NURSING WORKLOAD
Staffing should reflect patient acuity
To determine whether nurse staffing and nursing workload are associated with multiple organ failure and mortality, a cross-sectional study was conducted in a teaching hospital from 2008 to 2017. Investigators examined the association between nurse staffing, nursing workload, and prognosis using daily nurse-to-patient ratios, Therapeutic Intervention Scoring System scores, Intensive Care Nursing Scoring System scores, and Intensive Care Nursing Scoring System indexes. They also considered the timing of ICU admission. The final analysis included 10,230 patients.
The results showed that the proportion of understaffing was significantly more common in patients with multiple organ failure than in those without. The levels of nursing associated with workload and understaffing "were at their worst on weekends," the authors wrote. No difference was found in the proportion of understaffing among survivors and nonsurvivors. They concluded that "an adequate level of nurse staffing in relation to patient complexity is a prerequisite for the availability and quality of critical care."
According to the authors, this is the first study to evaluate nurse staffing and nursing workload as potential risk factors for multiple organ failure and mortality.
Source: Jansson M, Ohtonen P, Syrjala H, Ala-Kokko T. The proportion of understaffing and increased nursing workload are associated with multiple organ failure: a cross-sectional study. J Adv Nurs. [e-pub June 2, 2020]
COVID-19 INFECTION
Clinical course includes acute kidney injury
Researchers at a large academic medical center in New York City conducted a retrospective medical record review to describe the clinical course of patients with COVID-19 across the ED, nursing units, and ICUs. For the study, they extracted data on the first 1,000 consecutive patients admitted to the ED or hospital who had tested positive for COVID-19 on a reverse transcriptase polymerase chain reaction assay between March 1 and April 5, 2020.
The data showed that these patients faced major morbidity and mortality and long lengths of stay (median, 23 days). In addition, 78% developed acute kidney injury and 35% required dialysis. Time from symptom onset to intubation had a "bimodal distribution," the authors write, with the first mode at 3 to 4 days and the second at 9 days. At the end of April, 90 patients remained hospitalized and 211 had died in the hospital.
The authors write, "patients in hospital with COVID-19 in New York City had high rates of baseline comorbidities and a substantial proportion developed complications compared with previously studied US and international cohorts. Our characterization of patients could provide anticipatory guidance as the pandemic continues around the world."
Source: Argenziano MG, Bruce SL, Slater CL, et al. Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series. BMJ. 2020;369:m1996.
SMOKING CESSATION
New recommendations for adults, pregnant women
In a recently released draft recommendation statement, the US Preventive Services Task Force (USPSTF) recommends behavioral interventions and FDA-approved pharmacotherapy for smoking cessation in nonpregnant adults, and behavioral interventions for pregnant women. Recommended pharmacotherapy for nonpregnant patients includes nicotine replacement therapy, bupropion hydrochloride sustained-release tablets, and varenicline.
Based on a review of available research, the USPSTF concludes that the evidence is insufficient to assess the balance of risks and benefits of pharmacotherapy in pregnant women. However, the benefits of behavioral counseling for tobacco smoking cessation on perinatal outcomes and smoking cessation is "substantial." The evidence shows that smoking cessation during late pregnancy is greater for women receiving any type of behavioral interventions; in addition, behavioral interventions are associated with an increase in mean birth weight.
The risks and benefits of e-cigarette use for smoking cessation is insufficient to recommend this intervention. The USPSTF considers the lack of well-designed, randomized, controlled trials on e-cigarette use that report smoking abstinence or adverse events to be "a critical gap in the evidence."
Based on the evidence, the USPSTF urges clinicians to ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and pharmacotherapy (if appropriate) to aid cessation.
Source: US Preventive Services Task Force. Draft recommendation statement. Tobacco smoking cessation in adults, including pregnant persons: interventions. June 2, 2020. https://uspreventiveservicestaskforce.org.
CROHN DISEASE
Preventing a serious complication in youth
From 15% to 30% of people with Crohn disease develop painful and potentially debilitating perianal fistulas, which are especially common in children and young adults. A new study shows that patients treated with steroid-sparing therapies were significantly less likely to develop perianal fistulas than those who did not. The steroid-sparing therapies studied were immunomodulators and/or tumor necrosis factor-alpha inhibitors initiated before either development of a perianal fistula or the end of the study period.
This comparative effectiveness analysis matched 2,214 young people with Crohn disease without perianal fistulizing complications via propensity score. Almost 20% developed perianal fistulizing complications within 2 years of diagnosis. Treatment with steroid-sparing therapy was statistically significantly associated with a 59% reduction in perianal fistulizing complications. In addition, among patients who developed perianal fistulizing complications and who had been previously treated with steroid-sparing therapy, fewer underwent ostomy.
Despite advances in care for patients with Crohn disease, perianal fistulas are difficult to treat and commonly recur, the authors write, and about 70% of patients eventually undergo surgical interventions that may provide only temporary relief. They say their findings suggest that perianal fistulas may be preventable in young people treated with steroid-sparing therapies and these therapies should be considered for all patients with Crohn disease.
Source: Adler J, Lin CC, Gadepalli SK, Dombkowski KJ. Association between steroid-sparing therapy and the risk of perianal fistulizing complications among young patients with Crohn disease. JAMA Netw Open. 2020;3(6):e207378.
OLDER ADULTS
Hemorrhagic stroke remains a concern
Intracerebral hemorrhage (ICH) has the highest mortality of all stroke types and is the most serious complication of anticoagulation. In a cohort study of 10,333 participants from the Framingham Heart Study, researchers found a generally stable age-adjusted ICH incidence rate between 1985 and 2016. However, an age-stratified analysis indicated a continued increase in the incidence rate among adults age 75 and older, which coincides with a threefold increase in the use of anticoagulant medications. In addition, the findings showed that the use of statin medications is associated with the risk of a deep ICH event, but the authors caution against misinterpreting those findings. "We are not advocating that people stop taking statins or anticoagulants," says senior author Sudha Seshadri, MD. "Those therapies reduce the risk of ischemic strokes, which represent approximately nine of every 10 strokes, with intracerebral hemorrhages representing the other tenth." As the population ages, however, "we should find new means of prevention of these strokes, and at the same time healthcare systems should be ready to treat more hemorrhages in the future."
Sources: Lioutas V-A, Beiser AS, Aparicio HJ, et al. Assessment of incidence and risk factors of intracerebral hemorrhage among participants in the Framingham Heart Study between 1948 and 2016. JAMA Neurol. [e-pub June 8, 2020]. University of Texas Health Science Center at San Antonio. Stroke bleeds in the brain not decreasing, Framingham study finds. News release. June 8, 2020.
HOSPICE CARE
Educational video informs preferences
Many patients with advanced cancer and their families have misconceptions about hospice care that interfere with the timely use of this service. Common misconceptions concern eligibility for hospice, financial coverage, the extent of care provided, and the appropriate time for enrollment. To determine if an educational video would dispel misconceptions and encourage timely hospice use, researchers conducted a single-site randomized trial of a video educational tool versus a verbal description of hospice in 150 hospitalized patients with advanced cancer and their caregivers. In the intervention group, 75 patients and 18 caregivers viewed a 6-minute video depicting hospice. The control group (75 patients and 26 caregivers) received a verbal description identical to the video narrative. The primary outcome was patient preference for hospice. Secondary outcomes included patient and/or caregiver knowledge and perceptions of hospice, and hospice use.
Participants completed several standardized questionnaires before randomization and immediately after the video intervention or verbal narrative. The researchers found no difference between the two groups in terms of patient preferences for hospice but viewing the video did improve patients' knowledge and perceptions of hospice, enhanced their hospice use, and extended their length of stay in hospice. In addition, compared with caregivers in the control group, caregivers assigned to the video were:
* more likely to prefer hospice for their loved ones (94% versus 65%).
* better informed about hospice (10% versus 8%).
* less likely to believe hospice is only about death (0% versus 23%).
The authors conclude, "Given the potential for this scalable and low-cost intervention to improve hospice use ... a future multisite trial to confirm the efficacy and generalizability of this intervention across care settings is warranted."
Source: El-Jawahri A, Traeger L, Greer JA, et al. Randomized trial of a hospice video educational tool for patients with advanced cancer and their caregivers. Cancer. [e-pub June 8, 2020]
POST-COVID INFECTION
Giving athletes a game plan
Many hospitalized patients with COVID-19 infection experience significant cardiac morbidity. How soon after recovery from a COVID-19 infection can an athlete or highly active individual resume playing competitive or recreational sports without risking cardiac complications? While recognizing that evidence-based data are currently scant, the American College of Cardiology's Sports & Exercise Cardiology Council, with input from national leaders in sports cardiology, offers a consensus expert opinion algorithm to help clinicians advise highly active patients on return to play. The algorithm provides a guide according to one of three tracks: asymptomatic; mild symptoms, not hospitalized; and significant symptoms, hospitalized. For example:
* athletes who are asymptomatic should refrain from activity for 2 weeks following the positive test result and be closely monitored. After 2 weeks, they may slowly resume activity under the care of a healthcare provider or team.
* a patient with mild symptoms who was not hospitalized should rest during the symptomatic phase, followed by another 2 more weeks of convalescence without exercise after symptoms resolve. At that point, the patient should be evaluated based on a 12-lead ECG, testing for cardiac biomarkers, cardiac imaging, and other symptom-guided tests.
* a patient hospitalized with significant symptoms should undergo more extensive convalescence and testing before resuming strenuous activity.
Regardless of a patient's symptoms or fitness level, the authors stress the importance of resting without exercise during the acute phase of COVID-19. They also caution that their recommendations are "exclusive to cardiovascular considerations and concomitant pulmonary limitations also require consideration."
Source: Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiol. [e-pub May 13, 2020]