Health System Redesign of Cardiac Monitoring Oversight to Optimize Alarm Management, Safety, and Staff Engagement.

OBJECTIVE: The purpose of this quality improvement project was to improve health system patient safety by creating a cardiac monitoring structure aligned with national standards. BACKGROUND: Excessive alarms pose patient safety threats and are often false or clinically insignificant. The Joint Commission identified reduction of nonactionable alarms as a National Patient Safety Goal. METHODS: The conversion to structured monitoring occurred in 4 phases: 1) defining health system monitoring structure and processes; 2) co-create sessions; 3) implementation and impact analysis; and 4) ongoing evaluation and optimization. RESULTS: Twenty-two clinical units participated. At the conclusion of phase 4, total 30-day alarm rates decreased by 74% at the academic hospital and by 92% and 95% at the community hospitals and were sustained for 12 months. CONCLUSIONS: Decreasing alarm frequency can be safely achieved in academic and community hospitals by creating a system-wide monitoring infrastructure and standardized processes that engage interdisciplinary teams.

Implementing a Standardized Communication Tool in an Intensive Care Unit.

BACKGROUND: Effective communication is essential in critical care settings. Use of the SBAR (Situation, Background, Assessment, Recommendation) tool has been shown to standardize and improve communication among health care providers. LOCAL PROBLEM: This quality improvement project was designed to improve communication in an intensive care unit that lacked a standardized communication protocol. Communication practices differed greatly between nurses and advanced practice providers. As a result, patient safety was put at risk owing to incomplete, inaccurate, or delayed information when clinical concerns were reported or escalated. METHODS: This project used a pre-post design in which surveys were used to gather information on staff perceptions of communication and collaboration between nurses and advanced practice providers before and after an educational intervention. The 2 groups received identical education on SBAR guidelines adapted for use in the intensive care unit setting and patient safety. RESULTS: Results showed improvement in all areas of communication. Significant improvements were found on the General Perceptions subscale among advanced practice providers (P = .04) and among nurses (P = .007). In the combined study population, improvements were observed on all subscales, with significant results for the Open Communication (P = .03) and General Perceptions (P = .002) subscales. A significant increase was found in the percentage of nurses using the SBAR tool after the intervention (95%) compared with before the intervention (66%; P < .001). CONCLUSION: Implementation of the SBAR communication tool significantly improved general perceptions of communication in this intensive care unit.

Effect of Remote Cardiac Monitoring System Design on Response Time to Critical Arrhythmias.

INTRODUCTION: In many hospitals across the country, electrocardiograms of multiple at-risk patients are monitored remotely by telemetry monitor watchers in a central location. However, there is limited evidence regarding best practices for designing these cardiac monitoring systems to ensure prompt detection and response to life-threatening events. To identify factors that may affect monitoring efficiency, we simulated critical arrhythmias in inpatient units with different monitoring systems and compared their efficiency in communicating the arrhythmias to a first responder. METHODS: This was a multicenter cross-sectional in situ simulation study. Simulation participants were monitor watchers and first responders (usually nurses) in 2 inpatient units in each of 3 hospitals. Manipulated variables included: (1) number of communication nodes between monitor watchers and first responders; (2) central monitoring station location-on or off the patient care unit; (3) monitor watchers' workload; (4) nurses' workload; and (5) participants' experience. RESULTS: We performed 62 arrhythmia simulations to measure response times of monitor watchers and 128 arrhythmia simulations to measure response times in patient care units. We found that systems in which an intermediary between monitor watchers and nurses communicated critical events had faster response times to simulated arrhythmias than systems in which monitor watchers communicated directly with nurses. Responses were also faster in units colocated with central monitoring stations than in those located remotely. As the perceived workload of nurses increased, response latency also increased. Experience did not affect response times. CONCLUSIONS: Although limited in our ability to isolate the effects of these factors from extraneous factors on central monitoring system efficiency, our study provides a roadmap for using in situ arrhythmia simulations to assess and improve monitoring performance.

Implementing Cardiac Surgical Unit-Advanced Life Support Through Simulation-Based Learning: A Quality Improvement Project.

BACKGROUND: The European Association for Cardio Thoracic Surgery and the Society of Thoracic Surgeons endorse Cardiac Surgical Unit-Advanced Life Support, a protocol designed specifically for cardiothoracic surgical patients who suffer postoperative cardiac arrests. To enhance patient outcomes and to reduce death rates, cardiothoracic intensive care unit nurses must be able to perform the protocol with confidence, proficiency, and without delays. To this end, simulation-based learning (SBL) is a pedagogical method ideal for optimized learning. OBJECTIVES: This quality improvement project was designed to implement a post-cardiac surgery resuscitation protocol in a nonacademic, community medical center to enhance nurse knowledge, confidence, and proficiency for optimal patient outcomes. METHODS: The Cardiac Surgical Unit-Advanced Life Support is an evidence-based resuscitation protocol that was implemented using didactic, hands-on training, and SBL. It was evaluated using knowledge surveys, comparisons in nurse confidence and performance measures, and patient outcomes data. RESULTS: Nurses' knowledge gains (ie, mean test scores) on our test were statistically significant between 3 time points (F2,60 = 81.204, P < .001). Knowledge significantly increased from pre-education to immediate post-education (P < .001), but declined from immediate post-education to 3-month post-education assessments (P < .001); however, the 3-month post knowledge mean was still higher than the pre-education knowledge mean (P < .001). Nurses were confident in their ability to apply the protocol, although results failed to show a correlation between confidence and performance ability. Statistical significance for delay in cardiopulmonary resuscitation was found between pre- and post-nursing education patient cardiac arrest events (P = .05). CONCLUSIONS: Didactic and hands-on learning supported knowledge retention over time for cardiothoracic surgical intensive care unit nurses. Improving self-confidence and the application of an unfamiliar resuscitation protocol through SBL and any impact a training program has on patient outcomes will require ongoing practice and more evaluation.