Clinical Voices October 2023

Oct 05, 2023

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In this issue, read articles on end-of-life wound care strategies, APRN telehealth policy, protocol for CPR on cardiac surgery patients, and more. Plus, read a Q&A with a virtual nursing director and watch our latest Nurse to Nurse Town Hall.

Strategies to Enhance End-of-Life Wound Care

These strategies can help optimize wound management at end of life.

End-of-life skin and wound problems are frequent, complex and challenging, but these strategies can help optimize wound management, provide pain relief and improve patients' quality of life.

Seven Strategies for Optimizing End-of-Life Skin and Wound Care,” in Nursing2023, notes that since 2020, the National Pressure Injury Advisory Panel has held several conferences and webinars addressing end-of-life pressure injuries (PIs) and their regulatory and legal ramifications.

The following strategies for PIs and other wound types help provide consistency across the continuum of care and involve the patient's family in care plans.

  1. Develop guidelines and formularies. End-of-life wound care aims to minimize pain and avoid complications. Guidelines need to be general and not too prescriptive. Educators should teach staff to individualize wound care strategies, and nurses can share plans with the patient and family.
  2. Develop care plan templates. These templates reflect palliative goals, such as reducing dressing-change-related pain or controlling odor. Educators instruct staff to individualize these templates and document consistently.
  3. Educate providers. Educators should teach transfer facilities and other service providers your end-of-like skin care practices and how to provide them.
  4. Address process concerns. Obtain consults as necessary to determine causes and management of skin concerns and wounds. Educators need to regularly educate staff on assessment, documentation and consultation.
  5. Manage symptoms. Carefully assess patients for wound problems, including pain, odor and exudate, and develop individualized interventions to manage these issues.
  6. Educate patients, families and caregivers. Educate patients and families on wound care and document the education in the patient's healthcare record. Include documentation of the patient's and family's understanding or the need to reinforce the education.
  7. Make a preventive legal plan. Discuss/develop preventive legal strategies for end-of-life skin and wound care with your safety and quality departments.

Incorporating these strategies may reduce negative financial, regulatory and legal consequences. “Most importantly, these strategies can optimize quality of life and enhance dignity for patients at end of life and their circle of care,” the article concludes.

Components of Telehealth Policy for APRNs

The article covers topics such as practicing across state lines, professional requirements and reimbursement.

For advanced practice registered nurses (APRNs), understanding the highly regulated and ever-evolving telehealth policy landscape is essential for ensuring legal and regulatory compliance and advocating for positive change.

Telehealth Policy and the Advanced Practice Nurse,” a research article in JNP: The Journal for Nurse Practitioners, suggests that APRNs can make an impact by analyzing existing policies and recognizing inefficiencies. Based on their daily practice, APRNs are positioned to propose new policies and provide clinical insight for improvements.

“Specific emphasis on how telehealth can expand access to care and enhance patient care can support the development and implementation of future policies,” the article notes.

Telehealth has existed for decades, but the COVID-19 pandemic escalated it to the forefront of healthcare delivery. Rules, regulations and reimbursement policies remain in flux, and APRNs should familiarize themselves with federal and state laws as well as requirements governing their specific practice.

The article covers relevant topics, including nurses' ability to practice across state lines, professional requirements (credentialing and privileging, telehealth certification and malpractice) and reimbursement.

Further, by documenting outcomes, APRNs can help provide information on the effectiveness and potential cost savings of telehealth programs. “This information may be used by governing bodies to support expanded reimbursement for telehealth services,” the article adds.

To help APRNs keep pace with changes and growth, “AACN Tele-critical Care Nursing Practice: An Expert Consensus Statement Supporting Acute, Progressive and Critical Care 2022” provides recommendations, clinical vignettes and a framework to implement, evaluate and improve telemedicine practices. Developed by tele-critical care nursing leaders from diverse backgrounds, the statement shares best practices, evidence and lessons learned.

In addition, the vignettes in the statement demonstrate the benefits of tele-critical nursing interventions, including delivering a strong return on investment, identifying high-risk patients, decreasing mortality rates, and partnering with on-site nurses to provide expert evidence-based care.

Rapid Neurological Assessments Help Limit Brain Damage

The article provides detailed guidance on altered LOC.

Updated guidelines on treating patients with acute respiratory distress syndrome (ARDS) include evidence-based recommendations for intubated and non-intubated patients, as well as special cases that include COVID-19.

Nurses providing care for patients with altered level of consciousness (LOC) need to perform rapid comprehensive neurological assessments to identify subtle changes that may be life-threatening.

Assessing Patients With Altered Level of Consciousness,” in Critical Care Nurse, notes that bedside nurses who are new to neurological cases can learn what represents normal and abnormal behavior to alert the care team to potentially dangerous situations requiring a rapid response.

“Confidence and competence in performing a neurological assessment are crucial to providing excellent care to neurologically impaired, vulnerable patients who are often unable to communicate, advocate for, or defend themselves,” the article notes.

The article also provides guidance for conducting a thorough neurological assessment, including general behavior and body position, vital signs, LOC, mental status, motor control and sensory function, cranial nerve function, pupillary response, language and speech, reflexes and cerebellar function. “Nurses who understand the complexity of neurological assessments in patients with altered LOC can think critically and protect vulnerable patients.”

As front-line observers of patient activity or inactivity, nurses need to know that changes in status can occur rapidly and also be subjective, so astute ongoing monitoring may be necessary. “Obtaining accurate education, skills, and neurological assessment competency helps nurses empower patients and families, thereby increasing their involvement in patient care.”

The article includes in-depth explanations of how to perform assessments, as needed, and explains a patient's normal response compared with one that could indicate brain damage. “By understanding cerebral processes, these minute changes can be quickly identified and interventions critical for brain preservation can be rapidly implemented.”

Protocol on CPR for Cardiac Surgery Patients

Hospitals might consider the evidence-based CALS approach.

Cardiac advanced life support (CALS) is an evidence-based protocol for performing cardiopulmonary resuscitation (CPR) on patients with previous cardiac surgery, including valve and aneurysm repairs, pacemaker insertion and coronary artery bypass grafting.

Resuscitation After Cardiac Surgery: Best Practice Recommendations,” in American Nurse, explains that CALS differs from traditional CPR by advising against epinephrine use, which can lead to hypertension and potentially harm fresh cardiac grafts. Instead, the goal is to correct reversible causes of arrest, such as hypovolemia or bleeding, graft or valve failure, low cardiac output and tamponade.

“When the absence of cardiac pressure and respiratory waveforms is identified, a first responder should initiate the CALS protocol,” the article explains. “ECM [external cardiac massage] can be deferred for 1 minute to allow for rapid defibrillation or pacing as indicated.”

If the patient is in ventricular fibrillation — the most common cause of cardiac arrest after surgery — defibrillation is the first intervention, the article notes. If the patient is in asystole or severe bradycardia, pacing is recommended at 80 to 100 beats per minute by either an epicardial or transcutaneous pacemaker.

After all causes are considered and ensuing interventions have failed, resternotomy may be necessary to perform internal cardiac massage. However, resternotomy is recommended only within 10 days following cardiac surgery to avoid further harm to the patient.

“Nursing units caring for these patients should have protocols in place and the necessary supplies to act with haste in the event of cardiac arrest,” the article concludes. “All hospitals have protocols for cardiac resuscitation, but they also should consider the evidence-based CALS approach.”

Right Ventricle's Role in Pulmonary Hypertension

The new definition of PH identifies clinical risk earlier and in more patients.

With new guidelines and definitions for pulmonary hypertension (PH), cardiologists have placed new focus on the heart's right ventricle (RV) and potential issues with its failure as part of disease management.

In “Pulmonary Hypertension and the Right Ventricle: Forgotten No More,” in Cardiology, experts address the enhanced role the RV plays in early diagnosis of PH and the available treatments. “RV failure is a recognized complication of primary cardiac and pulmonary vascular disorders and is associated with a poor prognosis,” the article notes.

By lowering the threshold mean pulmonary arterial pressure to more than 20 mm Hg at rest, the new definition of PH identifies clinical risk earlier and in more patients. “Because PH is often overlooked or diagnosed late, a high index of clinical suspicion is needed to ensure appropriate diagnosis and clinical management of patients.”

The 2022 guidelines issued by the European Society of Cardiology take a three-step diagnostic approach to PH, going from clinician suspicion based on symptoms, to noninvasive testing, and then to confirmation with right heart catheterization.

“Knowing the right atrial pressure is high can provide a lot of information on these patients as a reflection of what the RV is doing,” Jessica Huston, a cardiologist and pulmonary hypertension specialist at University of Pittsburgh Medical Center, adds in the article.

Because left heart disease is the most common form of PH, the RV tends to receive less attention outside of specialists, the article notes. There are signs in RV physiology that clinicians can learn to observe to help generate an early diagnosis.

“With the RV, first there is dilation and then systolic dysfunction,” Huston says in the article. “So, when I see the RV is getting very dilated on echo, that's a sign of high afterload, whether it's from pulmonary vascular remodeling or congestion.”

Immunotherapy: Possible Approach for AFib

Hindering development of a specific immune cell could be a key strategy.

Research into the causes of atrial fibrillation (AFib) suggests the possible use of targeted immunotherapy to reduce inflammation and scarring, which could be a new treatment.

Recruited Macrophages Elicit Atrial Fibrillation,” in Science, notes that researchers led by a team at Massachusetts General Hospital (MGH) in Boston examined single cells from atrial heart tissue and found that macrophages, a type of immune cell, expanded more than other cells when AFib was present.

“We think that this research lays the groundwork for immunomodulatory therapy of AFib, and we are currently working on several strategies to make this happen,” senior author Matthias Nahrendorf, MGH's Center for Systems Biology, says in a news release.

To isolate the impactful cells, researchers studied atrial tissue from patients with and without AFib and created a mouse model to test the impact of macrophages introduced in the atria. The study adds that the immune cells supported inflammation and scarring, causing reduced electrical conduction between heart cells and leading to AFib.

According to the release, gene analysis finds that the SPP1 gene present in the macrophages during AFib produces a protein that promoted the tissue scarring and reached elevated levels in the blood of patients with AFib. The mice who lacked the protein produced lower numbers of atrial macrophages.

Cardiologists could use this research to test ways to target the macrophages or the gene and minimize their effect on atrial tissue. “By mapping cardiac and immune cells involved in atrial fibrillation, this research advances next steps toward studying how macrophage-targeted therapies may support existing treatment,” Michelle Olive, National Heart, Lung, and Blood Institute, adds in the release.

Nurse to Nurse: AACN Town Hall

AACN President Terry Davis, President-elect Jennifer Adamski and board member Joseph Falise share their insights on the nurse staffing shortage and then open the forum for discussion with participants to further understand the current state of nursing and continue advocacy efforts on behalf of nurses.

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Nurse Story: Caring Through Virtual Nursing

Virtual nursing leverages advanced technology to enhance patient care. Ryan Morcrette, director of virtual care for an East Coast health network, discusses how his team built real-time sepsis predictive scoring models and shares a personal story about his nursing journey.

Read the Q&A