Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital.

BACKGROUND10: The Joint Commission identified inpatient alarm reduction as an opportunity to improve patient safety; enhance patient, family and nursing satisfaction; and optimise workflow. We used quality improvement (QI) methods to safely decrease non-actionable alarm notifications to bedside providers. METHODS: In a paediatric tertiary care centre, we convened a multidisciplinary team to address alarm notifications in our acute care cardiology unit. Alarm notification was defined as any alert to bedside providers for each patient-triggered monitor alarm. Our aim was to decrease alarm notifications per monitored bed per day by 60%. Plan-Do-Study-Act testing cycles included updating notification technology, establishing alarm logic and modifying bedside workflow processes, including silencing the volume on all bedside monitors. Our secondary outcome measure was nursing satisfaction. Balancing safety measures included floor to intensive care unit transfers and patient acuity level. RESULTS: At baseline, there was an average of 71 initial alarm notifications per monitored bed per day. Over a 3.5-year improvement period (2014-2017), the rate decreased by 68% to 22 initial alarm notifications per monitored bed per day. The proportion of initial to total alarm notifications remained stable, decreasing slightly from 51% to 40%. There was a significant improvement in subjective nursing satisfaction. At baseline, 32% of nurses agreed they were able to respond to alarms appropriately and quickly. Following interventions, agreement increased to 76% (p<0.001). We sustained these improvements over a year without a change in monitored balancing measures. CONCLUSION: We successfully reduced alarm notifications while preserving patient safety over a 4-year period in a complex paediatric patient population using technological advances and QI methodology. Continued efforts are needed to further optimise monitor use across paediatric hospital units.

Laparoscopic repair of gastric herniation after extrapleural pneumonectomy for mesothelioma.

Acute herniation of intra-abdominal organs into the chest after extrapleural pneumonectomy is an uncommon but morbid and potentially mortal complication. We report a case of acute diaphragmatic hernia after extrapleural pneumonectomy for mesothelioma repaired laparoscopically. This approach is an alternative to repeated thoracotomy and is a viable option for treatment of this difficult problem with potentially less morbidity.

Anion gap, anion gap corrected for albumin, and base deficit fail to accurately diagnose clinically significant hyperlactatemia in critically ill patients.

Anion gap, anion gap corrected for serum albumin, and base deficit are often used as surrogates for measuring serum lactate. None of these surrogates is postulated to predict hyperlactatemia in the critically ill. We prospectively collected data from September 2004 through August 2005 for 1381 consecutive admissions. Patients with renal disease, ketoacidosis, or toxic ingestion were excluded. Anion gap, anion gap corrected for albumin, and base deficit were calculated for all patients. We identified 286 patients who met our inclusion or exclusion criteria. The receiver-operating characteristic area under the curve for the prediction of hyperlactatemia for anion gap, anion gap corrected for albumin, and base deficit were 0.55, 0.57, and 0.64, respectively. Anion gap, anion gap corrected for albumin, and base deficit do not predict the presence or absence of clinically significant hyperlactatemia. Serum lactate should be measured in all critically ill adults in whom hypoperfusion is suspected.

"Not-for-resuscitation" orders in Australian public hospitals: policies, standardised order forms and patient information leaflets.

OBJECTIVE: To determine the prevalence and content of policies, standardised order forms (SOFs) and patient information leaflets (PILs) pertaining to "not-for-resuscitation" (NFR) orders in Australian public hospitals. DESIGN AND SETTING: Cross-sectional postal survey conducted across Australia from August to December 2005, using a one-page questionnaire. PARTICIPANTS: Directors of Medical, Nursing or Clinical Services of all public hospitals in Australia with 60 or more beds, excluding psychiatric, military and private hospitals. MAIN OUTCOME MEASURES: Prevalence of documented NFR policies, by hospital characteristics, and content of these policies, SOFs and PILs. RESULTS: 222 hospitals were surveyed, and 157 responded (71%). Of these, 85 (54%) had NFR policies, 62 (39%) had SOFs, and four (3%) had PILs. Hospitals with more than 200 beds were more likely to have NFR policies than those with 60-200 beds (P = 0.04). More metropolitan than rural hospitals had NFR policies (P = 0.01). More hospitals with 60-100 beds had SOFs than hospitals with 101-200 beds (P = 0.03). "NFR" was defined in 53% of policies, while 97% of policies explicitly stated where NFR orders were to be documented, 89% stated who was allowed to make them, 37% stated that advanced care directives ("living wills") were to be respected, and 89% stated that competent patients should be involved in discussions regarding their NFR status. The most common items noted in SOFs were the name and signature of the issuing medical practitioner (92%) and documentation of the discussion with the patient (81%). CONCLUSIONS: There was wide variation in the content of hospital policies, SOFs and PILs pertaining to NFR orders. Aspects of current policies show room for improvement.

Identifying critically ill patients at high risk for developing acute renal failure: a pilot study.

BACKGROUND: Acute renal failure (ARF) occurs commonly in the intensive care unit (ICU), but predicting which patients will develop ARF is difficult. We set out to determine which risk factors would predict the development of ARF in critically ill patients who are admitted to the ICU without ARF. METHODS: From August 2002 to April 2003, we enrolled medical-surgical ICU admissions into a cohort using a sampling tool based on their risk factor (RF) profile. The risk factors we identified were separated into 3 categories: chronic major, chronic minor, and acute RFs. Combinations of these RFs were used to create a sampling tool and identify patients to enroll into our cohort. Patients with end-stage renal disease and ARF upon admission to the ICU were excluded. RESULTS: We enrolled 194 patients over a 14-month period. The mean age of the cohort was 64.6 +/- 14.7 years. The percentage of Caucasians, African Americans, and Hispanics was 40.7%, 50.5%, and 3.6%, respectively. In a univariate analysis of the entire cohort, increasing APACHE II quartile, increased A-a gradient, presence of systemic inflammatory response syndrome (SIRS), decreased levels of serum albumin, and presence of active cancer predicted ARF. In a multiple logistic regression analysis, decreased serum albumin (high levels of serum albumin were protective), increased A-a gradient, and cancer were associated with development of ARF (OR 2.17, 1.04, and 2.86, respectively). CONCLUSION: Decreased levels of serum albumin concentration, increased A-a gradient, and presence of active cancer predict which patients who are admitted to the ICU will develop ARF.