Clinical Voices June 2024

Jun 06, 2024

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In this issue, read articles on a bedside scan to detect PIs in all skin tones, oxygen level study for a long-term approach to care, 10 key points for care of patients with HF, and more. Plus, read a new nurse Q&A and Terry Davis' final President's Column.

Bedside Scan Detects Pressure Injuries in All Skin Tones

Daily SEM assessments reduced PIs by 100% during the study period.

Sub-epidermal moisture (SEM) assessment effectively detects early-stage hospital-acquired pressure injuries (HAPIs) regardless of skin tone, a finding that can help nurses intervene faster and reduce healthcare inequities for patients with darker skin.

Shedding New Light for Nurses: Enhancing Pressure Injury Prevention Across Skin Tones With Sub-epidermal Moisture Assessment Technology,” in JAN: Journal of Advanced Nursing, reports that daily SEM assessments reduced PIs by 100% during the study period in one hospital’s critical care unit in the District of Columbia.

The study recruited 140 adult patients from July to December 2022. Ninety patients received standard PI care assessments, and eight of them, who were African Americans with varying skin tones, developed HAPIs.

Subsequently, 50 patients, including 35 African Americans, received daily SEM assessments via a handheld device placed on their heels or sacrum. No incidents of PI occurred in the SEM group, the study notes, adding that patients receiving standard assessment had a 1.6 times greater risk of developing HAPIs.

Measuring changes in SEM can signal PIs and deep tissue injuries before signs are visible on the skin, the study adds. Eight staff nurses were taught to use SEM technology and to read and document the results. Implementing the technology can assist hospitals in meeting local and national standards of care for acute care patients, free up resources and achieve positive safety outcomes.

“For a population of dark skin tone patients who are chronically underserved, where it is hard to see early skin damage, the clinical utility of SEM assessments offers an opportunity to address health inequities,” the study adds.

Additional research should focus on using SEM technology across the hospital system, the study suggests. It would allow for large-scale data collection and analysis to determine how SEM assessments affect PI prevention and overall safety in a larger patient population.

Oxygen-Level Study Informs Long-Term Approach to Care

The study advances critical care by fostering a longitudinal vision for ICU-acquired morbidity.

The CO-PILOT study, which examined how varying oxygen levels impact cognition for mechanically ventilated patients, advances critical care medicine by encouraging clinicians to take a long-term approach to patients’ overall health and quality of life.

A New Era in Critical Care Trials: Linking ICU Practice to Long-Term Outcomes,” in American Journal of Respiratory and Critical Care Medicine, looks beyond physical health to assess the cognitive abilities of patients surviving acute respiratory distress syndrome (ARDS). These assessments strengthen evidence for decision-making that will benefit ICU practitioners, patients and their families.

CO-PILOT is the Cognitive Outcomes arm of Vanderbilt University’s large-scale PILOT (Pragmatic Investigation of Optimal Oxygen Targets) trial, which compared three arterial oxygen saturation (SpO2) targets – 90%, 94% and 98% – in ventilated patients. By 12 months, many patients enrolled in PILOT died, but 501 survivors completed the CO-PILOT assessments.

Results at 12 months show that oxygen-saturation targets were not associated with differences in cognition, disability, employment or quality of life. Specifically, median screening scores for long-term impairment were similar in the lower, intermediate and higher SpO2 groups.

Still, the study achieved several important findings relating to long-term outcomes:

  • Overall, reduced quality of life is common among survivors of mechanical ventilation: 42% were impaired at 12 months, and 66% of those were severely impaired.
  • Because median SpO2 values in the lowest target group were higher than intended – with values of at least 94% in each group – it remains unclear whether lower values such as 88% to 92% negatively affect cognition.

“Future studies enrolling patients with ARDS or conducted at altitude, where lower oxygenation levels are more common, could better address this important question.” In addition, while the CO-PILOT study examined several subgroups, including patients with cardiac arrest, other populations, such as those with sepsis, warrant further research, the article adds.

Deep Sedation Much More Common for Hispanic Patients

There’s an urgent need to understand and address disparities in sedation delivery.

Hispanic patients with acute respiratory distress syndrome are five times more likely to receive deep sedation than white patients, possibly due to language barriers, and it decreases their likelihood for survival.

Ethnic Disparities in Deep Sedation of Patients With Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial,” in Annals of the American Thoracic Society, notes that hospitals with at least one Hispanic patient were also likely to keep all patients deeply sedated longer than hospitals with no Hispanic patients. “There is an urgent need to understand and address disparities in sedation delivery,” the study adds.

The study reviewed data from 505 patients at 48 U.S. hospitals and found that over 90% were heavily sedated during their first five days of ventilation, with an average of 75% of the five days in deep sedation. The hospitals with at least one Hispanic patient had all patients sedated for 85.8% of ventilator days, compared with 65.5% for hospitals with no Hispanic patients.

Although no definite explanation for the differences could be isolated, the increased risk for a significant population group suggests the need for deeper understanding of the causes. “Given the widespread use of deep sedation we found in the study, this is an opportunity to improve sedation for everyone, but there is clearly a greater need to improve sedation for Hispanic patients because of what we know about disparities in their outcomes, notes study co-author Thomas Valley, University of Michigan, in a related article in HealthDay.

AACN resources on reducing barriers to care include the following:

Effective Intervention for Clinical Deterioration

Regression discontinuity provides an alternative method to analyze effectiveness.

Interventions prompted by an artificial intelligence (AI) model to prevent clinical deterioration were associated with improved outcomes.

Effectiveness of an Artificial Intelligence-Enabled Intervention for Detecting Clinical Deterioration,” in JAMA Internal Medicine, notes that a machine learning model produced a 10.4% absolute risk reduction in activation of a rapid response team, transfer to intensive care, or a cardiopulmonary arrest during hospitalization. “These results provide evidence for the effectiveness of this intervention and support its further expansion and testing in other care settings,” the study adds.

Using the Epic Deterioration Index (EDI) with a threshold score of 65.0 to define high risk of deterioration, the study analyzed a cohort of 9,938 patients hospitalized at a single-site academic center, with 963 patients meeting the target range within 7 points of the threshold. In addition to the primary outcome risk reduction, the study estimates a 7% reduction for a secondary outcome, which includes inpatient death as well as the three primary outcomes.

The study measured EDI scores as part of the intervention package that included the collaborative workflow for physicians and nurses to make contingency plans in the event the patient had further deterioration. “Our analysis does not attempt to identify and qualitatively assess which components of this workflow led to improved outcomes, only that the intervention as a whole was associated with improved outcomes.”

Because randomized clinical trials can be difficult to develop in testing a machine learning model in care delivery, the study explains why regression discontinuity provides an alternative method to analyze effectiveness. “This analysis method can be used by health systems that may not have the infrastructure or capacity to assess effectiveness in a randomized clinical trial of their own implementation of an early warning score.”

10 Key Points for Care of Patients With Heart Failure

The pathway aims to streamline care to effect the best outcomes for patients with HF.

Updated guidance provides clinicians with 10 practical strategies to treat patients with heart failure (HF) with reduced ejection fraction (HFrEF).

“2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee,” a 2024 expert consensus decision pathway (ECDP), in JACC: Journal of the American College of Cardiology [ACC], notes that cases of HF are projected to rise by 34% in coming decades. The recommendations and supporting tables reflect advancements since the previous guideline was published in 2021.

“Important breakthroughs have redefined opportunities to change the natural history of HF with a broad range of medical therapies, devices and care strategies,” the article notes.

As in the 2021 version, the update provides 10 points for optimal HFrEF management, notes a related article from ACC:

  1. Initiate, add or switch therapies with consideration of evidence-based, guideline-directed treatments for patients with HFrEF.
  2. Achieve the best possible drug therapy, including the use of clinical assessments, such as imaging tests, biomarkers and heart-filling pressures.
  3. Determine when to refer patients to an HF specialist.
  4. Enhance care coordination using a multidisciplinary, team-based approach.
  5. Improve adherence to HF therapies by considering the needs of individual patients.
  6. Tailor therapies to specific cohorts, such as Black patients, older adults and patients with frailty.
  7. Pursue strategies to reduce patients’ costs and increase access to HF medications.
  8. Assess and address social determinants of health that contribute to the increasing complexity of HF.
  9. Manage common comorbidities that impact patients with HF, such as diabetes, chronic kidney disease and sleep-disoriented breathing.
  10. Integrate palliative care support and contribute to decision-making by identifying goals, emphasizing quality of life and planning for transition to hospice care.

“Many opportunities to improve patient outcomes are being missed; hopefully, this ECDP will streamline care to realize the best possible patient outcomes in HF (heart failure),” the article adds.

Copatient Illness Severity and ICU Nurse Workload Add Risk

Matching nurses with patients based on illness severity or using 1:1 ratios in certain situations may help.

Patients assigned to intensive care nurses who were also treating more severely ill copatients requiring mechanical ventilation and/or vasoactive support had an increased risk of mortality.

“Association Between Nurse Copatient Illness Severity and Mortality in the ICU,” in Critical Care Medicine, suggests that even a 1:2 nurse-to-patient ratio could still be considered unsafe when one patient requires significantly more of the nurse’s time than the other. “Future work should focus on developing a better understanding of the relationship between copatient illness severity and patient outcomes to inform decision-making around nursing assignments and ultimately improve patient care in the ICU by mitigating the negative effects of workload,” adds the retrospective, cohort study.

Using data on 29,563 patients across 147,183 12-hour shifts at 24 ICUs at eight hospitals in one health system, researchers developed a primary cohort of patients with 1:2 or 1:3 nurse-to-patient ratios throughout their stay and secondary cohorts of patients with 1:2 ratios and patients with 1:1, 1:2 and 1:3 ratios. The vast majority of shifts were staffed at 1:2 in each cohort.

Compared with index patients whose copatient received neither mechanical ventilation nor vasoactive support, patients had a significantly higher 28-day mortality risk with a copatient requiring both (hazard ratio 1.30) or requiring vasoactive support only (hazard ratio 1.82). Risk did not increase significantly with a copatient on mechanical ventilation only.

The study theorizes that respiratory therapists might reduce nurses’ care of mechanically ventilated patients. “We suspect that this discrepancy arises from the relatively time-consuming nature of providing continuous intravenous drips for patients with hemodynamic instability, which places additional demands on nurses.”

The study suggests strategies such as matching nurses with patients based on severity of illness or limiting nurses to 1:1 ratios for certain patients. “Ultimately, policies may be needed to expand the pool of ICU nurses more aggressively, enabling more staffing flexibility.”

AACN resources for best practices in matching patient needs with nurses who are competent to care for them include the following:

President’s Column: Continuing the Journey

In the final column of her term, AACN President Terry Davis encourages nurses to be open to change and collaboration and to bridge generational gaps on our continuing journey. “To mentor the next generation of nurses is a fundamental role we must play … Our profession depends on it.”

Read the Column

Making a Change Through Well-Being

A nurse scientist and a patient safety director have worked together on well-being initiatives in their hospital system. And now they’re part of the National Academy of Medicine Change Maker Campaign for Health Workforce Well-Being. In this Q&A, read how they are helping nurses and sparking a national movement to support clinician well-being.

Read the Q&A