Clinical Voices September 2023

Sep 13, 2023

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In this issue, read articles on updated ARDS guidelines, new data on C. auris, how charge nurses can develop leadership skills and influence cultural inclusivity, and more. Plus, read the story of a nurse who has developed a bold approach to difficult discussions about race and bias.

Charge Nurses Build on Leadership Skills

Virtual technology is transforming healthcare.

A leadership development program helped hospital-based charge nurses (CNs) gain confidence in leadership skills that can benefit their patients, teams and careers.

"Evaluation of a Charge Nurse Leadership Development Program," in Nursing Management, notes that the pilot program developed at a Colorado teaching hospital enrolled 12 nurses from diverse units. "The average range of registered nursing practice was 11 to 15 years, and 92% had less than 10 years of experience as a CN."

During four, 90-minute, in-person classes (one each month) an experienced nurse leader led discussions on four main topics: understanding others, leadership, communication in charge and influencing others. Supplemental materials were emailed after each class, and a pre-post assessment using the Leadership Practices Inventory (LPI) measured participants' confidence in their leadership skills.

"Participants reported that learning application of the principles of authentic leadership, improved communication skills, and diversity training were the most helpful," the pilot study adds.

Regarding diversity, some nurses reported they personally experienced or witnessed events associated with racist comments made by patients or visitors. "The group shared how they handled the situation and what techniques could be used during a future incident."

Nurses also discussed the "hidden rules," or unspoken social cues, that could make some employees uncomfortable. "Examples shared by the participants led them to acknowledge that nursing units aren't always inclusive environments," the study explains, adding that further discussion centered on how CNs could influence a culture of inclusivity.

Nurses also discussed the "hidden rules," or unspoken social cues, that could make some employees uncomfortable. "Examples shared by the participants led them to acknowledge that nursing units aren't always inclusive environments," the study explains, adding that further discussion centered on how CNs could influence a culture of inclusivity.

At $709 per participant, the estimated cost of the four-month program for the hospital's staff of 111 CNs was $78,699, which is less than the average turnover cost of two direct care nurses ($46,100 each). "Investing in frontline leader education and self-development could improve the work environment and influence staff retention," the study concludes.

AACN's standards for a healthy work environment, including the newly revised, free assessment tool, can also help CNs make their optimal contributions to patients and teams.

Data on Candida auris

The findings emphasize the importance of C. auris surveillance and containment.

The crude mortality rate was 34% for Candida auris (C. auris)-associated hospitalizations, an increasing issue, notes a research letter from Centers for Disease Control and Prevention (CDC).

In "Candida auris-Associated Hospitalizations, United States, 2017-2022," in Emerging Infectious Diseases, the CDC reports a 95% increase in C. auris infections from 2020 to 2021 in the United States. "This analysis of hospitalization data supports previous targeted reports and demonstrates a need for strengthened national surveillance and further studies to identify risk factors for C. auris infection and colonization," notes the research letter.

Using data from over 1,000 hospitals looking for cultures positive with C. auris, the researchers found 192 hospitalizations in 42 locations, with 38 patients (20%) having bloodstream infections. The patients as a whole had a 31% mortality rate, with the number rising to 47% for bloodstream infections.

C. auris, a fungal pathogen that can be resistant to many treatments and is highly contagious, primarily caused hospitalizations in patients with sepsis (64%), diabetes (55%), chronic kidney disease (44%) and pneumonia (43%). "Our results support smaller previous investigations showing that infection and colonization with C. auris occurs most commonly in patients with complex medical conditions," the letter adds.

A related article in Becker's Hospital Review, which referenced several studies, notes that 3,270 infections were reported in the U.S. between 2016 and 2021. In 7,413 screening cases, hospitals detected the fungus but did not have any reported infections. "Additionally, the number of cases that were resistant to antifungal drugs tripled from 2019 to 2021."

Resources include the National Emerging Special Pathogens Training and Education Center, which offers courses and training for nurses, healthcare facility consulting, research assistance, and an opportunity to submit questions and receive answers from experts. CDC's C. auris fact pages can help clinicians learn more about identification, treatment and infection control measures.

Updated Guidelines for Acute Respiratory Distress Syndrome

These guidelines indicate how quickly the evidence base is changing.

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.

The first update since 2017, "ESICM Guidelines on Acute Respiratory Distress Syndrome: Definition, Phenotyping and Respiratory Support Strategies," in Intensive Care Medicine, focuses in part on subdividing patients with ARDS into subtype groups that may respond to different treatments, including patients with COVID-19 who are in a distinct category.

A new recommendation in the guidelines covers non-intubated patients with acute hypoxemic respiratory failure not known to be caused by preexisting lung disease or heart failure. The panel from the European Society of Intensive Care Medicine (ESICM) suggests high-flow nasal oxygen to reduce risk of intubation in these patients.

For intubated patients with ARDS, the panel recommends low tidal volume ventilation and discourages prolonged or brief high-pressure (≥ 35 cm H2O) recruitment maneuvers ("such strategies remain of unproven benefit and, indeed, could be harmful," the guidelines note). For intubated patients with moderate to severe ARDS, the panel recommends a prone position (16 consecutive hours or more) to improve survival chances, discourages continuous infusions of neuromuscular blockade, and suggests that patients who meet the criteria for extracorporeal membrane oxygenation (ECMO) be referred to ECMO centers.

Because of the unique aspects of COVID-19, mutations and fewer evidence-based studies, the panel had weaker recommendations for care. "These issues are not unique to COVID, but rather further highlight the challenges of predicting treatment effects from trials testing interventions in broad syndromes without a clear understanding of the evolving mechanisms by which interventions work or do not work in individual patients.

"Many studies aimed to find the optimal care for this syndrome, and the latest guidelines are testament to how quickly the evidence base is changing," adds a related article in JAMA: Journal of the American Medical Association.

Psychological Therapy for Patients With ICDs

Anxiety and depression were the highest within five months of discharge.

Depression and anxiety are common among patients with implantable cardioverter defibrillators (ICDs), especially for those who experience shocks, and post-traumatic stress disorder (PTSD) is of particular concern in the months after implantation.

"Burden of Mood Symptoms and Disorders in Implantable Cardioverter Defibrillator Patients: A Systematic Review and Meta-Analysis of 39,954 Patients," in EP Europace, suggests that psychological assessment, monitoring and therapy should be part of routine care for these patients, their partners and cardiac patients in general.

Overall, from pre-discharge to more than a year after implantation, 22.58% of patients with ICDs (mean age 64; 91% male) developed clinically relevant anxiety, and 15.42% were diagnosed with depression. "The most striking finding relates to PTSD, apparent in 12% of ICD patients more than 12 months after insertion," the review notes.

The prevalence of anxiety and depression were highest within five months of discharge, at about 32% and 23% respectively, and rates were typically higher among women and patients who experienced a shock from the device.

"ICDs are effective at extending patients' lives, but we need to make sure that's a good quality life," review co-author Hannah Keage, University of South Australia, says in a related article in Cardiovascular Business. "Rates of mood disorders in people with an ICD are much higher than in the general population, suggesting that psychological assessment and therapy should be integrated into the routine care of these patients."

Virtual reality therapy is one way medical professionals help patients cope with PTSD after an ICU stay, reports WQAD News 8 in Orlando, Florida. In a study led by critical care nurse Brian Peach of the University of Central Florida, patients wear a virtual reality headset to simulate the sights, sounds and even smells of the ICU to help them overcome their fears.

Outcomes for Heart Transplants From Circulatory Deaths

A five-year follow-up could lead to improved understanding of the long-term effects.

Six-month survival and serious adverse events are similar for transplant patients receiving hearts from circulatory-death donors to those from the usual brain-death donors.

"Transplantation Outcomes With Donor Hearts After Circulatory Death," in The New England Journal of Medicine, notes that recipients of hearts from circulatory-death donors had a 94% survival rate, compared with 90% from brain-death donors. "This multicenter trial showed that 6-month survival after transplantation with a donor heart that had been reanimated and assessed with the use of extracorporeal nonischemic perfusion after circulatory death was noninferior to 6-month survival after transplantation of a donor heart that had been preserved with the use of cold storage after brain death," the trial adds.

The randomized trial involved 90 transplant patients assigned from each category. "A total of 166 transplant recipients were included in the as-treated primary analysis (80 who received a heart from a circulatory-death donor and 86 who received a heart from a brain-death donor)." The most serious adverse effect, primary graft dysfunction, occurred in 22% of circulatory-death donor hearts and 10% of brain-death donor hearts, but with no difference in survival.

The trial notes a shorter average time from consent to transplant in the circulatory-death group, 24 days compared with 31 days in the brain-death group. "These differences may have contributed to the apparent improved survival after transplantation with a heart from a circulatory-death donor; however, the potential differences in risk factors associated with donors and recipients were addressed prospectively in the protocol and statistical analysis plan to include risk-adjusted analysis for the primary efficacy end point."

In 2020, about 25% of donor hearts in the U.S. were from circulatory deaths with long waiting lists, so the trial aimed to find better evidence of equivalent outcomes. "Five-year follow-up would permit better understanding of the long-term ramifications of transplantation of a heart obtained from a donor after circulatory death."

Inpatient Walking Program Makes Strides

The rate of discharge to an SNF was 8% compared with 13% before the program.

A supervised walking program for hospitalized older adults can reduce their odds of being discharged to a skilled nursing facility (SNF), but with no differences in hospital length of stay or inpatient falls.

"Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals: A Stepped-Wedge, Cluster Randomized Trial," in Annals of Internal Medicine, compares outcomes between patients who participated in a walking program called STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) and those who did not participate.

"Inactivity during hospitalization has been recognized as a key contributor to hospital-associated disability and other harms for decades. Low mobility has been linked to delirium, falls, longer lengths of stay (LOS), greater risk for readmission, and functional decline resulting in discharge to skilled nursing facilities," explains a news release posted on EurekAlert!

During the two-year STRIDE initiative (August 2017 – August 2019), more than 6,100 patients, ages 60 or older, were eligible to participate while hospitalized for at least two days at eight VA facilities. During that time, patients' rate of discharge to an SNF was 8%, compared with 13% before STRIDE, the trial adds.

"Participating hospitals received structured guidance to help plan and launch their programs but were responsible for identifying and training their clinical personnel to assess patients and conduct walks," the release notes.

The trial acknowledges that STRIDE participation was low and variable, with documented walks during a potentially eligible hospitalization ranging from 0.6% to 22.7% per hospital. Two of the VA hospitals paused or discontinued the walking program after launching it.

"Still, the authors say their findings suggest that health systems should consider hospital walking programs as a reasonable means to improve quality of care for older adults," the release adds. "Further development of strategies to support hospitals in implementation of new clinical programs are needed to enhance their effect."

Nurse Story: A BRAVE Approach to Difficult Discussions

As a Black nurse sharing a hotel room with a white colleague on a business trip in 2017, Latonya Brumfield had the first of many difficult talks about race and bias. "If we're going to change the world, we need to talk. As nurses, that's part of our ethical mandate." Learn her method for navigating uncomfortable conversations.

Read Her Story