Clinical Voices October 2022

Oct 17, 2022

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This issue features articles on how remote monitoring can enhance patient safety, an alternative to alteplase for stroke, a suicide prevention app that uses digital therapeutic strategies, and more. Plus, read a new President’s Column about ruffling feathers and nurse story Q&A.

Remote Monitoring Can Enhance Patient Safety

The article encourages health systems to overcome barriers to full implementation.

Advancements in remote pulse and heart rate monitoring in hospital and home settings that occurred out of necessity during the pandemic offer significant benefits for patient safety.

Remote Patient Monitoring During COVID-19: An Unexpected Patient Safety Benefit,” a Viewpoint article in JAMA: The Journal of the American Medical Association, notes that remote monitoring tools may reduce mortality, hospital stays and costs. “Based on a hypothetical cohort of 3100 patients, the study projected that remote monitoring could potentially be associated with 87% fewer hospitalizations, 77% fewer deaths, reduced per-patient costs of $11,472 over standard care, and gains of 0.013 quality-adjusted life-years,” the article notes.

“With the increased demand for hospital beds and the challenge of delivering care with staff shortages, some health care centers have advised individuals with milder symptoms to stay home ... Wireless monitors, cloud-based platforms, and telemedicine have allowed health systems to seamlessly use at-home continuous pulse oximetry to monitor patients and help avoid hospitalizations.”

Noting that payment reform provides added incentives to incorporate home-based monitoring, the article encourages health systems to overcome barriers to full implementation that so far have prevented wider use. Health systems are advised to:

  • Consider using continuous pulse oximetry and heart rate monitoring for all hospitalized patients and those in emergency departments.
  • Build a team to coordinate and research the program.
  • Create billing mechanisms.
  • Integrate technologies and collaborate with vendors.
  • Develop risk-based protocols.

“Home monitoring and hospital at-home models offer the potential to transform care and potentially allow a substantial proportion of hospitalized patients to receive care from home,” adds lead author Peter Pronovost in a related article in Medical Xpress.

AACN resources include “AACN Tele-critical Care Nursing Practice: An Expert Consensus Statement Supporting Acute, Progressive and Critical Care 2022,” which provides recommendations, clinical vignettes and a framework to implement, evaluate and improve the evolving practice of tele-critical care nursing.

Tenecteplase: Alternative to Alteplase for Stroke

The advantages of tenecteplase may increase its use.

Intravenous single-dose tenecteplase proved non-inferior to alteplase for patients with acute ischemic stroke, with no differences in safety outcomes, possibly making it a good alternative.

Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (AcT): A Pragmatic, Multicentre, Open-Label, Registry-Linked, Randomised, Controlled, Non-inferiority Trial,” in The Lancet, notes that patients receiving tenecteplase during a large randomized trial in Canada achieved the primary outcome of a score of 0 or 1 on the modified Rankin Scale at 90 to 120 days slightly more often than those receiving alteplase, 36.9% to 34.8%.

“Given the ease of administration of tenecteplase compared with alteplase, these results provide a compelling rationale to support switching the standard-of-care intravenous thrombolytic agent for acute ischaemic stroke from alteplase to tenecteplase at a dose of 0.25 mg/kg,” the study adds.

The 1,600 initially enrolled patients across 22 primary and comprehensive stroke centers in Canada were randomly given either treatment for blood clot reduction from 2019 to 2022. The data from 800 patients receiving tenecteplase and 763 receiving alteplase was ultimately used in the analysis. Patients had a median age of 74 and were 52.1% male.

The groups had similar mortality rates (15.4% of patients on alteplase and 15.3% on tenecteplase), symptomatic intracerebral hemorrhage within 24 hours (3.2% alteplase and 3.4% tenecteplase) and extracranial bleeding (0.8% for both). Tenecteplase, which is a genetically modified variation of alteplase, has been favored for patients with myocardial infarction and has a longer plasma half-life, the study adds.

With minimal differences in outcomes for either medication, the advantages of tenecteplase could lead to expanded use. “Unlike alteplase, the ease of administration of tenecteplase, including that the bolus-administered medication does not require infusion monitoring during intra-hospital or inter-hospital transfer, might help reduce dosing errors and improve patient workflow and, potentially, outcomes.”

Suicide Prevention App in Clinical Trials; 988 Goes Online

Recognize, respond and speak up if you notice suicidal risk factors.

Clinical trials are underway for a suicide prevention app that uses therapeutic strategies to reach people who are most at risk — those with previous suicide attempts or who have expressed a strong desire to die.

Drawing on Therapy Developed to Save Solders, an App Aims to Prevent Suicide in Those at Highest Risk,” in STAT, notes the app, called Aviva, is designed to quell suicidal impulses using in-person therapy. These methods reduced suicide attempts in high-risk soldiers by 60% in a randomized trial. Backed by $26 million from investors, Oui Therapeutics of New Haven, Connecticut, is testing the app. If you’re interested in participating or learning more about the clinical trials, sign up on the company’s webpage.

The app “guides patients through making and practicing a plan for what to do when they start feeling upset,” the article explains. “It also helps them find reasons for hope … to carry them through difficult times.”

The Aviva app is part of a broad effort to curb suicide, which takes over 45,000 people in the U.S annually, the article notes. A more immediate tool is the national 988 Suicide and Crisis Lifeline launched in July 2022. By calling or texting 988, anyone can connect 24/7 with mental health professionals at more than 200 crisis centers nationwide, adds a media release from the Federal Communications Commission.

An AACN blog, “Everyone Has a Role in Suicide Prevention,” says it’s important to recognize, respond and speak up if you notice suicidal risk factors in young people and others. The blog includes a list of warning signs and resources.

In addition, AACN offers resources to support nurses who may be dealing with their own feelings of mental and emotional stress. Topics for well-being include peer support, finding joy and meaning in your work, mindfulness, resilience and steps to support a team in crisis.

Removing Barriers to Research Participation

Consider participating in research to enhance clinical practice and improve care.

By participating in research, you can enhance clinical practice, improve patient care and shape healthcare policy, while strengthening your professional development, knowledge, work environment and other factors.

Why should I participate in nursing?” an AACN blog, points out that nurses face barriers to participation, including not having enough time, handling other priorities, lacking organizational support or feeling they don’t understand research methodology.

Those barriers are real, but “Nursing Research, Step by Step,” a series of articles in AJN: American Journal of Nursing, helps nurses take part in research. “Each column will present the concepts that underpin evidence-based practice — from research design to data interpretation,” explains the series introduction.

The Heilbrunn Family Center for Research Nursing at Rockefeller University in New York is coordinating the series. Nine previous articles are listed together in the article, and another appears separately, all in AJN’s August 2022 issue. Topics include:

  • Beginning the research process; identifying a topic of interest and developing a well-defined research question.
  • Developing eligibility criteria and a feasible recruitment plan for study participants.
  • Establishing a well-designed sampling plan so study participants align with your target population.
  • Choosing and implementing the correct instruments/processes to measure outcomes with validity and reliability. Careful selection enhances research accuracy.
  • Knowing the difference between primary and secondary data and how each aligns with research goals.
  • Learning the characteristics of case-control and cross-sectional studies.
  • Understanding the basic principles of qualitative and quantitative research.

An AACN webpage, Participate in Research Studies, is a convenient way to begin a journey in research participation. Review the current topics listed and consider participating in one that speaks to you. In addition, if you are planning a research project and need participants, details on how to submit your study are on the site.

Nursing Innovation: Seeing a Problem and Solving It

A nurse and an engineer collaborated on an innovative medical device.

Witnessing how easily intravenous lines can snag and pull away from patients’ bodies inspired a critical care nurse to help design and create a device to prevent inadvertent dislodgement of IV lines, tubes and cords.

Collaborative Nurse-Engineer Product Innovation,” in AJN: American Journal of Nursing, describes how nurse Lindsey Roddy and engineer Kyle Jansson partnered on the device, called SecureMove-TLC. This article is one in a series featuring nurse innovators.

According to the article, Roddy was studying toward a PhD in nursing at the University of Wisconsin-Milwaukee in 2016 with a focus on improving patient care through research. Earlier in her career, while helping an ICU patient get up from bed, an IV line delivering medication snagged and dislodged from the patient’s neck.

“While the patient survived, the incident created a lasting impression on Roddy, leaving her wondering what could be done to prevent this from happening to other patients and nurses,” the article notes. With permission from the university, Roddy teamed up with Jansson.

Together, they simulated patient falls and observed how patients move with IV lines. For two years, they adjusted the design nearly 40 times. The current version includes a versatile tension feature for IV lines, cords and tubes, and a series of grip channels that can hold up to eight lines.

“Most importantly, when a line is pulled, the force is absorbed by the device, saving the patient from a potentially life-threatening dislodgment, the article adds. “The product has been manufactured without the use of adhesives, and nurses can easily attach it to a patient’s arm, a bed rail, or an IV pole.”

Five years into the process, Roddy and Jansson have a startup company called Roddy Medical, which was established in 2019, and they’re working with investors to launch and market SecureMove-TLC.

Portable ICU Systems

The devices can help clinicians relocate patients within a hospital or in or out of transport without bulky machinery.

Portable ICUs with ventilators and anesthesia machines that helped clinicians manage COVID-19 overflow early in the pandemic are also helping war-zone patients in Ukraine.

How Toronto Firm’s Donated ICU-in-a-Suitcase Is Helping Treat Ukraine’s War Wounded,” in National Post, notes that Thornhill Medical donated battery-operated life-support systems to provide Ukraine’s strained medical workers a means to treat wounded patients who cannot reach hospitals quickly.

“If there isn’t medevac capability available, if the country doesn’t have control of the skies, the patient may have to be taken care of at the point of injury for an extended period of time,” adds Lesley Gouldie, CEO of Thornhill Medical, a Canadian company.

The 40-pound MOVES SLC combines a ventilator, an oxygen-creating concentrator, vital sign monitors and a suction device. The concentrator removes nitrogen from the air to remove the need for oxygen tanks.

Also donated were the even smaller MADM units (the size of toasters), which vaporize and deliver gas anesthesia. Ukrainian medical personnel say the ability to use the equipment in the field, in an ambulance or at a hospital is very valuable when providing life support in critical care situations.

Originally developed for military use, the portable ventilators gave strained Canadian units backup capability when electricity, oxygen or beds were in short supply. “The first role is to help with a surge in supply – if you want to open up a new ICU bed, all you need is this and a stretcher, and you can do that,” Thornhill co-founder Joe Fisher says in a related article in University of Toronto News.

Fisher says the portable devices offer clinicians the ability to relocate a patient within a hospital or in or out of transport without bulky machinery. Military contracts helped develop more versatility, he adds, and eliminating the explosive risk of oxygen tanks is a significant advantage.

President’s Column: Ruffling Feathers – Challenging the Status Quo

In her new article, AACN President Amanda Bettencourt explores a promise from her NTI keynote to ruffle some feathers and challenge the status quo in order to effect change. She asks, “What values will drive you to ruffle some feathers in nursing to create change for the better?”

Ready to Ruffle Some Feathers?

Nurse Story: Becoming a Voice for Excellence in Nursing

Casey Green, an ICU assistant nurse manager with nine credentials and certifications after her name, is a voice and leader for nursing. “Becoming a nursing voice was one of the unforeseen impacts of obtaining my certifications,” says Green. And, as a nurse of color, the negative experiences she saw propelled her to work to ensure they don’t continue to permeate through the nursing profession.

Read Her Story