Acute Care NP Examines the Deadly Cost of ECMO Shortage

Acute Care NP Examines the Deadly Cost of ECMO Shortage

Nearly 90% of COVID-19 patients who qualified for, but did not receive, ECMO (extracorporeal membrane oxygenation) due to a shortage of resources during the height of the pandemic died in the hospital, despite being young with few other health issues, according to a study published in the American Journal of Respiratory and Critical Care Medicine.

The Vanderbilt University Medical Center study, led by acute care NP Whitney Gannon, MSN, director of Quality and Education for the Vanderbilt Extracorporeal Life Support Program (ECLS), analyzed the total number of patients referred for ECMO in one referral region between Jan. 1, 2021, and Aug. 31, 2021.

Vanderbilt NP Whitney Gannon, MSN.Approximately 90% of patients for whom health system capacity to provide ECMO was unavailable died in the hospital, compared to 43% mortality for patients who received ECMO, despite both groups having young age and limited comorbidities.

“Even when saving ECMO for the youngest, healthiest and sickest patients, we could only provide it to a fraction of patients who qualified for it,” Gannon said. “I hope these data encourage hospitals and federal authorities to invest in the capacity to provide ECMO to more patients.”

Once a patient was determined to be medically eligible to receive ECMO, a separate assessment was performed of the health system’s resources to provide ECMO.

When health system resources — equipment, personnel and intensive care unit beds —were not available, the patient was not transferred to an ECMO center and did not receive ECMO.

Among 240 patients with COVID-19 referred for ECMO, 90 patients (37.5%) were determined to be medically eligible to receive ECMO and were included in the study. The median age was 40 years and 25 (27.8%) were female.

For 35 patients (38.9%), the health system capacity to provide ECMO at a specialized center was available; for 55 patients (61.1%), the health system capacity to provide ECMO at a specialized center was unavailable.

Death before hospital discharge occurred in 15 of the 35 patients (42.9%) who received ECMO, compared with 49 of the 55 patients (89.1%) who did not receive ECMO.

“Throughout the pandemic, it has been challenging for many outside of medicine to see the real-world impact of hospitals being ‘strained’ or ‘overwhelmed,’” said co-author Matthew Semler, MD, assistant professor of Medicine at VUMC. “This article helps make those effects tangible. When the number of patients with COVID-19 exceeds hospital resources, young, healthy Americans die who otherwise would have lived.”

In total, the risk of death for patients who received ECMO at a specialized center was approximately half of those who did not.

“Because some patients die despite receiving ECMO, there has been debate about how much benefit it provides. This study shows the answer is a huge benefit,” said senior author Jonathan Casey, MD, assistant professor of Medicine at VUMC.

“This data suggests that, on average, providing ECMO to two patients will save a life and give a young person the potential to live for decades,” he said.

The study was funded by NIH National Heart, Lung, and Blood Institute grants K23HL153584 and K23HL143053.

Adult-Gerontology Acute Care Nursing—What You Need to Know

Adult-Gerontology Acute Care Nursing—What You Need to Know

Working in gerontological nursing can be immensely rewarding, but in order to be successful, it’s critical to familiarize yourself with the characteristics unique to this age group. Here are some key areas to focus on if you are pursuing a career in adult-gerontology acute care nursing.

Bridge the Generation Gap

Generations previous to our own often have different sociocultural norms. Being mindful of this will facilitate their care. They may be uncomfortable being addressed by their first name, or they may be very private. Giving respect and space where needed will go a long way toward earning their trust and confidence, making it easier to care for them effectively.

Even elderly individuals without a cognitive impairment can experience a sudden change in mentation, often triggered by infection (UTIs are common culprits) or by a change in routine, geography or both. Safety is paramount, so be mindful of their room assignment as well as their potential for confusion to ensure that they are well monitored.

Making Sense

The elderly often lose acuity of one or more senses, so it’s important to accommodate these changes. Due to decreased activity levels, muscle mass, and food intake, they often complain of feeling cold. This is also attributable to chronic conditions such as anemia, kidney disease, underactive thyroid, or even the medications they take.

Offer them warm blankets, light jackets, or slipper socks to help their bodies retain warmth. Adjust the room temperature as appropriate. Elderly patients often will ask that their hot beverages or food be reheated. This alteration in heat perception is quite common in older patients, so reheat with caution to avoid injury.

Their hearing and vision are likely to be impaired to some degree, so speak deliberately and clearly. Let them see your face as you’re speaking. Repeat what you’ve said when asked. And encourage the use of eyeglasses and hearing aids where indicated.

The Physical

Functional impairments such as balance issues and weakness are common among the elderly. They should be closely monitored or assisted when ambulating. Be mindful of hazards that may cause falls: furniture placed too closely together, uneven walking surfaces, throw rugs, electrical cords, and IV tubing. Weakness may necessitate the use of assistive devices to ambulate. Monitor transfers to determine whether they may need greater assistance for the transfer order.

Due to their nutritional status, chronic conditions, and medication, many will have fragile skin—their skin may have a papery texture and is easily prone to tears and lacerations. Protect it by keeping it clean and well-moisturized. Choose an appropriate tape for dressings, IV tubing, etc.; this will help minimize damage to the skin and potential allergic reactions, or when appropriate use mesh sleeves.

Constipation is another common complaint, related to decreased fluid intake, reduced activity, and polypharmacy. Monitor their diet and fluid intake for fiber, nutrients, and adequate hydration; and encourage activity and fluids as tolerated per their doctor’s orders.

Want to know more about adult-gerontology acute care nursing? Visit here to determine which certification may be right for you.

A Day in the Life of an Acute Care Nurse

A Day in the Life of an Acute Care Nurse

I am a cardiac acute care nurse in a large Northeast suburban trauma hospital. I arrive at work twenty minutes early so that I can get to know my patients. I then check the chart for admitting diagnosis, pending labs, exams, point-of-care testing needs, etc. I do this because no matter how much I trust the nurse giving me the report, I recognize that any human is more liable to make mistakes and oversights after working at this level of intensity for thirteen hours.

After receiving the report, I introduce myself to my patients. The nursing ratio on my unit is 3:1 and at times up to 5:1. If the patient is awake, I assess them right away after introductions. I bring a computer-on-wheels (COW) in the room with me to document everything. The COW minimizes distractions and allows me to assess anything I forgot if needed. Next, I administer scheduled medications.

I find it most effective to complete tasks while in the room with the patient.  The hallway is an obstacle course of distractions. For example, it may seem reasonable to step out while your patient is on a nebulizer treatment knowing the treatment takes five to eight minutes to complete. In a high-acuity unit, eight minutes is an eternity. Therefore, no matter how much I plan, I can almost guarantee I will be sidetracked by a new task in that short time. On good days, my charting is done by 10 a.m., which happens about 60% of the time. This allows me to have my afternoons free to address anything that comes up. Afternoons are less predictable because usually the night shift has set up and stabilized the patient for the mornings.

The hospital I work in is not unionized, so taking breaks is not enforced.  We are entitled to one 30-minute and one one-hour break during a twelve-hour shift. Some nurses follow that timing fastidiously on each shift, while some nurses don’t take a break at all. I strongly discourage that. I perform better when I take a few 15-20 minute breaks throughout the day when my patients are settled. Otherwise, I use the extra time to prepare for later tasks, such as setting up and labeling IV medications. This ensures I leave on time, and I always do.

I have the opportunity today to precept new nurses and I always encourage them to find their own rhythm. In the beginning, I used to follow my preceptor and make an index card with a table of all the medications and point-of-care testing for each patient. Once I found my stride, I realized this card was actually wasting more time than it was saving, and I relied on the EMR instead anyway. Who knows? That may change again.

Evolving and learning are constant features of acute care nursing. A day in the life of an acute care nurse may be a misnomer as, lucky for me, no two patients are the same and no two days are the same.

To learn more about a career in acute care nursing, visit here.

Nurse Residency Programs: Future for Post-Acute Care

Nurse Residency Programs: Future for Post-Acute Care

The New Jersey Action Coalition, in response to the Institute of Medicine’s recommendation to implement nurse residency programs across all practice settings, initiated a statewide program for new graduate RNs working in post-acute care (PAC) beginning in 2014. To date, more than 100 nurses and their experienced preceptors from more than 50 facilities in the state have completed this education program. The new book, Developing a Residency in Post-Acute Care, that I co-authored shares the experiences, program content and lessons learned from that innovative project.

How can this book help nurse leaders in post-acute settings to meet the challenges they presently face to provide safe, person-centered, evidence-based nursing care? It provides current, ready-to-use education for PAC nurses as well as other caregivers. Nurses in PAC strive to care for increasingly complex patients; adapt to new regulations and financial restrictions; and incorporate patient care technologies previously unknown outside of acute care. The rapid rate of change is unprecedented, requiring continual, stressful and swift improvements in knowledge and skill. Preventing rehospitalization alone requires a nursing staff with proficiency in assessment, early identification of deterioration, and appropriate intervention. Adding to this environment is high nurse turnover with vacancies expected to increase as experienced nurses retire. These events will create a practice gap that nurse leaders will have to fill, much of it with education to insure the competence and confidence of nursing staff.

Clinical safety and competence are always critically important; however, nurses must be knowledgeable and skilled in many areas in order to be effective. For example, teamwork and collaboration are essential to thriving in an interprofessional environment. Expertise in communication is required for all interactions with patients, families and colleagues; and as consumers develop greater expectations for care, communication becomes an indispensable skill. Regulatory expectations for nurses to participate in evaluating and implementing best practices as well as leading performance improvement projects requires education in these areas as well. These are among the topics detailed in Developing a Residency in Post-Acute Care.

The need to intensify nursing professional development in PAC is compounded by often limited resources. Nurse educators with a dedicated role are less common than in acute care, and responsibility for education often falls on someone with multiple jobs. Management, infection control and/or employee health are commonly combined functions, and these may take precedence over education. PAC care settings may not be able to afford subscriptions to print or online journals, and usually do not have access to medical libraries. Even with those resources, the time to research best practices or innovative solutions to problems probably does not exist in the extremely busy life of a PAC nurse leader. The Internet is a vast store of educational resources, but locating and evaluating options can be very time consuming. This book can dramatically reduce the amount of effort spent researching and preparing educational sessions by suggesting content, methods and literature/media sources.

With education come increased nurse confidence, greater accomplishment and the possibility of role expansion. With that, staff engagement and satisfaction increase, yielding the added benefits of improved retention, workplace stabilization, renewed professional energy and a more successful PAC setting.

This story was originally posted on MedPage Today.

Nurse Residencies in Post-Acute Care Hinge on Leadership

Nurse Residencies in Post-Acute Care Hinge on Leadership

Experience in New Jersey showed programs faltered without strong leaders

Effective leadership is crucial to the success of initiatives like implementing a nurse residency program in a post-acute care (PAC) setting. These programs can be a valuable asset for recruiting, educating, and retaining nurses in a healthcare environment that’s increasingly in need of skilled and knowledgeable staff.

The New Jersey Action Coalition (NJAC) launched a statewide nurse residency program in 2014, achieving a retention rate of 86%. New nurses and their experienced preceptors attended interactive, in-person education. Preceptors then applied their new knowledge to helping their new nurses become competent and engaged. The success of their experiences depended on many things; a nurse leader who championed the program in the clinical setting was often a linchpin.

Effective leaders elucidated the benefits of participation to administration and staff, justifying the expense of sending nurses to the program. Continuing leadership ensured new nurses and preceptors were given time to attend class and to meet regularly, and were given encouragement when difficulties arose.

Perhaps even more importantly, wise nurse leaders were open to ideas that participating nurses brought back to the workplace. For a facility to benefit fully from the education, it had to be willing to embrace fresh strategies.

In the NJAC experience, it became clear that when a nurse leader resigned, the program often lost its main advocate. Negative effects were seen in reduced attendance and support for nurse resident/preceptor activities at the facility, such as performance improvement project work. Nurse leaders provide preceptors with the organizational support for what can be a stressful role. Leadership is also required for the maintenance of a healthy work environment in order to retain nurses.

Qualitative research completed during the project revealed that new nurses clearly see the need for robust leadership. Their comments about the needs of PACs yielded a desire for “visionary, hands-on management” and “teamwork, respect, and kindness between colleagues.” Such insights from new nurses indicate that PACs are ripe for organizational culture change through imaginative and innovative leadership.

NJAC offers this advice for nurse leaders considering a nurse residency program:

  • Know your costs for vacant positions (from overtime to onboarding). Quantifying savings achieved by improving retention via a residency program substantiates the return on investment.
  • Choose preceptors wisely. Look for knowledge, skill, ability to use clinical teaching strategies, and dedication to helping nurses thrive. The importance for a good fit between preceptor and nurse resident was apparent in the NJAC experience and identified by Moore & Cagle (2012) and Richards & Bowles (2012). Once preceptors are chosen, invest in their education. Remember, precepting requires that even the most expert nurses acquire a new set of skills.
  • Dedicate resources for success: time; space; supplies and computer/Internet access. Enlist other professionals, such as therapists, who have much to offer a novice nurse. Modify policies, job descriptions, and clinical assignments as needed.
  • Prepare for bumps in the road and stay actively involved. Check in regularly with preceptors and new nurses to offer advice, problem solving, praise, and inspiration.
  • Explore the wealth of literature available. NJAC and Rutgers School of Nursing have just published Developing a Residency in Post-Acute Care. Its guidance on implementing a residency program and detailed lesson plans will be valuable to nurse leaders/educators working with new nurses.
  • Once the new nurse is ready for new challenges, identify opportunities such as committee membership and performance improvement projects to enhance developing professionalism, meaningful engagement, and retention.

One of the often-quoted pearls of wisdom stressed to nurses in the NJAC program is to “lead from wherever you are.” Implementing a nurse residency program is one way for PAC leaders to do just that. The rewards will be worth the voyage through uncharted waters.

This story was originally posted on MedPage Today.