Clinical Voices November 2022

Nov 09, 2022

Added to Collection

This issue features articles on acute care simulation-based education, anesthesia guidelines for difficult airways, decreasing pediatric ventilation rates, and more. Plus, read a new nurse Q&A.

Updated Anesthesiology Guidelines for Difficult Airways

Areas covered include airway evaluation, preparation, anticipated and emergency situations, confirmation of tracheal intubation and extubation.

The American Society of Anesthesiologists’ updated guidelines for managing patients with difficult airways synthesize peer-reviewed literature and scientific findings to offer recommendations for interventions and treatments.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway,” in Anesthesiology 2021, the first update since 2013, covers adult and pediatric patients and can be used by anyone who performs anesthesia care or airway management in inpatient and ambulatory settings.

“For these practice guidelines, a difficult airway includes the clinical situation in which anticipated or unanticipated difficulty or failure is experienced by a physician trained in anesthesia care, including but not limited to one or more of the following: facemask ventilation, laryngoscopy, ventilation using a supraglottic airway, tracheal intubation, extubation, or invasive airway,” the report notes.

The guidelines seek to optimize the success of a clinician’s first attempt at airway management, improve patient safety and minimize adverse events. “The appropriate choice of medications and techniques for anesthesia care and airway management is dependent upon the experience, training, and preference of the individual practitioner, requirements or constraints imposed by associated medical issues of the patient, type of procedure, and environment in which airway management takes place,” the report adds.

Areas covered in the guidelines include evaluation of the airway, preparation, anticipated situations, emergency situations, confirmation of tracheal intubation, extubation and follow-up care. The report provides summaries of recommendations for each area based on evidence and best practices, along with literature and survey findings.

Additional resources in the guidelines include algorithm flow-charts and infographics as visual aids. An area not addressed is airway management during cardiopulmonary resuscitation.

HCV Does Not Add Significant Risk for Kidney Transplants

Many patients on a transplant waiting list should consider an HCV-RNA-positive donor kidney.

For kidney transplant recipients, the risk of five-year allograft failure is significantly no different whether the deceased donor was positive or negative for hepatitis C virus (HCV).

Five-Year Allograft Survival for Recipients of Kidney Transplants From Hepatitis C Virus Infected vs Uninfected Deceased Donors in the Direct-Acting Antiviral Therapy Era,” a research letter in JAMA: The Journal of the American Medical Association, notes that the findings may provide a rationale to reexamine the Kidney Donor Profile Index (KDPI) penalty assessed to HCV-positive donors.

“This study and others suggest that many patients on the transplant waiting list should weigh the option of transplant with an HCV-RNA-positive donor kidney,” the letter adds.

The U.S.-based retrospective cohort study from 2016 to 2021 involved 45,827 deceased donors, including 2,551 who were HCV-positive, and 75,905 kidney recipients. HCV-positive donors were younger (median age 35 vs. 39) and had better KDPI scores (median 32% vs. 47%) than negative donors.

Five-year allograft survival for recipients of HCV-positive kidneys was 72% compared with 69% for those who received HCV-negative kidneys. Mean allograft survival was 4.30 years for HCV-positive transplants versus 4.27 years for negative ones.

A related article in MedPage Today notes that before 2016, most HCV-positive kidney transplants occurred among patients who already had HCV, but the emergence of direct-acting antiviral therapy enabled trials with uninfected transplants.

Still, some patients are reluctant to receive an HCV-infected kidney, often because the donor died from a drug overdose, and potential recipients often have a low tolerance for risk, says study co-author Peter Reese, Perelman School of Medicine, in the article, noting that it’s important to talk to patients early about possibly receiving an HCV donor kidney.

“You need to address this while they are on the waiting list so they have some preparation when the donor comes,” he adds.

Initiative Decreased Pediatric CPR Ventilation Rates

The initiative reduced rates of clinically significant hyperventilation during pediatric CPR.

A quality improvement (QI) initiative designed to decrease ventilation rates during pediatric cardiopulmonary resuscitation (CPR) reduced hyperventilation nearly in half.

Improving Ventilation Rates During Pediatric Cardiopulmonary Resuscitation,” in Pediatrics, notes that a focused multifaceted program at a single institution decreased hyperventilation occurrences from 51% in a preintervention period to 29% postintervention. The program also lowered median respiratory rates from 30 breaths per minute preintervention to 21 breaths postintervention.

To achieve the reductions, CPR events were reviewed at three pediatric ICUs from April 2016 to December 2018 to estimate the baseline rates. Based on CPR team interviews, the QI team determined the barriers to reductions included knowledge gaps, cognitive overload and a need for more buy-in from the CPR team.

The QI team designed a program that included improved “provider education, CPR ventilation tools (ventilation reminder cards, ventilation metronome), and individual CPR team member feedback,” the report notes. Training focused on pediatric ICU nurses and respiratory therapists and included monthly presentations during team huddles and practice council meetings.

Hyperventilation (30 breaths per minute or more) has been linked to worse outcomes by decreasing venous return and coronary perfusion pressure, the report adds. A limitation of the study was having to exclude about 30% of cardiac arrests in the data group because of a lack of end-tidal carbon dioxide information.

Acute Care Simulations Build Confidence for New Graduate Nurses

Nurses had significantly higher perceptions of their ability to provide care after the simulation-based education.

Simulated patient scenarios can improve new graduate nurses’ (NGNs’) perceived ability in acute care situations, with positive effects on confidence, communication and patient involvement.

Ability to Care in Acute Situations — The Influence of Simulation-Based Education on New Graduate Nurses,” in Journal of Emergency Nursing, notes that participating in acute care simulations may have more influence on nurses’ perceptions than the length of their work experience.

Conducted in Sweden, the study involved 102 NGNs with less than two years of work experience. After a series of preliminary steps, participants engaged in four simulated scenarios involving four patients, each with one of these conditions:

  • Chest pain
  • Sepsis
  • Altered level of consciousness
  • Chronic obstructive pulmonary disease with opioid intoxication

The Perception to Care in Acute Situations scale measured outcomes for nurses in three categories: confidence in the provision of care, communication and the patient’s perspective. Compared with pretest results, mean scores in each category indicated that nurses had significantly higher perceptions of their ability to provide care after participating in the simulation-based education.

“This study also confirms the importance of providing experiences of acute situations during nursing education and posteducation to develop this ability in early working life.”

And while other studies have associated length of work experience with higher self-assessed confidence among nurses, these results indicate the “importance of a contextual experience of acute situations and not mere working experience,” the study adds. The findings could lead to further investigation into ways to modify simulated scenarios to support communication and patient perspectives in acute situations.

“Future studies could also explore how NGNs translate their knowledge into clinical practice and the possible long-term effects of simulation-based interventions for NGNs.”

Long-Term-Care Residents Need Monitoring for Sepsis

By knowing the risks, spotting the symptoms and acting fast, you can help stop an infection from becoming sepsis.

Residents in nursing homes, skilled nursing facilities and assisted living, who are prone to serious infections, require sepsis monitoring that includes elevated testing and communication of concerns.

In “Protecting Long-Term Care Residents From Sepsis,” a blog from the Centers for Disease Control and Prevention, author Heather Jones recommends teamwork with healthcare professionals and family members to detect early signs and symptoms associated with dangerous infections. “By knowing the risks, spotting the signs and symptoms, and acting fast, you can help stop an infection from developing into sepsis and save a life,” she says in the post.

Nurses working in long-term care can observe changes during regular interactions and be alert for a resident who has difficulty getting out of bed, lacks an appetite or appears disoriented. “If your facility does not have a plan for how to respond when a resident is suspected of having sepsis, consider talking with your supervisor or administration about developing a plan.”

Time is essential when beginning treatment, and although there is no single test to diagnose sepsis, clinicians “should closely monitor the resident’s vital signs – blood pressure, heart rate, respiratory rate, and temperature – and look for other signs and symptoms that might indicate an infection is present or worsening.”

The blog notes that long-term care settings can be challenging for making a diagnosis, because some symptoms are similar to other conditions that are typical for residents, such as cognitive changes or functional decline.

If a resident is developing sepsis, usual treatments include intravenous fluids, antibiotics, and noting possible low blood pressure or breathing difficulties. A patient requiring transfer to a hospital may have an advance directive, and facilities need quick access to records with patients’ goals of care.

AACN offers many sepsis resources that translate current sepsis guidelines, research, evidence and recommended practices specifically for application by nurses at the bedside.

Defining Chest Pain: New Terms Emphasize Consistency

The guideline recommends cardiac, possible cardiac and noncardiac as the preferred terminology for chest pain syndromes.

Newly released data elements and definitions for chest pain and acute myocardial infarction (MI) will help provide a consistent and universal clinical vocabulary related to cardiovascular care and research.

2022 ACC/AHA Key Data Elements and Definitions for Chest Pain and Acute Myocardial Infarction,” from the American Heart Association (AHA) and the American College of Cardiology (ACC), describes these terms and standards within the context of a 2021 joint practice guideline for evaluating and diagnosing chest pain. The information focuses on serious cardiovascular causes of chest pain that might be faced in emergency departments.

As outlined in the 2021 guideline, data elements are grouped in three categories: chest pain, myocardial injury and acute MI. Traditional terminology for describing chest pain symptoms as typical or atypical are no longer used due to perceived ambiguity.

“The recent chest pain guideline, therefore, recommends using ‘cardiac,’ ‘possible cardiac,’ and ‘noncardiac’ chest pain as the preferred terminology,” the report adds.

A related article in Medscape notes that the report underscores the importance of consensus language when describing chest pain.

“You want heart attack to mean the same thing in Miami Beach as in Western Pennsylvania, as in Oregon and Washington and every place in between,” writing committee chair H.V. “Skip” Anderson with UT Health Science Center in Houston notes in the article. “You want everybody to be using the same language, so that’s what these data standards are meant to do.” 

For specialized care of acute MI, the AHA and The Joint Commission established a new Comprehensive Heart Attack Center certification. To qualify for this highest level of care, hospitals must provide 24/7 coverage for primary percutaneous coronary interventions (PPCIs) and cardiac surgical services.

“The new certification joins our existing heart attack certifications to help hospitals elevate their cardiac programs, improving consistency of care for every patient,” notes Mariell Jessup, AHA’s chief science and medical officer, in an article in Cardiovascular Business.

Nurse Story: Sikhism and Patient Care

A practicing Sikh, Taranjeet Rathore is a nurse at the Mayo Clinic in Rochester, Minnesota. He advocates for safe, respectful care of patients and families of the Sikh faith and other religions, and continues to broaden cultural awareness in his role as a diversity champion.

Read His Story