Improving Quiet at Night on a Telemetry Unit: Introducing a Holistic Sleep Menu Intervention.

In a patient's recovery process, restful sleep is crucial. Although the essential role of sleep in healing has long been recognized, excessive noise in hospital environments remains a persistent and pervasive problem. For hospitalized patients, environmental noise can result in sleep deprivation and adverse health outcomes; not surprisingly, hospital noise ranks as a major patient complaint. At a small suburban community hospital, patients responding to a quiet-at-night question in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey gave the hospital's telemetry unit the lowest possible score: 1 out of 5 points. In response, the unit's quality improvement team, coordinated by a clinical nurse leader, introduced a holistic "sleep menu" intervention. The multicomponent intervention subsequently improved patients' care experience and staff engagement. The percentage of patients who self-reported five or more hours of uninterrupted sleep rose from 31% at baseline to 80% during the intervention. This improvement was sustained over the three-month intervention period and led to a quiet-at-night HCAHPS score of 4. The sleep menu initiative resulted in substantial benefits that optimized both patient and organizational outcomes.

Time motion analysis of nursing work in ICU, telemetry and medical-surgical units.

AIM: This study examined nurses' work, comparing nursing interventions and locations across three units in a United States hospital using Omaha System standardized terminology as the organizing framework. BACKGROUND: The differences in nurses' acute-care work across unit types are not well understood. Prior investigators have used time-motion methodologies; few have compared differences across units, nor used standardized terminology. METHODS: Nurse-observers recorded locations and interventions of nurses on three acute-care units using hand-held devices and web-based TimeCaT™ software. Nursing interventions were mapped to Omaha System terms. Unit-differences were analysed. RESULTS: Nurses changed locations approximately every 2 min, and averaged approximately one intervention/minute. Unit differences were found in both the interventions performed and the locations. Most interventions were case-management related, demonstrating the nurses' patient management/coordination role. CONCLUSIONS: Unit differences in nursing interventions and location were found among three unit types. Omaha System terminology, as well as the observational method used, were found to be feasible and practical. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing work varies by unit, yet managers have not been armed with empirical data with which to make more informed decisions about nurses' work priorities, clinical outcomes, patient satisfaction, staff satisfaction and cost. The results from this study will help them to do so.

Effect of a Nurse-Managed Telemetry Discontinuation Protocol on Monitoring Duration, Alarm Frequency, and Adverse Patient Events.

Telemetry monitoring is a limited resource. This quality improvement project describes a nurse-managed telemetry discontinuation protocol aimed at stopping telemetry monitoring when it is no longer indicated. After implementing the protocol, data were collected for 6 months and compared with a preintervention time frame. There was a mean decrease in telemetry monitor usage and a decreased likelihood of remaining on a telemetry monitor until discharge. A nurse-managed telemetry discontinuation protocol was effective in decreasing overmonitoring and ensuring telemetry availability.

Telemonitoring of CPAP therapy may save nursing time.

PURPOSE: Telemonitoring might enhance continuous positive airway pressure (CPAP) adherence and save nursing time at the commencement of CPAP therapy. We tested wireless telemonitoring (ResTraxx Online System®, ResMed) during the habituation phase of the CPAP therapy in obstructive sleep apnea syndrome (OSAS). METHODS: In total, 111 consecutive OSAS patients were enrolled. After CPAP titration, patients were followed with the telemonitoring (TM, N = 50) or the usual care (UC, N = 61). The TM group used fixed pressure CPAP device with and the UC group similar device without wireless telemonitoring. Patients and study nurses were unblinded. The evaluated end-points were hours of CPAP use >4 h/day, mask leak <0.4 L/s, and AHI <5/h. Nursing time including extra phone calls, visits, and telemonitoring time was recorded during the habituation phase. CPAP adherence was controlled in the beginning and at the end of the habituation phase and after 1-year of use. RESULTS: TM and UC groups did not differ in terms of patient characteristics. The average length of the habituation phase was 4 weeks in the TM group and fixed 3 months in the UC group. Median nursing time was 39 min (range 12-132 min) in the TM group and shorter compared to that of 58 min (range 40-180 min) (p < 0.001) per patient in the UC group. Both treatment groups had high CPAP usage hours (>4 h/day) and the change in usage at the end of the habituation phase did not differ between the groups (p = 0.39). Patients in both groups were equally satisfied with the treatment protocol. CPAP adherence (6.4 h in TM vs. 6.1 h in UC group, p = 0.63) and residual AHI (1.3 in TM vs. 3.2 in UC group, p = 0.04) were good in both groups at 1-year follow-up. CONCLUSIONS: Wireless telemonitoring of CPAP treatment could be relevant in closing the gap between the increasing demand and available health-care resources. It may save nursing time without compromising short- or long-term effectiveness of CPAP treatment in OSAS.

Tele-monitoring reduces exacerbation of COPD in the context of climate change--a randomized controlled trial.

BACKGROUND: A home based tele-monitoring system was developed to assess the effects of heat stress (days > 25°C) on clinical and functional status in patients with chronic obstructive pulmonary disease (COPD). METHODS: Sixty-two COPD patients (GOLD II-IV) were randomized into a tele-monitoring Group (TG, N = 32) or Control Group (CG, N = 30). Tele-monitoring included 1) daily clinical status (COPD Assessment Test-CAT), 2) daily lung function and 3) weekly 6-minute walk test (6MWT). Duration of monitoring lasted a total of nine months (9 M). RESULTS: From June 1st-August 31st 2012, 32 days with heat stress (29.0 ± 2.5°C) were recorded and matched with 32 thermal comfort days (21.0 ± 2.9°C). During heat stress, the TG showed a significant reduction in lung function and exercise capacity (FEV1% predicted: 51.1 ± 7.2 vs. 57.7 ± 5.0%; P <0.001 and 6MWT performance: 452 ± 85 vs. 600 ± 76 steps; P <0.001) and increase in CAT scores (19.2 ± 7.9 vs. 16.2 ± 7.2; P <0.001).Over summer, significantly fewer TG patients suffered exacerbation of COPD compared to CG patients (3 vs. 14; P = 0.006). Over entire 9 M follow-up, the TG group had fewer exacerbations compared to CG (7 vs. 22; P = 0.012), shorter cumulative hospital stay (34 vs. 97 days) and 43% fewer specialist consultations (24. vs. 42; P = 0.04). CONCLUSION: Heat stress affects clinical and functional status in COPD. Tele-monitoring reduces exacerbation frequency and health care utilization during heat stress and other periods of the year. TRIAL REGISTRATION DRKS-ID: DRK00000705.

Development of a modified early warning score using the electronic medical record.

The purpose of early warning scores is to help all nurses detect early deterioration in order to rescue patients from unexpected events, which arise from complications during the course of illness and recovery. This article describes one institution's work in developing a modified early warning score in conjunction with an electronic medical record to facilitate scoring and monitoring, in order to improve patient safety.

Applying evidence at the bedside: a journey to excellence in bedside cardiac monitoring.

Bedside cardiac monitoring is a nursing domain, and lead selection is determined by the monitoring needs of the patient. Understanding the rationale behind the evidence empowers the bedside critical-care nurse to make monitoring decisions that best meet the monitoring needs of the patient. This article discusses a journey to move beyond the sacred cows of monitoring and utilize the available literature to make monitoring choices that best meet the needs of each individual patient.

Responses to work complexity: the novice to expert effect.

The purpose of this study was to explore the differences in how advanced beginners, competent, and expert nurses prioritize and reprioritize patient care. This qualitative study had a purposive sample of 23 nurses on cardiac/ telemetry units at five hospitals. Four themes emerged from the data: cognitive strategies, communication, integration of roles, and response to the work environment. As the nurses progressed in expertise, they were better able to organize, more effectively deal with interruptions, anticipate patient needs, integrate varied nursing roles into their work, and communicate effectively. The significance of this study is the identification of factors that affect the nurse's ability to work productively in today's care environment. It increases understanding of the graduate nurses' perception and response to the complexity and work of nursing. An understanding of these factors provides the basis for further research to understand and promote transition of nurses from advanced beginner to expert.

Using problem-based learning in staff development: strategies for teaching registered nurses and new graduate nurses.

Problem-based learning, described as an active teaching strategy, provides a framework for the development of self-directed learning, self-evaluation, interpersonal communication, critical thinking, and access and retrieval of information. This teaching method can be modified to fit almost any situation. Problem-based learning provides an opportunity to actively engage staff members in learning situations, making it a great asset for teaching in staff development. This article describes the use of problem-based learning for teaching registered nurses and new graduate nurses. It provides a scenario and facilitator guide pertaining to a real patient situation on an inpatient telemetry unit and offers general tips for implementing problem-based learning in staff education.

Off-site expert support for nurses undertaking ECGs in primary care.

One of the aims of the Department of Health is to respond to patient needs by considering how services can be delivered in more innovative ways, including more services being provided in primary care and increased activities being undertaken by nursing staff. These activities may have previously been undertaken by the GPs, or patients would be sent elsewhere, such as the local hospital, for tests/investigations. Some general practices are already using cardiac telemetry while others are awaiting feedback from system users before deciding whether to purchase services from independent providers. However, identifying how generalized results and predicted benefits will apply in a specific practice is not always straightforward. This article aims to assist the decision-making process by providing the results of an audit from eight general practices and two walk-in centres in which the electrocardiograms (ECGs) were already being undertaken by nurses. The results, which are shown for each centre, showed that the frequency of use varied between one and 27 per month, depending upon the practice. As a result of the 373 patients who had an ECG performed in practice, 76 had altered management decisions, 14 were saved hospital referral (11 of these from one walk-in centre), 18 were admitted to an acute hospital (10 from the same walk-in centre), and another 24 were referred to hospital for investigation.