Clinical Voices September 2022

Sep 27, 2022

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This issue features articles on an IV push checklist aimed at reducing errors, a pulse oximeter study that points out racial disparities in care, violence in hospitals and preparing to respond, and more. Plus, read a first-person nurse story from an inspired pediatric critical care nurse.

Pulse Oximeter Study Indicates Racial Disparities in Care

One immediate strategy involves setting a pulse oximetry goal for critically ill patients.

Inconsistencies in pulse oximeter performance can lead to critically ill Asian, Black and Hispanic patients receiving less supplemental oxygen than white patients, a finding suggestive of racial and ethnic disparities in care.

"Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit," in JAMA Internal Medicine, explains that for a given hemoglobin oxygen saturation, pulse oximetry (SpO2) levels were higher among Asian, Black and Hispanic patients, which resulted in lower average oxygen delivery rates. The study involved 3,069 patients (mean age 66.9) admitted to intensive care at least 12 hours before needing advanced respiratory support.

"While patients of all races and ethnicities are subject to hidden hypoxemia, the higher incidence in patients of racial and ethnic minority groups could possibly lead to more insufficient treatment in this population and contribute to known population disparities in outcomes, including those seen during the COVID-19 pandemic," the study notes.

In a related article in Medical Xpress, study co-author Eric Gottlieb of Brigham and Women's Hospital in Boston says that while there's been "limited interest in solving the problems inherent in pulse oximeters," measurements from the study pose a problem that needs to be solved. "It's important that this kind of research continue and clinicians engage with engineers, regulators and other stakeholders to insist that this is an issue worth addressing."

One immediate strategy involves setting a pulse oximetry goal for critically ill patients, suggests a study in Respiratory Care. Noting inconsistencies in pulse oximeter measurements, it finds that frequency of occult hypoxemia is higher for Black patients (7.9%) than for white patients (2.9%).

"The highly variable magnitude and direction of measurement error precludes an individualized mitigation approach," the study concludes. "In advance of technological advancements, we recommend targeting a pulse oximetry saturation goal of 94-98% for all patients."

IV Push Checklist Aims to Reduce Errors

The checklist covers IV push competencies in planning, preparation and administration.

To reduce risk of patient injuries and standardize the administration of intravenous (IV) push medications, a nursing task force created a best practice checklist for nursing education programs and hospitals.

"IV Push Evidence-Based Practice Checklist," published by the Quality and Safety Education for Nurses (QSEN) Institute, lists standards to assess competencies in skills related to IV push administration. "Nurses that understand evidence-based practice create an environment of patient safety and a knowledgeable professional that can teach and mentor other nurses to ensure continued standardization," the strategy notes.

The QSEN Patient Safety Task Force notes that a survey of 380 U.S. nursing programs revealed wide variations in how nursing students learn to administer IV push medications. For example, many nursing programs teach students to unnecessarily dilute medications that are manufactured in ready-to-administer syringes. This process can lead to errors in concentration and labeling, and cause contamination.

A related article in INSider adds that the task force developed the checklist with input from various clinical practice settings and academia. They also referred to the INS (Infusion Nurses Society) 2021 Infusion Therapy Standards of Practice and the 2015 ISMP Safe Practice Guidelines for Adult IV Push Medications.

"The team determined the best place to create standardization was to start teaching the standard checklist in nursing school, then to broadcast the checklist into any area of practice where IV push occurs as part of the nursing process," notes the related article.

The checklist covers IV push competencies in three sections: planning, preparation and administration. Competencies include assessment of the appropriate vascular access device, rights of medication administration, flushing and locking, proper dilution and preparation, and rate of administration.

"The competencies in this checklist, which focus on patient safety, were noted in the survey results as areas of inconsistent education and competency validation," adds the related article.

Violence in Hospitals: Prepare to Respond

Staff should have annual active-shooter training with videos, classroom instruction and a facility walkthrough.

The mass shooting in a Tulsa, Oklahoma, hospital in June shows the importance of being prepared for an active shooter incident and how situations in healthcare facilities vary from those in schools, businesses and other settings.

"Code Blue — What to Do When the Shooting Starts," in JAMA: The Journal of the American Medical Association, notes that in hospitals and clinics, "many patients aren't mobile enough to run." And while healthcare personnel aren't legally obligated to risk their lives to save patients, many feel a professional responsibility not to abandon them.

"Can you help people who are immobile or sick? Yes, if you are safe yourself," Michelle Walsh, director of security at Pomona Valley Hospital Medical Center, California, says in the article. "You can't help others if you don't save yourself."

Walsh advises that hospital staff receive annual active-shooter training consisting of videos and classroom instruction followed by a facility walkthrough to plan how they could escape, hide or barricade themselves, if necessary. "Either voluntary or mandatory is fine, but if it's mandatory you have a better chance of getting the education out to everyone," Walsh adds in the article.

"AACN Position Statement: Preventing Violence Against Healthcare Workers" stresses that "healthcare facilities are responsible for ensuring the safety and security of staff, patients and visitors," adding that "institutions nationwide should require violence prevention plans to be in effect at all times in all patient care units, including inpatient or outpatient settings and clinics."

"Preventing Workplace Violence in Healthcare," an AACN blog, lists steps nurses can take, including violence awareness training, reporting acts of violence and seeking solutions as a team. "De-escalating Violence," a recorded session from NTI 2022, AACN's annual conference, describes techniques to help calm potentially aggressive or violent situations and develop prevention strategies.

Marijuana Use May Increase Arrhythmia Risk

Further research with a longitudinal design will help determine causation.

Current use and more frequent use of marijuana by older adults may increase arrhythmia risk, but a direct causal relationship cannot be determined because of data limitations and the small sample size.

In "Self-Reported Marijuana Use and Cardiac Arrhythmias (From the Multiethnic Study of Atherosclerosis),"[MESA] in The American Journal of Cardiology, current marijuana smokers undergoing extended ECG monitoring with a patch experienced more identified atrial and ventricular arrhythmias than non-users. "Understanding the associations between marijuana use and arrhythmias is important because atrial and ventricular arrhythmias can cause substantial negative health outcomes, including severe cardiovascular conditions and death," the study notes.

Study data was from a subset of 1,485 participants in a group of 6,814 MESA participants initially selected between 2000 and 2002 and undergoing follow-up exams. Participants in the most recent exam answered questions about past and current marijuana smoking, including frequency, and all received ECG monitoring.

About 10% of participants (140) reported marijuana use, with 3% (40) reporting current use, and 2% (29) indicating unspecified recency of use. Current users experienced more runs of supraventricular tachycardia per day, more premature atrial contractions per hour, and more runs of nonsustained ventricular tachycardia per day, as measured by monitoring.

The study did not find evidence that past use of marijuana increases the risk of arrhythmias, suggesting that effects are "acute rather than long lasting, and that after extended periods of nonuse, the risks subside." Data limitations, however, include self-reporting, lack of specific types of marijuana used or consumed in forms other than smoking, and lack of clarity on whether participants used it during monitoring.

The study notes that some wide confidence intervals and the small sample size could limit conclusions. "Additional studies using a longitudinal design are needed to clarify if marijuana use causes arrhythmias or other cardiovascular complications."

Algorithm Generates High-Performing Severity of Illness Score

GOSSIS-1 achieved excellent discrimination and calibration in three countries but was not validated externally.

A multinational project to create a generalizable severity of illness score resulted in a free, open-source algorithm to predict mortality in critically ill patients.

"The Global Open Source Severity of Illness Score (GOSSIS)*," in Critical Care Medicine, notes that patient data from the United States, Australia and New Zealand generated a predictive ability that scored highly on test data sets. "Our results indicate that GOSSIS-1 offers superior discrimination and calibration in our cohort when compared with the commonly used scoring systems, performed consistently well across patient subgroups ... and may provide a basis for benchmarking across countries," the report notes.

To generate the algorithm, researchers used data from 380,280 ICU admissions from 2014 to 2015 for patients who were at least 16, had an ICU stay of at least six hours, and were not ICU readmissions. Lab results and physiological variables collected over the first 24 hours were transformed to account for different measurement units and permissible ranges across various settings.

Researchers set aside 30% of the data for testing and used cross-validation across subsets to ensure accuracy of the preferred algorithm. "Our findings imply that machine/statistical learning methods are effective for imputing missing data in a harmonized database and that our methods for developing and evaluating a predictive model are advantageous," the report adds.

Potential limitations of GOSSIS-1 include differences in critical care unit structures in the United States compared with Australia and New Zealand, lack of low- or middle-income countries in the databases, and lack of COVID-19 variables due to the selected years. "At the time of publication, we were not able to externally validate GOSSIS-1 in an independent cohort of critical care patients though external validation is underway in several diverse cohorts," the report notes.

Apnea Testing Debate Addresses Legal, Ethical Concerns

Ongoing debate may lead to clarifying the Uniform Determination of Death Act.

Opposing editorials on obtaining informed consent for apnea testing (AT) to determine brain death illustrate the medical and legal complexities for clinicians who need to make accurate assessments.

Two editorials in CHEST, "POINT: Whether Informed Consent Should Be Obtained for Apnea Testing in the Determination of Death by Neurologic Criteria? Yes" and "COUNTERPOINT: Whether Informed Consent Should Be Obtained for Apnea Testing in the Determination of Death by Neurologic Criteria? No," address the risk of harm in performing AT versus the ethical necessity of obtaining a medical assessment quickly. The debate may help determine if the Uniform Determination of Death Act should be revised to clarify the consent requirement.

D. Alan Shewmon, David Geffen School of Medicine at UCLA, Los Angeles, arguing in favor of informed consent, begins by addressing the efficacy of the procedure: "Apnea testing (AT) should not be done in the first place; but if a physician insists on doing it anyway, informed consent should be obtained." Shewmon adds that AT lacks a consistent medical standard and may harm a patient who is not brain dead, thus warranting a consent requirement.

Thaddeus Mason Pope, Mitchell Hamline School of Law, St. Paul, Minnesota, arguing against informed consent, believes longstanding legal frameworks provide clinicians with the authority to decide and still give reasonable accommodations to family members who want more time before testing. Pope adds that determining a patient's status as alive or dead must be a prerequisite for further treatment: "Otherwise, they commit fraud by billing for services that are not medically necessary."

A related podcast from The New England Journal of Medicine features two physicians conducting a deeper analysis of the ethical and medical issues raised by the editorials in CHEST. Factors addressed include differences between pediatric and adult cases, and complications related to organ donation.

Nurse Story: Why I Am a Pediatric Nurse

For 29 years, Oliver Pelayo has been a pediatric critical care nurse. In his own words, Oliver shares how the spirit of his niece lifts and connects him to his patients and encourages other nurses to identify their passion, their "why."

Read His Story