Evaluation of a Novel Mechanical Venous Thromboembolism Compression Device in Trauma Patients: A Pilot Study.

BACKGROUND: Venous thromboembolism (VTE) is the fourth most common preventable hospital-acquired complication for hospitalized trauma patients. Mechanical prophylaxis, using sequential compression or intermittent pneumatic compression (IPC) devices, is recommended alongside pharmacologic prophylaxis for VTE prevention. However, compliance with device use is a barrier that reduces the effectiveness of mechanical prophylaxis. OBJECTIVE: This study aimed to determine whether using the Movement and Compressions (MAC) system compared with an IPC device impacts compliance with mechanical VTE prophylaxis in trauma patients. METHODS: This study used a before-and-after design with historical control at a Level II trauma center with a convenience sample of adult trauma patients admitted to the intensive care unit or acute care floor for at least 24 h. We trialed the MAC device for 2 weeks in November and December 2022 with prospective data collection. Data collection for the historical control group occurred retrospectively using patients from a point-in-time audit of IPC device compliance from August and September of 2022. RESULTS: A total of 51 patients met inclusion criteria, with 34 patients in the IPC group and 17 patients in the MAC group. The mean (SD) prophylaxis time was 17.2 h per day (4.0) in the MAC group and 7.5 h per day (8.8) in the IPC group, which was statistically significant (p < .001). CONCLUSION: Our findings suggest that the MAC device can improve compliance with mechanical prophylaxis.

Clinical Nurse Specialist Tracheostomy Management Improves Patient Outcomes.

BACKGROUND: Patients with a tracheostomy are a low-volume, high-risk population with long lengths of hospital stay and high health care costs. PROBLEM: Because of the complex nature of caring for patients with a tracheostomy, it is essential to provide a standardized care approach with ongoing monitoring to optimize outcomes. APPROACH: A pre/postimplementation design was used. A formal tracheostomy care management process using clinical nurse specialists (CNSs) was implemented. OUTCOMES: Between April 2019 and December 2020, this process resulted in a significant reduction in time between tracheostomy placement and discharge, from 16 to 12.9 days ( P = .02). Reductions were also seen in length of stay and incidence of tracheostomy-related pressure injuries. CONCLUSIONS: This project shows that a CNS-led care management process can improve patient outcomes. These improvements in patient outcomes resulted in a significant cost savings to the organization.

Challenges of de-implementing feeding tube auscultation: A qualitative study.

AIM: This qualitative study explored de-implementation of feeding tube auscultation practice in adult patients by critical care nurses. BACKGROUND: Despite years of evidence suggesting inaccuracy and harm, auscultation (air bolus method) continues to be used by the majority of critical care nurses to verify small-bore feeding tube placement in adults. DESIGN: This descriptive qualitative study used thematic analysis with telephone interview data. METHODS: Fourteen critical care nurses from four stratified groups within the United States (by hospital type and auscultation practice) participated in telephone interviews. RESULTS: Two major themes of individual influence and organizational leadership emerged from the data. Categories identified key components required for auscultation de-implementation. CONCLUSIONS: Nurses feel obligated to follow hospital policies and expressed less accountability for their own practice. Organizational leadership involvement is recommended to facilitate de-implementation of this tradition-based, low-value practice and mitigate harm events.

Improved Patient Safety and Quality Outcomes With Amiodarone Infusions.

BACKGROUND: Amiodarone is a common intravenous medication and a known irritant to the vessel wall when administered peripherally. LOCAL PROBLEM: Nurses identified an increase in phlebitis associated with peripheral amiodarone leading to multiple catheter replacements and interruptions in drug therapy. Central venous access is recommended by the manufacturer but not practical for a short-term infusion based on the risk to the patient, time, and cost. METHODS: A 4-phased approach was used to identify a more suitable peripheral intravenous catheter. INTERVENTIONS: A collaborative effort between bedside nurses and the vascular access team evolved to look at alternative products for peripheral intravenous catheters. RESULTS: The extended dwell peripheral catheter decreased phlebitis from 54% to 5%. It also decreased interruptions in drug therapy and improved patient comfort and satisfaction. CONCLUSIONS: A practice change was implemented utilizing extended dwell peripheral catheters for intravenous amiodarone and disseminated to other units.

Increasing capacity for nursing research in magnet-designated organizations to promote nursing research.

Nursing research is important in order to assure nursing interventions are beneficial and not harmful to patient care. Nurse leaders should encourage and develop a culture of inquiry. An infrastructure is the foundation for nursing research and is essential to facilitate and support clinical nurses conduct of research. Resources including personnel and time are essential. However, the most important element for a successful nursing research program is nursing staff that are inspired, empowered and encouraged to perform their own nursing research.

The Emeritus Nurse: Retired, Rehired, and Revolutionary.

A strong culture rooted in excellent nursing practice is essential to the future success of healthcare organizations. Nursing leaders face the challenge of establishing and retaining this culture with the exodus of nursing knowledge and clinical reasoning expertise from retirements of experienced nurses. This article presents a novel plan to mitigate this looming problem by rehiring and reengaging recently retired nurses to return to practice for an emeritus RN program.

Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients.

Objective: Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). Methods: We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. Results: After eliminating patients who were not eligible to receive TEA, the average patient bill was $59,123 ($10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -$21,429.55- -$7,794.66) and a 24% reduction in per-day billing (99% CI = -$3,745.99- -$1,276.14). Conclusions: Patients who received TEA were more severely injured and required longer treatments; controlling for these variables, the use of TEA associated with reductions in the cost of receiving care. From an administrative and insurance perspective, more frequent reliance on TEA may be indicated.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures.

OBJECTIVE: Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. METHODS: We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. RESULTS: Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. CONCLUSION: Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

Two Methods for Turning and Positioning and the Effect on Pressure Ulcer Development: A Comparison Cohort Study.

PURPOSE: We evaluated 2 methods for patient positioning on the development of pressure ulcers; specifically, standard of care (SOC) using pillows versus a patient positioning system (PPS). The study also compared turning effectiveness as well as nursing resources related to patient positioning and nursing injuries. DESIGN: A nonrandomized comparison design was used for the study. SUBJECTS AND SETTING: Sixty patients from a trauma/neurointensive care unit were included in the study. Patients were randomly assigned to 1 of 2 teams per standard bed placement practices at the institution. Patients were identified for enrollment in the study if they were immobile and mechanically ventilated with anticipation of 3 days or more on mechanical ventilation. Patients were excluded if they had a preexisting pressure ulcer. METHODS: Patients were evaluated daily for the presence of pressure ulcers. Data were collected on the number of personnel required to turn patients. Once completed, the angle of the turn was measured. The occupational health database was reviewed to determine nurse injuries. RESULTS: The final sample size was 59 (SOC = 29; PPS = 30); there were no statistical differences between groups for age (P = .10), body mass index (P = .65), gender (P = .43), Braden Scale score (P = .46), or mobility score (P = .10). There was a statistically significant difference in the number of hospital-acquired pressure ulcers between turning methods (6 in the SOC group vs 1 in the PPS group; P = .042). The number of nurses needed for the SOC method was significantly higher than the PPS (P ≤ 0.001). The average turn angle achieved using the PPS was 31.03°, while the average turn angle achieved using SOC was 22.39°. The difference in turn angle from initial turn to 1 hour after turning in the SOC group was statistically significant (P < .0001). No nurse injuries were reported for either group during the study. CONCLUSIONS: Findings suggest that assistive devices such as a PPS can be effective in achieving proper positioning of patients to prevent development of pressure ulcers.

Outcome Evaluation of a Health System Clinical Nurse Specialist Fellowship Program.

PURPOSE: Healthcare is a complex adaptive system, requiring agile, innovative leaders to transform care. Clinical nurse specialists (CNSs) are uniquely positioned to influence change and achieve high-quality outcomes. Nurse leaders need strategies to onboard and retain CNSs considering high demand across the nation. The purpose of this program evaluation was to describe the core components and outcomes of CNS fellowship programs. DESIGN: This program evaluation used the Kirkpatrick Model as a framework to assess learning and knowledge translation. METHODS: The study was conducted within 3 Indiana healthcare organizations. Clinical nurse specialist leaders from each organization identified fellowship core components and analyzed team composition (ie, percentage of CNS team that was current/past fellows). Current and past CNS fellows were invited to participate in a survey evaluating program effectiveness, impact on role transition, project leadership, and outcomes achieved. RESULTS: Overlap was identified among 85% (17/20) of the core components, team composition was 71% (25/35) past/current fellows, and retention was 100% (12/12). Of the 23 invited, 18 (78%) participated in the program evaluation. Program effectiveness was evaluated as very/extremely effective by 94% (17/18) of participants. Themes salient to independent practice transition were applying learning, achieving influence, and developing relationally, contributing to incremental gain of the CNS perspective (ie, CNS values and guiding principles influencing critical thinking and behavior). CONCLUSION: Nurse leaders should consider fellowship implementation to recruit and retain CNS talent within organizations.

Fasting Versus a Heart-Healthy Diet Before Cardiac Catheterization: A Randomized Controlled Trial.

BACKGROUND: Patients undergoing cardiac catheterization are ordered to take nothing by mouth after midnight before their procedure with no evidence to support this practice. OBJECTIVE: To identify best practice for fasting requirements before cardiac catheterization through comparative evaluation in a prospective randomized controlled study. METHODS: The study included a convenience sample of 197 patients undergoing elective cardiac catheterization in a progressive inpatient cardiac unit at a regional heart institute in the midwestern United States. The patients were randomized into 2 groups. Patients in the heart-healthy diet group could eat a specified diet with low-acid options until the scheduled procedure. Patients in the fasting group were restricted to nothing by mouth after midnight except for sips of water with medications until the scheduled procedure. Outcome measures included patient-reported satisfaction and complications. RESULTS: Compared with patients in the fasting group, those in the heart-healthy diet group had significantly more satisfaction with the preprocedural diet. Patients in the heart-healthy diet group had less thirst and hunger before and after the procedure. No patients experienced pneumonia, aspiration, intubation, or hypoglycemia after the procedure. Fatigue, glucose level, gastrointestinal issues, and loading dose of antiplatelet medication did not differ between the groups. CONCLUSIONS: Allowing patients to eat before elective cardiac catheterization posed no safety risk and benefited patient satisfaction and overall care. The results of this study may help identify best practice for allowing patients to eat before elective procedures using conscious sedation.

Effect of Weighted Blanket Versus Traditional Practices on Anxiety and Pain in Patients Undergoing Elective Surgery: A Multicenter Randomized Controlled Trial.

Perioperative anxiety is common in surgical patients and linked to poor outcomes. This multicenter randomized controlled trial assessed the effect of the use of a warm weighted blanket on presurgical anxiety and pain, as well as postsurgical restlessness, nausea, and vomiting. Levels of anxiety and pain were measured in adult patients using a 100-point visual analog scale before elective surgery. Patients received either a warm weighted blanket (n = 74) or a traditional sheet or nonweighted blanket (n = 74). Patients in the intervention group had significantly lower preoperative anxiety scores (mean [SD] = 26.28 [25.75]) compared to the control group (mean [SD] = 38.73 [30.55], P = .008). However, the intervention had no significant effect on presurgical pain or postsurgical nausea, vomiting, or restlessness. These results suggest that weighted blankets reduce preoperative anxiety in adult patients.

Innovative strategy to improve enteral nutrition in prone positioning with patients with COVID-19.

BACKGROUND: Enteral nutrition is essential to improve outcomes in patients who are critically ill. Patients in the prone position, including those diagnosed with coronavirus disease 2019 (COVID-19) present additional challenges for enteral nutrition initiation. METHODS: A novel technique for placing feeding tubes while in the prone position was developed using an electromagnetic placement device and specialty trained clinical nurse specialists. Data were assessed retrospectively to determine effectiveness of this new practice. RESULTS: Sixty-eight patients had feeding tubes placed while in the prone position; 75% were able to be placed through the postpyloric route, 22% were placed through the gastric route, and 3% unable to be placed. Use of this technique facilitated earlier initiation of feedings by 2 days from time of admission and almost half a day from intubation to feeding. There was no additional radiation exposure from using this technique. CONCLUSION: Ability to place feeding tubes early while patients were prone reduced delays for starting enteral nutrition. Patients with COVID-19 in the prone position were able to receive effective nutrition support earlier with no additional complications.

Multisite Evaluation of Toothbrushes and Microbial Growth in the Hospital Setting.

DESIGN: This observational, descriptive study was conducted to determine the prevalence of microbial growth on toothbrushes found in hospital patient rooms. METHODS: Toothbrush sampling was conducted in 136 acute care hospitals and medical centers from November 2018 through February 2022. Inclusion criteria for the units and patient rooms sampled were as follows: general adult medical-surgical units or critical care units; rooms occupied by adults 18 years or older who were capable of (1) mobilizing to the bathroom; (2) using a standard manual, bristled toothbrush; and (3) room did not have signage indicating isolation procedures. RESULTS: A total of 5340 patient rooms were surveyed. Of the rooms included, 46% (2455) of patients did not have a toothbrush available or had not used a toothbrush (still in package and/or toothpaste not opened). Of the used toothbrushes collected (n = 1817): 48% (872/1817) had at least 1 organism; 14% (251/1817) of the toothbrushes were positive for 3 or more organisms. CONCLUSIONS: These results identify the lack of availability of toothbrushes for patients and support the need for hospitals to incorporate a rigorous, consistent, and comprehensive oral care program to address the evident risk of microbe exposure in the oral cavity.

ARCCH Model of Resilience: A Flexible Multisystemic Resilience Framework.

The increasing prevalence and impact of trauma, such as adverse childhood experiences, race-based trauma, and a global pandemic, highlight the critical need for a flexible multisystemic framework of resilience. This manuscript outlines the universality of trauma and resilience and also provides a description of the gaps in existing resilience frameworks that led to the development of a flexible multisystemic resilience framework entitled the ARCCH Model of Resilience. Attachment, Regulation, Competence, Culture, and Health are elements of personal and cultural identities, families, communities, and systems that can be used to evaluate strengths, identify areas that need support, and provide steps for culturally responsive and ecologically valid interventions. A multisystemic application of ARCCH is provided.

When is enteral nutrition indicated?

Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients.

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Pneumothoraces Prevented With Use of Electromagnetic Device to Place Feeding Tubes.

BACKGROUND: A US Food and Drug Administration safety letter warned about the risk for pneumothoraces during feeding tube insertion despite the use of electromagnetic placement devices that provide real-time visualization of feeding tube position. OBJECTIVES: To systematically assess pulmonary placement and pneumothoraces in CORTRAK-assisted feeding tube insertions. METHODS: CINAHL, MEDLINE, and Cochrane databases were searched for studies of CORTRAK-assisted feeding tube insertion. Thirty-two studies documenting pulmonary placement and/or complications of feeding tube insertion were found. RESULTS: Operators recognized pulmonary placement on insertion tracings during 202 CORTRAK-assisted feeding tube insertion procedures, resulting in the immediate withdrawal of 199 feeding tubes. One pneumothorax was identified later by radiography. Seven pulmonary placements were not recognized by CORTRAK operators at the time of feeding tube insertion, resulting in 2 pneumothoraces. The incidence of pneumothorax for CORTRAK-assisted feeding tube insertions was 0.02% (3 of 17039). Of the feeding tubes inserted into the pulmonary system - either found during or after the procedure -1.4% (3 of 209) resulted in pneumothoraces (as opposed to the 19% to 28% incidence of pneumothorax for blind feeding tube insertions. Operators recognizing pulmonary placement on CORTRAK insertion tracings may have prevented 97% (202 of 209) of feeding tubes from being inserted farther into the respiratory tract. CONCLUSIONS: Feeding tube insertion with an electromagnetic placement device is advantageous over blind feeding tube insertion because the operator can recognize pulmonary placement early and withdraw the feeding tube, thus decreasing the risk of pulmonary complications.