Effect of bundle set interventions on physiologic alarms and alarm fatigue in an intensive care unit: A quality improvement project

ObjectiveTo determine if the implementation of an evidence-based bundle designed to reduce the number of physiologic monitor alarms reduces alarm fatigue in intensive care nurses.DesignThis quality improvement project retrospectively reviewed alarm data rates, types, and frequency to identify the top three problematic physiologic alarms in an intensive care unit. An alarm management bundle was implemented to reduce the number of alarms. The Nurses’ Alarm Fatigue Questionnaire was used to measure nurses’ alarms fatigue pre- and post-implementation of the bundle.SettingA combined medical surgical intensive care unit at an accredited hospital in the United States.ResultsThe top three problematic alarms identified during the pre-implementation phase were arrhythmia, invasive blood pressure, and respiration alarms. All three identified problematic physiologic alarms had a reduction in frequency with arrhythmia alarms demonstrating the largest decrease in frequency (46.82%). When measuring alarm fatigue, the overall total scores increased from pre- (M = 30.59, SD = 5.56) to post-implementation (M = 32.60, SD = 4.84) indicating no significant difference between the two periods.ConclusionAfter implementing an alarm management bundle, all three identified problematic physiologic alarms decreased in frequency. Despite the reduction in these alarms, there was not a reduction in nurses’ alarm fatigue.     

Clinical decision-making in the intensive care unit: A concept analysis

AimTo operationally define clinical decision-making as it relates to intensive care unit nursing.BackgroundClinical decision-making is an intricate cognitive process that is demanding on intensive care nurses due to the severity of their patients’ illnesses, consistent exposure to high-stakes situations, and prevalent patient mortality. When compromised, it can lead to adverse patient events. However, clinical decision-making specific to the intensive care unit is a concept seldom defined in nursing research.DesignConcept analysis.MethodsUsing Walker and Avant’s eight-step method, nursing databases were searched for studies between 1980 and 2022 describing the antecedents, defining attributes, consequences, and empirical referents of clinical decision-making in the intensive setting.FindingsIntensive care unit clinical decision-making is a complex cognitive process in which nurses recognize a clinical problem in their patient and respond promptly by implementing interventions to improve their patient’s rapidly and frequently changing health status to a more favorable condition in an intensive care setting. The defining attributes are: assessment of the patient situation, prompt recognition of cues, efficient comprehension of patient data abnormalities, prior knowledge and experience, prompt response to the clinical problem(s), colleague collaboration, formulation of interventions to treat clinical problem(s), and appraisal of risks/benefits.ConclusionIntensive care unit clinical decision-making is a skill that is different from traditional clinical decision-making in nursing. Prompt action characterizes this concept due to the unstable health status of these patients. More research on this concept is needed to enhance nurse performance and patient outcomes in intensive care.Implications for clinical practiceA definition of this concept opens doors for potential studies on promoting effective decision-making among intensive care nurses. This can improve the safety and outcomes of critically ill patients. Additionally, it generates new questions regarding how nursing schools and hospital orientation programs can promote and develop competent decision-making skills in future intensive care nurses.     

A national online survey on the effectiveness of clinical alarms

PURPOSE: To develop a national online survey to be administered by the American College of Clinical Engineers Healthcare Technology Foundation to hospitals and healthcare workers to determine the problems associated with alarms in hospitals. METHODS: An online survey was developed by a 16-member task force representing professionals from clinical engineering, nursing, and technology to evaluate the reasons health-care workers do not respond to clinical alarms. RESULTS: A total of 1327 persons responded to the survey; most (94%) worked in acute care hospitals. About half of the respondents were registered nurses (51%), and one-third of respondents (31%) worked in a critical care unit. Most respondents (>90%) agreed or strongly agreed with the statements covering the purpose of clinical alarms and the need for prioritized and easily differentiated audible and visual alarms. Likewise, many respondents identified nuisance alarms as problematic; most agreed or strongly agreed that the alarms occur frequently (81%), disrupt patient care (77%), and can reduce trust in alarms and cause caregivers to disable them (78%). CONCLUSIONS: Effective clinical alarm management relies on (1) equipment designs that promote appropriate use, (2) clinicians who take an active role in learning how to use equipment safely over its full range of capabilities, and (3) hospitals that recognize the complexities of managing clinical alarms and devote the necessary resources to develop effective management schemes.     

Emergency department monitor alarms rarely change clinical management: An observational study

Study objectiveMonitor alarms are prevalent in the ED. Continuous electronic monitoring of patients' vital signs may alert staff to physiologic decompensation. However, repeated false alarms may lead to desensitization of staff to alarms. Mitigating this could involve prioritizing the most clinically-important alarms. There are, however, little data on which ED monitor alarms are clinical meaningful. We evaluated whether and which ED monitor alarms led to observable changes in patients' ED care.MethodsThis prospective, observational study was conducted in an urban, academic ED. An ED physician completed 53 h of observation, recording patient characteristics, alarm type, staff response, whether the alarm was likely real or false, and whether it changed clinical management. The primary outcome was whether the alarm led to an observable change in patient management. Secondary outcomes included the type of alarms and staff responses to alarms.ResultsThere were 1049 alarms associated with 146 patients, for a median of 18 alarms per hour of observation. The median number of alarms per patient was 4 (interquartile range 2–8). Alarms changed clinical management in 8 out of 1049 observed alarms (0.8%, 95% CI, 0.3%, 1.3%) in 5 out of the 146 patients (3%, 95% CI, 0.2%, 5.8%). Staff did not observably respond to most alarms (63%).ConclusionMost ED monitor alarms did not observably affect patient care. Efforts at improving the clinical significance of alarms could focus on widening alarm thresholds, customizing alarms parameters for patients' clinical status, and on utilizing monitoring more selectively.     

重症医学科护士仪器设备报警疲劳现状及其影响因素分析

目的探讨重症医学科(ICU)护士仪器设备报警疲劳现状及其影响因素分析。方法2020年1月-6月应用一般资料调查问卷、仪器设备报警管理问卷、临床仪器报警疲劳量表对3所三甲医院共125名ICU护士进行调查,采用多元回归分析影响ICU护士仪器设备报警疲劳的相关因素。结果ICU护士仪器报警疲劳总评分为(19.25±3.78)分,处于较高水平。经多元回归分析结果显示,大专学历、科室为综合科室、职称为护士、值夜班、带病工作是影响ICU护士对仪器报警疲劳的主要因素(P<0.05),而护士设备报警功能认知能力及设备功能管理能力是保护因素(P<0.05)。结论ICU护士对仪器设备报警疲劳较明显,因此护理管理者应强化护士仪器设备报警安全意识,提高护士仪器设备管理能力,降低护士仪器设备报警疲劳感。     

Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital

BackgroundThere is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards.ObjectivesThe objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors.Methods, design, setting, and participantsThis was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital.Main outcome measuresThe main outcome measures were knowledge of post–intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors.ResultsThe overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care.ConclusionThere are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.     

品管圈管理工具在减少ICU床旁监护仪误报警应用效果

目的 探讨品管圈管理工具在减少重症加强护理病房(ICU)床旁监护仪误报警应用效果.方法 纳入2018年1月—2019年12月98例ICU患者,其中2018年1—12月实施品管圈管理前共48例为对照组,2019年1—12月实施品管圈管理共50例为观察组,参与品管圈活动护士共7名.设定品管圈名为"HOPE圈",以"采用品管...     

The role of the intensive care nurse in the medical emergency team: A constructivist grounded theory study

BackgroundIntensive care nurses are essential members of rapid response systems (RRSs) with little qualitative data available to capture what intensive care nurses do as they navigate their way around the complexity of a medical emergency call.ObjectiveThe study aims to describe and explain the role of the intensive care nurse within the medical emergency team (MET) of a tertiary-level hospital to develop an understanding of the intensive care nurse role, the way it is enacted, and their responsibilities within the team.MethodA constructivist grounded theory research approach collected qualitative data from intensive care nurses who had experience attending MET calls. Data were collected through participant observation (16 MET calls), followed by 12 semistructured interviews.FindingsA substantive theory was developed that ‘keeping patient's safe’ is a fundamental role of the intensive care nurse within the MET. This is derived from four key concepts: Systematic framework for decision making, Figuring it out, Directing care, and Patient safety. Each of these concepts was developed from categories that describe the role of the intensive care unit nurse on the MET. They include performing assessments and interventions, figuring it out, critical thinking, prioritising care, directing care, being supportive, and ensuring patient safety.ConclusionThis study provides new insights into and an understanding of the ways intensive care nurses work within the MET, making a significant contribution to our existing understanding of the role.     

Improvements in alarm care speed for the clinical monitor system

Hypoxia often occurs in the course of emergency treatment the monitoring systems alarm is not heard promptly by the nurses in attendance. In this study, nurses were monitored for the speed of their reactions to such alarms in 326 clinical instances. In 128 instances (39 percent) the nurses reacted immediately (within ten seconds), and in 198 instances (61 percent) the nurses took more than ten seconds to react. In relation to the reactions that took longer than ten seconds, it was discovered that there was: a lack of alertness about dealing with alarms, insufficient knowledge about setting alarms, no coordinated response mechanism, a failure to hear the alarm, limitations affecting the equipment and difficulty detecting the direction of origin of the alarm sound. For these reasons the hospital implemented briefings about alarms during morning meetings, a coordinated response mechanism, improvements in standards concerning the setting and inspection of alarms, the setting of limits on the frequency of patient's visits and the numbers of visitors, and the setting of a standard alarm volume level. As a result, the percentage of nurses responding to alarms within ten seconds increased to eighty percent, raising standards of nursing care, medical treatment and patient safety.     

Nursing handover from ICU to cardiac ward: Standardised tools to reduce safety risks

BackgroundStandardising handover processes and content, and using context-specific checklists are proposed as solutions to mitigate risks for preventable errors and patient harm associated with clinical handovers.ObjectivesAdapt existing tools to standardise nursing handover from the intensive care unit (ICU) to the cardiac ward and assess patient safety risks before and after pilot implementation.MethodsA three-stage, pre-post interrupted time-series design was used. Data were collected using naturalistic observations and audio-recording of 40 handovers and focus groups with 11 nurses. In Stage 1, examination of existing practice using observation of 20 handovers and a focus group interview provided baseline data. In Stage 2, existing tools for high-risk handovers were adapted to create tools specific to ICU-to-ward handovers. The adapted tools were introduced to staff using principles from evidence-based frameworks for practice change. In Stage 3, observation of 20 handovers and a focus group with five nurses were used to verify the design of tools to standardise handover by ICU nurses transferring care of cardiac surgical patients to ward nurses.ResultsStage 1 data revealed variable and unsafe ICU-to-ward handover practices: incomplete ward preparation; failure to check patient identity; handover located away from patients; and information gaps. Analyses informed adaptation of process, content and checklist tools to standardise handover in Stage 2. Compared with baseline data, Stage 3 observations revealed nurses used the tools consistently, ward readiness to receive patients (10% vs 95%), checking patient identity (0% vs 100%), delivery of handover at the bedside (25% vs 100%) and communication of complete information (40% vs 100%) improved.ConclusionClinician adoption of tools to standardise ICU-to-ward handover of cardiac surgical patients reduced handover variability and patient safety risks. The study outcomes provide context-specific tools to guide handover processes and delivery of verbal content, a safety checklist, and a risk recognition matrix.     

Clinical validation of expert consensus statements for respiratory physiotherapy management of invasively ventilated adults with community-acquired pneumonia: A qualitative study

ObjectivesTo conduct multidisciplinary peer-review of expert consensus statements for respiratory physiotherapy for invasively ventilated adults with community-acquired pneumonia, to determine clinical acceptability for development into a clinical practice guideline.Research methodologyA qualitative study was undertaken using focus groups (n = 3) conducted with clinician representatives from five Australian states. Participants were senior intensive care physiotherapists, nurses and consultants. Thematic analysis was used, with a deductive approach to confirm clinical validity, and inductive analysis to identify new themes relevant to the application of the 38 statements into practice.SettingAdult intensive care.FindingsSenior intensive care clinicians from physiotherapy (n = 16), medicine (n = 6) and nursing (n = 4) participated. All concurred that the consensus statements added valuable guidance to practice; twenty-nine (76%) were deemed relevant and applicable for the intensive care setting without amendment, with modifications suggested for remaining nine statements to enhance utility. Overarching themes of patient safety, teamwork and communication and culture were identified as factors influencing clinical application. Cultural differences in practice, particularly related to patient positioning, was evident between jurisdictions. Participants raised practicality and safety concerns for two statements related to the use of head-down patient positioning.ConclusionMultidisciplinary peer-review established clinical validity of expert consensus statements for implementation with invasively ventilated adults with community-acquired pneumonia.     

“Noise Factory”: A qualitative study exploring healthcare providers’ perceptions of noise in the intensive care unit

ObjectivesThis study aimed to explore healthcare providers’ perceptions of noise in the intensive care unit.DesignA qualitative exploratory study was conducted using group interviews.SettingThe setting comprised a total of 15 participants (five physicians and ten registered nurses) working in an 18-bed medical surgical intensive care unit at a teaching hospital in Istanbul, Turkey. Semi-structured questions were formulated and used in focus group interviews, after which the recorded interviews were transcribed by the researchers. Thematic analysis was used to identify significant statements and initial codes.FindingsFour themes were identified: the meaning of noise, sources of noise, effects of noise and prevention and management of noise. It was found that noise was an inevitable feature of the intensive care unit. The most common sources of noise were human-induced. It was also determined that device-induced noise, such as alarms, did not produce a lot of noise; however, when staff were late in responding, the sound transformed into noise. Furthermore, it was observed that efforts to decrease noise levels taken by staff had only a momentary effect, changing nothing in the long term because the entire team failed to implement any initiatives consistently. The majority of nurses stated that they were now becoming insensitive to the noise due to the constant exposure to device-induced noise.ConclusionThe data obtained from this study showed that especially human-induced noise threatened healthcare providers’ cognitive task functions, concentration and job performance, impaired communication and negatively affected patient safety. In addition, it was determined that any precautions taken to reduce noise were not fully effective. A team approach should be used in managing noise in intensive care units with better awareness.     

Nurse decision-making when managing noradrenaline in the intensive care unit: A naturalistic observational study

ObjectiveIntensive care nurses care for critically ill patients in a complex, fast paced environment. Management of noradrenaline (norepinephrine) is core business for intensive care nurses and nurse decision-making on noradrenaline is poorly understood. The study objective was to investigate decision-making processes nurses use when caring for intensive care unit patients receiving noradrenaline.Research MethodologyA qualitative exploratory design used the Cognitive Continuum Theory as a framework for naturalistic observations and interviews in two medical/surgical intensive care units in Melbourne, Australia.Main Outcome MeasuresObservational and interview data from field notes and audiovisual recordings were transcribed and coded to develop themes using reflexive thematic analysis.FindingsFourteen nurse and patient dyads were recruited to observational sessions from December 2019 to June 2021. Three major themes developed were Learning through doing; Individualised patient care; and Clinical expertise, with six supporting sub-themes. Nurses learned to manage noradrenaline experientially and developed titration and weaning strategies to support decision-making. Blood pressure targets and monitor alarms were used consistently to aid decision-making processes. Nurses were observed practicing across the cognitive continuum depending on knowledge structure, complexity of interventions, response time, and patient acuity.ConclusionExperiential learning of complex and high-risk interventions in the absence of guidelines or algorithms meant nurses developed their own titration and weaning strategies based on constant evaluation and re-evaluation of patient cues. Patient heterogeneity, cue ambiguity and a dynamic practice environment contributed to decision-making complexity that would benefit from development of evidence-based practice resources.Implications for Clinical PracticeNurses learn to manage noradrenaline through experiential learning, using blood pressure targets and monitor alarms to support decision-making when titrating and weaning noradrenaline. Nurses develop noradrenaline titration and weaning strategies to support decision-making in the absence of guidelines or algorithms. Supporting nurse decision-making and streamlining practice would reduce practice variation and cognitive workload.     

应急预案在重症监护室护士危机意识培训中的应用研究

目的探讨应急预案在重症监护室护士危机意识培训中的应用及效果评价。方法 2015年1月至2016年12月对125名重症监护室护士进行应急预案培训,包括组建培训师资、设置培训内容及实施培训方案。结果培训后,重症监护室护士理论、操作成绩考核,危机意识及病人满意度均优于培训前(P0.01或P0.05)。结论通过应急预案培训,有效提升了重症监护室护士的危机意识及正确采取应急应对措施的能力,从而有效提高重症监护室护理管理质量,降低护患纠纷,提高病人满意度。     

Healthcare professionals’ values about and experience with facilitating end-of-life care in the adult intensive care unit

ObjectivesTo evaluate values and experience with facilitating end-of-life care among intensive care professionals (registered nurses, medical practitioners and social workers) to determine perceived education and support needs.Research designUsing a cross-sectional study design, 96 professionals completed a survey on knowledge, preparedness, patient and family preferences, organisational culture, resources, palliative values, emotional support, and care planning in providing end-of-life care.SettingGeneral adult intensive care unit at a tertiary referral hospital.ResultsCompared to registered nurses, medical practitioners reported lower emotional and instrumental support after a death, including colleagues asking if OK (p = 0.02), lower availability of counselling services (p = 0.01), perceived insufficient time to spend with families (p = 0.01), less in-service education for end-of-life topics (p = 0.002) and symptom management (p = 0.02). Registered nurses reported lower scores related to knowing what to say to the family in end-of-life care scenarios (p = 0.01).ConclusionFindings inform strategies for practice development to prepare and support healthcare professionals to provide end-of-life care in the intensive care setting. Professionals reporting similar palliative care values and inclusion of patient and family preferences in care planning is an important foundation for planning interprofessional education and support with opportunities for professionals to share experiences and strengths.