Travel Distance Between Participants in US Telemedicine Sessions With Estimates of Emissions Savings: Observational Study.

BACKGROUND: Digital health and telemedicine are potentially important strategies to decrease health care's environmental impact and contribution to climate change by reducing transportation-related air pollution and greenhouse gas emissions. However, we currently lack robust national estimates of emissions savings attributable to telemedicine. OBJECTIVE: This study aimed to (1) determine the travel distance between participants in US telemedicine sessions and (2) estimate the net reduction in carbon dioxide (CO2) emissions attributable to telemedicine in the United States, based on national observational data describing the geographical characteristics of telemedicine session participants. METHODS: We conducted a retrospective observational study of telemedicine sessions in the United States between January 1, 2022, and February 21, 2023, on the doxy.me platform. Using Google Distance Matrix, we determined the median travel distance between participating providers and patients for a proportional sample of sessions. Further, based on the best available public data, we estimated the total annual emissions costs and savings attributable to telemedicine in the United States. RESULTS: The median round trip travel distance between patients and providers was 49 (IQR 21-145) miles. The median CO2 emissions savings per telemedicine session was 20 (IQR 8-59) kg CO2). Accounting for the energy costs of telemedicine and US transportation patterns, among other factors, we estimate that the use of telemedicine in the United States during the years 2021-2022 resulted in approximate annual CO2 emissions savings of 1,443,800 metric tons. CONCLUSIONS: These estimates of travel distance and telemedicine-associated CO2 emissions costs and savings, based on national data, indicate that telemedicine may be an important strategy in reducing the health care sector's carbon footprint.

Risk Stratification in Noninvasive Respiratory Support Failure: A Narrative Review.

TOPIC/CLINICAL RELEVANCE: The use of noninvasive respiratory support, including noninvasive ventilation and high-flow nasal cannula therapy, has increased over the years. Failure of noninvasive respiratory support, defined as the need for invasive mechanical ventilation, increases the mortality rate. PURPOSE: To familiarize critical care nurses with available risk stratification assessments and identify common concepts and limitations. CONTENT COVERED: Few risk stratification assessments are available to identify patients at risk of failure of noninvasive respiratory support. Although many studies have analyzed risk, substantial variation in study design, definitions, terminology, and outcomes have led to a wide range of findings, making clinical application difficult. Further study is needed to broaden known assessments to general patient populations, determine diagnostic accuracy during critical periods, and analyze noninvasive ventilation and high-flow nasal cannula therapy. Risk stratification could allow for better implementation of preventive strategies and patient education. CONCLUSION: Future research opportunities include improving study design for risk stratification and implementing preventive strategies for patients requiring noninvasive respiratory support. Clinically, risk stratification can provide an opportunity to share knowledge and facilitate conversations with patients and families.

Oral Care in Critically Ill Patients Requiring Noninvasive Ventilation: An Evidence-Based Review.

TOPIC: Hospital-acquired pneumonia commonly develops after 48 hours of hospitalization and can be divided into non-ventilator-acquired and ventilator-acquired pneumonia. Prevention of non-ventilator-acquired pneumonia requires a multimodal approach. Implementation of oral care bundles can reduce the incidence of ventilator-acquired pneumonia, but the literature on oral care in other populations is limited. CLINICAL RELEVANCE: Use of noninvasive ventilation is increasing owing to positive outcomes. The incidence of non-ventilator-acquired pneumonia is higher in patients receiving noninvasive ventilation than in the general hospitalized population but remains lower than that of ventilator-acquired pneumonia. Non-ventilator-acquired pneumonia increases mortality risk and hospital length of stay. PURPOSE: To familiarize nurses with the evidence regarding oral care in critically ill patients requiring noninvasive ventilation. CONTENT COVERED: No standard of oral care exists for patients requiring noninvasive ventilation owing to variation in study findings, definitions, and methods. Oral care decreases the risk of hospital-acquired pneumonia and improves comfort. Nurses perform oral care less often for nonintubated patients, as it is perceived as primarily a comfort measure. The potential risks of oral care for patients receiving noninvasive ventilation have not been explored. Further research is warranted before this practice can be fully implemented. CONCLUSION: Oral care is a common preventive measure for non-ventilator-acquired pneumonia and may improve comfort. Adherence to oral care is lower for patients not receiving mechanical ventilation. Further research is needed to identify a standard of care for oral hygiene for patients receiving noninvasive ventilation and assess the risk of adverse events.

Hemostatic Disorders: Physiology, Diagnostics, and Management.

A defect in any step of hemostasis can lead to potentially catastrophic results. The purpose of this article is to review hemostatic physiology, laboratory studies, and management of platelet and coagulation disorders to familiarize the advanced practice RN (APRN) with this often overlooked but critical system. Learning the underlying mechanisms allows for better understanding of the various disease states that can occur in the hematology and oncology settings.

Readiness Assessment for Extubation Planning in the Intensive Care Unit: A Quality Improvement Initiative.

BACKGROUND: Extubation failure is the reintubation of patients meeting criteria for weaning from mechanical ventilation. Extubation failure is correlated with mortality, prolonged mechanical ventilation, and longer hospital stays. Noninvasive ventilation or high-flow nasal cannula oxygen therapy after extubation is recommended to prevent extubation failure in high-risk patients. LOCAL PROBLEM: The extubation failure rate is unknown. Prophylactic measures (noninvasive ventilation or high-flow nasal cannula) after extubation are not commonly used and vary among clinicians. The objective was to assess extubation planning readiness by determining extubation failure rate, identifying high-risk patients, and determining prophylactic measure compliance. METHODS: A quality improvement initiative included an evidence-based extubation failure risk assessment that identified high-risk patients and determined prophylactic measure compliance. A 2-year retrospective medical record review was used to determine baseline patient characteristics and extubation failure rate. Results Extubation failure rate within the retrospective cohort was 13 of 146 patients (8.9%). Extubation failure did not correlate with previously identified risk factors; however, 150 identified patients were excluded from analysis. During risk assessment integration, the extubation failure rate was 3 of 37 patients (8.1%) despite identifying 24 high-risk patients (65%). Few high-risk patients received prophylactic measures (noninvasive ventilation, 17%; high-flow nasal cannula, 12%). CONCLUSIONS: Extubation failure should be routinely measured because of its effects on patient outcomes. This project reveals the multifactorial nature of extubation failure. Further research is needed to assess patients' risk and account for acute conditions. This project used best practice guidelines for routine patient care and added transparency to a previously unmeasured event.

Hypopituitarism: Case Study Involving Hypernatremia Prompting Discovery of a Pituitary Disorder in a Patient With Lymphoma.

BACKGROUND: The endocrine system contributes to numerous physiologic processes. Compensatory mechanisms are in place that can assist when endocrine dysfunction occurs, which may make it difficult to identify pathologic states. OBJECTIVES: The case study in this article presents a 74-year-old woman with diffuse large B-cell lymphoma who was admitted to an oncology critical care unit with neutropenic fevers and suspicion of gastrointestinal bleeding. She was placed on NPO status (no oral intake) overnight and quickly developed hypernatremia. This prompted further investigation, resulting in the discovery of hypopituitarism. METHODS: A case study illustrates how altered endocrine function can contribute to rapid patient deterioration beyond hypothyroidism, diabetes, or other common endocrine conditions. FINDINGS: Compensatory mechanisms involving the endocrine system can mask dysfunction, which can cause providers to miss signs of altered endocrine function. Experienced clinical nurses should use critical thinking and assessment skills to monitor patients for abnormal signs and symptoms.