Cognitive Training Before Coronary Artery Bypass Surgery
Patients were 57% less likely to develop hospital-acquired delirium.
A study of 208 patients finds that cognitive training before coronary artery bypass grafting (CABG) surgery helps prevent postoperative delirium, but larger trials, including outpatient settings, are needed.
“Cognitive Training for Reduction of Delirium in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial,” in JAMA Network Open, reports that patients receiving preoperative training were 57% less likely to develop hospital-acquired delirium than those in a routine care group. The benefit was apparent even though patients completed a median of only six of 10 requested training hours.
The “clinical trial was conducted at 3 university teaching hospitals in southeastern China with enrollment between April 2022 and May 2023. Eligible participants included those scheduled for elective coronary artery bypass grafting who consented and enrolled at least 10 days before surgery.”
About half (102) of the patients in the study were randomized to receive cognitive training, which consisted of online tasks designed to enhance memory, imagination, reasoning, reaction time, attention and processing speed. The other group (106 patients) received routine care.
During the first postoperative week, 28 patients (27.5%) developed delirium in the cognitive training group compared with 46 patients (43.4%) with routine care. Patients in the training group exhibited lower incidence of severe delirium and fewer delirium-positive days.
“Our primary outcome was occurrence of delirium during postoperative days 1 to 7 while patients remained hospitalized, assessed using the confusion assessment method (CAM) or CAM for the intensive care unit (CAM-ICU), as appropriate,” the study explains, noting that patients were evaluated twice a day.
The study acknowledges that the primary analysis, with fewer than 75 delirium cases, has limitations and should be considered fragile. In addition, cognitive training sessions occurred while patients were in the hospital prior to surgery, which isn’t typical.
“Less benefit is therefore likely in patients receiving outpatient care,” the study notes. “Our results should, thus, be considered exploratory and a basis for future larger trials.”
Steps to Improve Ventilator Weaning
A committee’s literature review led to the development and release of four recommendations.
A new guideline from the American Association of Respiratory Care (AARC) provides four recommendations for performing spontaneous breathing trials (SBTs), a critical component to accelerate ventilator weaning and enhance patient outcomes.
“AARC Clinical Practice Guideline: Spontaneous Breathing Trials for Liberation From Adult Mechanical Ventilation,“ in Respiratory Care, seeks to fill gaps in previous guidelines, help bedside clinicians discontinue adult mechanical ventilation faster, and safely extubate critically ill patients.
A committee of respiratory therapists, physicians and others with extensive ventilator liberation experience used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rate the best available evidence. The guideline addresses four questions about SBT, defined as spontaneous breathing with minimal or no positive-pressure ventilatory assistance for 30 to 120 minutes.
The committee’s extensive literature review led to the following recommendations:
- Calculation of a rapid shallow breathing index (RSBI) is not needed to determine readiness for an SBT.
- SBTs can be conducted with low levels of pressure support ventilation (PSV) or without PSV.
- A standardized approach to assessment is recommended and, if appropriate, an SBT should be completed before noon each day.
- Despite the practice in some ICUs, fraction of inspired oxygen (FiO2) should not be increased during an SBT.
The recommendations can be added to local protocols, leading to more rapid SBT implementation, the guideline notes. However, it also specifies that the recommendations are conditional and some lack a high level of support.
“This means that different choices are likely to be appropriate for different patients and therapy should be tailored to the individual patient’s circumstances. Those circumstances may include the patient’s or family’s values and preferences,” the guideline adds.
The committee notes there are many opportunities for more research. “Hopefully additional evidence will strengthen our recommendations or, in some cases, might change what is recommended.”
Stroke Screenings May Have Limitations for Spanish-Speaking Patients
The study involved 796 patients (37% Spanish-speaking) who received BEFAST positive stroke screens.
Stroke screening tools may have limitations for Spanish-speaking patients, who are less likely to progress to complete evaluations despite similar rates of strokes.
“Stroke Screening Process for Spanish-Speaking Patients,” a retrospective, observational study in Journal of Emergency Nursing, notes some differences in experiences for Spanish-speaking patients being evaluated for possible acute ischemic stroke (AIS) that may lead to under-evaluations.
“In this study, there was no clinical difference in ability to detect AIS among Spanish- versus non-Spanish-speaking patients, but this study underlines the importance of further investigation into timely hospital arrival and the potential for refinement of the screening process to enhance specificity.”
Conducted in 2020, the study included 796 patients (37% Spanish-speaking) at an urban academic center who received Balance Eyes Face Arms Speech Time (BEFAST) stroke screens from nurses. 25.8% of Spanish speakers were converted to complete evaluations, compared with 32.8% for the rest of the population studied. Over one year, 13% of escalated cases overall resulted in an AIS diagnosis. The rate of acute ischemic stroke diagnosis between Spanish- and non-Spanish-speakers was not different.
Spanish-speaking patients in the study were more likely to arrive in the emergency department (ED) without being transported by ambulance and had longer duration of “last known well” by an average of one hour compared with non-Spanish speakers. “We hypothesize that language discordance at triage and concern for missing a stroke may lead to overtriaging, which leads to lower rates of actual AIS diagnosis in Spanish-speaking patients,” the study adds.
The study identifies implications for ED nurses, including addressing language barriers and the impact of patients’ limited English proficiency and health literacy.
“Although the goal of nursing triage is to identify every stroke quickly, improvements could be made to reduce the proportion of unnecessary stroke evaluations if existing screens tend to overtriage Spanish-speaking patients.”
In addition, related articles in Stroke and Vascular Neurology and American Heart Association News note that alternative nurse screening tools such as AHORA and RAPIDO, specifically designed for Spanish-speaking individuals, should be considered.
AI Tools Offer Innovation for Nursing Practice, Education
Consider the implications of both predictive and generative AI.
Understanding artificial intelligence (AI), its variations and limitations can help nurses bring innovative computing tools to practice and education.
“Comparison of Generative Artificial Intelligence and Predictive Artificial Intelligence,” in AACN Advanced Critical Care, notes that nurses can learn the implications of introducing both predictive and generative AI into practice settings and envision current and future applications. “The combination of prediction and creativity in one AI tool will further enhance the value of data as well as the science and practice of nursing,” the article notes.
Predictive AI primarily works with structured data, although it can work with unstructured data in some applications, and it helps identify early warning signs in patients or predict future outcomes based on available data. These tools can assist clinicians with early identification and intervention, but “rigorous studies and publication in peer-reviewed journals are essential before the release of AI tools to ensure reliability and validity. Otherwise, the need to rigorously pilot new AI tools in practice settings where they will be used is imperative.”
Generative AI, including ChatGPT, can operate from unstructured data and create new outputs, but it can be prone to inventing information that clinicians need to know about. For example, in a randomized clinical documentation trial, ChatGPT generated inaccurate information about patients.
“FAQs: AI and Prompt Engineering,” a related article in American Nurse, notes that clinicians and nurse educators can learn to develop prompts for an AI tool in order to receive the requested outputs. AI tools offer promise in generating personal learning experiences and addressing issues of bias and equity.
Including prompt engineering in nursing education requires an understanding of both capabilities and limitations. “Ethical concerns, potential technology dependence, and the standardization of learning further underscore the need for thoughtful integration of AI tools into the nursing curriculum,” adds the related article.
Study Notes Flaws in HIT Diagnosis Algorithm
To improve accuracy, the study proposes using diagnostic machine-learning tools.
A substantial number of patients with suspected heparin-induced thrombocytopenia (HIT) are misclassified by the currently recommended algorithm, resulting in diagnosis delays and potential overtreatment with anticoagulants.
“Accuracy of Diagnosing Heparin-Induced Thrombocytopenia,” in JAMA Network Open, reports that with the current algorithm, about half of patients require antibody testing to confirm the diagnosis. However, because many are still incorrectly classified, they are exposed to the possibility of serious thromboembolic complications or bleeding.
Conducted from January 2018 to May 2021, the study evaluated the accuracy of diagnosing HIT among patients in 11 centers in Switzerland, Germany and the United States. Specifically, it focused on the recommended algorithm, which combines a patient’s 4Ts score (thrombocytopenia, timing, thrombosis and other causes) with chemiluminescent immunoassay testing if the 4Ts score indicates an elevated risk.
For the 1,318 patients assessed, the recommended algorithm identified 15 patients as false-negative and 50 patients as false-positive. This limited sensitivity confirms that a relevant proportion of patients with HIT are missed, while a substantial number of patients classified as HIT-positive are negative.
“These patients (false-positive) are treated with alternative anticoagulants because functional tests are often not available or only available after a few days,” the study notes. “However, the risk of severe bleeding is very high in these patients, exceeding 40%.”
To improve accuracy, the study proposes using diagnostic machine-learning tools, which can integrate and model various clinical and laboratory information while accounting for complex interventions.
For example, the TORADI-HIT algorithm is “substantially more accurate” than the currently recommended algorithm. “The algorithm reduces the number of patients with false-positive and false-negative results, so that functional assays are necessary in approximately 10% of HIT patients only,” the study adds, noting that research is underway to validate the TORADI-HIT algorithm in various settings.
Interviews With ICU Clinicians Indicate WMV Opportunities
Based on survey responses, the study provides a wide range of recommendations.
A study of intensive care practices for withdrawal of mechanical ventilation (WMV) finds that effective communication and planning can help reduce distress for patients, families and clinicians.
“Process of Withdrawal of Mechanical Ventilation at End of Life in the ICU,” a prospective two-center observational study in Chest Critical Care, notes that surveys and interviews with ICU nurses and other clinicians involved in end-of-life care provide insights into the challenges and offer guidance for best practices.
“These study findings suggest the need for more integrated, supportive teams and enhanced communication strategies within teams and between teams and families, as well as improved implementation of established palliative care principles to optimize comfort for patients, families and staff when pursuing WMV.”
Using detailed responses from 312 in-person surveys completed by nurses, respiratory therapists and clinicians who managed 152 patient cases at two Boston medical centers, the study provides a wide range of recommendations. “A good process was almost uniformly seen as one in which the family was well informed about and understanding of the terminal state of their loved one and the nature of the WMV process.”
Notable findings in the communication area include a need to remain nimble and adaptable to the needs of patients, families and care teams, and for “processes that empower bedside nurses to rapidly respond and effectively manage distress at end of life.”
In the planning area, the findings stress the need for a plan to “address nursing-specific needs from medications to specific actions, and it should anticipate less-common scenarios that may arise; a plan for the physician, pharmacy and RT to be physically available at the bedside for the nurse after WMV is deemed critical,” the study adds.
Finding Purpose Through Passion
The nursing journey has many paths. For Marché Foushee, BSN, RN, her nursing career started in 2019, just before the pandemic. After receiving education and training in many forms of advanced life support, she branched out into travel nursing. “This allowed me to work with patients in underprivileged areas. I witnessed so many miraculous things with this patient population.”