Clinical Voices November 2023

Nov 08, 2023

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In this issue, read articles on on the link between COVID-19 staffing disruptions and higher delirium rates, higher cardiac events in recreational drug users, how nurse shortages negatively affect Magnet Hospitals, and more. Plus, read a Q&A with the nurse leaders of new grad nurse support program and watch a new President's Video.

COVID-19 Staffing Disruptions Linked to Higher Delirium Rates

Pandemic-related disruptions in care may be factors for higher delirium and prescription rates.

During the pandemic, delirium rates among acute care hospitalized adults ages 66 and older in Ontario, Canada, increased significantly, as did new prescriptions for antipsychotic and benzodiazepine medications, post-discharge.

"Trends in Delirium and New Antipsychotic and Benzodiazepine Use Among Hospitalized Older Adults Before and After the Onset of the COVID-19 Pandemic," in JAMA Network Open, suggests that pandemic-related disruptions in patient care – including staff shortages, overwhelmed hospital capacity, reduced staff time at the bedside and visitor restrictions – may have factored into the higher delirium and prescription rates.

Conducted from January 2017 to March 2022, the cross-sectional study of 2.1 million acute care hospitalizations in Ontario, Canada, reveals that delirium rates per 1,000 older patients rose from 35.9 pre-pandemic to 41.5 during the pandemic. In addition, monthly rates of new antipsychotic prescriptions increased from 6.9 to 8.8 per 1,000 patients, while new benzodiazepine prescriptions rose from 4.4 to 6.0 per 1,000 patients.

These rates remained elevated throughout the first two years of the pandemic (March 2020 through March 2022), suggesting that health systems should renew their efforts to implement well-described nonpharmacologic interventions to prevent and manage in-hospital delirium.

"Government and hospital policies are imminently needed to address ongoing staff shortages, mandate flexible hospital visitation, and consider delirium care in future decision-making about isolation practices," the study adds.

Family intervention could be one safe and feasible means to reduce postoperative delirium for ICU patients, notes a separate study in Heart & Lung. The study, which involved cardiac surgery patients, says that teaching family caregivers to participate in delirium management during ICU visits can reduce the incidence of postoperative delirium and shorten hospital stays. "These findings suggest that family intervention could be incorporated into routine nursing practice."

Cardiac Events Higher in Recreational Drug Users

The observational study took place at 39 centers across France.

Positive tests for recreational drug use occurred in 11% of patients in intensive cardiac care units (ICCUs) in France, and positivity greatly increased the likelihood of a major adverse event.

In "Prevalence and Impact of Recreational Drug Use in Patients With Acute Cardiovascular Events," in Heart, patients testing positive for recreational drug use significantly underreported their use and were over four times more likely to die in the hospital, have a resuscitated cardiac arrest, or have hemodynamic shock. "Multiple recreational drugs users had the worst in-hospital prognosis, with a doubling of MAE [major adverse event] risk, compared with single-drug users."

The observational study, which took place at 39 centers across France in April 2021, included 1,411 patients screened via urinalysis for use of cannabis, opioids, cocaine, amphetamine and MDMA. There were 161 patients testing positive for at least one drug and 45 of them for multiple drugs. Only 91 of the 161 patients (56.5%) admitted to any drug use during an admissions questionnaire, which supports automatic screening.

The study finds significant variation by age group, with one third of patients younger than 40 testing positive, and men at a higher rate than women, 11.9% to 8.1%. Patients testing positive were more likely to be tobacco smokers and HIV positive but less likely to have diabetes, hypertension or dyslipidemia.

Patient outcomes include 61 MAEs, including 25 deaths (19 due to ventricular arrhythmias) for those with positive tests at a rate of 13% compared with 3% for patients not using drugs. The nature of the study precluded knowing which recreational users had higher habitual use leading to hospitalization, addiction, or identifying drug use as a specific cause of cardiac events.

"These results highlight that declarative studies severely underestimate the actual prevalence of drug use," the study notes. Contrary to current guidelines, "these findings suggest the potential value of urine screening in selected patients with acute cardiovascular events to improve risk stratification in ICCUs."

Lactated Ringers Reduces Pancreatitis Severity

A large randomized clinical trial will help confirm the findings in this study.

For patients with acute pancreatitis (AP), early administration of lactated ringers (LR) can decrease the risk of moderately severe to severe pancreatitis.

"Lactated Ringers Use in the First 24 Hours of Hospitalization Is Associated With Improved Outcomes in 999 Patients With Acute Pancreatitis," in AJG: The American Journal of Gastroenterology, involved patients at 22 international sites between 2015 and 2018. The study collected data on demographics, fluid administration and AP severity to examine the link between LR and outcomes for patients with AP.

Findings reveal the odds of developing moderately severe/severe AP decreased 48.2% for patients who received LR compared with those who received normal saline, adds an article in Gastroenterology Advisor. There was no significant difference, however, in AP severity between patients receiving normal saline and those treated with a combination of LR and saline fluids.

After excluding patients who developed organ failure within the first 12 hours of fluid administration, AP severity odds were 56.2% less for patients treated with LR. Similarly, the odds decreased 59.3% when excluding AP patients who received more than 4 liters of fluid within the first 24 hours.

The study lists several limitations, including failure to include patients transferred from outside hospitals, which could have introduced a selection bias. In addition, it's undetermined if fluid resuscitation was done in a goal-directed manner, and whether the race variable was collected in a manner that conflated race and ethnicity.

"We found a lack of adoption of society guidelines' recommendations to use LR in the first 24 hours around the world," study authors note in Gastroenterology Advisor. "In our cohort, LR usage varied widely in the four different geographic regions. These findings strongly indicate a misalignment between society guideline recommendations and the real-life clinical practice."

Cardiomyopathy Guidelines Emphasize Phenotype Diagnostics

The guidelines strive to provide clinicians with a practical diagnostic and treatment framework.

A task force from the European Society of Cardiology developed a set of clinical guidelines and recommendations for treating patients with cardiomyopathies, the first to address them beyond hypertrophic cardiomyopathy (HCM).

"2023 ESC Guidelines for the Management of Cardiomyopathies: Developed by the Task Force on the Management of Cardiomyopathies of the European Society of Cardiology (ESC)," in European Heart Journal, provides in-depth guidance on diagnostic approaches with a focus on describing morphological and functional phenotypes.

"The aim is to provide healthcare professionals with a practical diagnostic and treatment framework for patients of all ages and, as an increasing number of patients have a known genetic basis for their disease, the guideline also considers the implications of a diagnosis for families and provides advice on reproduction and contraception," the guidelines add.

A related article from American College of Cardiology highlighting the key points of the ESC guidelines notes the need for genetic testing and counseling for patients with cardiomyopathy and their families, multidisciplinary approaches to care, pregnancy risks, exercise recommendations and distinctions for pediatric cases. "Beyond the first year of life, genetic causes of childhood-onset cardiomyopathies are similar to those in adults."

The focus on HCM comes as mavacamten (or Camzyos), a new drug therapy approved by the FDA in 2022, becomes more widely available and increases demand for detection and risk stratification for patients who might benefit.

"You want to reassure patients who do not have high-risk features that they will do well," Ted Abraham, co-director of HCM Center of Excellence, says in an article in Cardiovascular Business. "But you also want to identify those who will need an intervention," he adds.

"Abraham explained that HCM is believed to be the most common inherited genetic cardiac condition in the world. In the U.S., it is estimated there are between 700,000 to 900,000 patients at risk for HCM. … He added that 90% of patients with an HCM diagnosis will generally live normal, healthy and full lives," the article notes.

Lack of Nurses Affects Magnet Hospitals

The findings are promising for clinicians who work together to effect changes in their work environments.

A survey of nurses and physicians in U.S. Magnet hospitals finds that rates of clinician burnout, staff turnover and patient safety concerns are higher in hospitals viewed as having too few nurses and unfavorable work environments.

"Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety," in JAMA Health Forum, also says that respondents aren't confident that hospitals will take the necessary steps to enhance staff well-being and retention.

More than 15,700 RNs practicing in 60 U.S. Magnet-designated hospitals responded to the cross-sectional survey, along with about 5,300 physicians in 53 of those hospitals. The survey was distributed in 2021, with analysis completed in March 2023.

Among the findings:

  • Nearly half of nurses (47%) and a third of physicians (32%) reported high burnout, and over 40% of nurses said they would leave their current hospital if possible.
  • Nurses (26%) and physicians (12%) gave their hospitals unfavorable grades on patient safety, and both groups reported having too few nurses.
  • Nearly half of both groups (46% nurses, 42% physicians) lacked confidence in management to resolve problems in patient care.
  • Improving nurse staffing ranked highest among a list of desired interventions (87% nurses, 45% physicians).

"Clinicians wanted action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments; they were less interested in wellness programs and resilience training."

The study lists several limitations, including being conducted during the pandemic when clinician well-being was likely worse than before. Still, nearly 90% of nurses and physicians reported good professional relations, and that their care teams worked together efficiently.

"These findings hold promise for clinicians acting together to bring about important changes in their work environments," the study adds. "However, clinicians need management support for change, and our findings on clinician-management relations were concerning."

Persistent COVID-like Symptoms

Two studies highlight the prevalence of ongoing health challenges.

About one in six patients with COVID-like symptoms continued to report a range of persistent symptoms up to 12 months later, whether they initially tested positive or negative.

"Prevalence of Symptoms ≤12 Months After Acute Illness, by COVID-19 Testing Status Among Adults – United States, December 2020 – March 2023," in Morbidity and Mortality Weekly Report (MMWR), notes that about 16% of adults who presented for COVID-19 testing at one of eight medical centers nationally reported at least one symptom across eight categories that emerged or reemerged over the following year.

"Improved understanding of the persistent and fluctuating nature of symptoms could guide clinical care and public health response to post-COVID-like conditions," the study adds.

Using self-reported follow-ups from 1,296 patients at three-, six-, nine- and 12-month intervals, the study finds a substantial decline in symptoms after three months and a gradual decrease thereafter. "Many participants experienced new symptoms ≥6 months after the acute illness, suggesting that the prevalence of emerging symptoms in the months after acute COVID-like illness might be considerable."

An additional study on long COVID, in MMWR, notes the prevalence of long COVID in Americans decreased from June 2022 to June 2023, but about 25% of those surveyed online reported significant limitations in their activity. Among respondents who reported at least one COVID-19 case, prevalence of long COVID decreased from 18.9% to 11.0%, and among all respondents it decreased from 7.5% to 6.0%.

This study notes that patients with long COVID are more likely to be unemployed or work less than full time and present an ongoing national healthcare challenge. "Limited ability to carry out day-to-day activities because of long COVID symptoms can have a significant impact on quality of life, functional status, and ability to work or provide care to others."

"My Continued Journey With Long COVID," a blog by clinical supervisor Nikki Dotson-Lorello, includes symptoms, challenges and resources.

President's Video: The Right Tool for the Job: 2.0

In 2004, AACN President Terry Davis implemented the first teleICU at Inova Health System and used AACN's Healthy Work Environment (HWE) standards as the building blocks. Now, AACN has launched the new HWE Assessment Tool 2.0. "Nearly two decades ago my team began our HWE journey. Today, you can take the next step on your path."

Watch Now

Nurse Story: Support for New Grad Nurses

As part of its onboarding process, Inova Health System developed a Clinical Mentor Extender program. Its goal is to support new graduate nurses after orientation and through their first year of practice. Learn more about this supportive program.

Read the Q&A