Clinical Voices August 2023

Aug 04, 2023

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In this issue, read articles on virtual nursing technology, dual-chamber leadless pacemakers, trauma care for LGBTQ+ patients, and more. Plus, read a new President’s Column and the story of a critical care nurse who is also Miss New Jersey International.

Virtual Nursing: A New Model of Care

Virtual technology is transforming healthcare.

An overview illustrates how virtual technology is transforming healthcare and creating the potential to advance nursing practice.

In "Overview and Summary: Virtual Opportunities for Nurses," in OJIN: The Online Journal of Issues in Nursing, Carol Boston-Fleischhauer, the Advisory Board's chief nursing officer, writes that the "virtual technology field for nursing is dynamic, with growing choices" for existing technology platforms.

"Amidst clinical workforce shortages and unresolved nurse burnout due to excessive workloads, leveraging virtual technology to streamline work or offload tasks that can be automated is particularly important as well," she adds. Data shows significant impacts on process efficiency, care quality and safety, and consumer and nurse satisfaction.

The overview summarizes six examples of virtual technology, including applications for nurse educators and front-line practitioners. One example, "The Virtual Nurse Program in a Community Hospital Setting," emphasizes virtual nursing as a "distinctly new model of care delivery," moving away from one nurse assuming all tasks for each patient assignment.

"Instead, the virtual nursing model includes both in-room care delivery staff as well as RNs located in remote locations supported by virtual technology; all of this comprises an integrated care delivery team," the overview notes. "This model is a substantial investment to address workforce and staffing challenges."

An AACN consensus statement offers recommendations, clinical vignettes and a framework to implement, evaluate and improve the evolving practice of tele-critical care nursing. The statement can inform implementation planning for virtual nursing models.

"The vignettes are real-world examples of how each key recommendation is implemented to provide continuity of care; demonstrate the value of tele-critical care nursing for a strong return on investment; identify high-risk patients; and decrease mortality rates by leveraging clinician expertise and technology, and partnering with on-site nurses to provide expert evidence-based care," explains the AACN news release.

Terry Davis, AACN president, adds that tele-critical care was a pioneer in the world of virtual nursing. As the demand for tele-critical care coverage continues to grow, video technology is becoming more advanced through two-way video and consultation capabilities. The addition of the virtual nurse program expands these capabilities beyond critical care into medical-surgical areas, progressive care and telemetry units. This program opens opportunities to improve patient flow, reduce the workload of direct care nurses and increase their satisfaction.

Dual-Chamber Leadless Pacemakers

The FDA-approved technology could greatly broaden patient access to leadless pacing.

In a large-scale study, a dual-chamber leadless pacemaker system, consisting of two devices implanted percutaneously, exceeded safety and performance goals while providing atrial pacing and reliable atrioventricular (AV) synchrony three months after implantation.

The study, in The New England Journal of Medicine, reports that two functioning leadless pacemakers were implanted in 295 patients with sinus-node dysfunction or AV block as primary pacing indicators. Serious adverse events occurred for 29 patients, but 90.3% of patients met the primary safety endpoint. The system also exceeded two performance endpoints, including 97.3% of patients achieving at least 70% AV synchrony.

The FDA-approved technology, known as the Aveir Leadless Pacemaker System, could greatly broaden patient access to leadless pacing, which has been limited to single-chamber pacing, reports a related article in Cardiovascular Business.

"For the first time we were able to demonstrate the bidirectional, wireless beat-to-beat communication so each device knows what the other is doing, so you have fully synchronous action between the upper and lower chambers of the heart," co-investigator Daniel Cantillon, a senior VP at Masimo, adds in the above article.

Leadless pacemaker technology may also be an effective short-term treatment for children with congenital heart disease, according to a separate study in Circulation: Arrhythmia and Electrophysiology. Data involving 62 patients, ages 4 to 21, who received a transcatheter leadless pacemaker reveals a high rate of implant success, excellent electrical performance and infrequent major complications, adds another article in Cardiovascular Business.

With modifications, the technology could be offered to a wider pediatric population, study author Maully J. Shah, Children's Hospital of Philadelphia, says in the above article. "Techniques and tools to place the device must be designed for smaller patients, specifically children, and there needs to be a mechanism to remove and replace this pacemaker without surgery when the battery runs out since pediatric patients will likely require pacing for the rest of their lives, which is several decades after implantation."

Optimal Mean BP Range for Hospitalized Patients With Stroke

The study involved a single-site stroke center in China from December 2020 to July 2021, with 649 patients.

A retrospective study finds that the ideal mean systolic blood pressure (BP) range for patients with acute ischemic stroke is 135 to 150 mm Hg, with poorer outcomes associated with higher and lower numbers.

In "Relationship Between Mean Blood Pressure During Hospitalization and Clinical Outcome After Acute Ischemic Stroke," in BMC Neurology, mean systolic BP measured at the same time daily throughout hospitalization above 150 mm Hg or below 135 mm hg correlated with lower odds of a favorable outcome on the modified Rankin Scale (scores of 3 or better) after three months.

"These findings have significant potential implications for managing BP in acute stroke, as they support the need to initiate treatment for high BP early rather than conservatively delaying therapy to a certain point after symptom onset," the study adds.

The data came from a single-site stroke center in China from December 2020 to July 2021, with a cohort of 649 patients (65.8% male, median age 69) with acute ischemic stroke and stays of at least five days. The study found a non-linear U-shaped relationship between mean BP and outcomes, with the bulk of the 92 poor outcomes (14%) and deaths in patients outside the 135-150 mm hg range.

Although the data does not permit specific clinical recommendations, the study notes the high use of antihypertensive drugs in China and suggests that "ideal BP management should be personalized."

The limitations of a small sample size and the need to exclude patients with short stays and fewer BP measurements were addressed. "Further studies are required to elucidate the mechanism and clinical significance of the relationship between mean blood pressure and functional outcome in patients with acute ischemic stroke during hospitalization."

Trauma Care for LGBTQ+ Patients

Provide care with a collaborative, multidisciplinary approach.

Nursing considerations during trauma care for LGBTQ+ patients should include awareness of culturally appropriate terminology, understanding clinical implications and helping to ensure safety.

"The Complexity of Trauma for LGBTQ+ People: Considerations for Acute and Critical Care," in Critical Care Nursing Clinics, places acute care considerations in the context of potentially traumatic life experiences and the implicit bias that may be present when caring for LGBTQ+ patients. The goal is countering historical disparities in care. "When it is apparent to a patient that the providers caring for them are comfortable working with LGBTQ+ clients, stress can be minimized and healing optimized," the review notes.

Lead author Damon Cottrell, a past AACN Certification Corporation board member, and the co-authors provide three primary takeaways for clinicians: Know and use appropriate language when communicating with LGBTQ+ patients; screen them for intimate partner violence, violent crime causality and suicidality; and use trauma-informed care strategies. "Recognizing the impact of traumatic stress on critical care patients as it affects their ability to cope with the stresses of treatment is vital, and simple actions can help to decrease discomfort."

In addition, the review encourages clinicians to become educated on differences between sex, gender, gender identity and related aspects to address patients with understanding and the appropriate words. Facilities can create more welcoming environments with gender-neutral restrooms, educational pamphlets and visual cues of acceptance, such as posting a nondiscrimination statement.

The review emphasizes potential complexities associated with transgender patients due to different gender-affirming surgical and procedural histories, and possible non-prescribed hormone therapies. Other considerations include using a patient's chosen name and personal pronouns, and being sensitive to possible differences between legal identification and how a patient identifies. The review suggests some recommended questions to provide clarity.

AACN offers several resources, including an NTI recorded session, an article in Critical Care Nurse, a Nurse Story about a critical care nurse's journey, a Nurse Story about celebrating diversity, and a blog on imposter syndrome.

New Approaches to Cardiogenic Shock

Future research on CS treatment will include trials comparing advanced temporary MCS devices.

A review of methods for treating patients with cardiogenic shock (CS) concludes that individualized approaches examining shock severity, phenotype and exit strategy produce better outcomes than a single course of therapies.

"Advances in the Management of Cardiogenic Shock," in Critical Care Medicine, includes a literature review and recent conference workshop discussions on CS and suggests that research focus on clinical trials for the safety and efficacy of current strategies for individualized care. "The marked heterogeneity observed within the CS population precludes a one-size-fits-all approach to the care of CS patients," the review notes.

The review assesses changes in the definitions of CS and its causes, adding that acute myocardial infarction is not necessarily the leading identified cause based on a separate categorization for heart failure. This shift "has implications for both therapy and RCTs [randomized controlled trials], as patients with [each cause] have divergent pathophysiology, clinical presentation, and therapeutic approaches."

Classifying CS by severity from shock stages A through E (getting progressively worse) requires examination and laboratory assessment whether reduced blood flow is occurring (likely CS at stages C, D or E) or if the patient has abnormal blood pressure (likely CS at stages A or B). The review employs a model that separates the markers of shock severity from assessment of shock phenotype to determine optimal interventions.

The review includes evidence-based strategies for interventions as well as an algorithm based on expert consensus for general approaches that should be adjusted based on the individual patient's identified factors. It also reviews early identification and evaluation, initial respiratory and hemodynamic stabilization, temporary mechanical circulatory support (MCS), and right ventricular predominant CS for current best practices.

Future research on CS treatment will include ongoing trials that compare advanced temporary MCS devices. The review encourages inclusion of phenotyping and shock severity classification to learn more about the mechanisms that might lead to treatments for different subgroups.

Five Practices for Treating Native American Elders

Native American elders need culturally appropriate care and accessible resources.

To care for aging Native Americans, nurses and other healthcare professionals need to understand cultural differences and implement practices to improve outcomes.

"Understanding and Honoring the Needs of Native American Elders," in American Nurse, reports that tribal nations expect to have 300,000 elders over age 85 by 2050, a significant increase from 42,000 in 2012. This population faces four significant healthcare issues: "healthcare disparities, historical trauma, healthcare shortages afflicting rural areas and reservations, and a lack of culturally appropriate care in long-term care facilities."

Nearly every nurse will treat Native American patients at some point, the article notes, adding that the following practices can help improve care and outcomes:

Implement trauma-informed care: Obtain a basic understanding of Native Americans' generational trauma, including genocide and societal abuse. Help these patients feel physically and emotionally safe, and collaborate on a care plan that prioritizes their spiritual needs and well-being.

Provide appropriate cultural services: Each tribal nation in the U.S. has its own traditions, religious beliefs, language and culture. Ask cultural workers in these nations to recommend appropriate treatments and interactions.

Ask questions: Asking respectful questions demonstrates recognition of Native Americans' expertise on their background, values and experiences. "When you're honest about the limits of your knowledge, Native patients are more likely to trust your sincerity in offering respectful and effective care," the article adds.

Listen to patients and families: Native Americans have a history of being disrespected by the healthcare system. Listen carefully to the challenges of patients and families, and focus on building trust and rapport.

Prepare for end-of-life traditions with family: Consider the family's role in Native American culture. Prepare for many visitors who want to pay their respects and honor their elder. Ask the family about their traditions before moving the body.

President's Column: Preparing for Change With Adaptive Thinking

As a young trauma nurse, AACN President Terry Davis admits she was a blunt communicator. Today, she leads directors who manage teams and initiatives, and she considers herself an adaptive thinker. In this column, she explores how this way of thinking can help us embrace problems as opportunities.

Read Column

Nurse Story: Empowering Beauty for a Cause

What do nursing and beauty pageants have in common? For critical care nurse and Miss New Jersey International Soumya Karne, it's self-love and self-development. "Preparing for a pageant taught me the courage to find my voice. That translates off-stage by giving me the confidence to advocate for my patients, myself and my co-workers."

Read Her Story