According to the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States. Type 2 diabetes is one of the most commonly occurring chronic diseases, which affects about 90-95% of those diagnosed. According to a 2018 study published in Health and Quality of Life Outcomes, there were over 415 million adults between 20-79 years living with diabetes globally. The American Diabetes Association estimates that over $327 billion is the annual cost of diabetes care in the United States alone.
A serious complication of diabetes is hypoglycemia, a blood sugar level less than 70 mg/dL. Hypoglycemia comes on suddenly and patients display symptoms such as profuse sweating, tremors, irritability, altered mental status, loss of consciousness, among others. Hypoglycemia has several adverse effects including cardiac arrhythmias, seizures, and can be fatal in severe cases. The fear of inadvertent hypoglycemia is among the biggest barriers patients face while working towards glycemic control. Hence, one may conclude that frequent hypoglycemic incidents are disruptive to the normal life, and may result in injury, increased medical costs, loss of wages, and the need for constant monitoring by another person.
Real-time continuous glucose monitoring (CGM) may provide an ideal solution for individuals with a high risk of hypoglycemia. CGM measures glucose levels continuously via a transdermal glucose sensor and sends data to one or more monitoring devices. It is configurable to alert the user and/or designated provider when blood glucose levels are too high or too low. In a 2017 study, David Rodbard, MD, demonstrated that the use of CGMs resulted in significant reduction of hypoglycemia risk and improved patients’ quality of life. Since the invention and subsequent improvement of the quality of monitoring and reporting, CGM systems have become very reliable tools for real-time monitoring of blood glucose and prevention of dangerous hypoglycemia. CGM systems also help reduce health care costs and improve quality of life and productivity of patients.
A Brief Introduction to CGM Systems
The first CGM system hit the market in 1999. Early CGM systems were bogged down with issues related to accuracy, delayed transmission, and patient teaching. Rapid advancements in technology have influenced development of highly accurate, versatile, and user-friendly CGM machines. In 2015, the American Association of Clinical Endocrinologists and American College of Endocrinology included CGM systems into their clinical practice guidelines. Three medical device manufacturers—Abbott Laboratories, Medtronic, and Dexcom Inc.—have emerged as leaders in today’s CGM marketplace at a global level.
CGM’s Role in Preventing Hypoglycemia and Improving Quality of Life
The main idea behind the introduction of CGM systems was to achieve enhanced real-time blood glucose monitoring of diabetic patients and prevention of abnormal glycemic highs and/or lows and its accompanying complications. Multiple studies have successfully demonstrated that diabetic patients are at a risk of undetected hypoglycemia. According to a 2017 study published in Diabetes Technology & Therapeutics, 22% of sudden unexpected deaths in persons under 40 with type 1 diabetes were due to hypoglycemia. The study concluded that using CGM systems helped reduce hypoglycemia and improve glucose control.
Inadequate glycemic control is associated with complications that lead to reduced quality of life, work absenteeism, increased hospitalization, among others. Fear of hypoglycemia and its associated costs may discourage patients from adhering to a treatment plan formulated by their primary care provider. And yet, the Diabetes Technology & Therapeutics study estimated an annual savings of $936-$1,346 per person in hypoglycemia prevention with the use of CGM systems.
A recent randomized controlled trial published in The Journal of Clinical Endocrinology & Metabolism found that type 1 diabetics on real-time CGM systems demonstrated a marked improvement in glycemic control and enhanced of quality of life in the form of reduced incidences of hospitalization, work absenteeism, and lesser fear of hypoglycemia.
Furthermore, recent advances in wireless and data-enabled cellphones have enabled medical technology corporations to improve the functionality and accuracy of CGM systems. Modern CGM systems can now send information to the patient and designated caregivers when the blood glucose levels are too high or too low. CGM systems help promote safety and efficacy of glycemic control for both type 1 and type 2 diabetics and reduces the risk of hypoglycemia significantly.
The benefits of CGM systems are yet to be completely utilized by health care providers and patients due to lack of awareness, suspicion about the safety, efficacy, and cost of these systems. Using CGM systems may lead to long-term financial savings and improved quality of life for patients. It is up to primary care providers to educate patients and families to benefit from available technologies and improve their health.
One of the most commonly heard phrases right from day one of nursing school is “critical thinking.” The common consensus is that everyone has to develop sound critical thinking in order to be a safe and effective, registered nurse (RN). This necessity is magnified when it comes to critical care areas where one decision by the RN can change the patient’s outcome. Nursing has changed from a simple caregiving job to a complex and highly responsible profession. Hence, the role of nurses has changed from being task-oriented to a team-based, patient-centered approach with an emphasis on positive outcomes. Strong critical thinking skills will have the greatest impact on patient outcomes.
So, what is critical thinking and how do we develop this? A precise definition was proposed in a statement by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987. “Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness,” reads the document.
Simply put, critical thinking in nursing is a purposeful, logical process which results in powerful patient outcomes. “Critical thinking involves interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes,” according to a 2010 study published in the Journal of Nursing Education. This definition essentially covers the nursing process and reiterates that critical thinking builds upon a solid foundation of sound clinical knowledge. Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet. Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.
How does one develop critical thinking skills? A good start is to develop an inquisitive mind, which leads to questioning, and a quest for knowledge and understanding of the complex nature of the human body and its functioning. A vital step in developing critical thinking for new nurses is to learn from those with a strong base of practical experience in the form of preceptors/colleagues. An open-minded nurse can learn valuable lessons from others’ critical thinking ability and will be able to practice for the good of their patients.
Critical thinking is self-guided and self-disciplined. Nursing interventions can be reasonably explained through evidence-based research studies and work experience. A strong sense of focus and discipline is also important for critical thinking to work. If thinking is unchecked, nurses can be easily misguided and deliver flawed patient care. A constant comparison of practice with best practices in the industry will help guide a nurse to think critically and improve care. This makes it easier to form habits which continue to have a positive impact on patients and colleagues. Every decision a critical thinking nurse makes affects not only the patient but also his or her families, coworkers, and self.
In summary, the take-home message for nurses is that critical thinking alone can’t ensure great patient care. A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside.
One of the most common but preventable hospital-acquired infections is a central line-associated bloodstream infection (CLABSI), also known as a catheter-related bloodstream infection. There are approximately 250,000 cases annually in hospitals across the country, including 80,000 in intensive care units according to a study published in the Clinical Journal of Oncology Nursing. Additionally, CLABSIs cost over $6 billion health care dollars and about 50,000 preventable deaths per a study published in the Journal of Infusion Nursing.
Bedside nurses have the responsibility to implement the right interventions to prevent them. Appropriate training and education in central line management can go a long way in preventing this problem. Nurses are in a unique position to prevent CLABSIs across the health care spectrum. It would not be an overstretch to say that CLABSI prevention is completely a nursing responsibility. Let us consider the current health care scenario: the nursing scope of practice has increased vastly over the past decade and our profession continues to gain significance.
The most common central used in acute care—peripherally inserted central catheter (PICC) lines—are mostly inserted by specially trained nurses. It is also the bedside nurse that accesses the central line to administer medications, obtain blood samples, et cetera. Finally, when the patient is discharged and does not need the central line, it is the bedside nurse that discontinues and removes the line safely. Granted, few central lines are accessed by radiology and rarely by doctors, but the bottom line is that nurses are the ones inserting, maintaining, and removing the lines.
Two distinct situations place patients at a risk of acquiring a CLABSI: insertion and hub manipulation for blood sampling, medication administration, and routine line maintenance. Improper skin cleansing before insertion of the central line poses the risk of introducing deadly pathogens into the bloodstream. The hub, or needleless catheters, are known for harboring biofilms (e.g., bacterial colonies), which can enter the bloodstream during care episodes that involve hub manipulation. One of the most common sources of a CLABSI is the frequent hub manipulation by nursing for care purposes.
What can frontline nurses do to prevent CLABSIs?
The Centers for Disease Control and Prevention and the Infusion Nurses Society provide the following guidelines on insertion, care, and maintenance of central lines:
- Maintain a closed system.
- Scrub access ports (needleless caps) with antiseptic solution (70% alcohol) for at least 15-20 seconds before access.
- Use intermittent infusion caps of luer-lock design to ensure a secure junction.
- Change hubs or needleless connectors when it is removed from the line; if there is blood/debris within the cap; prior to blood sampling; upon known contamination; and per organization or manufacturer guidelines, policies or practice procedures.
- Change hubs or needleless connectors before and after blood sampling provides greater protection to the patient.
The Journal of Infusion Nursing study found that two beliefs among nurses predisposed them to disinfect the needleless cap before manipulation: nurses’ perceptions of peer beliefs regarding disinfection and personal belief that not cleaning the cap will increase the likelihood of patient acquiring an infection. Another significant finding of the study is that older and more experienced nurses were “less likely to consistently use the best practice disinfection techniques” while manipulating needleless IV systems.
One of the biggest lessons we can take from these studies and statistics is the fact that nurses have the power to prevent infection. The researchers found that some older and more experienced nurses tend to neglect disinfection practices, but it is important to remember that nursing is about caring for the patient. Education departments of hospitals can remind nurses by conducting classes on the fundamental values of nursing: caring, patient advocacy, beneficence, non-malfeasance, and so on.
Sometimes patients are discharged home with central lines in place for long-term antibiotic therapy or chemotherapy. Educating the patients and families on the best practices of central line care and infection prevention is the responsibility of nursing staff. Making patients and caregivers partners in therapy by creating educational materials in simple language will help motivate adult learners to assimilate the knowledge. An interactive nurse-led demonstration accompanied by an illustrated guide to best practices of central line management will ensure compliance to strict infection prevention practices. Again, this responsibility of educating patients falls on nurses, and patient education is a powerful tool to prevent CLABSIs. Education empowers the patient and gives them ownership of their own care and condition.
To sum up, evidence-based research points to the fact that frontline nurses are the main stakeholders in CLABSI prevention. Improving practice to prevent CLABSIs will not only save about $6 billion annually, but it will also ensure that 50,000 more patients survive hospitalization and go home to their loved ones. It is up to nurses to make hospitals places to get treatment, rest, and rejuvenation, rather than scary buildings where one remains on the edge of acquiring a hospital-acquired infection. Nurses have been making a difference in patient outcomes for several decades—and now is the time to up the ante.