Evaluating and Enhancing Nursing Caregiver Well-being Using a Systematic Approach.

OBJECTIVE: The aims of this study were to evaluate nursing caregiver well-being and identify interventions for improving well-being and practice environments. BACKGROUND: Healthcare worker well-being and burnout command increasing attention in the wake of the pandemic. Experts recommend utilization of validated measurements to assess burnout, well-being, and contributing factors. METHODS: Using a descriptive, cross-sectional, mixed-methods study design, an online survey, which included the Professional Quality of Life-5, Meaning and Joy in Work Questionnaire, and open-ended questions, was administered to nurses and unlicensed assistive caregivers in an academic health system. RESULTS: Caregivers reported moderate compassion satisfaction, low burnout and compassion fatigue, and low-moderate levels of meaning and joy in work. Overall and subscale scores varied primarily based on age, experience, and role. Top causes of stress and recommendations for improvement were identified. CONCLUSION: The levels of meaning and joy in work among nursing caregivers continue to be of concern for organizational leaders. The engagement of nurses and other caregiver team members in a systematic mixed-methods approach, including using validated tools to evaluate caregiver well-being, can lead to meaningful, data-driven action planning to promote well-being and increase the meaning and joy of the work they perform.

Comparison of Infant Length Measurements Using Tape Measure Versus Length Board.

BACKGROUND: For infants requiring intensive care, infant length is a primary gauge of nutrition and forms the basis for important future treatment decisions. However, existing evidence demonstrates discrepancies in infant length measurements between tape measure and length board. PURPOSE: To compare the accuracy and reliability of infant length measurements using tape measure (standard practice) and length board in a neonatal intensive care unit (NICU) at a public academic medical center. METHODS: Using a single-group, quasi-experimental, repeated-measures design, 108 infants (35.58 ± 3.68 weeks, male 59%, 2124.83 ± 881.69 g) admitted to the NICU were prospectively enrolled. Clinical nurses measured infants weekly per unit-based protocol using tape measures. Study team measured length using length boards within 24 hours of tape measurement. Primary outcome was infant length. Length measurements were converted to sex-specific Fenton or WHO growth percentiles. Linear mixed-effects regression, κ coefficient, intraclass correlation coefficient, and positive predictive value were calculated. FINDINGS/RESULTS: The main effect of measurement conditions and time was significant. Predicted length was 0.38 cm lower for length board than for tape measure over time. Weighted κ coefficient and intraclass correlation coefficient indicated good to excellent agreement. More than 37% of infants shifted to a new percentile category based on both measurements. Positive predictive value of length board at time 1 was 63%. IMPLICATIONS FOR PRACTICE: Length board measurements are reliable for accurate classification of an infant's growth curve to influence diagnosis and future plan of care. IMPLICATIONS FOR RESEARCH: Future research warrants replication using a longitudinal design across multiple sites.

Ethics and frontline nursing during COVID-19: A qualitative analysis.

BACKGROUND: Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses' experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. RESEARCH AIM: To analyze frontline U.S. nurses' experiences of ethics during the COVID-19 pandemic. RESEARCH DESIGN: Qualitative analysis using a directed content methodology. PARTICIPANTS AND RESEARCH CONTEXT: The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. ETHICAL CONSIDERATIONS: Participant privacy and data confidentiality were addressed. FINDINGS: Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. DISCUSSION: This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. CONCLUSIONS: Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available.

Success in Supporting Early Mobility and Exercise in a Cardiothoracic Intensive Care Unit.

Early mobility contributes to improved patient outcomes and reduced hospital length of stay during acute and intensive care hospitalization. The Bedside Mobility Assessment Tool was implemented in a cardiothoracic intensive care unit during participation in a nationwide evidence-based quality improvement initiative. One outcome included a high level of mobility that was sustained over time. Using the Dynamic Sustainability Framework model, this article describes the key components that contributed to this sustained mobility performance over 4 years.

Nursing perspectives about the critical gaps in public health emergency response during the COVID-19 pandemic.

INTRODUCTION: The purpose of this qualitative study was to synthesize frontline U.S. nursing perspectives about the current state of U.S. public health emergency preparedness and response. The study findings may inform public health policy change and improve future national pandemic planning and responses. DESIGN: We conducted a secondary thematic qualitative analysis using grounded theory methodology. METHODS: Data collection occurred through semi-structured, in-depth focus groups between July and December 2020, from 43 frontline nurses working in hospitals in four states (Ohio, California, Pennsylvania, and New York). Data were analyzed deductively, aligned with Khan et al.'s Public Health Emergency Preparedness Framework and inductively for emergent themes. RESULTS: Three themes emerged: (1) Validation of the presence of health disparities and inequities across populations; (2) Perceived lack of consistency and coordination of messaging about pandemic policies and plans across all levels; and (3) challenges securing and allocating nursing workforce resources to areas of need. CONCLUSION: From a frontline nursing perspective, this study demonstrates the critical need to address health inequities and inequalities across populations, a consistent national vehicle for communication, and national plan for securing and allocating nursing workforce resources.

Reflections From the Middle: Exploring the Experience of Nurse Managers Across the United States During the COVID-19 Pandemic.

OBJECTIVE: The objective of this multisite study was to explore the professional and personal experiences of US nurse managers (NMs) during the COVID-19 pandemic. BACKGROUND: NMs are the most accessible and visible nurse leaders to the frontline staff during this pandemic. METHODS: Thirty-nine NMs from 5 health systems across the US participated in focus groups in this qualitative study. Data were analyzed using a constant comparative method. RESULTS: Three major themes were identified: challenges, feelings and emotions, and coping. Subthemes emerged within each major theme. CONCLUSION: NMs across the country accepted considerable responsibility at great professional and personal consequence during the pandemic. NMs experienced challenges, ethical dilemmas, and expressed negative emotions. As the usual coping strategies failed, NMs reported that they are considering alternative career choices. This work provided evidence to help senior leaders strategize about mechanisms for reducing managerial dissonance during times of stress.

United States nurses' experiences during the COVID-19 pandemic: A grounded theory.

OBJECTIVE: The objective of this study was to explore nurses' experiences and perceptions at selected United States (U.S.) healthcare sites during the COVID-19 pandemic. BACKGROUND: The COVID-19 pandemic brought rapid changes to the healthcare community. While a few studies have examined the early pandemic experiences of nurses in China and Europe, nurses' experiences across the United States have remained relatively underexplored. DESIGN: A qualitative study design was used. METHODS: Using a constructivist grounded theory methodology and methods, we conducted eight focus groups across four hospital sites in the eastern, midwestern and western United States. Registered nurses with a minimum of six months' experience working in all clinical specialties were eligible. Forty-three nurses participated. Data were analysed iteratively using the constant comparative method. The COREQ guidelines supported the work and reporting of this study. RESULTS: The nurses experiencing a pandemic (NEXPIC) grounded theory emerged positing associations between four interrelated themes: Challenges, Feelings, Coping and Ethics. Nurses reported Challenges associated with changes in the work environment, community and themselves. They expressed more negative than positive feelings. Nurses coped using self-care techniques, and teamwork within the healthcare organisation. Moral dilemmas, moral uncertainty, moral distress, moral injury and moral outrage were ethical issues associated with nurses' Challenges during the pandemic. Moral courage was associated with positive Coping. CONCLUSIONS: Awareness of frontline nurses' complex and interrelated needs may help healthcare organisations protect their human resources. This new theory provides preliminary theoretical support for future research and interventions to address the needs of frontline nurses. RELEVANCE TO CLINICAL PRACTICE: Nurses face added distress as frontline at-risk caregivers. Interventions to promote nurses' ability to cope with personal and professional challenges from the pandemic and address ethical issues are needed to protect the nursing workforce. This study offers a new substantive theory that may be used to underpin future interventions.

A Comparison of Local Anesthetics for Intravenous Catheter Insertion in Hospitalized Pediatric Patients: A Randomized Clinical Pilot Trial.

Peripheral intravenous catheter (PIVC) insertion is one of the most painful procedures pediatric patients undergo during hospitalization. To date, local anesthetics delivered via cream, patch, and needle-free injection have not been rigorously evaluated together. This study aimed to investigate feasibility and potential efficacy of local anesthetics on pain intensity during PIVC insertion in an unblinded, single-center, randomized clinical pilot trial. Between March 2017 and February 2020, 88 hospitalized children aged 12 months to 18 years in an acute pediatric unit at an academic medical center were randomized to 1 of 3 local anesthetics: 1) lidocaine/prilocaine cream, 2) lidocaine/tetracaine patch, and 3) unbuffered lidocaine needle-free injection. Feasibility outcomes were recruitment and protocol adherence. Pain intensity was measured using the Face, Legs, Activity, Cry, Consolability (age <8 years) and Verbal Numeric Rating (VNRS) scales (age ≥8 years) before, during, and after procedure. Secondary outcomes included catheterization attempts, procedure time, and parent satisfaction. Recruitment rate was acceptable (2.7 patients per month). Protocol adherence was high (92%). Preliminary clinical findings showed no significant difference in pain intensity across treatments. Procedure time to successful insertion differed in the VNRS group, favoring unbuffered lidocaine needle-free injection. Conduct of a definitive, full-scale randomized clinical trial in the hospitalized pediatric population is feasible.

Nursing Management of a Patient With COVID-19 Receiving ECMO: A Case Report.

INTRODUCTION: Venovenous extracorporeal membrane oxygenation has been recommended as an effective rescue therapy for select critically ill patients with COVID-19. This case report describes a first experience caring for a patient with COVID-19 who received venovenous extracorporeal membrane oxygenation and expands the literature by discussing relevant nursing management and operational considerations. CLINICAL FINDINGS: A 46-year-old man presented to a hospital emergency department with pleuritic chest pain, dyspnea, anorexia, and chills. The patient was intubated for pneumonia-associated acute respiratory distress syndrome. DIAGNOSIS: A nasopharyngeal swab specimen was positive for SARS-CoV-2, and chest radiography confirmed a diagnosis of COVID-19 with acute respiratory distress syndrome. INTERVENTIONS: After no improvement with mechanical ventilation and prone positioning, the patient began receiving venovenous extracorporeal membrane oxygenation and was transferred to an extracorporeal membrane oxygenation center. Frontline critical care nurses played a vital role in coordinating patient care activities, monitoring changes in the patient's condition, and detecting complications early. OUTCOMES: The patient was decannulated on day 15 and extubated on day 17. The patient was successfully discharged home on hospital day 24. CONCLUSION: Caring for a patient with COVID-19 receiving venovenous extracorporeal membrane oxygenation posed unprecedented challenges that required deviations from standards of care to optimize infection control measures and staff safety while providing quality care. This case report may inform, prepare, and guide other critical care nurses who will be caring for similar patients during this pandemic.

The Impact of Boost Methodology on Nurse Knowledge Retention: A Longitudinal, Quasi-Experimental Sepsis Simulation Pilot Study.

Boost methods for reinforcing educational content have been found to train the brain to designate information as important. A longitudinal, quasi-experimental study design evaluated the effect of an interprofessional simulated patient sepsis video with educational boosts on knowledge retention among acute care nurses at a large academic health system using linear mixed-effects modeling. Findings suggest that boost methods may impact nurse knowledge retention, potentially eliminating the need to repeat costly, traditional educational efforts.

Implementing SAFE™ care: Evaluation of a geriatric model of care for real-world practice.

Systems Addressing Frail Elders (SAFETM) Care is a geriatric model of care that identifies high-risk hospitalized older adults, and provides targeted interprofessional interventions for risk factors associated with frailty. This post, mixed methods study sought to evaluate SAFETM Care implementation retrospectively at one public academic medical center and describe practical "real-world" considerations for implementation using the Consolidated Framework for Implementation Research (CFIR). In addition to barriers and facilitators, hidden characteristics to consider for implementation include initiating conditions, skills and experiences of implementers, interpersonal challenges, unique facilitators and barriers, surprising conditions, and threats to and requirements for sustainability. Implementation of SAFETM Care demonstrated effective adoption and implementation, but faced multiple threats that led to failed sustainability. The public sharing of these successes and failures will help implementers understand and make progress in adapting such important geriatric programs and quality improvement initiatives.

Current Perspectives on Coronavirus Disease 2019 and Cardiovascular Disease: A White Paper by the JAHA Editors.

Coronavirus Disease 2019 (COVID-19) has infected more than 3.0 million people worldwide and killed more than 200,000 as of April 27, 2020. In this White Paper, we address the cardiovascular co-morbidities of COVID-19 infection; the diagnosis and treatment of standard cardiovascular conditions during the pandemic; and the diagnosis and treatment of the cardiovascular consequences of COVID-19 infection. In addition, we will also address various issues related to the safety of healthcare workers and the ethical issues related to patient care in this pandemic.

Comparison of family centered care with family integrated care and mobile technology (mFICare) on preterm infant and family outcomes: a multi-site quasi-experimental clinical trial protocol.

BACKGROUND: Family Centered Care (FCC) has been widely adopted as the framework for caring for infants in the Neonatal Intensive Care Unit (NICU) but it is not uniformly defined or practiced, making it difficult to determine impact. Previous studies have shown that implementing the Family Integrated Care (FICare) intervention program for preterm infants in the NICU setting leads to significant improvements in infant and family outcomes. Further research is warranted to determine feasibility, acceptability and differential impact of FICare in the US context. The addition of a mobile application (app) may be effective in providing supplemental support for parent participation in the FICare program and provide detailed data on program component uptake and outcomes. METHODS: This exploratory multi-site quasi-experimental study will compare usual FCC with mobile enhanced FICare (mFICare) on growth and clinical outcomes of preterm infants born at or before 33 weeks gestational age, as well as the stress, competence and self-efficacy of their parents. The feasibility and acceptability of using mobile technology to gather data about parent involvement in the care of preterm infants receiving FCC or mFICare as well as of the mFICare intervention will be evaluated (Aim 1). The effect sizes for infant growth (primary outcome) and for secondary infant and parent outcomes at NICU discharge and three months after discharge will be estimated (Aim 2). DISCUSSION: This study will provide new data about the implementation of FICare in the US context within various hospital settings and identify important barriers, facilitators and key processes that may contribute to the effectiveness of FICare. It will also offer insights to clinicians on the feasibility of a new mobile application to support parent-focused research and promote integration of parents into the NICU care team in US hospital settings. TRIAL REGISTRATION: ClinicalTrials.gov, ID NCT03418870. Retrospectively registered on December 18, 2017.

Validation of a radioimmunoassay of serum trypsin-like immunoreactivity in ferrets.

Measurement of serum trypsin-like immunoreactivity (TLI) is used to assess exocrine pancreatic function in dogs and cats. Ferrets ( Mustela putorius furo) serve as valuable animal models for human diseases such as cystic fibrosis and other pulmonary diseases, and may be a useful model of other diseases including pancreatitis. We developed and analytically validated a competitive radioimmunoassay (RIA) for measurement of TLI in ferret serum by determination of analytical sensitivity, assay linearity, accuracy of spiking recovery, precision, and reproducibility. Analytical sensitivity of the assay was 0.55 µg/L. Observed-to-expected (O/E) ratio for dilutional parallelism was 90.2-127.9% (mean: 108.1 ± 11.9%). The O/E ratio for spiking recovery was 94.5-113.0% (mean: 103.9 ± 7.2%). The intra- and inter-assay coefficients of variation (CVs) were 2.7-5.7% and 3.5-8.2%, respectively. The reference interval (RI) for serum TLI derived from 31 healthy ferrets was 28-115 µg/L; the 90% confidence interval for the lower and upper limits of the RI were 10.0-32.1 µg/L and 103-126 µg/L, respectively. This TLI RIA is analytically sensitive, sufficiently linear, accurate, precise, and reproducible for the measurement of TLI in ferret serum samples.

Developing Policies and Protocols in the Age of Evidence-Based Practice.

Prior to evidence-based practice, policies and procedures were reviewed annually or even triennially to ensure that they reflected current practice and demonstrated adherence to regulatory standards. With the publication of the Institute of Medicine report, a shift to operationalization of best evidence practices, formal statements, and frameworks for care has gained increased importance. Processes for policy and protocol development and revision are now based on the inclusion of best evidence, clinician expertise, and patient values or preference. Policies and protocols are now updated when new evidence justifies a revision and are designed to share the most recent evidence and facilitate staff adherence to new practices. This article describes the essential practices for policy and protocol development, including leadership support, team commitment, identification of current resources, recognition of current practices, development of the policy and protocol to logically flow with nursing practices, effective dissemination methods, and evaluation and sustainability practices. J Contin Nurs Educ. 2017;48(2):87-92.

Effects of the Use of the Provider Resilience Mobile Application in Reducing Compassion Fatigue in Oncology Nursing.

BACKGROUND: Oncology nurses have increased exposure to the prolonged illness, tragedy, loss, and premature death of patients. As a result, they are at higher risk for developing compassion fatigue. OBJECTIVES: The aim of this study was to examine if use of the Provider Resilience mobile application (PRMA) will improve oncology nurses' professional quality of life. METHODS: The quasiexperimental design was comprised of a longitudinal approach to evaluate the effect of an intervention program, PRMA, on professional quality of life between two nonrandomized groups (intervention and control) using pre- and post-tests in a sample of oncology RNs. FINDINGS: The findings of this study demonstrated no significant relationships between the intervention and control groups on secondary traumatic stress, compassion satisfaction, and burnout among oncology nurses.

Effect of high-frequency chest wall oscillation versus chest physiotherapy on lung function after lung transplant.

PURPOSE: The aim of this study is to compare the effects of chest physiotherapy (CPT) and high-frequency chest wall oscillation (HFCWO) on lung function in lung transplant recipients. BACKGROUND: Chest physiotherapy and HFCWO are routinely used after lung transplant to attenuate dyspnea, increase expiratory flow, and improve secretion clearance. METHODS: In a two-group experimental, crossover design with repeated-measures, 45 lung transplant recipients (27 single, 18 bilateral; 64% male; mean age, 57 years) were randomized to receive CPT at 10:00 AM and 2:00 PM followed by HFCWO at 6:00 PM and 10:00 PM (n=22) or vice versa (n=23) on postoperative day 3. Dyspnea (modified Borg score), Spo2/FiO2, and peak expiratory flow (PEF) were measured pre-treatment and post-treatment. Data were analyzed using chi-square tests, t tests, and linear mixed effects models. RESULTS: There was no statistically significant treatment effect for dyspnea or PEF in patients who received HFCWO versus CPT. However, there was a significant treatment effect on the Spo2/FiO2 ratio (p<0.0001). CONCLUSIONS: Preliminary results suggest that lung function (measured by Spo2/FiO2) improves with HFWCO after lung transplantation. Although dyspnea and PEF did not differ significantly between treatment types, HFCWO may be an effective, feasible alternative to CPT.

Exhaustion, immuno-inflammation, and pathogen burden after cardiac surgery: an exploratory study.

BACKGROUND: Exhaustion, a consequence of prolonged stress characterized by unusual fatigue, is associated with increased risk of cardiac morbidity and mortality. In patients recovering from coronary artery bypass (CABG), little is known about the relationship of 1) immune-mediated inflammation and resultant endothelial activation, and 2) cumulative exposure to infectious pathogens (pathogen burden (PB)) implicated in coronary atherosclerosis to exhaustion. AIM: The aim of this exploratory study was to investigate the association of PB, inflammatory markers (interleukin (IL)-6, IL-10) and a marker of endothelial activation (soluble intercellular adhesion molecule-1 (sICAM-1)) to exhaustion. METHODS: One to two months post-CABG, 42 individuals who met inclusion criteria were assessed for exhaustion using the Maastricht Interview for Vital Exhaustion. Serum IgG antibodies to herpes simplex virus (HSV)-1, HSV-2, cytomegalovirus, Epstein Barr virus, and inflammatory and endothelial activation markers were measured by enzyme-linked immunosorbent assay. Pathogen burden was defined as the total number of seropositive exposures: low (0-1), moderate (2-3), and high (4). RESULTS: Prevalence of exhaustion was 40.5%. Relative to non-exhausted patients, exhausted patients demonstrated a higher frequency of moderate PB (h=0.73, p=0.04) but lower frequency of high PB (h=1.05, p=0.03). Exhaustion showed a non-significant trend for positive correlations with IL-6 and sICAM-1 levels, and inverse relation to PB. In subgroup analysis, exhausted patients had stronger correlations with IL-6 and IL-6:IL-10 and a tendency towards higher serum IL-10 concentrations compared with their non-exhausted counterparts. CONCLUSION: This hypothesis-generating study provides preliminary evidence that elevated post-CABG exhaustion may be associated with PB, inflammation, and endothelial activation.

CNE article: pain after lung transplant: high-frequency chest wall oscillation vs chest physiotherapy.

Background Chest physiotherapy and high-frequency chest wall oscillation (HFCWO) are routinely used after lung transplant to facilitate removal of secretions. To date, no studies have been done to investigate which therapy is more comfortable and preferred by lung transplant recipients. Patients who have less pain may mobilize secretions, heal, and recover faster. Objectives To compare effects of HFCWO versus chest physiotherapy on pain and preference in lung transplant recipients. Methods In a 2-group experimental, repeated-measures design, 45 lung transplant recipients (27 single lung, 18 bilateral) were randomized to chest physiotherapy (10 AM, 2 PM) followed by HFCWO (6 PM, 10 PM; group 1, n=22) or vice versa (group 2, n=23) on postoperative day 3. A verbal numeric rating scale was used to measure pain before and after treatment. At the end of the treatment sequence, a 4-item patient survey was administered to assess treatment preference, pain, and effectiveness. Data were analyzed with χ(2) and t tests and repeated-measures analysis of variance. Results A significant interaction was found between mean difference in pain scores from before to after treatment and treatment method; pain scores decreased more when HFCWO was done at 10 AM and 6 PM (P =.04). Bilateral transplant recipients showed a significant preference for HFCWO over chest physiotherapy (11 [85%] vs 2 [15%], P=.01). However, single lung recipients showed no significant difference in preference between the 2 treatments (11 [42%] vs 14 [54%]). Conclusions HFCWO seems to provide greater decreases in pain scores than does chest physiotherapy. Bilateral lung transplant recipients preferred HFCWO to chest physiotherapy. HFCWO may be an effective, feasible alternative to chest physiotherapy. (American Journal of Critical Care. 2013;22:115-125).

Clinical and socio-demographic predictors of postoperative vital exhaustion in patients after cardiac surgery.

BACKGROUND: Vital exhaustion, a psychological state characterized by extreme fatigue, is an independent predictor of future cardiac events. However, the attributes of vital exhaustion following coronary artery bypass (CABG) surgery are poorly understood. OBJECTIVE: The study objective was to assess correlates of vital exhaustion following CABG surgery. METHODS: In a descriptive, exploratory study, 42 patients who had CABG surgery were evaluated for exhaustion 4-8 weeks post-hospital discharge. Demographic and clinical data were obtained from self-report and medical chart review. RESULTS: Of the total sample (mean age 67.9 ± 12.5, 90% male, 70% Caucasian, 3.12 ± 1.3 grafts), approximately 41% reported exhaustion. When compared to their exhausted post-CABG counterpart, non-exhausted post-CABG patients had a significantly higher frequency of preoperative insulin use. Exhausted patients were significantly more likely to have higher left ventricular ejection fraction ([LVEF], OR: 1.07, p = 0.04), and elevated hemoglobin (OR: 2.98, p = 0.03) and eosinophils (OR: 1.02, p = 0.02) than those who were not exhausted. CONCLUSION: Clinicians should evaluate all patients for exhaustion post-CABG surgery; patients with elevated LVEF, hemoglobin, and eosinophil levels warrant increased scrutiny.