Clinical Voices September 2021
This month we feature pediatric brain death protocols, updated C. diff infection guidelines and healing wounds without scars, among other topics. Plus, read the new President’s Column and an inspirational Nurse Q&A.
Pediatric Brain Death Testing Varies Among Hospitals
Current guidelines alone cannot ensure uniform brain death protocols at pediatric facilities.
Protocols to determine pediatric death by neurologic criteria (DNC) vary widely in the U.S., particularly with apnea and ancillary testing, and better alignment with national guidelines could improve consistency and accuracy.
“Variability in Pediatric Brain Death Determination Protocols in the United States,” in Neurology, compares DNC protocols from 130 pediatric institutions, noting that 118 protocols came after national guidelines were updated in 2011. Protocols were analyzed across five domains: general DNC procedures, prerequisites, neurologic examination, apnea testing and ancillary testing.
Of the 118 protocols, 97% require identification of a mechanism of irreversible brain injury, but just 67% mandate an observation period before DNC evaluation, the study notes. A total of 84% require the guideline-recommended two apnea tests, and only 64% of protocols match the guidelines’ CO2 targets. In addition, conflicting with the guidelines, “15% required ancillary testing for all patients and 15% permitted ancillary studies that are not validated in pediatrics.”
In a related article in Neurology Today, study author Matthew Kirschen, University of Pennsylvania Perelman School of Medicine, says researchers were surprised that nearly 10% of the 130 total protocols weren’t updated after release of the 2011 guidelines, which were developed by the Child Neurology Society, the Society of Critical Care Medicine and the American Academy of Pediatrics.
“Our findings show that the current guidelines alone are insufficient to ensure uniform brain death protocols at pediatric institutions, which likely translates into variations in clinical practice,” Kirschen adds. “There is also variability in state laws, which may contribute to some of the variability in protocols and clinical practice. Ongoing efforts are needed to educate both health care providers and the public about brain death.” Focused Update on Clostridioides difficile Infection
The evidence-based recommendations rely on recent randomized clinical trials but also consider cost factors.
A focused update to existing guidelines for managing adult patients with Clostridioides difficile infection (CDI) recommends fidaxomicin for initial episodes and bezlotoxumab with standard antibiotics for recurrent episodes.
According to “Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults,” in Clinical Infectious Diseases, updated evidence since the release of the 2017 guidelines affects recommended treatment options for adults. Fidaxomicin and bezlotoxumab “have increased clinical efficacy and other advantages over older agents, but implementation may be challenging because of initial monetary cost and logistics,” note the new guidelines. The update includes two modifications of previous recommendations and one new one, offering both preferred and alternative treatments for an initial CDI episode, first CDI recurrence, and second or subsequent CDI recurrences. There are no changes in the pediatric recommendations.
The evidence-based recommendations rely on recent randomized clinical trials but also consider factors such as cost; fidaxomicin may be cost-prohibitive for many patients without adequate insurance. “Additional, well-designed, independent, cost-effectiveness studies for patients with CDI are needed to improve the strength of this recommendation given that cost is a substantial barrier to fidaxomicin use.”
Bezlotoxumab was FDA-approved in 2016, and real-world studies have supported clinical trial results demonstrating a reduced incidence of CDI recurrence. “The panel agrees that the overall balance of benefits and harms favors adding bezlotoxumab to SOC [standard-of-care] antibiotics for patients with a CDI episode and at least 1 risk factor for recurrence … but seems more favorable in patients with multiple risk factors of recurrent CDI and especially in patients with a prior CDI in the last 6 months.” Research on Wound Generation Without Scarring
In the future it may be possible for wounds to heal without scarring.
Research on skin cells in mice may help develop genetic activation methods to reprogram adult human wounds to heal without scarring.
According to “Preventing Engrailed-1 Activation in Fibroblasts Yields Wound Regeneration Without Scarring,” in Science, an inhibitor may stop the scarring process before it begins and allow healing that retains skin’s usual properties. “We have demonstrated fully regenerative skin healing in a postnatal mammal that normally scars; this finding has translational implications for the tens of millions of patients each year who develop scars and other fibroses,” notes the research article.
The research aims to alter the usual fibrotic process of scarring, which differs from surrounding skin in critical ways, including nerve sensitivity, flexibility and strength. “When mechanical signaling was inhibited in these cells (using either genetic deletion or small-molecule inhibition), skin wounds in mice no longer formed scars but instead healed by regeneration, restoring skin with normal hair follicles and glands, extracellular matrix, and mechanical strength,” the article adds.
“How to Heal Skin Without the Scars,” a related article in NIH Director’s Blog, notes both the cosmetic benefits of reducing visible scars and the medical benefits potentially unlocked once clinical trials can be conducted on humans. “The findings also may have implications for many other medical afflictions that involve scarring, such as liver and lung fibrosis, burns, scleroderma, and scarring of heart tissue after a heart attack,” the article notes. Update on Assessing Pain in the ICU
These treatments could help minimize the need for opioids and other pharmacologic interventions.
Pain management for ICU patients should involve multiple assessment methods performed while patients are resting and while undergoing procedures, and it should address scores above an acceptable range.
“Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit,” a review in Dove Medical Press, also recommends nonpharmacologic methods of pain control, such as massage, relaxation, music/sound and cold therapies, as part of a comprehensive pain protocol. These treatments could help minimize the need for opioids and other pharmacologic interventions, which can lead to delirium and other adverse effects. Caregivers are advised to assess critically ill patients regularly for pain, using self-report methods if possible. For patients who cannot communicate, the review suggests using behavioral pain assessments, including facial expressions, body movements, muscle tension and compliance with mechanical ventilation.
“Vital signs should not be used as surrogates for pain assessment,” the review notes. “Pain should be reassessed every 2-3 hours and more frequently before painful procedures or mobilization.”
One major focus of future research will be to identify modifiable risk factors or interventions to help prevent ICU patients from developing chronic pain syndromes after discharge. “Over a third of ICU survivors report functional or physical limitations even at one-year post-ICU discharge, and a third suffer from depression,” the review adds. “Many patients report pain as a contributing factor to their physical limitations, which has a profound impact on these patients from a quality of life and economic standpoint.” Newly Licensed Nurses Face Stress, Lack of Support
This qualitative systematic review may be the first in 10 years to consider the transition from student to RN.
Several factors may impede new graduate registered nurses (NGRNs) from smoothly transitioning to clinical practice, including lack of organizational support, work stress and insufficient educational preparation.
“Newly Graduate Registered Nurses’ Experiences of Transition to Clinical Practice: A Systematic Review,” in American Journal of Nursing Research, notes that while NGRNs play a significant role in patient care and safety, they also experience high turnover associated with various work stresses and challenges.
“This limited support is reflected by unfair and punitive actions taken against them in the form of duty shifts, patient assignment and workload, and the use of sick and vacation leave, which impedes their transition,” the review notes.
The review analyzed 24 studies conducted from 2001 to 2019 that focused on student nurse transition as viewed by a total of 526 NGRNs, nurse directors and nurse educators. Ten studies were conducted in the U.S., while others originated in Canada, the U.K., Australia and other countries.
Healthcare organizations can assist new nurses by assigning them to the clinical settings of their preference and providing orientation programs that promote familiarity with clinical settings and organizational rules and policies, the review adds. There is also a need to promote a positive work environment that focuses on effective teamwork and supportive staff with healthy working relationships.
One nurse leader, Brigitte Nastally, clinical operations manager for Indiana University Health, attempts to counteract turnover among first-year nurses by scheduling regular one-on-one meetings, reports a related article in HealthLeaders.
“During the tumultuous year of 2020, I anticipated that new nurses may need ongoing support, coaching, and development conversations,” Nastally notes in the article. “Beginning at orientation, we set up a meeting schedule between the new nurse, clinical educator, and unit manager.” Survivors of Critical COVID-19 May Require Pulmonary Evaluation
The study, conducted at a hospital in Spain, recommends a larger cohort from more areas for further research.
An observational study of patients post-discharge for COVID-19 indicates high percentages of pulmonary structural abnormalities and functional impairment, leading to a recommendation for pulmonary evaluation after 90 days.
“Pulmonary Function and Radiologic Features in Survivors of Critical COVID-19: A 3-Month Prospective Cohort,” in CHEST, notes that over 70% of these patients showed abnormal results on CT scans, and 82% had reduced lung capacity after three months. “Because more severe differential lung involvement is seen in critically ill patients with COVID-19, close monitoring after discharge is deserved.”
Critically ill patients with COVID-19 displayed “a unique inflammatory and proteomic profile” compared with non-critical patients and have a higher risk of “organ-specific cellular death and damage,” the study notes. “In addition to the typical diffuse alveolar damage, compared with lungs from patients with H1N1, lungs from patients with critical COVID-19 disease showed severe endothelial injury associated with the presence of intracellular virus, disrupted cell membranes, and a higher prevalence of thrombosis and microangiopathy.” The clinical implications of the research, the study adds, include an imperative to monitor these patients in the first 90 days after hospital discharge, with a therapeutic focus on pulmonary rehabilitation and physical conditioning, including chest CT imaging and complete pulmonary testing. The study also notes high levels of anxiety and depression among survivors with lower quality-of-life scores than the public and people with other chronic diseases.
Since the single-site study in Spain was limited to a complete evaluation for 62 participants out of 125 potential patients, it recommends a larger cohort from more areas for further research. Lead study author Jessica Gonzalez discusses the findings and other long-term COVID-19 concerns in a related Chest podcast. President’s Column: What Would I Tell Others? In her new column, AACN President Beth Wathen discusses the importance of communicating. She has spoken with her fellow nurses from across the country and read their compelling social media posts. Their unrelenting challenges underscore the importance of communicating to others without ambiguity what we see and what we need from them. Keep Reading Nurse Story: The Power of Community Learn how Cathy Hayes, a nurse manager at a hospital in Lynchburg, Virginia, and dozens of volunteers, organized a vaccine effort and how the community supported her. She says, “While we are still nurses, let’s continue to be kind, and kindness will come back to you. That’s been my motto.” Read Her Story If you have questions or comments please contact us at ClinicalVoices@aacn.org.