DRUG ADMINISTRATION
Nurses respond to "dynamic" education
Many hospitalized patients are prescribed anticoagulant therapy for venous thromboembolism (VTE) prophylaxis, but research has shown that nurses don't administer up to 12% of prescribed doses; the most commonly documented reason is patient refusal. To address this problem, researchers at Johns Hopkins Hospital, Baltimore, Md., designed a course of online education to give nurses the tools they need to communicate the critical importance of VTE prophylaxis to their patients.
The 1-year study period involved over 900 permanently employed nurses on 21 medical or surgical units. Two types of learning experiences were tested: a "dynamic" module involving scenarios in which nurses select responses, and a "static" module consisting of a slide show and a voiceover explaining the information. The units were randomly assigned to use either the dynamic or static module for nurse education. Researchers tracked nonadministration rates from the hospital's electronic health record system and analyzed data in three time periods: baseline, education intervention, and postintervention. The primary and secondary outcomes were nonadministration of prescribed VTE prophylaxis medication and nurse-reported satisfaction with the education modules.
During the study period, 214,478 doses of medications prescribed for VTE prophylaxis were administered on the 21 participating units. Overall, nonadministration rates dropped from 12.4% to 11.1%. The reduction in nonadministration rate was greater for nurses who completed the dynamic module (10.8% to 9.2%) compared with the static module (14.5% to 13.5%). Nurse satisfaction scores were also higher for the dynamic module, which was considered more engaging and enjoyable.
"Our study adds to evidence that the way something is taught to professionals has a great influence on whether they retain information and apply it," remarks lead investigator Brandyn Lau, MPH, CPH. The online education course is expected to become mandatory throughout the Johns Hopkins Medicine system; researchers say they'd like to make it available to all nurses nationwide.
Sources: Lau BD, Shaffer DL, Hobson DB, et al. Effectiveness of two distinct web-based education tools for bedside nurses on medication administration practice for venous thromboembolism prevention: a randomized clinical trial. PLoS One. 2017;12(8):e0181664. Online education boosts proper use of drugs that prevent blood clots. Johns Hopkins Medicine. News release. August 16, 2017.
KYMRIAH
First gene therapy approved for use in U.S.
In what it termed "a historic action," the FDA has approved Kymriah (tisagenlecleucel), the first gene therapy available in the United States. Kymriah is a CD19-directed genetically modified autologous T cell immunotherapy indicated for the treatment of patients up to age 25 with B-cell precursor acute lymphoblastic leukemia that is refractory or in second or later relapse. Kymriah doses are customized to individual patients in a process that genetically programs the patient's own T-cells to recognize and destroy leukemic B cells that have a specific surface antigen (CD19).
In clinical trials, the overall remission rate within 3 months of treatment was 83%. However, the drug can cause life-threatening adverse reactions, including neurologic toxicities, which may be severe or life-threatening, and cytokine release syndrome (CRS). CRS can cause high fever, hypotension, hypoxia, hemodynamic instability, respiratory distress, and renal, hepatic, and cardiac dysfunction. Both are the subject of a boxed warning in the labeling. Because the drug can cause prolonged neutropenia, patients are also at prolonged risk for infections.
Administered I.V., Kymriah contains human cells genetically modified with a lentivirus and may carry a risk of transmitting infectious viruses to healthcare professionals. When handling the drug, clinicians should follow standard precautions.
Sources: FDA approval brings first gene therapy to the United States. Food and Drug Administration. News release. August 30, 2017. Kymriah (tisagenlecleucel) suspension for intravenous infusion. Prescribing information. https://www.pharma.us.novartis.com/sites/www.pharma.us.novartis.com/files/kymria.
OPIOID USE DISORDER
Patients in acute pain need holistic nursing care
Although the CDC has provided guidelines for treating chronic pain in patients with opioid use disorder (OUD), no guidelines have been issued for managing acute pain in this population. Based on a thorough literature review, author Coleen Dever, MSN, AGCNS-BC, CEN, TRCN, advocates a holistic, multimodal approach to managing acute pain in patients who are opioid-dependent or at risk for OUD. Outlining practical, evidence-based strategies, she recommends:
* starting opioid therapy at the lowest dose and then titrating appropriately to achieve effective pain control. The goal isn't to eliminate pain, but to reduce it to a manageable level.
* educating clinicians and patients alike about behaviors and attitudes, such as negative stereotypes about drug users, that can influence pain management strategies and patient response to treatment.
* learning about and using screening tools to identify patients at risk for OUD.
* talking with patients and families about pain, the risks and benefits of opioid use, and patient expectations about pain control.
* considering the use of alternative medications that can help manage pain and reduce opioid use, such as nonsteroidal anti-inflammatory drugs, antiepileptic drugs, and antidepressants.
* continuing to monitor patients for pain relief and opioid use after discharge. Dever writes, "There is a great need for future research regarding safe prescribing of opioids at time of discharge from the acute care setting."
Sources: Dever C. Treating acute pain in the opiate-dependent patient. J Trauma Nurs. 2017;24(5):292-299. Treating acute pain in opioid-dependent patients-review and recommendations. Wolters Kluwer Health. News release. September 13, 2017.
OXYGEN THERAPY
No value found for many patients with AMI
New research indicates that routine oxygen therapy doesn't improve survival in patients with acute myocardial infarction (AMI) who don't have hypoxemia at baseline. A prospective, randomized, open-label trial enrolled 6,629 patients with suspected AMI from 35 hospitals in Sweden. All patients had an oxygen saturation level of 90% or higher at baseline. Half of the patients received supplemental oxygen via face mask (6 L/min for 6 to 12 hours) and half remained on room air. The primary outcome was mortality from any cause 1 year after randomization.
The results showed no significant differences in survival between the two groups. The rate of rehospitalization for AMI within 1 year was also similar for both groups.
"The study results will likely have an immediate impact on clinical practice and future guidelines," says coauthor Stefan K. James. "Our findings do not support the routine use of oxygen therapy in all patients with symptoms of heart attack. The general use of oxygen in these cases is still widespread in the world but can now be adjusted."
Sources: Hofmann R, James SK, Jernberg T, et al. Oxygen therapy in suspected acute myocardial infarction. N Engl J Med. [e-pub Aug. 28, 2017.] Oxygen therapy does not improve survival in patients with heart attack symptoms (DETO2X-AMI). European Society of Cardiology. News release. August 28, 2017.