Identifying determinants of noise in a medical intensive care unit.

Continuous and intermittent exposure to noise elevates stress, increases blood pressure, and disrupts sleep among patients in hospital intensive care units. The purpose of this study was to determine the effectiveness of a behavior-based intervention to reduce noise and to identify determinants of noise in a medical intensive care unit. Staff were trained for 6 weeks to reduce noise during their activities in an effort to keep noise levels below 55 dBA during the day and below 50 dBA at night. One-min noise levels were logged continuously in patient rooms 8 weeks before and after the intervention. Noise levels were compared by room position, occupancy status, and time of day. Noise levels from flagged days (>60 dBA for >10 hr) were correlated with activity logs. The intervention was ineffective, with noise frequently exceeding project goals during the day and night. Noise levels were higher in rooms with the oldest heating, ventilation, and air-conditioning system, even when patient rooms were unoccupied. Of the flagged days, the odds of noise over 60 dBA occurring was 5.3 dBA higher when high-flow respiratory support devices were in use compared to times with low-flow devices in use (OR = 5.3, 95% CI = 5.0-5.5). General sources, like the heating, ventilation, and air-conditioning system, contribute to high baseline noise and high-volume (>10 L/min) respiratory-support devices generate additional high noise (>60 dBA) in Intensive Care Unit patient rooms. This work suggests that engineering controls (e.g., ventilation changes or equipment shielding) may be more effective in reducing noise in hospital intensive care units than behavior modification alone.

MECHANICAL VENTILATION FOR THE LUNG TRANSPLANT RECIPIENT.

Mechanical ventilation (MV) is an important aspect in the intraoperative and early postoperative management of lung transplant (LTx)-recipients. There are no randomized-controlled trials of LTx-recipient MV strategies; however there are LTx center experiences and international survey studies reported. The main early complication of LTx is primary graft dysfunction (PGD), which is similar to the adult respiratory distress syndrome (ARDS). We aim to summarize information pertinent to LTx-MV, as well as PGD, ARDS, and intraoperative MV and to synthesize these available data into recommendations. Based on the available evidence, we recommend lung-protective MV with low-tidal-volumes (≤6 mL/kg predicted body weight [PBW]) and positive end-expiratory pressure for the LTx-recipient. In our opinion, the MV strategy should be based on donor characteristics (donor PBW as a parameter of actual allograft size), rather than based on recipient characteristics; however this donor-characteristics-based protective MV is based on indirect evidence and requires validation in prospective clinical studies.

Achieving endoscopic competency in a general surgery residency.

BACKGROUND: In 2006, the Residency Review Committee for Surgery increased the total number of required endoscopy cases for graduating residents. Our goal was to evaluate general surgery resident competency in endoscopy, focusing on quality measures. METHODS: A 9-year retrospective review was conducted of 29 residents. Total number of endoscopies performed throughout residency was recorded. Procedures performed as fifth-year residents with indirect supervision were evaluated for quality measures. RESULTS: An average of 76 esophagogastroduodenoscopies and 147 colonoscopies were performed through their first 4 years of residency. Chief residents performed an average of 16 esophagogastroduodenoscopies and 22 colonoscopies. Of colonoscopies performed during their fifth year, 191 were performed while the resident had only indirect supervision. During these cases, cecal intubation was achieved in 90.6% of cases, an average of .48 polyps were identified, and average scope withdrawal time was 13.4 ± 7.1 minutes. CONCLUSIONS: Our data indicate that surgery residents achieve competency in colonoscopy before performing 140 colonoscopies, supporting the concept that surgery residencies can function as an excellent training ground for endoscopy.