Hospitals Need Safer Tubing Connections
Enteral tubing misconnections persist at an alarming rate in U.S. hospitals.
Despite the availability of improved connectors, enteral tubing misconnections persist at an alarming rate in U.S. hospitals, highlighting a critical gap in patient safety and delays in implementing new practices.
“The Lingering Safety Menace: A 10-Year Review of Enteral Misconnection Adverse Events and Narrative Review,” in Nutrition in Clinical Practice, stresses the importance of using ENFit connectors, an international standard for enteral devices, including feeding tubes, administration sets, tubing, syringes and drainage bags.
Before ENFit, a 2011 study revealed more than 100 cases of patient harm associated with accidental connections between enteral feeding systems and nonenteral systems. Even though ENFit became available in 2016, a data search uncovered 96 new instances of misconnections through 2023, including 73% resulting in patient harm or death, the article adds.
ENFit connectors are designed with male and female configurations at connection points, ensuring a secure connection with compatible devices, the article notes. However, U.S. acute care hospitals have been slow to adopt the products, with up to 40% still using older connection methods as of 2023.
The article details several key factors for successful ENFit conversion, including making sure planning includes all key stakeholders, such as nurses, nutritionists, pharmacists and suppliers. Hospitals also should consider partnering with regional facilities so patients can expect the same standard of care everywhere.
“With some healthcare facilities having safer connections, whereas others do not, patients are left in limbo with a variety of products being available where they seek care,” the article adds.
Staff training is also important for introducing the new products and processes and ensuring that everyone understands purpose and function. “A failure to understand the ‘why’ could lead to workarounds that defeat the intent of the safer connection.”
Heart Failure Update Prioritizes Patient Outcomes
The 2024 update reflects the latest research and recommendations.
The American College of Cardiology (ACC) and the American Heart Association (AHA) have updated their clinical performance and quality measures for heart failure (HF), focusing on key areas for improving patient outcomes and informing public reporting initiatives.
Published in Journal of the American College of Cardiology, this 2024 update reflects the latest research and recommendations from the 2022 guidelines issued by ACC, AHA and the Heart Failure Society of America. The document also provides key take-home messages for measures involving:
- Optimal blood pressure control for patients with HF with preserved ejection fraction
- Use of sodium-glucose cotransporter-2 inhibitors for patients with HF across the spectrum of ejection fraction
- Optimizing guideline-directed medical therapy before intervention for chronic secondary severe mitral regurgitation
- Continuing guideline-directed therapy for patients with improved ejection fraction
- Targeting known risks for cardiovascular disease and social determinants of health, as well as patient-centered counseling regarding contraception and pregnancy risks for patients with cardiomyopathy
In a related article in Cardiovascular Business, Steven Hollenberg, Emory Heart and Vascular Center, Atlanta, says the update increases the emphasis on establishing all four pillars of guideline-directed medical therapy for HF. “Clinicians should be assessing and optimizing therapy during a hospital stay to not only provide a good clinical response in the hospital, but also to address a patient’s long-term trajectory after discharge,” Hollenberg adds in the article.
These AACN resources are available to enhance your knowledge of HF care:
- NTI recorded session on pharmacology decision making for HF
- Project focused on reducing 30-day readmission rates for HF by introducing a self-care program for patients and families
- Blog describing how to assess and manage sleep disorders for patients with HF
Another related study, in The Journal of Nurse Practitioners, notes that combining nurse practitioners (NPs) and pharmacists in a team-based strategy is an effective way to implement guideline-directed medical therapy (GDMT) for HF with reduced ejection fraction and to optimize patient outcomes.
The study notes that NPs are particularly skilled in recognizing and preventing gaps in patient care, while pharmacists provide a different perspective, particularly regarding the complex pharmacologic needs of patients with HF. This collaboration demonstrates the ability of NPs and pharmacists to advance GDMT in clinical practice safely and systemically.
Advanced Imaging May Help Detect Cognitive Activity
Data from fMRI or EEG found potential cognitive activity in 25% of patients without observable responses to commands.
A study to assess cognitive motor dissociation in patients with unresponsive brain injury finds that some cognitive tasks are detectable only through functional magnetic resonance imaging (fMRI) or electroencephalography (EEG).
“Cognitive Motor Dissociation in Disorders of Consciousness,” in The New England Journal of Medicine, notes that data from fMRI or EEG found potential evidence of cognitive activity in 25% of patients without observable responses to commands. “Although task-based fMRI and EEG are not yet widely available for the clinical assessment of disorders of consciousness, the knowledge that cognitive motor dissociation is not rare should prompt further study to explore whether its detection can lead to improved outcomes,” adds the prospective cohort study.
The study included 241 patients from six international centers, with fMRI or EEG available for 65% of them and data from both available for 35%. Data reviews found cognitive motor dissociation (covert consciousness) in 60 patients, using the Coma Recovery Scale-Revised methodology.
The study notes that the percentage of patients testing affirmatively is “5 to 10 percentage points higher … than in previous studies.” It suggests that had all patients received both imaging techniques the percentage probably would have been higher.
One possible limitation to the data could be survival bias, since all participants had survived long enough to reach facilities capable of advanced imaging. “Access to both the specially trained personnel and techniques that are needed to assess persons for cognitive motor dissociation is currently available in only a few academic medical centers worldwide, which limits the feasibility of performing these assessments in general practice.”
A related study in Critical Care Medicine, “Covert Consciousness in the ICU,” estimates that 15%-20% of ICU patients who appear unresponsive have conscious awareness, bringing enhanced possibility for recovery. “The results of such investigations may improve outcomes for patients and families by informing discussions about continuation of life-sustaining therapy and rehabilitative care,” adds the related study.
Acute Chest Syndrome: A Risk for Patients With SCD
Treatment may require IV fluids, blood transfusions, pain medication and antibiotics.
Sickle cell disease (SCD) can quickly lead to acute chest syndrome (ACS), and nurses should be aware of signs and care of this complication.
“Acute Chest Syndrome in Sickle Cell Disease,” a case study in Nursing2024, shows how changes in respiration and vital signs along with chest pain could indicate the onset of ACS in a hospitalized patient with SCD. “Frequent nursing assessments are essential for monitoring changes in the patient’s condition and facilitating prompt diagnosis and treatment,” the article notes.
In discussing the nature of SCD and how nurses can assess escalations and diagnose ACS, the case study illustrates a wide range of potential signs and lab results requiring attention. Upon diagnosis, the patient’s treatment and care may require IV fluids, blood transfusions, pain medication and antibiotics.
Prevention and patient education play a role in preventing escalation, the case study adds, placing an emphasis on infection prevention and respiratory exercises. AACN resources include “Sickle Cell Disease and Care Considerations for the Acute and Critically Ill,” an NTI recorded session that reviews complications these patients may face that require acute or intensive care.
A related retrospective study in JAMA Internal Medicine finds that lactated Ringer solution for fluid resuscitation in patients with SCD who have vaso-occlusive episodes (VOEs) was “associated with more hospital-free days, shorter hospital length of stay, and lower 30-day readmission risk compared with normal saline.” The review of over 55,000 cases finds “a small but significant improvement” that warrants a large-scale randomized clinical trial to verify.
Patients receiving the lactated Ringer solution, which helps reduce sickling, averaged 0.4 fewer hospital days and a 5.8% lower marginal risk difference for readmission than patients receiving normal saline solution. “Thus, it is important to provide adequate fluid resuscitation that minimizes risk for metabolic acidosis in patients with VOEs,” adds a related article in MedPage Today.
Fasting or No Fasting Before Cardiac Catheterization?
Removing fasting requirements is safe and may improve patient satisfaction.
For patients fasting before undergoing cardiac procedures under conscious sedation, no fasting was better than fasting and they had significantly higher satisfaction scores.
“Fasting vs No Fasting Prior to Catheterization Laboratory Procedures: the SCOFF Trial,” in European Heart Journal, notes that guidelines for patients undergoing coronary device-related procedures encourage fasting as common practice but lacked data support, and a randomized trial upended that conventional approach.
“In patients undergoing cardiac catheterization and CIED related procedures, no fasting was non-inferior and superior to fasting for the primary composite outcome of aspiration pneumonia, hypotension, hyperglycaemia and hypoglycaemia,” the trial adds.
Conducted with 716 patients at multiple sites in Australia from 2022 to 2023, the trial randomized patients 1:1 either to refrain from solid foods for six hours and clear liquid for two hours or to receive no fasting instructions. The primary composite outcome occurred in 19.1% of fasting patients and 12% of non-fasting patients.
Presenting at the European Society of Cardiology Congress, lead trial author David Ferreira, John Hunter Hospital, Australia, said multiple trials have now determined that removing fasting requirements is safe and possibly advantageous for these patients, according to a related article in Healio. “With this new evidence, and the evidence that has come before, I do think now that the evidence has shifted, and I would suggest that removing fasting requirements is safe and improves patient satisfaction for the procedures that were enrolled in the trial,” Ferreira notes in the article.
Ferreira suggests that a meta-analysis of all related trials could help change common practice by emphasizing the potential advantages or at least the non-inferiority of not fasting. Patients could improve their experience just by drinking coffee in the morning or drinking water while awaiting surgery, he adds.
New PICC App for Neonatal and Pediatric Nurses
The health app improved nurses’ knowledge of safe PICC maintenance.
A health app for preventing adverse events from peripherally inserted central catheters (PICCs) improved understanding for neonatal and pediatric nurses.
“PiccPed App Impact on Nurses’ Knowledge to Prevent Adverse Events for Peripherally Inserted Central Catheters (PICC) in Pediatric and Neonatal Healthcare: A Quasi-Experimental Study,” in Journal of Pediatric Nursing, notes that increased use of the PiccPed app resulted in higher scores on a test of nurses’ knowledge of safe PICC maintenance. The app “can be used for training and continuing education of nurses who care for children and neonates with PICCs, free of charge, with anywhere access, mobility, flexibility, and portability,” the study adds.
Pediatric and neonatal nurses at two hospitals in Brazil tested their knowledge before and after using the app, with 15 multiple-choice questions covering several areas of PICC management. The 56 nurses who completed both assessments answered all questions better in the post-use test with statistically significant improvement in 10 of them and mean overall scores improving from 9.3 to 12.2.
The study also found that nurses with specialization showed more statistically significant improvement than non-postgraduate nurses, and each minute reported using the app increased scores. “Therefore, the PiccPed can be used as a tool to improve the clinical practice in a variety of nursing teams; it can be utilized in training or continuing education, whether in hospitals or educational settings, including training focused on the prevention of specific adverse events, such as CLABSI, thrombosis, occlusion, phlebitis, incorrect positioning, and catheter rupture.”
The study is limited by its size and lack of long-term review of information retention. Available in English or Portuguese, the PiccPed app “can be an important ally in the pursuit of patient safety in healthcare institutions,” the study notes. (Note: if the app, which is accessible on a desktop, is in Portuguese, click on “ingles” for the English version.)
Empowering Nurses with Disabilities
To highlight and amplify the value of an inclusive workforce and the important roles of disabled employees, we interviewed two board members with the National Organization of Nurses with Disabilities (NOND). They share the stories of their own disabilities, and their roles in advocating for and supporting their fellow nurses with disabilities.