To help ensure that all obstetric patients receive high-quality, safe analgesia and anesthesia care during labor and delivery, the American Association of Nurse Anesthesiology (AANA) has published its updated Analgesia and Anesthesia for the Obstetric Patient practice guidelines. This comprehensive revision provides evidence-based practice recommendations and closes equity gaps in obstetric pain management and anesthesia care.
According to the Commonwealth Fund, U.S. women have the highest rate of maternal deaths among high-income countries, with Black women being nearly three times more likely to die from pregnancy-related complications than white women.
“Many of the complications related to maternal care are preventable,” says Beth Ann Clayton, DNP, CRNA, FAANA, FAAN, lead revision subject matter expert. “We know that there is a significant equity gap in maternal care between races and that one of the best ways to close that gap is to have standardized, evidence-based care. AANA’s new guidelines offer obstetric anesthesia providers current practice recommendations to support optimal maternal care and improve the delivery of care, patient safety, and patient outcomes.”
Research confirms racial and ethnic disparities in pain control for maternal care. Therefore, standardization of care supported by these guidelines is important in addressing these disparities. The updated guidelines cover topics such as physiologic changes during pregnancy, pre-anesthesia assessment and evaluation, patient education, preparing a plan of care, analgesia and anesthesia options during labor, delivery, and postpartum care, as well as complications and emergency care. In addition, recommendations highlight care for high-risk patients, including those with hypertensive disorders such as preeclampsia and obstetric complications and emergencies such as obstetric hemorrhage and amniotic fluid embolism.
“These guidelines and their protocols promote equity of care. For example, when a patient has preeclampsia, direct steps for hypertension management can be taken,” Clayton says. “In an emergency, if clinicians do not have a protocol available, they may miss a step. These guidelines are in place to increase communication between the anesthesia, obstetric, and pediatric professionals regarding labor status and patient-specific considerations to create an optimal environment for safe maternal and neonatal care. The document also highlights how CRNAs help drive change to reduce maternal-related deaths and implement prevention strategies to reduce racial and ethnic disparities in pregnancy-related mortality.
CRNAs are highly educated, trained, and qualified anesthesia experts. They provide 50 million anesthetics annually in the U.S., working in every setting where anesthesia is delivered. CRNAs are the primary providers of anesthesia care in rural locations, enabling facilities in these medically underserved areas to offer obstetrical, surgical, pain management, and trauma stabilization services.
Rounding checklists can help hospital care teams improve patient outcomes. New research points to the potential for patient-specific checklists as a valid way to effectively translate the latest evidence into clinical practice.
These checklists can be helpful tools during daily rounds when multidisciplinary patient care team members convene to discuss each patient’s status and care plan. However, if too complex or generic, the checklists may instead become a burden, taking up valuable time with minimal impact.
One way to customize rounding checklists is to have an individual serve as a checklist prompter, listen to the conversation, eliminate items as they are addressed, and remind the team to consider any remaining elements that should be discussed. These customized approaches assume that a prompter is reliable for confirming whether each checklist element is addressed
“Measuring Performance on the ABCDEF Bundle During Interprofessional Rounds via a Nurse-Based Assessment Tool” found that a single trained observer serving as a checklist prompter can reliably assess whether rounding discussions among the multidisciplinary patient care team addressed elements of the ABCDEF bundle. The evidence-based bundle includes various elements related to pain, agitation, delirium, ventilator care, and family engagement.
Researchers from the University of Pittsburgh, Pennsylvania, and other institutions conducted the study at two intensive care units (ICUs) at UPMC, a tertiary care medical center that is an academic affiliate of the university.
The team developed a paper-based assessment tool with a series of Yes/No items related to the ABCDEF bundle, allowing a nurse observer to circle whether an element had been addressed during rounds
Two nurses performed in-person observations of multidisciplinary morning rounds on 15 observation days in the fall of 2021. Most rounding discussions occurred in the hallway rather than the patient rooms due to institutional norms and COVID-19. The observers listened independently only to the rounding team’s discussions, without looking at the patient’s electronic health record or looking for visual cues from the patient’s room
In total, 53 different patients were observed, with 33 of them receiving invasive mechanical ventilation. Because ICU admissions often last multiple days, discussions often address the same patient over different days. The nurse observers documented 118 patient discussions, and their dually observed discussions are the basis for calculating reliability and agreement.
“Checklists are frequently used as a strategy for increasing adoption of the ABCDEF bundle, and our research has several important implications for performance improvement and quality measurement in the ICU,” says lead author Andrew J. King, PhD, research assistant professor of critical care medicine at the University of Pittsburgh School of Medicine.
The results indicate that nurses can identify when a rounding checklist element has been addressed and, therefore, might not need to be repeated during a readout of the checklist. This added flexibility enables a shorter, patient-specific checklist, which could streamline workflows.
In addition to empowering clinicians to customize checklists for each patient, the study shows that critical care nurses are ideal candidates to be independent checklist prompters during rounds.
The researchers also conclude that the assessment tool created for the study could serve as the basis for occasional strategic measurement of team performance, especially during emergency response, shift handoffs, and other times when team communication is essential.
Many people, including nurses, carry some bias, whether it is recognized by the individual or not. One study in the March issue of the Journal of Emergency Nursing sought to explore that more in-depth.
“This study is critical because not responding to bias harms patients and colleagues,” says ENA Director of Emergency Nursing Research and primary investigator Lisa Wolf, PhD, RN, CEN, FAEN, FAAN. “No one goes into nursing to harm people; we all want to help. By doing this study, we wanted to help nurses recognize their biases, then learn how to interpret and respond to them.”
Among the 1,140 survey participants and 23 focus group participants, significant differences existed between white and non-white participants in their experiences of institutional, structural, and personal microaggressions. Another area where differences were noticed among different groups was empathetic awareness. On average, those who identified as Christians ranked lower for empathic awareness, while those who identified as non-heterosexual scored higher.
“This study has filled a gap in the research within emergency nursing yet is foundational to our practice. With this information, we hope that nurses and institutions will reflect on their biases and educate themselves better to serve themselves, their patients, and their colleagues,” says JEN Editor-in-Chief Anna Valdez, PhD, RN, RN, who also contributed to this study.
A New York hospital reduced the incidence of medical device-related pressure injuries (MDRPIs) following a tracheostomy to zero for four years, according to a study published in AACN Advanced Critical Care.
The intervention used evidence-based resources from the Preventing Pressure Injuries Toolkit funded by the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services.
A key part of the new clinical process was a revised PDT tracheostomy procedural kit and documentation. During insertion, a polyurethane foam dressing was placed under the tracheostomy flange and secured with sutures and a flexible holder. The foam dressing remained in place for seven days, with primary care nurses assessing the site at least every 12 hours. As clinically indicated, the dressing was changed to a standard nonwoven gauze drain sponge after seven to 10 days.
The results showed that suturing a foam dressing as part of PDT tracheostomy insertion can reduce the incidence of associated MDRPIs.
The authors are Hazel Holder, DNP, MSN, RN, ACCNS-AG, CCRN, and Brittany “Ray” Gannon, PhD, MSN, AGPCNP-BC. Holder is a critical care clinical nurse specialist at NewYork-Presbyterian Westchester, and Gannon is a nurse scientist at NewYork-Presbyterian Hospital, New York City.
“When COVID-19 increased demand for healthcare equipment, we were able to refine our processes, transition to a revised PDT tracheostomy kit and maintain the integrity of the initiative,” Holder says. “We took a multidisciplinary approach that engaged all related specialties, with surgical site assessment and any clinician concerns discussed during daily rounds.”
Before the initiative, in 2018, the incidence of healthcare-associated pressure injuries (HAPIs) was 1.39% for all ICU patients. Tracheostomy MDRPIs accounted for 0.19% of the incidents (15 HAPIs, including two MDRPIs in 1,077 patients). However, of the two PDT tracheostomies performed, both patients experienced MDRPIs.
In 2019, the overall HAPI incidence decreased to 1.30%, with nine tracheostomies and no MDRPIs. The tracheostomy MDRPI incidence remained at zero for the next three years.
During the four years of this project, 22 PDT tracheostomies were performed in the ICU, with the foam dressing placed at the point of insertion in all procedures.
The project was conducted with another unit-based program to address the overall rate of unit-acquired HAPIs, which may have contributed to increased vigilance.
Adam Francis, MSN, RN, is the Director of Nursing at Brooks Rehabilitation Hospital – Bartram Campus. Phot credit: Brooks Rehabilitation.
How did you get interested in being a physical rehabilitation nurse? What drew you to it? How long have you been doing it?
I began my career in healthcare as an Inpatient Rehabilitation Technician in a large acute care hospital. I originally wanted to go into physical therapy or sports medicine because of my years playing football, baseball, and wrestling.
After working in the field for a few years and attending a local college for prerequisites, I decided to go into nursing instead. I worked as a solid organ transplant RN with critically ill patients for several years. Many of these patients went on for inpatient rehabilitation services at Brooks Rehabilitation, and when they would come back to visit, they would rave about the great care they received. We could see the progress they made.
When the opportunity came up to continue my leadership career at Brooks as the Director of Nursing for a new 60-bed hospital they were opening, I couldn’t pass it up. I chose them for their stellar reputation, Magnet status (we’re one of only five freestanding rehabilitation hospitals in the country to have Magnet status), and patient outcomes.
Explain what a physical rehabilitation nurse does. What types of patients do you serve? What do you provide for them?
At Brooks specifically, we serve the top 3% complexity in the nation. These patients range from traumatic brain injury, spinal cord injury, stroke, trauma, orthopedic, trauma, transplant, Hem/Onc, and many other specialties. We provide high-quality, individualized care, training, and education to them and their caregivers so they can become as independent as possible to prepare them for discharge.
Did you need to get additional education for this position?
There are many disease/injury-specific processes and care the RNs need to learn to care for the patients properly. For example, traumatic brain injury patients need calm redirection not to become heightened or agitated while working to improve their memory. Depending on the severity of the stroke, stroke patients may need extensive memory cues, approaching them from the affected side to force them to look your direction, in addition to strength and fine motor skills training on the affected side. Spinal cord injury patients may need varying transfer training or equipment fitting and training for mobility.
The Certified Rehabilitation Registered Nurse (CRRN) certification can help validate a higher level of knowledge in the specialty. In addition to specific pathophysiology around an injury or impairment, a CRRN has training in ethics, advocacy, the legislative policies that impact individuals with disabilities, accessibility, improving quality of life, and improving levels of independence.
What do you like most about working as a physical rehab nurse?
It is rewarding to know our impact on our patients and their caregivers.ers.
We take tough—sometimes life-altering situations—find the good in them, and help patients build confidence in leading a meaningful life. As a result, some patients recover fully, like watching miracles before our own eyes.
Rehab RNs and staff go out of their way to provide unique opportunities for patients to interact with their loved ones, friends, and pets. We help them regain their independence, and the compassion of a rehab RN is unmatched!
What are your biggest challenges as a physical rehab nurse?
When you’re newer to the Inpatient Rehab setting, there is much to learn about injuries or illnesses. This specific care must be provided to each individual and the short stay in which we are expected to have vast improvement in their outcomes. Regulatory practices by insurance or CMS limit the time a patient can spend at this level of care, so we have to work fast and furious to push the limits for our patient’s recovery.
Seeing a patient that could benefit from weeks of intense therapy but only has an insurance benefit providing 14 days of coverage is heart-wrenching.
What are your greatest rewards as one?
Watching our patients and families smile, cry, and hug us as they ring the bell upon discharge.This puts into perspective how much they appreciate us and the care we provided them while they were with us.You do not experience this type of nursing in many acute care areas, making this such a special environment.
The battle against infectious diseases has been present for the longest time in history. Yet, even today, we continue to witness outbreaks such as the recent COVID-19 pandemic. Unfortunately, infectious diseases tend to occur suddenly, causing havoc and uncertainty in communities due to their ability to spread fast. Moreover, growing globalization and interconnectedness have made outbreaks more lethal.
However, technological advancements boost traditional surveillance techniques, which offers a glimpse of hope in this fight. Data analytics and artificial intelligence are helping healthcare workers and critical decision-makers find timely insights and information that play a crucial role in predicting, understanding, preventing, and mitigating risks of infectious diseases.
Gathering Data to Understand Infectious Diseases
Data used by healthcare workers to understand the risk of infectious diseases has to be gathered from reliable sources. Big data analytics helps collect phone data from telecom companies. Telecoms hold data that can show patient behavior during an outbreak. A good example is how health workers worked with a telecom company to track people’s movement using mobile phone data in the 2010 earthquake in Haiti. The same data proved valuable ten months later when a cholera outbreak happened. Health workers could see population movement quickly, which gave them a leg up in containing the spread.
Another useful source is social media. With millions of people active daily on popular social platforms such as Twitter, Facebook, WeChat, and the like, these platforms offer a reliable stream of data. This data can be analyzed in real-time to give insights into infectious disease transmission in terms of time and geographical locations. Other sources include search engine activity, travel, tourism, hospitality companies, community follow-ups, and hospital and clinic data.
Data Analysis and Classification
Gathering data from multiple sources results in both structured and unstructured data. For healthcare workers to make sense of the data, it has to be analyzed and classified accordingly. When done successfully, big data analytics can help healthcare workers get insights that are valuable in the following ways:
Predicting infectious diseases outbreak – This helps hospitals take proactive preparations, such as ensuring enough patient beds and personal protective equipment for healthcare workers.
Predicting disease spread progression to show areas where infectious diseases are unfolding and where they are more likely headed.
Identifying most vulnerable communities – This gives insights on areas or populations where most or urgent care is needed to inform decisions on preventive measures, emergency funds allocation, and response efforts.
Understanding adverse drug reactions and antibiotic resistance – This is important in drug and vaccine development.
Limitations of Data Analytics When Drawing Conclusions
The role of data analytics in understanding infectious diseases is challenging. However, understanding the possible limitations can help healthcare workers find ways to overcome them. Here are a few of them.
-Use of Experts
Big data analytics in healthcare involves using AI, machine learning, deep learning, and other techniques to make sense of data for infectious diseases such as Zika, Ebola, SARS, seasonal flu, and more. In addition, correct analysis requires reliable and relevant data. This calls for high-level expertise, so it’s essential to consult with a data analyst. Less understood diseases require a team of experts ranging from data scientists, geographers, epidemiologists, vets, and ecologists.
-Human Biases
Data streaming from internet sources and phone companies are likely to miss critical demographic identifiers such as sex and age. In addition, people that don’t frequent the internet, such as the elderly, infants, and children, might be underrepresented in the data. This also includes populations from less developed countries. This can be overcome by having traditional data streams such as hospital and clinic data and insurance claim data in the analysis.
-Data Privacy
Data privacy can be a concern, so it is paramount to adhere to ethical data use. Healthcare organizations must set up data privacy regulations and policies to protect individual privacy. This can include coming up with clear guidelines regarding the use of personal data.
Conclusion
Infectious diseases have been prevalent globally for a long time. However, big data analytics provide a way to understand the risk of these diseases. Data gathered from various sources is essential in preventing outbreaks and the severity of the diseases. However, data must be reliable and accurate for it to make sense. Using the knowledge of experts and eliminating biases can go a long way. Moreover, data privacy and security have to be prioritized.
