major bleeding than new warfarin users.

"Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation," in Annals of Internal Medicine, notes that “in this comparative effectiveness study using practice-based claims data, patients with valvular AF who were new users of DOACs had lower risks for ischemic stroke or system embolism and major bleeding than new users of warfarin. These data may be used to guide risk-benefit discussions regarding anticoagulant choices for patients with valvular AF.”

Reviewing the case history of 56,336 patients from January 2010 to June 2019 who were newly prescribed either DOACs or warfarin, the study finds 787 DOAC patients had an ischemic stroke or systemic embolism in the follow-up period, compared with 1,211 taking warfarin, for a hazard ratio of 0.64. Major bleeding occurred in 1,465 patients taking DOACs, compared with 2,155 warfarin users, for a hazard ratio of 0.67.

The new-user study also compared four different DOAC medications. Apixaban and rivaroxaban achieved consistent outcomes for effectiveness and safety. For dabigatran, “results were consistent for the major bleeding outcome … but not for effectiveness.”

A related article in 2 Minute Medicine notes that the differences in effectiveness and safety outcomes “persisted across subgroups defined by age, sex, cancer, abnormal coagulation, and type of valvular heart disease.” The article also indicates the study was “limited by the lack of data regarding the concomitant use of over-the-counter drugs and the severity of valvular disease.”

President’s Column: Healing and Wise Hope

In her farewell column, AACN President Elizabeth Bridges delves into the healing power of storytelling and returning from her deployment to Afghanistan in 2009. Today, many nurses don’t want to look back over the past year. But Bridges wonders, “If we don’t talk about it and process it, can we truly move forward?"

Read Her Story

Nurse Story: A Transition to Find Herself

Ashley Anderson, a critical care nurse, recently underwent gender confirmation surgery in the final phase of her transition from male to female. Ashley discusses her experience, offers insights for caring for transgender patients and shares why visibility for transgender nurses is important to her..

Read Her Story

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