Clinical Voices March 2023

Mar 10, 2023

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This issue, read about a patient acuity tool that leads to appropriate staffing and better care, balanced IV solutions and serum chloride in PICU, skeletal muscle mass declines daily in ICU, and more. Plus, read a new story on certified nurses.  

Nurse-Driven Scoring System Rates Patient Acuity

The tool rates patient acuity as low, moderate or high in various categories of care.

A nurse-driven patient acuity tool (PAT) implemented in a 20-bed progressive care unit accurately accounts for nurse workload, leading to appropriate staffing ratios, improved nurse satisfaction and better patient care.

A New Patient Acuity Tool to Support Equitable Patient Assignments in a Progressive Unit,” in Critical Care Nursing Quarterly, reports that a Detroit-based hospital unit specializing in pulmonary medicine developed the tool after an assessment using the application template for AACN’s Beacon Award for Excellence. The assessment provided insight into the unit’s structure, patient population, staff interaction and workload challenges.

The PAT rates patient acuity as low, moderate or high in various categories of care. Responses from a nurse survey led to creating and piloting the scoring system, which was revised several times based on staff feedback. Nurses complete the PAT by circling items that apply to the patient and totaling the score. Charge nurses use the information to create the next shift’s assignments.

“Overall, the PAT appeared to have enhanced nurses’ satisfaction and perceptions of nurse-patient assignment equity,” the study notes. “The tool was also believed to be an accurate representation of the patients’ acuity, much more so than the previous tool that was in use.”

The study lists several limitations, including the PAT not being embedded in the electronic medical record platform, meaning that all calculations are done by hand.

“Implications for future studies include the need to conduct a longitudinal study to determine the tool’s impact on missed nursing care, a comparison with the embedded electronic acuity tool, the impact of the PAT on workload and staffing ratios, and potential impact on hospital-acquired conditions.”

Balanced IV Solutions and Serum Chloride in PICU

The clinical trial included 516 patients younger than 16 at a center in Australia.

Patients in a pediatric intensive care unit (PICU) who required intravenous (IV) fluids were less likely to develop increases in serum chloride when treated with balanced solutions.

Effect of Saline vs Gluconate/Acetate-Buffered Solution vs Lactate-Buffered Solution on Serum Chloride Among Children in the Pediatric Intensive Care Unit,” in JAMA Pediatrics, notes that children receiving gluconate/acetate-buffered solution or lactate-buffered solution had significantly lower rises in serum chloride in the first 48 hours of therapy than those receiving saline.

The clinical trial included 516 patients younger than 16 (median age 3.8 years) at a center in Australia between November 2019 and April 2021. The children requiring IV therapy received one of the three solutions randomly, and they were assessed for a primary outcome of a serum chloride rise of 5 mEq/L or more from baseline within 48 hours of randomization.

Of the 178 children receiving gluconate/acetate-buffered solution, 37 patients (25.2%) experienced an increase; of the 171 receiving a lactate-buffered solution, 34 patients (23.9%) had an increase; and of the 167 in the 0.9% saline group, 58 patients (40.0%) showed an increase.

A secondary outcome of “new-onset acute kidney injury was observed in 10 patients (6.1%), 6 patients (3.7%), and 5 patients (3.2%) in the gluconate/acetate-buffered solution, lactate-buffered solution, and saline groups, respectively,” the study notes, and there were no significant differences in length of stay or post-ICU survival. “The odds of a rise in plasma chloride 5 mEq/L or more was halved with the use of gluconate/acetate-buffered solution compared with saline.”

A related article in Physician’s Weekly adds that the findings could be affected by IV fluids administered before randomization. “The relative clinical significance of hyperchloremia is also not entirely clear, although a previous retrospective study linked a 5 mEq/L serum chloride increase in critically ill children with significantly increased adjusted odds of mortality.” It adds that “though further study using clinical outcomes would provide additional value, this study supports the increasingly common use of buffered solutions over saline in the PICU setting.”

Skeletal Muscle Mass Declined 2% Daily in ICU

The review used data from 3,251 patients across 52 studies that met the selection criteria.

A review of studies involving ICU patients determined they lost an average of 2% of skeletal muscle mass a day during the first week of ICU admission.

The Rate and Assessment of Muscle Wasting During Critical Illness: a Systematic Review and Meta-Analysis,” in Critical Care, describes a literature review of ICU-acquired loss of muscle mass, finding that patients lost -1.75% of rectus femoris thickness and -2.10% of the rectus femoris cross-sectional area on average each day in the ICU. In 85% of the studies, clinicians used ultrasound to assess muscle mass, and in 15% they used computed tomography.

The review incorporated data from 3,251 patients across 52 studies that met the selection criteria, which included having at least 20 critically ill adult patients measured for a muscle-mass variable at least twice daily. The included studies measured the rate of muscle wasting in 1,773 (55%) of patients and assessed ICU-acquired muscle weakness in 1,478 (45%) of patients.

The review shows that quadriceps muscle thickness decreased by -1.82% daily, biceps brachii muscle cross-sectional decreased by -2.23%, and the biceps brachii thickness decreased -1.64%. Overall, ICU-acquired weakness was noted in 48% of patients.

AACN offers many resources on early mobility, including a CE article on early mobility interventions and an article in Critical Care Nurse on implementing an interdisciplinary protocol.

Resources from AACN’s Clinical Scene Investigator Academy include projects related to an early mobility protocol, early progressive mobility in the ICU and implementing an early mobility program.

Ebola Virus Vaccines Safe and Effective

Adverse effects, including injection-site reactions, were largely low grade.

Three Zaire Ebola virus disease (EVD) vaccine strategies elicited immune responses lasting at least 12 months, with no safety concerns for adults and children in four West African nations.

Randomized Trial of Vaccines for Zaire Ebola Virus Disease,” in The New England Journal of Medicine, finds that immunity began by day 14 after the initial vaccine injection. Adverse effects, including injection-site reactions, were largely low grade.

Conducted by the Partnership for Research on Ebola Vaccinations consortium, the vaccine trial involved 1,400 adults (ages 18 and older) and 1,401 children (ages 1 to 17) in Guinea, Sierra Leone, Liberia and Mali from April to December 2018. Participants were randomly assigned to one of four study groups:

  • Ad26.ZEBOV vaccine with MVA-BN-Filo vaccine 56 days later (Ad26-MVA group)
  • rVSVΔG-ZEBOV-GP vaccine with placebo 56 days later (rVSV group)
  • rVSVΔG-ZEBOV-GP vaccine with booster dose 56 days later (rVSV-booster group)
  • Saline placebo

At 12 months, antibody responses significantly favored the three active vaccines:

  • Ad26-MVA: 41% adults, 78% children
  • rVSV: 76% adults, 87% children
  • rVSV-booster: 81% adults, 93% children
  • Placebo: 3% adults, 4% children

Noting the higher immunity responses among children, the study notes: “Our results regarding the safety of these vaccines have implications for the use of Ebola vaccines in children. Although the Ad26-MVA regimen has received marketing authorization for persons 1 year of age or older from the European Medicines Agency, the licensing of the rVSVΔG-ZEBOV-GP vaccine has thus far been limited to adults.”

A related article in 2 Minute Medicine notes the study is limited by an inability to evaluate protection from disease or to identify a correlate of protection. “Nevertheless, these study’s findings are significant, as they demonstrate that vaccines for the prevention of EVD are efficacious in eliciting an immune response and have no reportable safety concerns,” the article adds.

Long COVID Outcomes at One Year

The study used data from non-hospitalized patients with positive PCR tests.

Long COVID symptoms in patients with mild initial cases lingered for several months, but most symptoms were normal within a year after the initial infection.

Long COVID Outcomes at One Year After Mild SARS-CoV-2 Infection: Nationwide Cohort Study,” in BMJ, finds a significant association with increased risks in the short and long term for many common symptoms. “Although the long COVID phenomenon has been feared and discussed since the beginning of the pandemic, we observed that most health outcomes arising after a mild disease course remained for several months and returned to normal within the first year,” notes the retrospective study.

The study used data for non-hospitalized patients with positive PCR tests between March 2020 and October 2021, from a nationwide Israeli healthcare organization that includes about a quarter of the country’s population in all cross-sections, with 1.9 million patients of all ages and groups of vaccinated and unvaccinated patients. The study captured 70 symptoms based on medical codes and looked for new and recurring events, and the length of time receiving the diagnosis.

Using monthly hazard ratios, symptoms such as labored breathing, weakness and loss of taste or smell persisted throughout the year, and others such as coughing declined by the fourth month. Patients ages 41-60 had the most long COVID outcomes that were significantly elevated within the year after infection.

In addition, “our findings suggest that mild COVID-19 in vaccinated people was significantly associated with reduced risk for dyspnea compared with unvaccinated patients up to three months after infection,” the study notes.

AACN resources on long COVID include blog posts on a patient’s journey, emerging evidence and management, and ICU survivors.

Substance Use: A Risk Factor for Atrial Fibrillation

The study showed a pattern of increased incident AF rates associated with substance use.

Use of methamphetamine, cocaine, opiates or cannabis increases the chances of developing incident atrial fibrillation (AF), but efforts to reduce substance use could be a new approach to AF prevention.

Cannabis, Cocaine, Methamphetamine, and Opiates Increase the Risk of Incident Atrial Fibrillation,” in European Heart Journal, reports that methamphetamine presents the highest risk for developing incident AF among the four substances. Next were opiates, followed by cocaine and cannabis.

The analysis involved more than 23.5 million California adults receiving care in emergency departments, outpatient surgery sites or hospitals from January 2005 through December 2015. Of that population, 998,747 patients (4.2%) developed incident AF during the study period.

Among the more than 23.5 million patients, substance use was reported as follows:

  • Cannabis users– 132,834
  • Methamphetamine – 98,271
  • Cocaine – 48,701
  • Opiates – 10,032

After adjusting for conventional AF risk factors, such as age, race, hypertension, diabetes, coronary artery disease and others, the study determined a pattern of increased incident AF rates associated with substance use.

“Our work supports the continued medical and community efforts aimed at reducing substance abuse and shows that these efforts may have the potential to reduce long-term cardiovascular complications associated with AF,” the study adds.

Noting a rise in recreational cannabis use in the United States due to legalization, the study says the results add clarity to potential long-term health consequences. “Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AF, specifically that cannabis use is a risk factor for AF even after adjusting for conventional risk factors.”

The study lists many limitations and suggests that “further exploration is required to better elucidate the causal links between these substances and the arrhythmias observed.”

Nurse Story: Inspiring Nurses to Achieve Certification

Recognize and applaud certified nurses and motivate colleagues (or yourself) to pursue certification. Read experiences from certified nurses, find resources to become certified and submit your own certification story idea.

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