Clinical Voices June 2023

Jun 07, 2023

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In this issue, read about how pediatric mental health is the top safety concern for 2023, the benefits of a liberal fasting policy, less accuracy in stroke predictors for Black adults, and more. Plus, read a new President’s Column and a conversation with four nurses.

Pediatric Mental Health Leads Safety Concerns

Consider any possible patient safety concerns in your organization.

Anxiety and depression among children — exacerbated by the pandemic and other factors — top ECRI's annual list of safety risks for patients and healthcare workers.

"Top 10 Patient Safety Concerns 2023: Special Report," on, estimates that 4.0% of children ages 3 to 17 years experienced depression in 2020 while 9.2% had anxiety; rates for both conditions are rising steadily. Compared with 2016, anxiety in this age group increased 29% and depression rose 27%.

Prepared by ECRI and its affiliate, the Institute for Safe Medication Practices, the report includes stressors linked to delivering care during the pandemic and a challenging political climate.

Following is the list for 2023, as also noted in a related ECRI blog:

  1. "The pediatric mental health crisis
  2. Physical and verbal violence against healthcare staff
  3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine
  4. Impact on clinicians expected to work outside their scope of practice and competencies
  5. Delayed identification and treatment of sepsis
  6. Consequences of poor care coordination for patients with complex medical conditions
  7. Risks of not looking beyond the 'five rights' to achieve medication safety
  8. Medication errors resulting from inaccurate patient medication lists
  9. Accidental administration of neuromuscular blocking agents
  10. Preventable harm due to omitted care or treatment"

This year's issues are heavily influenced by the No. 1 concern on the 2022 list - staffing shortages. "Staffing shortages continue to plague healthcare and are contributing to challenges related to the pediatric mental health crisis, violence against healthcare staff, mismatches between assignments and competencies, and missed care treatment."

The blog includes four recommendations from the National Steering Committee for Patient Safety:

  • "Cultivating leadership, governance, and cultures that reflect a deep commitment to safety
  • Engaging patients and families as partners in designing and producing care
  • Fostering a healthy, safe, and resilient environment for the workforce
  • Supporting continuous and shared lessons learned to improve safety and quality of care and reduce the risk of harm."

Benefits of Liberal Fasting Policy

A liberal fasting policy was associated with improved patient outcomes.

A quality improvement study says that a liberal fasting policy is associated with improved patient outcomes.

Association of a Liberal Fasting Policy of Clear Fluids Before Surgery With Fasting Duration and Patient Well-being and Safety," in JAMA Surgery, notes that the study was conducted from January 2016 to July 2021 at University Medical Center Utrecht, in the Netherlands. Participants were composed of adult patients scheduled for nonemergency surgery with anesthesia. Any patients undergoing obstetric procedures or those who were intubated before their surgery were not included.

Standard fasting guidelines recommend that adults abstain from solids for six hours and from clear fluids two hours before receiving anesthesia. Patients could also take 1 g of acetaminophen with a sip of water from one hour to 15 minutes before anesthesia.

For the liberal fasting policy, patients could drink clear liquids until they arrived in the operating room. The maximum amount was one glass per hour, with acetaminophen if needed, but no solid food for six hours before surgery. Of the 76,451 total patients (mean age 56 years), 78% followed the standard policy, and 22% used the liberal fasting policy.

"Patients who participated in the new policy also reported decreased thirst (from 46% to 37%), decreased postoperative nausea and vomiting (PONV, from 10.6% to 9.4%) and a decrease in antiemetic administration during recovery (from 11% to 9.5%)," adds a related article in MedPage Today.

However, the incidence of aspiration increased from 1.7 to 2.4 per 10,000 cases during implementation, and regurgitation increased from 18 to 24 per 10,000.

"Although a slightly higher incidence of regurgitation could not be ruled out, wider implementation of such a policy may be advocated as results are still within the clinically accepted risks margins. Results suggest that surgical procedures in patients who drink clear fluids within 2 hours before anticipated anesthesia should not be postponed or canceled," the study notes.

Stroke Predictors Less Accurate for Black Adults

Better data collection and including more risk factors could improve assessments.

Existing and new machine learning algorithms for identifying the future risk of strokes were less accurate for Black study participants than white ones.

"Predictive Accuracy of Stroke Risk Prediction Models Across Black and White Race, Sex, and Age Groups," in JAMA: The Journal of the American Medical Association, notes that common risk algorithms and advanced machine learning did not outperform existing cohort equations, with the Reasons for Geographical and Racial Differences in Stroke (REGARDS) self-reporting model proving the most accurate.

"All algorithms exhibited worse discrimination in Black individuals than in white individuals, indicating the need to expand the pool of risk factors and improve modeling techniques to address observed racial disparities and improve model performance," adds the retrospective study.

The study included 62,482 adults ages 45 and older who had no stroke history at the onset of the original studies, followed by a 10-year evaluation period. The discrimination concordance index for all models was 0.76 for white women compared with 0.69 for Black women, and from 0.71 to 0.72 for white men compared with 0.64 to 0.66 for Black men.

Study author Michael Pencina, Duke University School of Medicine, says in a related article in Healio that some risk factors might not be captured and suggests that better data collection and a larger number of included risk factors could improve the assessments. "For example, the algorithms tested here generally do not account for social determinants of health and some other factors suggested in Stroke Prevention Guidelines."

Pencina adds in the article that artificial intelligence might not be as efficient or as cost-effective for stroke prevention as gathering more basic data; noting the strength of the self-reporting REGARDS tool. "It suggests a need to go out into patient communities, listen, learn, and allow that knowledge to shape our health care tools of tomorrow."

Potential Interventions for Noncommunicative Intubated Patients

The observation scale seems to detect and monitor respiratory difficulties reasonably well.

A small clinical trial to determine if the Mechanical Ventilation - Respiratory Distress Observation Scale (MV-RDOS) can detect dyspnea in noncommunicative intubated patients shows that some therapeutic interventions may help.

In "Interventions Relieving Dyspnea in Intubated Patients Show Responsiveness of the Mechanical Ventilation - Respiratory Distress Observation Scale," in American Journal of Respiratory and Critical Care Medicine, nonverbal patients with breathing difficulties during mechanical ventilation received either ventilator adjustments or morphine administration to relieve their distress. "Our study shows that MV-RDOS can contribute to identify respiratory suffering in mechanically ventilated patients and to evaluate the effects of relieving interventions," the trial notes.

Conducted with 50 patients (ages 61-76) at a single site in Paris, the trial also provided the relief given to 25 communicative patients to 25 noncommunicative patients and measured the biomarker outcomes with MV-RDOS to determine effectiveness. In the noncommunicative patients, MV-RDOS decreased from 5.5 at baseline to 4.2 after ventilator adjustments and 2.5 following morphine dosage.

"Despite the study limitations, we therefore believe that MV-RDOS can become a valuable tool for doctors and nurses to better help their mechanically ventilated patients achieve respiratory comfort in routine care," the trial adds. "We also believe that MV-RDOS can become a useful outcome for interventional trials testing pharmacological or nonpharmacological interventions with this particular objective."

Limitations include the small cohort population as well as potential variability in clinicians' ability to detect physiological factors such as neck muscle contraction or facial expressions similarly, and noncommunicative sedated patients could still be experiencing undetected distress.

The trial also notes the risks in increasing ventilator pressure to a level of over-assistance, the potential for patient injury and other adverse effects and using opioids as a safer option should be considered for a future clinical trial.

Rapid Blood Test to Detect Mild TBI

The new lab test offers results in about 18 minutes.

The Food & Drug Administration (FDA) cleared a blood lab test that runs on standard hospital equipment and can quickly detect evidence of mild traumatic brain injury (TBI).

Abbott Laboratories announced in a news release that its Alinity i TBI lab test received FDA clearance that will make concussion testing more available, because the test operates on the same Alinity i equipment already in use at hospitals and labs across the U.S. The test for two blood biomarkers correlated to brain injury can rule out the need for a CT scan, potentially providing significant cost savings in addition to offering clinicians a rapid tool for diagnosing and triaging patients.

A negative result on the rapid blood test can potentially replace the use of the 15-point Glasgow Coma Scale, subjective clinical assessment or a CT scan, according to an FDA news release announcing its original approval.

Abbott's release says its test for elevated concentrations of Ubiquitin C-terminal Hydrolase L1 (UCH-L1) and Glial Fibrillary Acidic Protein (GFAP) has 96.7% sensitivity and a 99.4% negative predictive value.

"People sometimes minimize a hit to the head, thinking it's no big deal," Beth McQuiston, medical director of Abbott's diagnostics business, notes in the news release. "Others wonder if a visit to the doctor or emergency room for a possible concussion will provide them with meaningful answers or care.

"Now that this test will be widely available in labs across the country, medical centers will be able to offer an objective blood test that can aid in concussion assessment."

Methylene Blue Improves Septic Shock Outcomes in Trial

The medication was not associated with any serious adverse effects.

For patients with septic shock, initiating methylene blue (MB) within 24 hours reduces vasopressor duration and time spent in the ICU and in the hospital without any severe adverse effects.

"Early Adjunctive Methylene Blue in Patients With Septic Shock: A Randomized Controlled Trial," in Critical Care, also finds that compared with placebo, MB administration increased patients' vasopressor-free days, while mortality and days on a mechanical ventilator were similar.

Conducted in Mexico, the single-center study assigned 45 adults with septic shock, defined by Sepsis-3 criteria, to receive three infusions of 100 mg of MB beginning within 24 hours of diagnosis, while another 46 patients were assigned to placebo. Patients' median age was 46 years, 60% were men, and 46% presented with acute kidney injury.

For the MB group, median time to vasopressor discontinuation, the primary outcome, was 69 hours compared with 94 hours for the control group. In addition, patients in the MB group had one more vasopressor-free day at 28 days of follow-up, along with 1.5 fewer ICU days and 2.7 fewer days in the hospital.

"The most common adverse effect was green-blue discoloration of urine in 42 of 45 (93%) patients in the MB group," the study adds.

Limitations include the fact that patients in the Mexico center typically have shorter ICU/hospital stays than those in larger multicenter trials. "Thus, a different effect of MB on length of stay in other settings cannot be ruled out."

Still, the study concludes that MB's safety profile, wider availability and lower cost than other catecholamine-sparing agents could make it a viable therapy. "The clinical implications of our results might shift the current understanding of MB as a rescue therapy to an adjunctive one at earlier stages of the disease," the study notes, adding that the findings support future research in larger clinical trials.

President's Column: Starting Now: A Revolutionary Shift

In the final message of her term, AACN President Amanda Bettencourt urges us to participate in a "collective act of ethical visualization," like our country's founders. "This is the start of a revolution of hope. Hope that we can crack open many of the fundamental principles of our current healthcare system, because it needs to look so different from what we have now."

Read Now

Nurse Story: Celebrating Diversity in Nursing

We interviewed four nurses to discuss their journeys of embracing their differences and improving the lives of patients and families. Celebrate their stories with us.

Read Their Stories