Research Spotlight

Boehm, L. M., B. T. Pun, J. L. Stollings, T. D. Girard, P. Rock, C. L. Hough, S. J. Hsieh, B. A. Khan, R. L. Owens, G. A. Schmidt, S. Smith and E. W. Ely (2020). “A multisite study of nurse-reported perceptions and practice of ABCDEF bundle components.” Intensive Crit Care Nurs 2020 May 7;102872. [Epub ahead of print]. 102872.

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OBJECTIVES: ABCDEF bundle implementation in the Intensive Care Unit (ICU) is associated with dose dependent improvements in patient outcomes. The objective was to compare nurse attitudes about the ABCDEF bundle to self-reported adherence to bundle components. RESEARCH METHODOLOGY/DESIGN: Cross-sectional study. SETTING: Nurses providing direct patient care in 28 ICUs within 18 hospitals across the United States. MAIN OUTCOME MEASURES: 53-item survey of attitudes and practice of the ABCDEF bundle components was administered between November 2011 and August 2015 (n = 1661). RESULTS: We did not find clinically significant correlations between nurse attitudes and adherence to Awakening trials, Breathing trials, and sedation protocol adherence (r(s) = 0.05-0.28) or sedation plan discussion during rounds and Awakening and Breathing trial Coordination (r(s) = 0.19). Delirium is more likely to be discussed during rounds when ICU physicians and nurse managers facilitate delirium reduction (r(s) = 0.27-0.36). Early mobilization is more likely to occur when ICU physicians, nurse managers, staffing, equipment, and the ICU environment facilitate early mobility (r(s) = 0.36-0.47). Physician leadership had the strongest correlation with reporting an ICU environment that facilitates ABCDEF bundle implementation (r(s) = 0.63-0.74). CONCLUSIONS: Nurse attitudes about bundle implementation did not predict bundle adherence. Nurse manager and physician leadership played a large role in creating a supportive ICU environment.

Barrocas, A., D. B. Schwartz, J. M. Hasse, D. S. Seres and C. M. Mueller (2020). “Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID-19.” Nutr Clin Pract Jun 3. [Epub ahead of print].

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The coronavirus disease (COVID-19) pandemic has impacted all aspects of our population. The “Troubling Trichotomy” of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.

Armstrong, E. S., J. Reynolds, C. Sturdivant, S. Carroll and M. S. Suterwala (2020). “Assessing Swallowing of the Breastfeeding NICU Infant Using Fiberoptic Endoscopic Evaluation of Swallowing: A Feasibility Study.” Adv Neonatal Care 20(3): 244-250.

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BACKGROUND: Premature infants may demonstrate feeding difficulties requiring an instrumental swallowing assessment. Fiberoptic endoscopic evaluation of swallowing (FEES) is one assessment that can evaluate bottle feeding and breastfeeding. PURPOSE: This pilot study investigated the safety and feasibility of FEES for neonatal intensive care unit (NICU) infants during breastfeeding. METHODS: The setting for this prospective, descriptive study was an urban level III NICU that provided care for premature and critically ill infants. Participants were 5 infants recruited from a convenience sample who were at least 37 weeks postmenstrual age, demonstrated feeding difficulties during a bedside feeding and swallowing examination, and were breastfeeding. Each participant received a FEES assessment while breastfeeding (FEES-B). Adverse events and vital signs including prefeeding and postfeeding respiratory rate, heart rate, and oxygen saturation level were recorded to assess safety. Visualization of milk, laryngeal penetration, and tracheal aspiration assessed feasibility. RESULTS: Participants had a mean postmenstrual age of 39.8 weeks. No adverse events, including epistaxis or laryngospasm, were reported; there were no instances of autonomic instability; and there were no statistically significant differences between prefeeding and postfeeding respiratory rate, heart rate, or oxygen saturation level. Two infants successfully breastfed during FEES-B. Human milk was observable, and laryngeal penetration was noted with 1 infant. IMPLICATION FOR PRACTICE: FEES-B was found to be safe, with limited data supporting feasibility. Infants demonstrated no physiologic instability during FEES-B, and milk was visualized in the pharynx during breastfeeding with 2 infants. IMPLICATION FOR RESEARCH: Further studies are warranted to assess effectiveness of FEES-B in infants.

Armstrong, A. W., A. Blauvelt, J. J. Crowley, K. B. Gordon, G. G. Krueger, J. G. Krueger, J. M. Sobell, B. E. Strober, B. Srivastava and A. Menter (2020). “Defining drug-free remission of skin disease in patients with plaque psoriasis.” Br J Dermatol 182(6): 1484-1487

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We conducted an investigator-initiated, consensus-building exercise to develop a practical definition of drug-free remission of skin disease for plaque psoriasis based on the Delphi method, which is a process by which group communication among a panel of experts helps attain consensus on complex issues. The Delphi method has been used to build consensus on other areas of clinical importance in psoriasis, such as the treat-to-target guidelines recently published by the National Psoriasis Foundation. [No abstract; excerpt from article].

Al-Azizi, K. and M. Szerlip (2020). “Mitral Stenosis After MitraClip: How to Avoid and How to Treat.” Curr Cardiol Rep 22(7): 50.

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PURPOSE OF REVIEW: The goal of the paper is to highlight the importance of procedural planning and patient selection when using the MitraClip device in treating severe mitral regurgitation (MR). RECENT FINDINGS: Following the recent results of the COAPT trial and FDA approval for functional MR patients, the indications for mitral clip are continuing to expand. Because of this, mitral stenosis from mitral clip can become a problem if the appropriate patients are not selected. Proper valve imaging, utilizing 3D transesophageal echocardiography to identify the pathology, is important to prevent iatrogenic mitral stenosis. In the unfortunate event of severe mitral stenosis as a result of the MitraClip device, surgery is the only treatment.