Clinical Voices October 2021

Oct 04, 2021

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This month we feature articles on a protocol to shorten ECMO time, virtual bedside family visits and reducing pediatric transfers to ICU. Plus, read the new President’s Column and an uplifting Nurse Story Q&A.

Virtual Bedside Visits

Families receive video instructions to connect with ICU patients via an iPad on a bedside stand.

To improve virtual interactions between patients with COVID-19 and their families, an Australian hospital introduced HowRU, a videoconferencing system that simulates on-demand, bedside visits with little effect on nurses’ workloads.

Developing an Innovative System of Open and Flexible, Patient-Family-Centered, Virtual Visiting in ICU During the COVID-19 Pandemic: A Collaboration of Staff, Patients, Families, and Technology Companies,” a research article in Journal of Intensive Care Medicine, notes that health systems worldwide have adapted during the pandemic to provide virtual visits via videoconferencing. However, ICUs vary greatly in the type and setup of video platforms and in how nurses and other staff coordinate visits.

To overcome these limitations, Wollongong Hospital in Australia collaborated with a technology consultant to develop an ICU videoconferencing platform that:

  • Is private, secure and meets hospital data-protection guidelines
  • Closely simulates standard open and flexible visiting
  • Accommodates differences in patients’ family size, preferred type of interactions and other dynamics
  • Is easy to use, requiring minimal technical skills and no special teams to organize or facilitate meetings
  • Does not increase ICU staff workload

The consultant’s website features a two-minute video demonstrating the system. Families receive online video instructions to connect with ICU patients via an iPad on a portable bedside stand.

“The nurse can go to the bedside, tap twice and open the family space, and there’s a virtual connection set up for a family member to visit,” the video notes. “It could facilitate visitation between family and patients very easily and very flexibly.”

HowRU is a fully supported, cloud-based system that uses Webex and additional automated programming tailored to ICU needs, according to the journal article, which notes that the system is commercially available and can be easily added to ICUs.

Protocol May Shorten Time on ECMO

This study adds to available data on the process of ECMO weaning during usual care.

A daily protocol to assess patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) can be accomplished safely and could help identify readiness for decannulation earlier than gradual approaches to weaning.

Safety and Feasibility of a Protocolized Daily Assessment of Readiness for Liberation From Venovenous Extracorporeal Membrane Oxygenation,” in Chest, reports that the protocol could be used across diverse ICUs for patients with various indications requiring cardiopulmonary support.

“Given the widely recognized risks and resource implications of prolonged ECMO, the need to identify strategies that may safely shorten the length of time on ECMO is urgent,” adds the prospective study.

Conducted at Vanderbilt University Medical Center, Nashville, Tennessee, the study involved 26 adult patients who received a total of 385 ECMO-free daily assessments over five months in 2020. Each of the hospital’s four ICUs — medical, cardiovascular, trauma and COVID-19 — participated in the three-phase protocol that included:

  • Screening to identify patients who could not participate safely
  • Non-ECMO FiO2 titrated up to 0.60 via mechanical ventilation or high-flow nasal cannula
  • 30-minute ECMO-free trial, during which sweep gas flow was turned off, meaning that blood still passes through the ECMO circuit, but no oxygenation or carbon dioxide clearance occurs within the circuit

During the study, 16 patients passed the ECMO-free trial without adverse effects, and 14 patients were decannulated. Results revealed a median of two days from a patient’s first passed trial to decannulation.

Study limitations include the single-center design and the limited number of patients. However, along with creating a protocol that may identify patients for earlier decannulation, the study notes that “by performing 385 prospective daily assessments, this study is a considerable addition to the data available on the process of ECMO weaning in usual care.”

Program Reduces Pediatric Transfers to ICU

A program to identify potential deterioration in pediatric patients reduced emergency transfers to the ICU more than 70%.

A single-site watcher program to identify potential deterioration in pediatric patients reduced emergency transfers to the ICU more than 70%, with nurses reporting increased satisfaction.

According to “Implementing a Watcher Program to Improve Timeliness of Recognition of Deterioration in Hospitalized Children,” in Journal of Pediatric Nursing, the program’s success was due primarily to “inclusion of key stakeholders, developing objective and subjective criteria based upon your [organization’s] own internal data, and creating defined structures for communication.” The program “allowed the team to proactively manage situations in a timely, safe, and controlled manner.”

Using a model derived from other evidence-based systems, the 336-bed Arkansas Children’s Hospital built a multidisciplinary team that included clinical nurses, nurse leadership and Medical Emergency Team nurses. The team developed objective criteria to help predict possible patient deterioration (“watcher patients”) across five risk factors and also allow for subjective criteria such as staff or family concerns outside established criteria.

An algorithm standardizes the response once a patient is determined to be a watcher, and a team that includes a primary care nurse develops a collaborative plan, including interventions, measurable outcomes and time frames. The “pre-defined escalation plan empowers nursing staff to escalate on behalf of their patient, reducing the risk of delays and uncertainty around next steps,” the article notes.

The hospital implemented two daily huddles to discuss the watcher patients. “We attribute the success of the program to improved situational awareness of frontline nurses and physicians through standardized structure and process for proactive identification and planning for high-risk patients.”

Malnutrition in Some Patients After Hospitalization for COVID-19

Malnutrition screening may be needed for patients who recover from COVID-19.

Although most gastrointestinal (GI) complications in patients recovering from COVID-19 resolve within six months, malnutrition and difficulty gaining weight persist for many.

According to “Gastrointestinal Sequelae 3 and 6 Months After Hospitalization for Coronavirus Disease 2019,” in Clinical Gastroenterology and Hepatology, malnutrition remains in many patients three months after hospitalization discharge and in some patients after six months, with significant weight loss. “Therefore, it may be imperative to establish malnutrition screening practices in post-COVID 19 patients who have recovered from acute infection,” the study notes.

The retrospective study followed outcomes for 17,462 patients who tested positive for COVID-19 from March 2020 to January 2021 in 12 New York hospitals, with some patients not yet reaching the six-month follow-up. There were 3,229 patients (18.5%) with GI symptoms, including gastroenteritis, GI bleeding, malnutrition and idiopathic pancreatitis.

At least 90% of symptoms resolved after three months in all categories except malnutrition, with 81 of 181 unresolved after three months and 44 after six months. Median weight loss for the malnourished patients was 4.9 pounds at three months and 2.2 pounds at six months, but for those unable to regain weight the median loss was 14.7 pounds and 17.8 pounds, respectively.

“Inability to gain weight in patients diagnosed with COVID and malnutrition is a lingering symptom that deserves more attention,” notes study co-author Arvind Trindade, Northwell Health System, in a related article in Healio Gastroenterology. “These patients should follow up with a nutritionist.

“Future research needs to identify the mechanism of why these patients are unable to gain weight,” Trindade adds in the article. “In addition, we will be looking at 1-year follow up data to determine if this resolves within this time span.”

Decision Fatigue Scale: A Tool to Help Nurses

Nurses were asked to rate the degree their decision-making was impeded.

The nine-item decision fatigue scale (DFS) is a valid and reliable tool to help measure stress, anxiety and other psychological factors that could impede a nurse’s ability to make clinical decisions.

Decision Fatigue Among Clinical Nurses During the COVID-19 Pandemic,” in JCN: Journal of Clinical Nursing, discusses the first-known psychometric validation of the DFS for clinical nurses, and the results could inform future research focused on maintaining nurses’ psychological well-being.

“Given the relationship between traumatic stress and the nursing work environment, decision fatigue may be a modifiable target for interventions that can enhance the quality of decision-making among clinical nurses,” the study notes.

The study recruited 160 RNs from across the United States who worked at least 20 hours a week during the pandemic. Of those nurses, 61% recently cared for a patient with COVID-19, and 67.3% had COVID-19 themselves or had a friend or family member with the virus.

Nurses were asked to rate the degree their decision-making was impeded over the previous 24 hours based on nine factors, including stress, inability to concentrate, lack of confidence and their mood at the time, using a four-point Likert scale.

“Scores on the DFS were strongly correlated with symptoms of traumatic stress and moderately correlated with the nursing work environment,” the study adds. “As expected, the DFS did not demonstrate a meaningful correlation with their practice environment nor their personal experience having or knowing someone diagnosed with COVID-19.”

The study cites limitations, including the possibility that the findings were exaggerated by the pandemic’s negative psychological impact on health systems. Overall, however, the evidence supports the validity and reliability of the DFS among the nurses sampled, the study adds.

Cannabis Screening Recommended for Elective Surgery

Although 14% of surgical patients self-report cannabis use, evidence suggests the numbers could be higher.

Primary care screening for elective surgery should include a discussion of patients’ cannabis use to address potential safety issues with anesthesia and postoperative complications.

Cannabis Use: Change in Screening for Primary Care Preoperative Clearance,” in JNP: The Journal for Nurse Practitioners, encourages advanced practice registered nurses (APRNs) to engage in a “frank conversation with patients regarding potential surgical risks linked to recent cannabis ingestion of all forms” and to explain why abstinence from cannabis before surgery is necessary. “Communication between APRN primary care providers and the surgical team is paramount to the patient’s well-being, safety, and continuity of care,” the article adds.

With screenings 30 days in advance of elective surgery, practitioners have the opportunity to provide a confidential review of a patient’s cannabis habits, including the method of administration, frequency, timing and last use. The article stresses the need for patients to avoid using cannabis a minimum of 12 to 72 hours before surgery (and ideally longer) because of risks associated with anesthesia and adverse airway events.

The article adds that 14% of surgical patients self-report cannabis use, but trends in legalization and reported use among younger adults suggest the numbers could be higher and the risk elevated. Besides inhalation, users may also report use of edibles, topical oils or rectal suppositories; potency and effects can vary based on the method.

Some common effects during and after surgery include altered pain responses, adverse cognitive effects, respiratory and cardiovascular complications, and impacts on coagulation. “To further reduce surgical morbidity and minimize costly surgical delays, presurgical testing is considered vital to patient safety and a component to favorable surgical outcomes,” the article notes.

President’s Column: Can They Hear Us?

“Nursing represents the largest segment of the healthcare workforce, yet our voices often go unheard.” This month, Beth Wathen explores how nurses on the front lines of this pandemic have shone a light on nursing that’s never been brighter. “We have a unique opportunity to focus the spotlight and cultivate our growing influence.”

Read Now

Nurse Story: Going to Bat for Nurses

Meet a medical ICU and COVID biocontainment unit nurse and learn how her relationship with a father figure led to donations from two professional baseball healthcare organizations. They will provide scholarships to more than 80 critical and progressive care nurses who are AACN members ready to pursue CCRN or PCCN certification.

Read Her Story

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