Monitoring the performance of a dedicated weaning unit using risk-adjusted control charts for the weaning rate in prolonged mechanical ventilation.

BACKGROUND: Weaning rate is an important quality indicator of care for patients with prolonged mechanical ventilation (PMV). However, diverse clinical characteristics often affect the measured rate. A risk-adjusted control chart may be beneficial for assessing the quality of care. METHODS: We analyzed patients with PMV who were discharged between 2018 and 2020 from a dedicated weaning unit at a medical center. We generated a formula to estimate monthly weaning rates using multivariate logistic regression for the clinical, laboratory, and physiologic characteristics upon weaning unit admission in the first two years (Phase I). We then applied both multiplicative and additive models for adjusted p-charts, displayed in both non-segmented and segmented formats, to assess whether special cause variation existed. RESULTS: A total of 737 patients were analyzed, including 503 in Phase I and 234 in Phase II, with average weaning rates of 59.4% and 60.3%, respectively. The p-chart of crude weaning rates did not show special cause variation. Ten variables from the regression analysis were selected for the formula to predict individual weaning probability and generate estimated weaning rates in Phases I and II. For risk-adjusted p-charts, both multiplicative and additive models showed similar findings and no special cause variation. CONCLUSION: Risk-adjusted control charts generated using a combination of multivariate logistic regression and control chart-adjustment models may provide a feasible method to assess the quality of care in the setting of PMV with standard care protocols.

[Increasing the Accuracy of Extracorporeal Membrane Oxygenation Critical Event Management in the Medical Intensive Care Unit].

BACKGROUND & PROBLEMS: Extracorporeal membrane oxygenation (ECMO) is an intervention that replaces cardiopulmonary function temporarily to reduce injury to vital organs. As important members of the ECMO medical team, intensive care unit nurses must be well trained and alert to possible critical events. Failure to troubleshoot and manage ECMO promptly and correctly significantly increases the risk of mortality. A previous ECMO critical event in our unit resulted in lingering concerns and stress among nurses related to implementing this intervention. A survey conducted among our medical intensive care unit (MICU) nurses identified an implementation accuracy level for ECMO critical event management of only 59.1%. This poor result was attributed to a lack of technical assessment standards, in-service training, clinical experience, and instruction materials and the failure to offer online courses. PURPOSE: This study was designed to increase the accuracy of ECMO critical event management implementation among intensive care unit nurses to >86%. RESOLUTIONS: We conducted a problem-based training project to improve ECMO critical event management that: introduced a technical assessment sheet and technical simulation exercise, organized in-service training, implemented irregular simulation exercises, and produced multiple different instructional materials. RESULTS: The accuracy of ECMO critical event management implementation among the intensive care unit nurses increased from 59.1% pretest to 95.9% posttest. CONCLUSIONS: This project improved the ECMO care ability of MICU nurses in our hospital significantly, resulting in increased ECMO critical event management implementation accuracy, better patient care, higher nursing staff confidence, and lower perceived stress among nursing staff.

[Using the Model of Motivation to Improve the Accuracy of Nurses Conducting Aerosol Therapy in Mechanically Ventilated Patients].

ACKGROUND & PROBLEMS: Aerosol therapy is increasingly used in pulmonary critical care and in patients with respiratory disease. However, improper application of the aerosol delivery device will decrease the therapeutic effect as well as increase the incidence of pulmonary infection. An initial assessment conducted in our intensive care unit found an accuracy rate for nursing staff aerosol-therapy execution of only 55.9%. Possible reasons identified for this low rate included lack of learning experience and resources, lack of related standard operating procedures, lack of related performance assessments, complicated / unfamiliar device assembly procedure, diffuse storage of device components, and a lack of illustrations. PURPOSE: This project was developed to increase the accuracy rate of performing aerosol therapy to over 90% in our intensive care unit. METHODS: We designed diverse learning materials using the model of motivation, developed an evaluation system, simplified the assembly of components based on evidence-based research, improved the storage situation, and added reference illustrations. RESULTS: The accuracy rate in aerosol therapy execution for our nursing staff increased from 55.9% to 95.0% after the intervention. CONCLUSIONS: This project used the model of motivation to develop the teaching materials. By using diverse teaching methods, including both in-person classes and online interactive quizzes, we realized high learning satisfaction and efficacy. Along with simplifying equipment handling, improving the working environment, enhancing nurses' aerosol therapy techniques, establishing standard operating procedure guidelines, and adding an evaluation system, we standardized the entire procedure for potential promotion to other intensive care units.

The Costs and Cardiovascular Benefits in Patients With Peripheral Artery Disease From a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study.

BACKGROUND: Patients with peripheral artery disease (PAD) are at high risk for major cardiovascular events, including myocardial infarction, stroke, and hospitalization for heart failure. We have previously shown the clinical efficacy of a fourth-generation synchronous telehealth program for some patients, but the costs and cardiovascular benefits of the program for PAD patients remain unknown. OBJECTIVE: The telehealth program is now widely used by higher-risk cardiovascular patients to prevent further cardiovascular events. This study investigated whether patients with PAD would also have better cardiovascular outcomes after participating in the fourth-generation synchronous telehealth program. METHODS: This was a retrospective cohort study. We screened 5062 patients with cardiovascular diseases who were treated at National Taiwan University Hospital and then enrolled 391 patients with a diagnosis of PAD. Of these patients, 162 took part in the telehealth program, while 229 did not and thus served as control patients. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to mitigate possible selection bias. Follow-up outcomes included heart failure hospitalization, acute coronary syndrome, stroke, and all-cause readmission during the 1-year follow-up period and through the last follow-up. RESULTS: The mean follow-up duration was 3.1 (SD 1.8) years for the patients who participated in the telehealth program and 3.2 (SD 1.8) for the control group. The telehealth program patients exhibited lower risk of ischemic stroke than did the control group in the first year after IPTW (0.9% vs 3.5%; hazard ratio [HR] 0.24; 95% CI 0.07-0.80). The 1-year composite endpoint of vascular accident, including acute coronary syndrome and stroke, was also significantly lower in the telehealth program group after IPTW (2.4% vs 5.2%; HR 0.46; 95% CI 0.21-0.997). At the end of the follow-up, the telehealth program group continued to exhibit a significantly lower rate of ischemic stroke than did the control group after IPTW (0.9% vs 3.5%; HR 0.52, 95% CI 0.28-0.93). Furthermore, the medical costs of the telehealth program patients were not higher than those of the control group, whether in terms of outpatient, emergency department, hospitalization, or total costs. CONCLUSIONS: The PAD patients who participated in the fourth-generation synchronous telehealth program exhibited lower risk of ischemic stroke events over both mid- and long-term follow-up periods. However, larger-scale and prospective randomized clinical trials are needed to confirm our findings.

[Experience Caring for a Severe COVID-19 Patient With ARDS in the Intensive Care Unit].

The author's experience caring for a patient with COVID-19 whose condition deteriorated rapidly into a critical illness in the negative pressure room of the intensive care unit is described in this article. The onset of severe acute respiratory distress syndrome led this patient to receive endotracheal intubation with mechanical ventilation and subsequent extracorporeal membrane oxygenation for life support. He was isolated in the negative air pressure room in the intensive care unit for infection control for this emerging respiratory infectious disease. This patient was also confronted with emotional pressures arising from the general uncertainty regarding the progress of this novel disease and from being isolated from the outside world. The care period was from April 5th to May 12th, 2020. The data was collected through direct care, written conversations, physical communication, observation, medical record reviews, diagnosis reports, and nursing assessments of physical, psychological, social, and spiritual distress. The health problems of this patient were identified as gas exchange disorder, infection, anxiety, and other problems. Our chest physiotherapy team comprised nurses, physicians, and respiratory therapists. After administering individualized treatments, including monitoring vital signs and installing an external life support system, the lung consolidation and lung collapse problems of the patient improved, allowing the ventilator to be removed. To address the patient's psychological problems, we used a humanoid diagram and whiteboard drawing as communication tools to explain to the patient the reasons for and functions of the different tubes on his body to reduce his anxiety and maintain the safe use of these tubes. Moreover, bedside care was replaced by mobile phone video and phone calls, allowing the patient to communicate with family members, which reduced his isolation-related anxiety and enhanced his compliance with treatment and care protocols. This experience supports the benefit of installing two-way video devices and viewing monitors in negative pressure rooms in the ICU to facilitate effective communications between patients, patient family members, and the medical team to reduce patient-perceived anxiety and social isolation. This case report provides a reference demonstrating a patient-centered caring model for treating COVID-19 patients in the ICU.

Use of the CHA2DS2-VASc Score for Risk Stratification of Hospital Admissions Among Patients With Cardiovascular Diseases Receiving a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study.

BACKGROUND: Telehealth programs are generally diverse in approaching patients, from traditional telephone calling and texting message and to the latest fourth-generation synchronous program. The predefined outcomes are also different, including hypertension control, lipid lowering, cardiovascular outcomes, and mortality. In previous studies, the telehealth program showed both positive and negative results, providing mixed and confusing clinical outcomes. A comprehensive and integrated approach is needed to determine which patients benefit from the program in order to improve clinical outcomes. OBJECTIVE: The CHA2DS2-VASc (congestive heart failure, hypertension, age >75 years [doubled], type 2 diabetes mellitus, previous stroke, transient ischemic attack or thromboembolism [doubled], vascular disease, age of 65-75 years, and sex) score has been widely used for the prediction of stroke in patients with atrial fibrillation. This study investigated the CHA2DS2-VASc score to stratify patients with cardiovascular diseases receiving a fourth-generation synchronous telehealth program. METHODS: This was a retrospective cohort study. We recruited patients with cardiovascular disease who received the fourth-generation synchronous telehealth program at the National Taiwan University Hospital between October 2012 and June 2015. We enrolled 431 patients who had joined a telehealth program and compared them to 1549 control patients. Risk of cardiovascular hospitalization was estimated with Kaplan-Meier curves. The CHA2DS2-VASc score was used as the composite parameter to stratify the severity of patients' conditions. The association between baseline characteristics and clinical outcomes was assessed via the Cox proportional hazard model. RESULTS: The mean follow-up duration was 886.1 (SD 531.0) days in patients receiving the fourth-generation synchronous telehealth program and 707.1 (SD 431.4) days in the control group (P<.001). The telehealth group had more comorbidities at baseline than the control group. Higher CHA2DS2-VASc scores (≥4) were associated with a lower estimated rate of remaining free from cardiovascular hospitalization (46.5% vs 54.8%, log-rank P=.003). Patients with CHA2DS2-VASc scores ≥4 receiving the telehealth program were less likely to be admitted for cardiovascular disease than patients not receiving the program. (61.5% vs 41.8%, log-rank P=.01). The telehealth program remained a significant prognostic factor after multivariable Cox analysis in patients with CHA2DS2-VASc scores ≥4 (hazard ratio=0.36 [CI 0.22-0.62], P<.001). CONCLUSIONS: A higher CHA2DS2-VASc score was associated with a higher risk of cardiovascular admissions. Patients accepting the fourth-generation telehealth program with CHA2DS2-VASc scores ≥4 benefit most by remaining free from cardiovascular hospitalization.

Assessment of the Relationship Between Ambient Temperature and Home Blood Pressure in Patients From a Web-Based Synchronous Telehealth Care Program: Retrospective Study.

BACKGROUND: Decreased ambient temperature significantly increases office blood pressure, but few studies have evaluated the effect of ambient temperature on home blood pressure. OBJECTIVE: We aimed to investigate the relationship between short-term ambient temperature exposure and home blood pressure. METHODS: We recruited patients with chronic cardiovascular diseases from a telehealth care program at a university-affiliated hospital. Blood pressure was measured at home by patients or their caregivers. We obtained hourly meteorological data for Taipei (temperature, relative humidity, and wind speed) for the same time period from the Central Weather Bureau, Taiwan. RESULTS: From 2009 to 2013, we enrolled a total of 253 patients. Mean patient age was 70.28 (SD 13.79) years, and 66.0% (167/253) of patients were male. We collected a total of 110,715 home blood pressure measurements. Ambient temperature had a negative linear effect on all 3 home blood pressure parameters after adjusting for demographic and clinical factors and antihypertensive agents. A 1°C decrease was associated with a 0.5492-mm Hg increase in mean blood pressure, a 0.6841-mm Hg increase in systolic blood pressure, and a 0.2709-mm Hg increase in diastolic blood pressure. This temperature effect on home blood pressure was less prominent in patients with diabetes or hypertension. Antihypertensive agents modified this negative effect of temperature on home blood pressure to some extent, and angiotensin receptor blockers had the most favorable results. CONCLUSIONS: Short-term exposure to low ambient temperature significantly increased home blood pressure in patients with chronic cardiovascular diseases. Antihypertensive agents may modify this effect.

Effect of Contract Compliance Rate to a Fourth-Generation Telehealth Program on the Risk of Hospitalization in Patients With Chronic Kidney Disease: Retrospective Cohort Study.

BACKGROUND: Chronic kidney disease (CKD) is prevalent in Taiwan and it is associated with high all-cause mortality. We have shown in a previous paper that a fourth-generation telehealth program is associated with lower all-cause mortality compared to usual care with a hazard ratio of 0.866 (95% CI 0.837-0.896). OBJECTIVE: This study aimed to evaluate the effect of renal function status on hospitalization among patients receiving this program and to evaluate the relationship between contract compliance rate to the program and risk of hospitalization in patients with CKD. METHODS: We retrospectively analyzed 715 patients receiving the telehealth care program. Contract compliance rate was defined as the percentage of days covered by the telehealth service before hospitalization. Patients were stratified into three groups according to renal function status: (1) normal renal function, (2) CKD, or (3) end-stage renal disease (ESRD) and on maintenance dialysis. The outcome measurements were first cardiovascular and all-cause hospitalizations. The association between contract compliance rate, renal function status, and hospitalization risk was analyzed with a Cox proportional hazards model with time-dependent covariates. RESULTS: The median follow-up duration was 694 days (IQR 338-1163). Contract compliance rate had a triphasic relationship with cardiovascular and all-cause hospitalizations. Patients with low or very high contract compliance rates were associated with a higher risk of hospitalization. Patients with CKD or ESRD were also associated with a higher risk of hospitalization. Moreover, we observed a significant interaction between the effects of renal function status and contract compliance rate on the risk of hospitalization: patients with ESRD, who were on dialysis, had an increased risk of hospitalization at a lower contract compliance rate, compared with patients with normal renal function or CKD. CONCLUSIONS: Our study showed that there was a triphasic relationship between contract compliance rate to the telehealth program and risk of hospitalization. Renal function status was associated with risk of hospitalization among these patients, and there was a significant interaction with contract compliance rate.

[Reducing the Incidence of Back Pain in Post-Percutaneous Coronary Intervention Patients With Femoral Sheath].

BACKGROUND & PROBLEMS: Patients undergoing percutaneous coronary interventions (PCIs) are restricted to bedrest and immobilization of the affected leg for sheath retention. These result in high incidences of back pain and emotional irritation, which may negatively affect cardiac rehabilitation. One-hundred percent of the post-transfemoral PCI patients in our unit had a back-pain score of 3 or higher, with an average pain score of 6. Analysis showed the main causes to be: poor awareness of nurses regarding back pain and physical activity; lack of physical activity guidelines and no regular auditing of physical activity; and lack of education and related materials. PURPOSE: To increase the completion rate of instruction for physical activity to over 90.0% and to reduce the incidence of back pain (score of 3 or higher) among post-PCIs to 35.0% or less. RESOLUTIONS: We conducted in-service education, revised related instruction materials, filmed the recommended physical activity for post-PCIs, and conducted a quality assurance audit. RESULTS: The completion rate among post-PCIs for the instructions for physical activity increased from 32.5% to 90.0%. The incidence of back pain (score >3) reduced from 100% to 26.8%. CONCLUSIONS: Implementing a physical activity education program with multimedia materials and regular audits effectively reduces the discomfort of patients following PCIs.

[Application of Care Bundles to Reduce Medical-Device-Related Pressure Injury (MDRPI) Incidence in a Coronary Care Unit].

BACKGROUND & PROBLEMS: Pressure injuries increase the cost of medical care and prolong hospitalization. The incidence of pressure injury at the target coronary care unit (CCU) from January to August 2016 was 1.1%, which was significantly higher than the 0.4% defined in the 2015 Taiwan Clinical Performance Indicators (TCPI) system. Medical device related pressure injury (MDRPI) accounted for 73.1% of the pressure injuries (incidence: 0.8%). The main causes of the high incidence of MDRPI were: (1) inadequate decompression dressing and restraint equipment, (2) incomplete implementation of prevention interventions in the CCU, (3) inadequate knowledge of MDRPI prevention among nurses, (4) deficient standards for preventing MDRPI, (5) ineffective MDRPI-related education, and (6) insufficient auditing frequencies. PURPOSE: To reduce the incidence of MDRPI in the target CCU to 0.4% or less. RESOLUTION: Promote a seed-teacher system and a care bundle that "increased skin tolerance, decompression, medical dressing, change, and removal" using education, the adoption of PE-foam binding gloves, and regular audits. RESULTS: The incidence of MDRPI was reduced from 0.8% to 0.3% between October 2016 and April 2017 and further reduced to 0.1% during the maintenance phase between May and July 2017. CONCLUSIONS: The results indicate that the improvement program effectively reduced the incidence of MDRPI and thus increased the quality of nursing care. Therefore, the use of a care bundles should be promoted in intensive care units.

Mortality Benefit of a Fourth-Generation Synchronous Telehealth Program for the Management of Chronic Cardiovascular Disease: A Longitudinal Study.

BACKGROUND: We have shown that a fourth-generation telehealth program that analyzes and responds synchronously to data transferred from patients is associated with fewer hospitalizations and lower medical costs. Whether a fourth-generation telehealth program can reduce all-cause mortality has not yet been reported for patients with chronic cardiovascular disease. OBJECTIVE: We conducted a clinical epidemiology study retrospectively to determine whether a fourth-generation telehealth program can reduce all-cause mortality for patients with chronic cardiovascular disease. METHODS: We enrolled 576 patients who had joined a telehealth program and compared them with 1178 control patients. A Cox proportional hazards model was fitted to analyze the impact of risk predictors on all-cause mortality. The model adjusted for age, sex, and chronic comorbidities. RESULTS: There were 53 (9.3%) deaths in the telehealth group and 136 (11.54%) deaths in the control group. We found that the telehealth program violated the proportional hazards assumption by the Schoenfeld residual test. Thus, we fitted a Cox regression model with time-varying covariates. The results showed an estimated hazard ratio (HR) of 0.866 (95% CI 0.837-0.896, P<.001; number needed to treat at 1 year=55.6, 95% CI 43.2-75.7 based on HR of telehealth program) for the telehealth program on all-cause mortality after adjusting for age, sex, and comorbidities. The time-varying interaction term in this analysis showed that the beneficial effect of telehealth would increase over time. CONCLUSIONS: The results suggest that our fourth-generation telehealth program is associated with less all-cause mortality compared with usual care after adjusting for chronic comorbidities.

Assessment of the cost-effectiveness and clinical outcomes of a fourth-generation synchronous telehealth program for the management of chronic cardiovascular disease.

BACKGROUND: Telehealth programs are a growing field in the care of patients. The evolution of information technology has resulted in telehealth becoming a fourth-generation synchronous program. However, long-term outcomes and cost-effectiveness analysis of fourth-generation telehealth programs have not been reported in patients with chronic cardiovascular diseases. OBJECTIVE: We conducted this study to assess the clinical outcomes and cost-effectiveness of a fourth-generation synchronous telehealth program for patients with chronic cardiovascular diseases. METHODS: We retrospectively analyzed 575 patients who had joined a telehealth program and compared them with 1178 patients matched for sex, age, and Charlson comorbidity index. The program included: (1) instant transmission of biometric data, (2) daily telephone interview, and (3) continuous decision-making support. Data on hospitalization, emergency department (ED) visits, and medical costs were collected from the hospital's database and were adjusted to the follow-up months. RESULTS: The mean age was 64.5 years (SD 16.0). The mean number of monthly ED visits (mean 0.06 SD 0.13 vs mean 0.09 SD 0.23, P<.001), hospitalizations (mean 0.05 SD 0.12 vs mean 0.11 SD 0.21, P<.001), length of hospitalization (mean 0.77 days SD 2.78 vs mean 1.4 SD 3.6, P<.001), and intensive care unit admissions (mean 0.01 SD 0.07 vs mean 0.036 SD 0.14, P<.001) were lower in the telehealth group. The monthly mean costs of ED visits (mean US$20.90 SD 66.60 vs mean US$37.30 SD 126.20, P<.001), hospitalizations (mean US$386.30 SD 1424.30 vs mean US$878.20 SD 2697.20, P<.001), and all medical costs (mean US$587.60 SD 1497.80 vs mean US$1163.60 SD 3036.60, P<.001) were lower in the telehealth group. The intervention costs per patient were US$224.80 per month. Multivariate analyses revealed that age, telehealth care, and Charlson index were the independent factors for ED visits, hospitalizations, and length of hospitalization. A bootstrap method revealed the dominant cost-effectiveness of telehealth care over usual care. CONCLUSIONS: Better cost-effectiveness and clinical outcomes were noted with the use of a fourth-generation synchronous telehealth program in patients with chronic cardiovascular diseases. The intervention costs of this new generation of telehealth program do not increase the total costs for patient care.

Clinical outcome and cost-effectiveness of a synchronous telehealth service for seniors and nonseniors with cardiovascular diseases: quasi-experimental study.

BACKGROUND: Telehealth based on advanced information technology is an emerging health care strategy for managing chronic diseases. However, the cost-effectiveness and clinical effect of synchronous telehealth services in older patients with cardiovascular diseases has not yet been studied. Since 2009, the Telehealth Center at the National Taiwan University Hospital has provided a range of telehealth services (led by a cardiologist and staffed by cardiovascular nursing specialists) for cardiovascular disease patients including (1) instant transmission of blood pressure, pulse rate, electrocardiography, oximetry, and glucometry for analysis, (2) mutual telephone communication and health promotion, and (3) continuous analytical and decision-making support. OBJECTIVE: To evaluate the impact of a synchronous telehealth service on older patients with cardiovascular diseases. METHODS: Between November 2009 and April 2010, patients with cardiovascular disease who received telehealth services at the National Taiwan University Hospital were recruited. We collected data on hospital visits and health expenditures for the 6-month period before and the 6-month period after the opening of the Telehealth Center to assess the clinical impact and cost-effectiveness of telehealth services on cardiovascular patients. RESULTS: A total of 141 consecutive cardiovascular disease patients were recruited, including 93 aged ≥65 years (senior group) and 48 aged <65 years (nonsenior group). The telehealth intervention significantly reduced the all-cause admission rate per month per person in the nonsenior group (pretelehealth: median 0.09, IQR 0-0.14; posttelehealth: median 0, IQR 0-0; P=.002) and the duration (days per month per person) of all-cause hospital stay (pretelehealth: median 0.70, IQR 0-1.96; posttelehealth: median 0, IQR 0-0; P<.001) with increased all-cause outpatient visits per month per person (pretelehealth: median 0.77, IQR 0.20-1.64; posttelehealth: mean 1.60, IQR 1.06-2.57; P=.002). In the senior group, the telehealth intervention also significantly reduced the all-cause admission rate per month per person (pretelehealth: median 0.10, IQR 0-0.18; posttelehealth: median 0, IQR 0-0; P<.001) and the duration (days per month per person) of all-cause hospital stay (pretelehealth: median 0.59, IQR 0-2.24; posttelehealth: median 0, IQR 0-0; P<.001) with increased all-cause outpatient visits per month per person (pretelehealth: median 1.40, IQR 0.52-2.63; posttelehealth: median 1.76, IQR 1.12-2.75; P=.02). In addition, telehealth intervention reduced the inpatient cost in the nonsenior group from $814.93 (SD 1000.40) to US $217.39 (SD 771.01, P=.001) and the total cost per month from US $954.78 (SD 998.70) to US $485.06 (SD 952.47, P<.001). In the senior group, the inpatient cost per month was reduced from US $768.27 (SD 1148.20) to US $301.14 (SD 926.92, P<.001) and the total cost per month from US $928.20 (SD 1194.11) to US $494.87 (SD 1047.08, P<.001). CONCLUSIONS: Synchronous telehealth intervention may reduce costs, decrease all-cause admission rates, and decrease durations of all-cause hospital stays in cardiovascular disease patients, regardless of age.

Improving the Process of Shared Decision-Making by Integrating Online Structured Information and Self-Assessment Tools.

The integration of face-to-face communication and online processes to provide access to information and self-assessment tools may improve shared decision-making (SDM) processes. We aimed to assess the effectiveness of implementing an online SDM process with topics and content developed through a participatory design approach. We analyzed the triggered and completed SDM cases with responses from participants at a medical center in Taiwan. Data were retrieved from the Research Electronic Data Capture (REDCap) database of the hospital for analysis. Each team developed web-based patient decision aids (PDA) with empirical evidence in a multi-digitized manner, allowing patients to scan QR codes on a leaflet using their mobile phones and then read the PDA content online. From July 2019 to December 2020, 48 web-based SDM topics were implemented in the 24 clinical departments of this hospital. The results showed that using the REDCap system improved SDM efficiency and quality. Implementing an online SDM process integrated with face-to-face communication enhanced the practice and effectiveness of SDM, possibly through the flexibility of accessing information, self-assessment, and feedback evaluation.

Effect of implementing decision support to activate a rapid response system by automated screening of verified vital sign data: A retrospective database study.

AIM: Activating a rapid response system (RRS) at general wards requires memorizing trigger criteria, identifying deterioration, and timely notification of abnormalities. We aimed to assess the effect of decision support (DS)-linked RRS activation on management and outcomes. METHODS: We retrospectively analyzed general ward RRS activation cases from 2013 to 2017 and the incidence of cardiopulmonary resuscitations (CPR) from 2013 to 2020. A DS-alerting mechanism was added to the conventional RRS activation process in 2017, with an alert window appearing whenever the system automatically detected any verified abnormal vital sign entry, alerting the nurse to take further action. Logistic and linear regression analyses were used to compare outcomes. RESULTS: We analyzed 27,747 activations and 64,592 DS alerts. RRS activations increased from 3.5 to 30.3 per 1,000 patient-days (P < 0.001) after DS implementation. The first DS activations occurred earlier than conventional ones (-2.9 days, 95% confidence interval = -3.6 to -2.1 days). After adjustment with inverse probability of treatment weighting, main (conventional vs DS-linked activations after implementation) and sensitivity analyses showed that DS activation cases had a lower risk of CPR and in-hospital mortality. Cases with more DS alerts before RRS activation had a higher risk of CPR (P trend = 0.017) and in-hospital mortality (P trend < 0.001). The incidence of CPR at the general ward decreased. CONCLUSION: Implementing a DS mechanism with an automated screening of verified abnormal vital signs linked to RRS activations at general wards was associated with improved practice and timeliness of hospital-wide RRS activations and reduced in-hospital resuscitations and mortality.

The Association Between Short-term Exposure to Ambient Air Pollution and Patient-Level Home Blood Pressure Among Patients With Chronic Cardiovascular Diseases in a Web-Based Synchronous Telehealth Care Program: Retrospective Study.

BACKGROUND: The association between short-term exposure to ambient air pollution and blood pressure has been inconsistent, as reported in the literature. OBJECTIVE: This study aimed to investigate the relationship between short-term ambient air pollution exposure and patient-level home blood pressure (HBP). METHODS: Patients with chronic cardiovascular diseases from a telehealth care program at a university-affiliated hospital were enrolled as the study population. HBP was measured by patients or their caregivers. Hourly meteorological data (including temperature, relative humidity, wind speed, and rainfall) and ambient air pollution monitoring data (including CO, NO2, particulate matter with a diameter of <10 µm, particulate matter with a diameter of <2.5 µm, and SO2) during the same time period were obtained from the Central Weather Bureau and the Environmental Protection Administration in Taiwan, respectively. A stepwise multivariate repeated generalized estimating equation model was used to assess the significant factors for predicting systolic and diastolic blood pressure (SBP and DBP). RESULTS: A total of 253 patients and 110,715 HBP measurements were evaluated in this study. On multivariate analysis, demographic, clinical, meteorological factors, and air pollutants significantly affected the HBP (both SBP and DBP). All 5 air pollutants evaluated in this study showed a significant, nonlinear association with both home SBP and DBP. Compared with demographic and clinical factors, environmental factors (meteorological factors and air pollutants) played a minor yet significant role in the regulation of HBP. CONCLUSIONS: Short-term exposure to ambient air pollution significantly affects HBP in patients with chronic cardiovascular disease.

Multimodal interventions for bundle implementation to decrease central line-associated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 2009-2013.

BACKGROUND: Central line (CL)-associated bloodstream infection (CLABSI) poses a major threat to patient safety and is associated with additional cost. This study investigated the sustained effect of multimodal interventions focusing on CL bundle improvement in the adult intensive care units (ICUs) of a teaching hospital in Taiwan. METHODS: A before-after prospective study was conducted in 17 adult ICUs of a medical center in northern Taiwan from January 2009 to December 2013. Many interventions that aimed to facilitate CL bundle implementation were initiated in January 2011. The incidence rates of CLABSI and catheter-related bloodstream infection (CRBSI) were compared between the baseline and intervention periods. Catheter utilization ratios and microbiological characteristics were also analyzed. RESULTS: The incidence rates of both CLABSI and CRBSI decreased significantly from the baseline to the intervention periods (from 9.27 to 7.66 per 1000 CL-days and from 1.51 to 0.89 per 1000 CL-days, respectively). The yearly incidence rate decreased by up to 31% (incidence rate ratio [IRR], 0.69; 95% confidence interval [CI], 0.59-0.81) for CLABSI and 59% (IRR, 0.41; 95% CI, 0.26-0.65) for CRBSI since the initiation of the interventions. The catheter utilization ratio also decreased from 0.71 to 0.63 (p < 0.001). Microbiological analysis showed that among all CLABSI isolates, the proportion of coagulase-negative staphylococci significantly decreased during the intervention period. CONCLUSION: Implementing multimodal interventions focusing on CL bundle improvement was effective in reducing the incidence rates of CLABSI and CRBSI in Taiwan's adult ICUs.

The development of a computer-assisted instruction system for clinical nursing skills with virtual instruments concepts: A case study for intra-aortic balloon pumping.

The purpose of this research was to develop a computer-aided instruction system for intra-aortic balloon pumping (IABP) skills in clinical nursing with virtual instrument (VI) concepts. Computer graphic technologies were incorporated to provide not only static clinical nursing education, but also the simulated function of operating an expensive medical instrument with VI techniques. The content of nursing knowledge was adapted from current well-accepted clinical training materials. The VI functions were developed using computer graphic technology with photos of real medical instruments taken by digital camera. We wish the system could provide beginners of nursing education important teaching assistance.

[Improving the facial skin and oral mucosa integrity of patients with oral endotracheal intubation].

The problems of damage to facial skin and oral mucus affecting intubated patients have seldom been effectively improved. The purpose of this project was to reduce the incidence of defects in facial skin and oral mucosa integrity in patients with oral endotracheal intubation. The main factors identified by data collection were: 1. Inappropriate endotracheal tube securement. 2. Dry lip mucosa. 3. Pressure points caused by large bite-blocks. 4. Patient's frequent movement of mouth. 5. Allergic reaction caused by adhesive tape. Through the implementation of a new standard for oral endotracheal tube securement and the application of new bite-blocks to deal with the problems mentioned above, the incidence rate of defects in facial skin and oral mucosa integrity decreased from 67% to 25%. The results indicate that the new standard of securement and the new bite-block can help to solve these problems.

Continuous lateral rotational therapy in the medical intensive care unit.

BACKGROUND AND PURPOSE: The efficacy of continuous lateral rotational therapy (CLRT) for mechanically ventilated patients is not well established. This study investigated the effect of CLRT on gas exchange and the incidence of ventilator-associated pneumonia (VAP) in mechanically ventilated patients in a medical intensive care unit (ICU). METHODS: Thirty five mechanically ventilated patients in a medical ICU received CLRT for 5 days, while 35 control patients matched for age, gender, cause of respiratory failure, and admission Acute Physiology and Chronic Health Evaluation (APACHE) score, received routine positional change. The results of blood gas analysis, incidence of VAP, findings on chest radiograph, length of ICU stay, and sputum characteristics were recorded. RESULTS: Greater improvement in oxygenation index (the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen) was noted in the patients who received CLRT (31 +/- 42 vs 6 +/- 76, p = 0.03). Patients who received CLRT also had lower VAP incidence (0 vs 5, p < 0.001), were more likely to have improvement in pulmonary infiltrates (17 vs 12, p = 0.04) and had shorter ICU stay (22 +/- 8 days vs 27 +/- 12 days, p = 0.09). The ICU discharge status (dead, ventilator dependent, alive) was not significantly different between the 2 groups. CONCLUSION: Mechanically ventilated patients in the medical ICU who received CLRT had improved oxygenation and reduced incidence of VAP compared to controls.