Effects of Pneumatic Tube Transport on Blood Gas and Supplemental Analytes.

BACKGROUND: Pneumatic tube transport of blood gas samples is a common method of delivery within a facility. The effects of pneumatic tube transport on blood gas analysis has been studied. However, other analytes that are often assessed in blood gas analysis (eg, electrolytes, metabolites, and oximetry) are not typically included in these studies. We sought to investigate the impact of pneumatic tube transport on some of these other analytes. METHODS: The study was conducted at the blood gas laboratory at the University of Utah Hospital. A split sample comparison was performed. Both samples were walked to a pneumatic tube station, where one sample was sent via tube to the blood gas laboratory, while the other sample was walked back to blood gas laboratory. We examined 2 samples from each of the 27 different pneumatic tube stations in this hospital. Results were graphed with upper and lower control limits set to conform to acceptable College of American Pathologists proficiency testing evaluation criteria. Data were compared using the Student t test. RESULTS: Differences between walked and tubed specimens were neither clinically nor statistically significant. CONCLUSIONS: Pneumatic tube transport of blood gas specimens is acceptable for blood gas and supplementary analytes, as evidenced by multiple points of evaluation, including statistical analysis, clinical judgment, and concordance with regulatory guidelines.

Interruptions and Delivery of Care in the Intensive Care Unit.

OBJECTIVE: This study samples interruption frequency in intensive care unit (ICU) settings to assess the relationship between interruptions and common patient hazards. BACKGROUND: Task interruptions are accident contributors in numerous industries. Recently, studies on health care interruptions and their impact on patient hazards have received attention. METHOD: Seven ICUs in four hospitals participated in a 24-month study. Experienced ICU nurses directly observed nursing tasks, interruptions, and patient hazards (delays in care, breaks in device task protocols, and patient safety hazards). RESULTS: During 1,148 hours of observation, 175 nurses performed 74,733 nursing tasks. Interruptions occurred at a rate of 4.95 per hour, and 8.4% of tasks were interrupted. Interruptions originated mostly from humans (65.9%), alarms (24.1%), and others (10%). A total of 774 patient hazards were observed, with a hazard occurring on average every 89 minutes. Relative to noninterrupted tasks, device alarm interrupted nonstructured tasks were associated with increased rates of delays in care and safety hazards (rate ratio [RR] = 3.19). In contrast, rate of delays in care and safety hazards did not increase during human interrupted tasks (RR = 1.13). Rates of protocol nonadherence varied by device type and were highest during artificial airway, medication administration, chest tube, and supplemental oxygen management. CONCLUSION: Interruptions in the ICU are frequent and contribute to patient hazards, especially when caused by device alarms during nonstructured tasks. Nonadherence to protocols is common and contributed to patient hazards. APPLICATION: The findings suggest a need for improvement in task and device design to reduce patient hazards.

Improved Success Rate of Arterial Puncture for Blood Gas Analysis Through Standardization.

BACKGROUND: Arterial puncture for blood gas analysis is a common procedure in hospitals. The aim of the study is to determine if standardizing technique elements of the arterial puncture process could improve the success rate of technicians through the full scope of an academic medical center. METHODS: The study is conducted by the Blood Gas Laboratory at University of Utah Health's main campus. During the baseline period, technicians tallied whether arterial puncture attempts were successful or unsuccessful from December 2014 through February 2015. A small team reviewed the steps of performing arterial puncture and selected segments of the process for standardization. Starting in March 2015, staff were trained individually in the standard processes. All staff continued to tally outcomes of puncture attempts through March 2017. RESULTS: During the baseline period, the puncture success rate was 83.6%. From April 2015 through March 2017 the success rate was 89.2%. CONCLUSION: Standardizing arterial puncture technique for blood gas analysis leads to fewer punctures.

Impact of Laboratory Charge Display Within the Electronic Health Record Across an Entire Academic Medical Center: Results of a Randomized Controlled Trial.

OBJECTIVES: To determine the impact of systemwide charge display on laboratory utilization. METHODS: This was a randomized controlled trial with a baseline period and an intervention period. Tests were randomized to a control arm or an active arm. The maximum allowable Medicare reimbursement rate was displayed for tests in the active arm during the intervention period. Total volume of tests in the active arm was compared with those in the control arm. Residents were surveyed before and after the intervention to assess charge awareness. RESULTS: Charge display had no effect on order behavior. This result held for patient type (inpatient vs outpatient) and for insurance category (commercial, government, self-pay). Residents overestimated the charges of tests both before and after the intervention. Many residents failed to notice the charge display in the computerized order entry system. CONCLUSIONS: The impact of charge display depends on context. Charge display is not always effective.

Safe Reduction of Blood Volume in the Blood Gas Laboratory.

BACKGROUND: Phlebotomy is a significant cause of iatrogenic anemia in the critical care environment. It is estimated that one-third of all transfusions of packed red blood cells in intensive care units (ICU) result from phlebotomy. The aims of this study were to determine if utilizing the 1mL blood gas syringe for an adult population would impact the rate at which specimens were acceptable for testing and result reporting based on lab specimen rejection criteria; and to compare blood utilization between the 2 different syringes. METHODS: This study was conducted in 1 of the adult ICUs at the University of Utah Hospital. Over a baseline period a standard adult 3 mL blood gas syringe was utilized. Subsequently the standard adult syringe was replaced by a 1 mL syringe produced by the same manufacturer with the same heparin concentration. RESULTS: The change to the 1 mL syringe had no effect on specimen integrity in regards to laboratory's ability to process the specimen. With use of the 1 mL syringe there was a 60% reduction in the volume of blood drawn compared with the baseline period. CONCLUSION: Standardizing the 1 mL syringe for Blood Gas Laboratory tests will reduce patient blood loss without appreciably affecting specimen rejection relative to current rates.

Single-breath diffusing capacity for carbon monoxide instrument accuracy across 3 health systems.

BACKGROUND: Measuring diffusing capacity of the lung for carbon monoxide (DLCO) is complex and associated with wide intra- and inter-laboratory variability. Increased D(LCO) variability may have important clinical consequences. The objective of the study was to assess instrument performance across hospital pulmonary function testing laboratories using a D(LCO) simulator that produces precise and repeatable D(LCO) values. METHODS: D(LCO) instruments were tested with CO gas concentrations representing medium and high range D(LCO) values. The absolute difference between observed and target D(LCO) value was used to determine measurement accuracy; accuracy was defined as an average deviation from the target value of < 2.0 mL/min/mm Hg. Accuracy of inspired volume measurement and gas sensors were also determined. RESULTS: Twenty-three instruments were tested across 3 healthcare systems. The mean absolute deviation from the target value was 1.80 mL/min/mm Hg (range 0.24-4.23) with 10 of 23 instruments (43%) being inaccurate. High volume laboratories performed better than low volume laboratories, although the difference was not significant. There was no significant difference among the instruments by manufacturers. Inspired volume was not accurate in 48% of devices; mean absolute deviation from target value was 3.7%. Instrument gas analyzers performed adequately in all instruments. CONCLUSIONS: D(LCO) instrument accuracy was unacceptable in 43% of devices. Instrument inaccuracy can be primarily attributed to errors in inspired volume measurement and not gas analyzer performance. D(LCO) instrument performance may be improved by regular testing with a simulator. Caution should be used when comparing D(LCO) results reported from different laboratories.

Vascular leak is a central feature in the pathogenesis of systemic sclerosis.

OBJECTIVE: The main histopathological focus of systemic sclerosis (SSc) has concentrated on fibrotic changes. We investigated the microvasculature alterations in the skin of patients with SSc at various stages of disease duration with whole-field digital microscopy. METHODS: Twenty consecutive patients with SSc, 1 with Raynaud's phenomenon (RP) without SSc, and 4 healthy controls underwent punch biopsy on the medial forearm. Eighteen patients were included in the primary analysis. Two with recent-onset diffuse cutaneous disease, 1 repeat SSc biopsy, and 1 patient with RP without SSc were also evaluated. All specimens were processed with histochemical stains and immunohistochemistry. We analyzed microvasculature abnormalities in an objective and systematic manner taking advantage of recent advances in whole-field digital microscopy. This analysis was coupled with ultrastructural evaluation performed with transmission electron microscopy (TEM). RESULTS: Whole-field digital microscopy and TEM of SSc skin biopsies revealed that endothelial abnormalities are a universal feature regardless of clinical features and/or duration of disease. These features were not seen in any healthy control specimens or in the single RP patient samples. Whole-field digital microscopy identified increased interstitial edema (31.0% ± 9.6% vs 17.6% ± 3.3% in controls; p = 0.009) and fibrosis (75.6% ± 5.7% vs 66.1% ± 9.8% in controls; p = 0.02) in all patients with SSc. Lower CD34 staining was seen in SSc compared to healthy controls (0.32% ± 0.22% vs 1.31% ± 0.34%; p < 0.0001) and within the SSc population with interstitial lung disease (0.55% ± 0.22% vs 0.15% ± 0.16%; p = 0.01). Perivascular and interstitial infiltrate of mast cells was present in all SSc specimens. CONCLUSION: Whole-field digital microscopy offers a means of rapidly carrying out objective, fully quantitative, and reproducible measurements of microscopic features of SSc microvascular change. The universal morphologically abnormal endothelial cells and interstitial edema in all patients with SSc biopsied suggests that SSc may be intrinsically a disease of the endothelium characterized by vascular leak.

Evaluation of an integrated intensive care unit monitoring display by critical care fellow physicians.

In the past two far-view displays, which showed vital signs, trends, alarms, infusion pump status, and therapy support indicators, were developed and assessed by critical care nurses (Görges et al. in Dimens Crit Care Nurs. 30(4):206-17, 2011). The aim of the current study is to assess the generalizability of these findings to physicians. The first aim is to test whether an integrated far-view display, designed to be readable from 3 to 5 m, enables critical care physicians to more rapidly and accurately (1) recognize a change in patient condition; (2) identify alarms; and (3) identify near-empty infusion pumps, than a traditional patient monitor and infusion pump. A second aim is to test if the new displays reduce the mental workload required for this decision making. Fifteen critical care fellow physicians (median age of 34 years, with 2-8 years of ICU experience) were asked to use the three displays to compare the data from two patients and decide which patient required their attention first. Each physician made 60 decisions: 20 with each of the two far-view displays and 20 decisions with a standard patient monitor next to an infusion pump. A 41 and 26 % improvement in decision accuracy was observed with the bar and clock far-view displays, respectively. Specifically, the identification of near empty infusion pumps, a task normally performed by nurses, and patients with a single alarm were better with the new displays. Using the bar display physicians made their decision 12 % faster than when using the control display, a median improvement of 2.1 s. No significant differences were observed in measured workload. Displays that present patient data in a redesigned format enables critical care clinicians to more rapidly identify changes in patient conditions and to more accurately decide which patient needs their attention. In a clinical setting, this could improve patient safety. In future work, an evaluation of the display using live patient data from an ICU should be performed.

Clinical findings and demographic factors associated with ICU admission in Utah due to novel 2009 influenza A(H1N1) infection.

BACKGROUND: Novel 2009 influenza A(H1N1) infection has significantly affected ICUs. We sought to characterize our region's clinical findings and demographic associations with ICU admission due to novel A(H1N1). METHODS: We conducted an observational study from May 19, 2009, to June 30, 2009, of descriptive clinical course, inpatient mortality, financial data, and demographic characteristics of an ICU cohort. A case-control study was used to compare the ICU cohort to Salt Lake County residents. RESULTS: The ICU cohort of 47 influenza patients had a median age of 34 years, Acute Physiology and Chronic Health Evaluation II score of 21, and BMI of 35 kg/m2. Mortality was 17% (8/47). All eight deaths occurred among the 64% of patients (n = 30) with ARDS, 26 (87%) of whom also developed multiorgan failure. Compared with the Salt Lake County population, patients with novel A(H1N1) were more likely to be obese (22% vs 74%; P < .001), medically uninsured (14% vs 45%; P < .001), and Hispanic (13% vs 23%; P < .01) or Pacific Islander (1% vs 26%; P < .001). Observed ICU admissions were 15-fold greater than expected for those with BMI > or = 40 kg/m2 (standardized morbidity ratio 15.8, 95% CI, 8.3-23.4) and 1.5-fold greater than expected among those with BMI of 30 to 39 kg/m(2) for age-adjusted and sex-adjusted rates for Salt Lake County. CONCLUSIONS: Severe ARDS with multiorgan dysfunction in the absence of bacterial infection was a common clinical presentation. In this cohort, young nonwhites without medical insurance were disproportionately likely to require ICU care. Obese patients were particularly susceptible to critical illness due to novel A(H1N1) infection.

Improving alarm performance in the medical intensive care unit using delays and clinical context.

INTRODUCTION: In an intensive care unit, alarms are used to call attention to a patient, to alert a change in the patient's physiology, or to warn of a failure in a medical device; however, up to 94% of the alarms are false. Our purpose in this study was to identify a means of reducing the number of false alarms. METHODS: An observer recorded time-stamped information of alarms and the presence of health care team members in the patient room; each alarm response was classified as effective (action taken within 5 min), ineffective (no response to the alarm), and ignored (alarm consciously ignored or actively silenced). RESULTS: During the 200-h study period, 1271 separate entries by an individual to the room being observed were recorded, 1214 alarms occurred and 2344 tasks were performed. On average, alarms occurred 6.07 times per hour and were active for 3.28 min per hour; 23% were effective, 36% were ineffective, and 41% were ignored. The median alarm duration was 17 s. A 14-s delay before alarm presentation would remove 50% of the ignored and ineffective alarms, and a 19-s delay would remove 67%. Suctioning, washing, repositioning, and oral care caused 152 ignored or ineffective ventilator alarms. DISCUSSION: Introducing a 19-s alarm delay and automatically detecting suctioning, repositioning, oral care, and washing could reduce the number of ineffective and ignored alarms from 934 to 274. More reliable alarms could elicit more timely response, reduce workload, reduce noise pollution, and potentially improve patient safety.

Decreased serum linezolid levels in a critically ill patient receiving concomitant linezolid and rifampin.

Serious gram-positive infections present an increasingly common therapeutic dilemma. Combination antimicrobial regimens (e.g., linezolid with rifampin) aimed at improving bacterial eradication and preventing resistance are often used; however, most data supporting this treatment strategy are not from randomized controlled trials. We describe a patient with disseminated community-acquired methicillin-resistant Staphylococcus aureus infection who experienced a possible drug interaction between linezolid and rifampin that resulted in decreased serum linezolid levels. To our knowledge, this is the first published report of a possible drug interaction in a critically ill patient receiving concomitant linezolid and rifampin. Although we hypothesize that the reaction was caused by P-glycoprotein expression, further study is warranted.

Comparative performance of three anti-factor Xa heparin assays in patients in a medical intensive care unit receiving intravenous, unfractionated heparin.

The availability of automated anti-Xa heparin assays provides the opportunity to manage patient unfractionated heparin levels directly, rather than by the activated partial thromboplastin time. Because critically ill patients can acquire an antithrombin deficiency, we compared the performance of 3 anti-Xa heparin assays, 1 with and 2 without antithrombin supplementation, by analyzing in vitro aliquots of plasma with defined antithrombin levels and specimens from intensive care patients receiving intravenous heparin therapy. Heparin concentration recovery, in vitro, was dependent on the plasma antithrombin concentration for all 3 assays. The antithrombin-supplemented assay demonstrated improved heparin recovery in direct correlation to the heparin concentration in the plasma. The greatest effect of antithrombin supplementation occurred when the antithrombin level dropped below 40%, a level present in only 5% of the patient specimens. Analysis of patient specimens demonstrated significant correlation among the 3 assays. Classification of the clinical adequacy of patient heparin levels showed agreement of 80% or more between the antithrombin-supplemented and nonsupplemented assays. The antithrombin-supplemented assay did not significantly improve clinical usefulness.