JOURNAL Watch THE USE OF PROTOCOLS IN SEPTIC SHOCK According to this study: • • Patients with septic shock gained no additional benefits when treated according to specific protocols, as compared with usual care.


arly goal-directed therapy (EGDT) is a six-hour protocol for the hemodynamic management of septic shock that requires the insertion of a central venous catheter to aid in the administration of iv fluids, vasopressors, and dobutamine and in red-cell transfusion. In a 2001 study the practice was found to significantly reduce mortality. A new study, the Protocolized Care for Early Septic Shock study, sought to determine whether EGDT measures were still superior to either a less-invasive protocol or usual care for the treatment of septic shock. Thirty-one academic hospitals across the United States participated in the randomized trial over a five-year period (2008 to 2013). Patients were enrolled while in the ED after presenting with suspected sepsis into one of three treatment arms: an EGDT arm, a standardprotocol arm, and a usual-care arm. The standard protocol was also a six-hour set of directives on the hemodynamic management of sepsis but was less aggressive: placement of a central catheter wasn’t required, and limits were placed on when red-cell transfusions should be performed. Usual care was care provided by a hospital clinician using medical judgment instead of a prescribed protocol. A total of 1,341 patients were analyzed: 439 in the EGDT group, 446 in the standard-protocol group, and 456 in the usual-care group. How resuscitation was carried out varied among the three groups. Patients in the standardprotocol arm received the most fluid (a mean of 3.3 liters) during [email protected]

By Andrea Kayyali, MSN, RN

the initial six hours of their treatment course and overall, followed by the EGDT arm (2.8 liters) and the usual-care arm (2.3 liters). Patients in both protocol groups were more often given vasopressors than those receiving usual care (54.9% in the EGDT arm, 52.2% in the standard-protocol arm, and 44.1% in the usual care arm). Dobutamine administration and red-cell transfusion were more frequent in the EGDT group (8%) than in either the standard-protocol group (1.1%) or the usual-care group (0.9%). Despite the significant differences in treatment management, the investigators found that inhospital mortality at day 60 was similar in all three groups—21% in the EGDT group, 18.2% in the standard-protocol group, and 18.9% in the usual-care group— which led them to conclude that there was no observed benefit to protocol-driven care in sepsis management. The ProCESS Investigators. N Engl J Med 2014;370(18):1683-93.

THE IMPACT OF TURNOVER IN NURSING HOMES According to this study: • • The quality of care in nursing home patients is adversely affected by turnover of both licensed nurses (RNs, LPNs, and LVNs) and certified nursing assistants.


mong the toughest challenges for nursing administrators is recruiting skilled and experienced nursing staff. Even harder is retaining them. The results of a new study underscore the importance of reducing turnover in a nursing home setting to sustain high levels of care. The study involved retrospective analyses of two large data sets from 2004. The first data set came from the National Nursing Home Survey (NNHS), which collected information on individual nursing homes’ staffing levels, types of staff, and turnover rates, among other

variables, such as facility size and resident characteristics. The second data set came from the Online Survey, Certification and Reporting (OSCAR) database. OSCAR reported “deficiencies” in nursing homes, as measured by independent auditors who evaluated the homes’ compliance with 180 federally defined standards. The study focused on 50 specific deficiencies that best aligned to care delivered by the nursing staff: 25 pertained to quality-ofcare (QOC) indicators (such as activities of daily living, pressure ulcer development, and continence care), 19 to quality-of-life (QOL) indicators (such as housekeeping and social services), and six to resident-behavior (RB) indicators (such as restraint use and treatment of the residents by staff). The researchers linked the data from the NNHS to the OSCAR database to cross-reference turnover rates among licensed nurses (RNs, LPNs, and LVNs) and certified nursing assistants (CNAs) with reported deficiencies in 1,151 nursing homes. The mean turnover rates over a three-month period among CNAs and licensed nurses were 16.2% and 11.7%, respectively. Nursing homes with high turnover rates of CNAs (those above the 75th percentile in the sample) saw the greatest total number of deficiencies and the greatest number of deficiencies in QOC and RB indicators, even after adjustment for staffing and skill mix. Licensed-nurse turnover, after the same adjustments, was also significantly associated with total deficiencies and QOC deficiencies. When licensed nurses and CNAs were evaluated within the same model, high licensed-nurse turnover, but not CNA turnover, was significantly associated with QOC and total deficiencies. Given the effect of nursing staff turnover on the quality of resident care, the authors recommended additional research focused on AJN ▼ September 2014

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JOURNAL Watch strategies to reduce turnover among both licensed nurses and CNAs in nursing homes. Lerner NB, et al. J Am Med Dir Assoc 2014; 15(2):102-7.

SURGICAL TECHNIQUES FOR APICAL VAGINAL PROLAPSE According to this study: • • Two years after surgery, sacrospinous ligament fixation and uterosacral ligament suspension used to improve urinary incontinence had comparable outcomes. Pelvic floor–muscle training had no effect on incontinence.


pical prolapse, a prolapse of the upper vaginal walls that can lead to urinary incontinence, can be corrected with either of two transvaginal surgical approaches: sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (ULS). The Operations and Pelvic Muscle Training in the Management of Apical Support Loss trial is the first randomized study to compare two-year postprocedural outcomes of each approach and the impact of perioperative behavioral therapy with pelvic floor–muscle training (BPMT) on reported urinary symptoms. The five-year study involved nine U.S. institutions that were all members of the Pelvic Floor Disorders Network. Women with vaginal or uterine prolapse at stages 2 to 4, 374 subjects in total, were randomized in two ways: according to procedure type (186 undergoing SSLF and 188 undergoing ULS) and by receipt of either perioperative BPMT (186 patients) or usual care (188 patients). The follow-up rate was 84.5% at two years after surgery. Surgical success was defined as no descent of the vaginal apex more than a third of the way into the vaginal canal, no anterior or posterior vaginal wall drop beyond the hymen, no reported problems with vaginal bulging, 70

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and no need for retreatment. On these measures, the success rate with ULS was 59.2%, compared with 60.5% with SSLF. No significant differences in other outcomes, such as length of hospitalization, blood loss, surgical time, and postoperative treatment, were seen. Serious adverse events, most often intraoperative bladder perforation or vaginal-tissue granulation, occurred at nearly the same rate in the two groups (ULS, 16.5%; SSLF, 16.7%). Neurologic pain occurred more frequently with SSLF—12.4%, compared with 6.9% with ULS—and continued in 4.3% of the SSLF patients for at least four to six weeks. BPMT hadn’t delivered any significant improvements in perceived urinary symptoms at either the sixmonth mark or the two-year mark. These results suggest that pelvic floor–muscle training might not be helpful in this patient population. Barber MD, et al. JAMA 2014;311(10): 1023-34.

FATTY ACIDS AND CORONARY RISK According to this study: • • Cardiovascular guidelines that recommend eating foods with high levels of polyunsaturated fat and foods with low levels of saturated fat aren’t supported by study evidence.


ccording to a new analysis of existing research on fatty acids and heart risks, there is little evidence to support recommendations to consume more polyunsaturated fat and less saturated fat to reduce heart disease. The researchers conducted a systematic review and meta-analysis of studies available in medicaljournal databases through July 2013 that included the following: 32 prospective observational studies that concerned fatty acids from food intake; 17 prospective observational studies involving fatty acid biomarkers found in

blood; and 27 randomized controlled trials that investigated fatty acid supplements. All eligible studies evaluated these factors with respect to coronary events. The resulting data pool comprised more than 600,000 subjects globally and involved both healthy subjects and subjects with cardiac disease. In the 32 studies with subjects who reported their consumption of foods from fatty acids, the researchers compared the top third of subjects with the bottom third (in terms of fatty acid intake). They found insignificant associations between coronary events and the intake of long chain ω-3 and ω-6 polyunsaturated fatty acids, saturated fats, and monounsaturated fats. The 17 studies that examined blood biomarkers of fatty acids showed that two specific circulating saturated fatty acids, palmitic and stearic acids, had positive but not statistically significant associations with cardiovascular disease. Margaric acid (found in milk and dairy products), however, was significantly associated with a lower risk of coronary events. No other fatty acid biomarker had a statistically significant effect on coronary risk. The 27 randomized controlled trials analyzing the effect of fatty acid supplements on coronary risk involved more than 100,000 subjects; 5,726 had a coronary event. Of the subjects who had taken linolenic acid or ω-3 or ω-6 polyunsaturated fatty acid supplements, none had significant reductions in coronary risk, as compared with control subjects. The authors proposed that in light of the lack of significant correlations between polyunsaturated and saturated fats and coronary risk, current dietary guidelines may need to be reevaluated and revised to better reflect the research evidence. Chowdhury R, et al. Ann Intern Med 2014; 160(6):398-406. ▼

The impact of turnover in nursing homes.

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