Customizing Physiologic Alarms in the Emergency Department: A Regression Discontinuity,Quality Improvement Study

IntroductionClinical alarms promote patient safety by alerting clinicians when there is an indication or change in a condition requiring a response. An excessive volume of alarm fires, however, contributes to sensory overload and desensitization, referred to as alarm fatigue, which has significant implications when alarms are missed. This evidence-based, practice project aimed to implement and evaluate a program that reduces the number of clinically nonactionable, physiologic alarms in an emergency department. Although alarm fatigue is an important negative consequence, the focus of this project is not on alarm fatigue but on measures to reduce the volume of clinically nonactionable alarms that lead to alarm fatigue. The Iowa Model was used as a conceptual framework.MethodsThis project involved adjusting default alarm settings and implementing an education plan on the safe use of alarms. The sample population included all patients on physiologic monitors at an emergency department. Retrospective data were collected, and regression discontinuity design was applied to compare the rate of alarm fires triggered by the physiologic monitor between pre- and postimplementation of an alarm protocol.ResultsA significant change in the rate of alarm fires occurred with an estimated reduction of 14.96 (P = 0.003). There were no reports of adverse outcomes such as a delay in responding to a change in patient condition or delay leading to cardiopulmonary arrest.DiscussionA reduction in nonactionable, physiologic alarms was attained after implementing multimodal strategies inclusive of adjusting default settings, staff education on managing alarms, and emphasis on staff accountability.     

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.     

Whats that noise? Bedside monitoring in the Emergency Department

ObjectiveTo determine the frequency, duration and type of audible monitor alarms in an ED, utilising the standard manufacturer’s classification.MethodsThe audible monitor alarms and the timing of any intervention related to the patient monitoring was observed and recorded.Results110 Patients admitted to the Majors area or Resuscitation Room were observed for a total of 93 hours. One monitor was observed at a time. Alarm noise was generated 29% of the observation time. Overall, 429 alarms lasting 21 hours 27 minutes were judged to be positive and 143 alarms lasting 5 hours 47 minutes, negative. 74% of Resuscitation Room and 47% of Majors alarms were silenced or paused. Alarm limit parameters were only adjusted after 5% of alarms in Resuscitation Room and 6% of alarms in Majors.ConclusionsWhilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. We have demonstrated that there is a high probability of near-continuous alarm noise from patient monitoring in a 10-bedded Majors area. We make suggestions for methods of noise reduction and intend to implement some of these within our own ED.     

Collection of annotated data in a clinical validation study for alarm algorithms in intensive care—a methodologic framework

Introduction

Monitoring of physiologic parameters in critically ill patients is currently performed by threshold alarm systems with high sensitivity but low specificity. As a consequence, a multitude of alarms are generated, leading to an impaired clinical value of these alarms due to reduced alertness of the intensive care unit (ICU) staff. To evaluate a new alarm procedure, we currently generate a database of physiologic data and clinical alarm annotations.

Methods

Data collection is taking place at a 12-bed medical ICU. Patients with monitoring of at least heart rate, invasive arterial blood pressure, and oxygen saturation are included in the study. Numerical physiologic data at 1-second intervals, monitor alarms, and alarm settings are extracted from the surveillance network. Bedside video recordings are performed with network surveillance cameras.

Results

Based on the extracted data and the video recordings, alarms are clinically annotated by an experienced physician. The alarms are categorized according to their technical validity and clinical relevance by a taxonomy system that can be broadly applicable. Preliminary results showed that only 17% of the alarms were classified as relevant, and 44% were technically false.

Discussion

The presented system for collecting real-time bedside monitoring data in conjunction with video-assisted annotations of clinically relevant events is the first allowing the assessment of 24-hour periods and reduces the bias usually created by bedside observers in comparable studies. It constitutes the basis for the development and evaluation of “smart” alarm algorithms, which may help to reduce the number of alarms at the ICU, thereby improving patient safety.     

The effects of a research utilization in-service program on nurses

The objective of this quasi-experimental design study was to evaluate an 8-week course of research utilization training provided for nurses. Eighty-nine nurses participated in the complete study. Age and education background of the nurses in the control group matched that of the participants in the experimental group. The research instruments included a scale of attitudes toward nursing research, a scale of perceived support for nursing research, a research participation questionnaire, and a research utilization questionnaire. Repeated measures analysis of covariance and the Mann-Whitney U test were adopted for statistical analysis. The results showed that there were significant differences in attitudes between the two groups toward research and perceived support of institutions. Participation in research also differed significantly when analyzed at posttests 2 and 6 months after the course. There was no significant difference in research utilization. These results suggest that continuous consultation and assistance should be provided to the nurses after the course, so as to implement the results of research utilization.     

Frequency and reliability of alarms in the monitoring of cardiac postoperative patients

Postoperative monitoring of cardiac operated patients requires appropriately functioning monitor alarms as well as intensive nursing activity. The limit alarms can be used for detection of life-threatening situations and monitoring of physiological changes in the patient's state. We studied the significance and the frequency of audible alarms during the postoperative intensive care of ten cardiac patients. Of 1307 occasions when such an alarm was activated during the study period of approximately 26 hours per patient, only 139 (10.6%) were significant. The highest proportion of significant audible limit alarms was found during the immediate postoperative period. Heart rate alarms were more reliable than alarms of the other parameters monitored in the study. Possibilities for improving the physiological monitoring and alarm system are discussed.     

Frequency and reliability of alarms in the monitoring of cardiac postoperative patients

Postoperative monitoring of cardiac operated patients requires appropriately functioning monitor alarms as well as intensive nursing activity. The limit alarms can be used for detection of life-threatening situations and monitoring of physiological changes in the patient's state. We studied the significance and the frequency of audible alarms during the postoperative intensive care of ten cardiac patients. Of 1307 occasions when such an alarm was activated during the study period of approximately 26 hours per patient, only 139 (10.6%) were significant. The highest proportion of significant audible limit alarms was found during the immediate postoperative period. Heart rate alarms were more reliable than alarms of the other parameters monitored in the study. Possibilities for improving the physiological monitoring and alarm system are discussed.     

临床护士医学术语使用情况的调查

目的了解临床护士在日常护理工作中医学术语的使用情况,旨在规范护士使用医学术语,提高护理质量。方法从护理病历书写中调查护士使用不规范医学术语的情况,从健康教育、教学查房、护理治疗等3个方面调查护士使用医学术语不规范的人数和百分比。结果护士在日常护理工作中存在医学术语使用不规范现象较为普遍,相对医学术语使用不规范的构成比为护士最高、护师次之、主管护师最低。结论临床工作中应采取相应对策,使医学术语使用规范化,从而提高护理人员的综合素质,提高护理质量。     

枣仁安神胶囊治疗失眠症有效性、安全性的随机双盲安慰剂平行对照研究

目的:探讨枣仁安神胶囊治疗失眠的有效性及安全性.方法:采用随机、双盲、安慰剂对照试验设计.采用区组随机化法将受试者分为对照组和观察组,每组120例,对照组予以枣仁安神胶囊模拟剂,观察组予以枣仁安神胶囊,2组均连续服药4周.比较2组的临床疗效、匹兹堡睡眠质量指数(Pittsburgh Sleep Quality Index,PSQI)及各因子的变化、中医证候疗效及不良事件情况.结果:观察组的临床有效率为86.67%,对照组的临床有效率为50.83%,2组有效率比较,差异有统计学意义(P<0.01).疗后观察组PSQI评分、中医证候疗效均显著低于对照组(P<0.05).观察组能够显著减少失眠患者的夜间觉醒的次数,与对照组比较差异有统计学意义(P<0.05),同时增加总睡眠时间.观察组的不良事件发生率为11.6%,对照组的不良事件发生率为10.0%,2组比较差异无统计学意义(P>0.05).结论:枣仁安神胶囊治疗失眠疗效肯定,显著缓解临床症状,提高睡眠质量,且不良反应少.     

复方守宫散治疗癌因性疲乏临床研究

目的:研究复方守宫散对癌因性疲乏患者的临床疗效。方法:将90例癌因性疲乏患者随机分为A、B、C3组,每组均为30例,复方守宫散治疗组(A组)给予对症治疗加口服复方守宫散联合治疗;复方斑蝥胶囊治疗组(B组)给予对症治疗加口服复方斑蝥胶囊联合治疗;空白对照组(C组)则仅给予单纯的对症治疗,观察时间为3个疗程。治疗前后对90例患者分别进行疲乏问卷调查,并检测治疗后3组患者外周血中T细胞亚群的数值。结果:3组患者治疗后的疲乏水平较治疗前明显减轻(P<0.05),A组患者较其他2组的疲乏程度明显减轻(P<0.05);A组CD3+、CD4+、CD4+/CD8+比值均明显高于B组、C组(P<0.05),CD8+细胞数值明显低于其他2组(P<0.05),A组患者的机体免疫功能改善情况明显优于其他2组。结论:复方守宫散在改善癌因性疲乏患者的疲乏程度方面有较好的疗效。     

Utilization of research evidence by nurses

This paper challenges the hegemony (the mindset prevailing within education and health-care environments) that produces and maintains the problems associated with nurses using research evidence in their practise. The challenge is organized around the construct of change. The envisaged changes concern what nurses think and do in relation to nursing research. The position held in the present paper is that the use of research evidence by nurses in their practise will remain a challenge until changes occur to the ways that nurses understand, value and initiate research. It is argued that changing the ways that nurses understand, value and initiate research requires an ideological shift: a re-education from one set of beliefs, perceptions, values and practises to another. The paper concludes with some suggestions for transforming the hegemonic influences of nurse education systems and the health-care organizations in which nurses work.     

急诊心肺复苏患者氧利用率的变化及意义

目的:探讨急诊心肺复苏患者氧利用率(O2UC)的变化及意义。方法:①将71例危重病人分为急诊心肺复苏组(A组,26例)、非心肺复苏危重病人组(B组,45例);设正常人对照组(C组,30例)。②A、B组患者于急诊入院抢救时和住院后1,2,3,5,7,10天分别于晨8时抽动、静脉血各一次查血气,并计算O2UC(C组仅做一次)。结果:①急诊入院时和住院第1天,A、B组的O2UC均显著高于C组(P<0.01),而A组亦高于B组(P<0.01)。②住院第3天起,A、B组O2UC均很快下降(与C组比较,P<0.05),且A组较B组下降更明显(P<0.05)。B组于第5天起O2UC逐渐回升至正常;而A组于第3天起,O2UC持续低于C组(P<0.01)。结论:急诊心肺复苏后患者早期O2UC常升高,而中晚期则常明显下降,且病情严重、预后差。O2UC可作为判断急诊心肺复苏病人组织缺氧、病情严重程度和评估预后的有效指标。     

护理干预对降低心电监护仪误报警率的效果观察

目的观察护理干预对降低心电监护仪误报警率的效果。方法选择2011年4月本院ICU实施心电监护的住院患者65例为对照组,心电监护仪参数报警值采用默认设置,并记录每例患者的报警原因;选择2011年6月本院ICU住院患者73例为实验组,对对照组患者心电监护仪的误报警情况进行分析,制订相应的护理干预措施去调整心电监护仪的报警值。比较两组患者心电监护仪误报警率的差异。结果实施护理干预后,实验组误报警率与对照组比较,χ2=23.04,P〈0.01,差异具有统计学意义,实验组心电监护仪误报警率低于对照组。结论护理干预能降低心电监护仪的误报警率,有利于提高护士对报警的敏感性,以及时对患者进行处理,保证患者的治疗安全。