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Choo YJ, Lee GW, Moon JS, Chang MC. Noncontact Sensors for Vital Signs Measurement: A Narrative Review. Med Sci Monit 2024; 30:e944913. [PMID: 38961611 PMCID: PMC11302200 DOI: 10.12659/msm.944913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/26/2024] [Indexed: 07/05/2024] Open
Abstract
Vital signs are crucial for monitoring changes in patient health status. This review compared the performance of noncontact sensors with traditional methods for measuring vital signs and investigated the clinical feasibility of noncontact sensors for medical use. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) database for articles published through September 30, 2023, and used the key search terms "vital sign," "monitoring," and "sensor" to identify relevant articles. We included studies that measured vital signs using traditional methods and noncontact sensors and excluded articles not written in English, case reports, reviews, and conference presentations. In total, 129 studies were identified, and eligible articles were selected based on their titles, abstracts, and full texts. Three articles were finally included in the review, and the types of noncontact sensors used in each selected study were an impulse radio ultrawideband radar, a microbend fiber-optic sensor, and a mat-type air pressure sensor. Participants included neonates in the neonatal intensive care unit, patients with sleep apnea, and patients with coronavirus disease. Their heart rate, respiratory rate, blood pressure, body temperature, and arterial oxygen saturation were measured. Studies have demonstrated that the performance of noncontact sensors is comparable to that of traditional methods of vital signs measurement. Noncontact sensors have the potential to alleviate concerns related to skin disorders associated with traditional skin-contact vital signs measurement methods, reduce the workload for healthcare providers, and enhance patient comfort. This article reviews the medical use of noncontact sensors for measuring vital signs and aimed to determine their potential clinical applicability.
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Affiliation(s)
- Yoo Jin Choo
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Gun Woo Lee
- Department of Orthopaedic Surgery, Yeungnam University Hospital, Daegu, South Korea
| | - Jun Sung Moon
- Division of Endocrinology and Metabolism, Yeungnam University Hospital, Deagu, South Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
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Kelly K, Kolbeinsson H, Blanck LM, Khan M, Kyriakakis R, Assifi MM, Wright GP, Chung M. Can we let our patients sleep in the hospital? A randomized controlled trial of a pragmatic sleep protocol in surgical oncology patients. J Surg Oncol 2024; 129:827-834. [PMID: 38115237 DOI: 10.1002/jso.27565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/07/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Postoperative inpatients experience increased stress due to pain and poor restorative sleep than non-surgical inpatients. OBJECTIVES AND METHODS A total of 101 patients, undergoing major oncologic surgery, were randomized to a postoperative sleep protocol (n = 50) or standard postoperative care (n = 51), between August 2020 and November 2021. The primary endpoint of the study was postoperative sleep time after major oncologic surgery. Sleep time and steps were measured using a Fitbit Charge 4®. RESULTS There was no statistically significant difference found in postoperative sleep time between the sleep protocol and standard group (median sleep time of 427 min vs. 402 min; p = 0.852, respectively). Major complication rates were similar in both groups (7.4% vs. 8.9%). Multivariate analysis found sex and Charlson Comorbidity Index to be significant factors affecting postoperative sleep time and step count. Postoperative delirium was only observed in the standard group, although this did not reach statistical significance. There were no in hospital mortalities. CONCLUSION The use of a sleep protocol was found to be safe in our study population. There was no statistical difference in postoperative sleep time or major complications. Institution of a more humane sleep protocol for postoperative inpatients should be considered.
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Affiliation(s)
- Kathrine Kelly
- Department of General Surgery, Spectrum Health/Michigan State University College of Human Medicine General, Grand Rapids, Michigan, USA
| | - Hordur Kolbeinsson
- Department of General Surgery, Spectrum Health/Michigan State University College of Human Medicine General, Grand Rapids, Michigan, USA
| | - Lauren M Blanck
- Department of Graduate Medical Education, Michigan State College of Human Medicine, Grand Rapids, Michigan, USA
| | - Mariam Khan
- Department of General Surgery, Spectrum Health/Michigan State University College of Human Medicine General, Grand Rapids, Michigan, USA
| | - Roxanne Kyriakakis
- Division of Colon and Rectal Surgery, Spectrum Health Colon and Rectal Fellowship, Grand Rapids, Michigan, USA
| | - M Mura Assifi
- Department of General Surgery, Spectrum Health/Michigan State University College of Human Medicine General, Grand Rapids, Michigan, USA
- Department of Graduate Medical Education, Michigan State College of Human Medicine, Grand Rapids, Michigan, USA
- Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
| | - G Paul Wright
- Department of General Surgery, Spectrum Health/Michigan State University College of Human Medicine General, Grand Rapids, Michigan, USA
- Department of Graduate Medical Education, Michigan State College of Human Medicine, Grand Rapids, Michigan, USA
- Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
| | - Mathew Chung
- Department of General Surgery, Spectrum Health/Michigan State University College of Human Medicine General, Grand Rapids, Michigan, USA
- Department of Graduate Medical Education, Michigan State College of Human Medicine, Grand Rapids, Michigan, USA
- Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
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Briggs J, Kostakis I, Meredith P, Dall'ora C, Darbyshire J, Gerry S, Griffiths P, Hope J, Jones J, Kovacs C, Lawrence R, Prytherch D, Watkinson P, Redfern O. Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-143. [PMID: 38551079 DOI: 10.3310/hytr4612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Background The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Objective Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact. Design Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Setting and participants Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Results Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. Conclusions We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. Study registration This study is registered as ISRCTN10863045. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Ina Kostakis
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Meredith
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Julie Darbyshire
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Jo Hope
- Health Sciences, University of Southampton, Southampton, UK
| | - Jeremy Jones
- Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Kovacs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | | | - David Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Oliver Redfern
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Hotta S, Ashida K, Tanaka M. Night-time detection and response in relation to deteriorating inpatients: A scoping review. Nurs Crit Care 2024; 29:178-190. [PMID: 37095606 DOI: 10.1111/nicc.12917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Although detection and response to clinical deterioration have been studied, the range and nature of studies focused on night-time clinical setting remain unclear. AIM This study aimed to identify and map existing research and findings concerning night-time detection and response to deteriorating inpatients in usual care or research settings. STUDY DESIGN A scoping review method was used. PubMed, CINAHL, Web of Science, and Ichushi-Web databases were systematically searched. We included studies focusing on night-time detection and response to clinical deterioration. RESULTS Twenty-eight studies were included. These studies were organized into five categories: night-time medical emergency team or rapid response team (MET/RRT) response, night-time observation using the early warning score (EWS), available resources for physicians' practice, continuous monitoring of specific parameters, and screening for night-time clinical deterioration. The first three categories were related to interventional measures in usual care settings, and relevant findings mainly demonstrated the actual situation and challenges of night-time practice. The final two categories were related to the interventions in the research settings and included innovative interventions to identify at-risk or deteriorating patients. CONCLUSIONS Systematic interventional measures, such as MET/RRT and EWS, could have been sub-optimally performed at night. Innovations in monitoring technologies or implementation of predictive models could be helpful in improving the detection of night-time deterioration. RELEVANCE TO CLINICAL PRACTICE This review provides a compilation of current evidence regarding night-time practice concerning patient deterioration. However, a lack of understanding exists on specific and effective practices regarding timely action for deteriorating patients at night.
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Affiliation(s)
- Soichiro Hotta
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kaoru Ashida
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Makoto Tanaka
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Holleck ME, Tikkanen K, Holleck JL, Frank C, Falco N, Cosentino D, Chang JJ. Reducing Nighttime Interruptions and Improving Sleep for Hospitalized Patients by Restructuring Nighttime Clinical Workflow. J Gen Intern Med 2023; 38:2091-2097. [PMID: 36697927 PMCID: PMC10361944 DOI: 10.1007/s11606-022-08005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/23/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Nighttime sleep disruptions negatively impact the experience of hospitalized patients. OBJECTIVE To determine the impact of adopting a sleep-promoting nighttime clinical workflow for hospitalized patients on nocturnal disruptions and sleep. DESIGN Survey-based pre- and post-intervention cross-sectional study using convenience samples. PARTICIPANTS Hospitalized veterans on a 23-bed general medical ward at a tertiary Veterans Administration Hospital. INTERVENTIONS Baseline sleep surveys (N=149) identified two major sources of interruptions: blood pressure checks at 4 am for telemetry patients and subcutaneous (SQ) heparin injections between 4:30 and 6 am for venous thromboembolism prophylaxis. Clinical workflow was restructured to eliminate these disruptions: moving 4 am blood pressure checks to 6 am and providing daily SQ enoxaparin at 9 am as an alternative to Q 8-h SQ heparin, which had prompted an injection between 4:30 and 6 am. The impact of these changes was assessed in a second round of surveys (N=99). MAIN MEASURES Frequency and sources for nighttime sleep disruptions; percentage of patients reporting longer time to fall asleep, more interruptions, and worse sleep quality (vs. home) before and after restructuring nighttime clinical workflow. KEY RESULTS After restructuring nighttime clinical workflow, medication administration as a source of nighttime disruption decreased from 40% (59/149) to 4% (4/99) (p<0.001). Blood pressure checks as a source of disruption decreased from 56% (84/149) to 42% (42/99) (p=0.033). Fewer patients reported taking longer to fall asleep in the hospital vs. home (39% pre-intervention vs. 25% post-intervention, p=0.021). Similarly, fewer patients experienced waking up more frequently in the hospital vs. home (46% pre-intervention vs. 32% post-intervention, p=0.036). Fewer patients reported sleeping worse in the hospital (44% pre-intervention vs. 39% post-intervention), though this trend was not statistically significant (p=0.54). CONCLUSIONS Nighttime disruptions in hospitalized patients frequently interfere with sleep. Restructuring of the clinical workflow significantly reduced disruptions and improved sleep.
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Affiliation(s)
| | | | - Jürgen L Holleck
- Yale School of Medicine, New Haven, USA
- VACT Healthcare System, West Haven, USA
| | | | | | | | - John J Chang
- Yale School of Medicine, New Haven, USA.
- VACT Healthcare System, West Haven, USA.
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Winters B, Serpas D, Fullmer N, Hughes K, Kincaid J, Rosario ER, Schnakers C. Sleep Quality Should Be Assessed in Inpatient Rehabilitation Settings: A Preliminary Study. Brain Sci 2023; 13:brainsci13050718. [PMID: 37239190 DOI: 10.3390/brainsci13050718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVES In this preliminary, longitudinal study, our objective was to assess changes in sleep quality during an inpatient stay in a rehabilitation setting in the United States and to relate changes to patients' demographic and clinical characteristics (i.e., age, gender, BMI, ethnicity, reason for hospitalization, pre-hospital living setting, prior diagnosis of sleep disorders, and mental health status). METHODS A total of 35 patients participated in this preliminary study (age = 61 ± 16 years old, 50% <65; BMI = 30 ± 7 kg/m2; 51% female; 51% Caucasian). The average length of hospitalization was 18 ± 8 days. Reasons for hospitalization included orthopedic-related issues (28%), spinal cord injury (28%), stroke (20%), and other (23%). In this sample, 23% had prior sleep disorders (mostly sleep apnea), and 60% came from an acute care unit. Patients' sleep quality was assessed using the Pittsburgh sleep quality index (PSQI) at admission and before discharge. Demographic and medical data were collected. Patients' mental health status was also assessed at the same intervals. Nighttime sound levels and the average number of sleep disturbances were also collected throughout the study (6 months). RESULTS Our data revealed that most patients had poor sleep (PSQI > 5) at admission (86%) and discharge (80%). Using a repeated ANOVA, a significant interaction was obtained between sleep quality and the presence of a diagnosed sleep disorder [F (1, 33) = 12.861, p = 0.001, η2p = 0.280]. The sleep quality of patients with sleep disorders improved over their stay, while the sleep of patients without such disorders did not. The mean nighttime sound collection level averages and peaks were 62.3 ± 5.1 dB and 86.1 ± 4.9 dB, respectively, and the average number of sleep disturbances was 2.6 ± 1.1. CONCLUSION The improved sleep observed in patients with vs. without sleep disorders might be related to the care received for treating such disorders over the stay. Our findings call for the better detection and management of poor sleep in acute inpatient rehabilitation settings. Furthermore, if our findings are replicated in the future, studies on the implementation of quiet times for medical staff, patients, and family should be performed to improve sleep quality in the inpatient rehabilitation setting.
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Affiliation(s)
- Benjamin Winters
- Department of Psychology, University of California, Los Angeles, CA 90095, USA
| | - Dylan Serpas
- Department of Psychology, University of South Florida, Tampa, FL 33620, USA
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA
| | - Niko Fullmer
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA
| | - Katie Hughes
- Department of Nursing, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA
| | - Jennifer Kincaid
- Respiratory Care Services, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA
| | - Emily R Rosario
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA 91767, USA
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Kadura S, Siala T, Arora VM. Perspective: leveraging the electronic health record to improve sleep in the hospital. J Clin Sleep Med 2023; 19:421-423. [PMID: 36448329 PMCID: PMC9892746 DOI: 10.5664/jcsm.10360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 09/05/2022] [Accepted: 10/16/2022] [Indexed: 12/05/2022]
Abstract
Inpatient sleep loss can worsen health outcomes, including delirium and falls. Sleep disruptions in the hospital often originate from provider-patient interactions ordered electronically through computerized provider order entry. These orders contain clinical decision support systems with default schedules. These defaults are often around-the-clock, may not align with patients' needs, and cause iatrogenic sleep loss. Optimizing clinical decision support in the electronic health record can decrease unnecessary sleep disruptions and influence sleep-friendly decision-making. CITATION Kadura S, Siala T, Arora VM. Perspective: Leveraging the electronic health record to improve sleep in the hospital. J Clin Sleep Med. 2023;19(2):421-423.
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Affiliation(s)
- Sullafa Kadura
- University of Rochester Medical Center, Rochester, New York
| | - Tarek Siala
- University of Rochester Medical Center, Rochester, New York
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Kamzan AD, Tsoi S, Arslanian T, Sim MS, Romero T, Newcomer CA. Admission Source Is Associated With the Risk of Rapid Response Team Activation in a Children's Hospital. Acad Pediatr 2022; 22:1477-1481. [PMID: 35858662 DOI: 10.1016/j.acap.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate source of admission to a children's hospital as a predictor of rapid response team (RRT) activation, both in the first 48 hours of admission and over the entire hospitalization. METHODS Retrospective cohort study of all patients admitted to the pediatric ward between March 1, 2013 and December 31, 2015. Source of admission was categorized as from the emergency department, transfer from another hospital facility, admission following a planned surgery, direct admission planned in advance, or unplanned direct admission. Information was collected including whether or not the patient had a RRT activation and survival to discharge. A Fisher's exact test was used to assess the association between source of admission and risk of rapid response. RESULTS Of 8083 admissions included in the study, 194 had at least one RRT event. The odds of having an RRT was significantly associated with source of admission (P < .001). Using admission from the emergency department as a reference group, planned elective admissions (odds ratio [OR] 0.27; P < .001) and admissions following planned surgery (OR 0.07; P < .001) were significantly associated with reduced odds of having at least one RRT activation during the admission. Planned elective admissions also demonstrated reduced odds of RRT in the first 48 hours of hospitalization (OR 0.14; P = .002). Source of admission was also associated with survival to discharge (P < .05). CONCLUSION Source of admission is associated with likelihood of RRT activation as well as with survival to discharge and should be considered by providers when assessing inpatient risk of decompensation.
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Affiliation(s)
- Audrey D Kamzan
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif.
| | - Stephanie Tsoi
- UCSF Department of Pediatrics (S Tsoi), San Francisco, Calif
| | - Talin Arslanian
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
| | - Myung Shin Sim
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Tahmineh Romero
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Charles A Newcomer
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
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Ragonese B, Denotti V, Re VL, Vizzini G, Corso B, Arena G, Girgenti R, Fazzina ML, Tuzzolino F, Pilato M, Luca A. How to Improve Patients' Perceived Quality of Sleep During Hospitalization Through a Multicomponent "Good Sleep Bundle": A Prospective Before and After Controlled Study. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2022; 5:56-64. [PMID: 37261208 PMCID: PMC10228997 DOI: 10.36401/jqsh-22-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/26/2022] [Accepted: 06/07/2022] [Indexed: 06/02/2023]
Abstract
Introduction Despite sound evidence on the importance of sleep for human beings and its role in healing, hospitalized patients still experience sleep disruption with deleterious effects. Many factors affecting patients' sleep can be removed or minimized. We evaluated the efficacy of a multicomponent Good Sleep Bundle (GSB) developed to improve patients' perceived quality of sleep, through which we modified environmental factors, timing of nighttime clinical interventions, and actively involved patients in order to positively influence their experience during hospitalization. Methods In a prospective, before and after controlled study, two different groups of 65 patients each were admitted to a cardiothoracic unit in two different periods, receiving the usual care (control group) and the GSB (GSB group), respectively. Sleep quality was evaluated by the Pittsburgh Sleep Quality Index (PSQI) at the admission, discharge, and 30 days after discharge in all patients enrolled. Comparisons between the two groups evaluated changes in PSQI score from admission to discharge (primary endpoint), and from admission to 30 days after discharge (secondary endpoint). Results The mean PSQI score difference between admission and discharge was 4.54 (SD 4.11) in the control group, and 2.05 (SD 4.25) in the GSB group. The mean difference in PSQI score change between the two groups, which was the primary endpoint, was 2.49 (SD 4.19). This difference was highly significant (p = 0.0009). Conclusion The GSB was associated with a highly significant reduction of the negative effects that hospitalization produces on patients' perceived quality of sleep compared with the usual care group.
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Affiliation(s)
- Barbara Ragonese
- Quality and Patient Safety Department, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Valeria Denotti
- Quality and Patient Safety Department, University of Pittsburgh Medical Center (UPMC) Italy, Rome, Italy
| | - Vincenzina Lo Re
- Neurology Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | | | - Brigida Corso
- Quality and Patient Safety Department, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Giuseppe Arena
- Corporate Nursing, Technical, and Rehabilitation Services, IRCCS-ISMETT, Palermo, Italy
| | - Rosario Girgenti
- Psychology Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Maria Luisa Fazzina
- Quality and Patient Safety Department, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | | | - Michele Pilato
- Cardiac Surgery and Heart Transplantation Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Angelo Luca
- Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
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McDaniel LM, Ralston SL. How Routine are Routine Vital Signs? Hosp Pediatr 2022; 12:e235-e238. [PMID: 35757931 DOI: 10.1542/hpeds.2021-006505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Frequent measurement of vital signs has been associated with disruptions to sleep and increased nursing workload. Since vital signs are often measured at the same frequency regardless of patient acuity, there may be inappropriate prioritization of limited resources. We sought to understand what hospitalists report as the default frequency of routine vital sign measurement in hospitalized pediatric patients at academic institutions. METHODS We surveyed pediatric hospital medicine leadership at Association of American Medical Colleges-affiliated medical schools on their perception of routine vital signs in general medicine inpatients. RESULTS Survey requests were sent to individuals representing 140 unique hospitals. Responses were received from 74 hospitalists, representing a 53% response rate. Routine vitals were most commonly characterized as those collected every 4 hours (78%; 95% confidence interval, 67%-87%), though at least 1 in 5 hospitalists reported obtaining all or select vital signs (eg, blood pressure) less frequently. Strategies to decrease vital sign frequency varied. CONCLUSIONS Our results suggest routine vital signs are not a normative concept across all patient populations in pediatrics. We further identify several conditions under which deviation from routines are sanctioned.
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Lin HM, Macias C, McGee C, Ribbeck M, Drees D, Koti A, Perry MF. "Help Me Sleep": A Quality Initiative to Reduce Overnight Vital Signs. Hosp Pediatr 2022; 12:142-147. [PMID: 35048103 DOI: 10.1542/hpeds.2021-006250] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Sleep is an essential part of the recovery process, yet inpatient sleep quality is poor. Patients and families report that vital signs are the most bothersome overnight disruption. Obtaining vital signs every 4 hours (Q4H) is not evidence-based and is frequently ordered indiscriminately. We aimed to decrease the percentage of patient nights with vital sign checks between 12 am and 6 am in a low-risk population from 98% to 70% within 12 months to minimize overnight sleep disruptions and improve inpatient sleep. METHODS We conducted a quality improvement project on 3 pediatric hospital medicine teams at a large free-standing children's hospital. Our multidisciplinary team defined low-risk patients as those admitted for hyperbilirubinemia and failure to thrive. Interventions were focused around education, electronic health record decision support, and patient safety. The outcome measure was the percentage of patient nights without a vital sign measurement between 12 am and 6 am and was analyzed by using statistical process control charts. Our process measure was the use of an appropriate vital sign order. Balancing measures included adverse patient events, specifically code blues outside the ICU and emergent transfers. RESULTS From March 2020 to April 2021, our pediatric hospital medicine (PHM) services admitted 449 low-risk patients for a total of 1550 inpatient nights. The percentage of patient nights with overnight vital signs decreased from 98% to 38%. There were no code blues or emergent transfers. CONCLUSION Our improvement interventions reduced the frequency of overnight vital sign monitoring in 2 low-risk groups without any adverse events.
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Affiliation(s)
| | | | | | - Melanie Ribbeck
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - David Drees
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Ajay Koti
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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Najafi N, Robinson A, Pletcher MJ, Patel S. Effectiveness of an Analytics-Based Intervention for Reducing Sleep Interruption in Hospitalized Patients: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:172-177. [PMID: 34962506 PMCID: PMC8715385 DOI: 10.1001/jamainternmed.2021.7387] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Sleep has major consequences for physical and emotional well-being. Hospitalized patients experience frequent iatrogenic sleep interruptions and there is evidence that such interruptions can be safely reduced. OBJECTIVE To determine whether a clinical decision support tool, powered by real-time patient data and a trained prediction algorithm, can help physicians identify clinically stable patients and safely discontinue their overnight vital sign checks. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial, with inpatient encounters randomized 1:1 to intervention vs usual care, was conducted from March 11 to November 24, 2019. Participants included physicians serving on the primary team of 1699 patients on the general medical service (not in the intensive care unit) of a tertiary care academic medical center. INTERVENTIONS A clinical decision support notification informed the physician if the patient had a high likelihood of nighttime vital signs within the reference ranges based on a logistic regression model that used real-time patient data as input. The notification provided the physician an opportunity to discontinue measure of nighttime vital signs, dismiss the notification for 1 hour, or dismiss the notification for that day. MAIN OUTCOMES AND MEASURES The primary outcome was delirium, as determined by bedside nurse assessment of Nursing Delirium Screening Scale scores, a standardized delirium screening tool (delirium diagnosed with score ≥2). Secondary outcomes included mean nighttime vital sign checks. Potential harms included intensive care unit transfers and code blue alarms. All analyses were conducted on the basis of intention-to-treat. RESULTS A total of 1930 inpatient encounters in 1699 patients (intervention encounters: 566 of 966 [59%] men; mean [SD] age, 53 [15] years) were randomized. In the intervention vs control arm, there was a significant decrease in the mean (SD) number of nighttime vital sign checks (0.97 [0.95] vs 1.41 [0.86]; P < .001) with no increase in intensive care unit transfers (49 [5%] vs 47 [5%]; P = .92) or code blue alarms (2 [0.2%] vs 9 [0.9%]; P = .07). The incidence of delirium was not significantly reduced (108 [11%] vs 123 [13%]; P = .32). CONCLUSIONS AND RELEVANCE While this randomized clinical trial found no difference between groups in the primary outcome, delirium incidence, the secondary findings indicate that a real-time prediction algorithm embedded within a clinical decision support tool in the electronic health record can help physicians identify clinically stable patients who can forgo routine vital sign checks, safely giving them greater opportunity to sleep. Other aspects of hospital care that depend on clinical stability, such as level of care or cardiac monitoring, may be amenable to a similar intervention. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04046458.
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Affiliation(s)
- Nader Najafi
- Department of Medicine, University of California, San Francisco
| | - Andrew Robinson
- University of California, San Francisco Medical Center, San Francisco
| | - Mark J Pletcher
- Department of Medicine, University of California, San Francisco
| | - Sajan Patel
- Department of Medicine, University of California, San Francisco
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14
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Williams KM. Sleep protocol-Use of evidence-based practice (EBP) to improve patient outcomes and patient satisfaction while hospitalized. Worldviews Evid Based Nurs 2022; 19:423-425. [PMID: 35044055 DOI: 10.1111/wvn.12562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anecdotal observation at a 55-bed training hospital indicated decreased patient satisfaction from patients not feeling rested during hospitalization related to staggered nighttime nursing care. AIMS The main aim of this study is to implement a new culture of patient centeredness to enhance patient care and improve outcomes at a 34-bed Medical-Surgical Inpatient Unit (MSIU) within the training hospital. METHODS An evidence-based practice approach was chosen to address the aim. This included the development of a PICOT (population, intervention, comparison, outcome, and time frame) question, a systematic search of the literature, a critical appraisal of the evidence, implementation of the intervention, evaluation of outcomes, and dissemination of the results. RESULTS Twenty-three articles were critically appraised, resulting in 11 keeper articles. The body of evidence reviewed demonstrated that minimizing nighttime patient interruptions through bundled care could improve patient sleep, pain perception, and patient outcomes and reduce fatigue. Bundled care was implemented in the MSIU for 1 year. During this year, there was a significant reduction in hydrocodone administration, a notable reduction in prescription sleep aid administration, a 75% reduction in fall rates, a cost savings of $64,000, and a decrease in patient length of stay. LINKING EVIDENCE TO ACTION Allowing patients to rest could have benefits. Rest improves outcomes, length of stay, satisfaction scores, and fall rates and reduces the need for medications. Clustering care allows patients to receive uninterrupted rest.
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15
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Lai CI, Lee CF, Wei FJ. Smart Clothing as a Noninvasive Method to Measure the Physiological Cardiac Parameters. Healthcare (Basel) 2021; 9:healthcare9101318. [PMID: 34682998 PMCID: PMC8544566 DOI: 10.3390/healthcare9101318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
In response to global aging, there have been improvements in healthcare, exercise therapy, health promotion, and other areas. There is a gradually increasing demand for such equipment for health purposes. The main purpose of smart clothing is to monitor the physical health status of the user and analyze the changes in physiological signals of the heart. Therefore, this study aimed to examine the factors that affect the measurement of the heart's physiological parameters and the users' comfort while wearing smart clothing as well as to validate the data obtained from smart clothing. This study examined the subjective feelings of users (aged 20-60 years) regarding smart clothing comfort (within 12 h); the median values were comfortable and above (3.4-4.5). The clothing was combined with elastic conductive fiber and spandex to decrease the relative movement of the fiber that acts as a sensor and increase the user's comfort. Future studies should focus on the optimization of the data obtained using smart clothing. In addition to its use in medical care and post-reconstructive surgery, smart clothing can be used for home care of older adults and infants.
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Affiliation(s)
- Ching-I Lai
- Graduate School of Design, National Yunlin University of Science and Technology, Yunlin 640301, Taiwan
- Correspondence: (C.-I.L.); (C.F.L.)
| | - Chang-Franw Lee
- Graduate School of Design, National Yunlin University of Science and Technology, Yunlin 640301, Taiwan
- Correspondence: (C.-I.L.); (C.F.L.)
| | - Fu-Jin Wei
- Department of Fashion Design, Shih Chien University, Taipei 104336, Taiwan;
- Institute of Plant and Microbial Biology, Academia Sinica, Taipei 115201, Taiwan
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16
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Mason NR, Orlov NM, Anderson S, Byron M, Mozer C, Arora VM. Piloting I-SLEEP: a patient-centered education and empowerment intervention to improve patients' in-hospital sleep. Pilot Feasibility Stud 2021; 7:161. [PMID: 34412696 PMCID: PMC8375174 DOI: 10.1186/s40814-021-00895-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/30/2021] [Indexed: 01/11/2023] Open
Abstract
Background Sleep disturbances in hospitalized patients are linked to poor recovery. In preparation for a future randomized controlled trial, this pilot study evaluated the feasibility and acceptability of a multi-component intervention (I-SLEEP) that educates and empowers inpatients to advocate for fewer nighttime disruptions in order to improve sleep during periods of hospitalization. Methods Eligible inpatients received I-SLEEP, which included an educational video, brochure, sleep kit, and three questions patients can ask their team to reduce nighttime disruptions. Following I-SLEEP, inpatients were surveyed on the primary feasibility outcomes of satisfaction with and use of I-SLEEP components. Inpatients were also surveyed regarding empowerment and understanding of intervention materials. Patient charts were reviewed to collect data on nighttime (11 PM–7 AM) vital sign and blood draws disruptions. Results Ninety percent (n = 26/29) of patients were satisfied with the brochure and 87% (n = 27/31) with the video. Nearly all (95%, n = 36/37) patients felt empowered to ask their providers to minimize nighttime disruptions and 68% (n = 26/37) intended to alter sleep habits post-discharge. Forty-nine percent (n = 18/37) of patients asked an I-SLEEP question. Patients who asked an I-SLEEP question were significantly more likely to experience nights with fewer disruptions due to nighttime vitals (19% vs. 2.1%, p = 0.008). Conclusion This pilot study found that I-SLEEP was well-accepted and enabled hospitalized patients to advocate for less disrupted sleep. Educating patients to advocate for reducing nighttime disruptions may be a patient-centered, low-cost strategy to improve patients’ care and in-hospital experience. These results suggest that I-SLEEP is ready to be evaluated against routine care in a future randomized controlled trial. Trial registration ClinicalTrials.Gov NCT04151251.
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Affiliation(s)
- Noah R Mason
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Nicola M Orlov
- Department of Pediatrics, University of Chicago Medicine, Chicago, IL, USA
| | - Samantha Anderson
- Department of Medicine, University of Chicago Medicine, 5841 S Maryland Ave, MC 2007, Chicago, IL, 60637, USA
| | - Maxx Byron
- Department of Medicine, University of Chicago Medicine, 5841 S Maryland Ave, MC 2007, Chicago, IL, 60637, USA
| | - Christine Mozer
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Vineet M Arora
- Department of Medicine, University of Chicago Medicine, 5841 S Maryland Ave, MC 2007, Chicago, IL, 60637, USA.
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Foo CT, O'Driscoll DM, Ogeil RP, Lubman D, Young AC. Barriers to sleep in acute hospital settings. Sleep Breath 2021; 26:855-863. [PMID: 34146229 DOI: 10.1007/s11325-021-02415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/12/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to examine the environmental and operational factors that disrupt sleep in the acute, non-ICU hospital setting. DESIGN, SETTING AND PARTICIPANTS This was a prospective study of adult patients admitted to an acute tertiary hospital ward (shared versus single room) and sleep laboratory (single room conducive to sleep). MAIN OUTCOME MEASURES This study measured ambient light (lux) and sound (dB), number of operational interruptions, and questionnaires assessing sleep and mental health. RESULTS Sixty patients were enrolled, 20 in a double bedroom located close to the nursing station ('shared ward'), 20 in a single bedroom located distant to the nursing station ('single ward') and 20 attending the sleep laboratory for overnight polysomnography ('sleep laboratory'). Sleep was disturbed in 45% of patients in the shared and single ward groups (Pittsburgh Sleep Quality Index > 5). Light levels were appropriately low across all 3 locations. Sound levels (significant effect of room F(1.38) = 6.452, p = 0.015) and operational interruptions (shared ward 5.6 ± 2.5, single ward 6.2 ± 2.9, sleep laboratory 2.7 ± 2.1 per night, p < 0.05 wards compared to sleep laboratory) were higher in the shared and single ward group compared to the sleep laboratory but not compared to each other. Noise was rated as the greatest environmental disturbance by 70% of ward patients compared to 10% in the sleep laboratory. CONCLUSION Higher noise levels and frequent operational interruptions are potential barriers to sleep and recovery on an acute medical ward which are not ameliorated by being in a single bedroom located distant to the nursing station.
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Affiliation(s)
- Chuan T Foo
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, VIC, Australia
| | - Denise M O'Driscoll
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Rowan P Ogeil
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia.,Turning Point, Eastern Health, Melbourne, VIC, Australia
| | - Dan Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia.,Turning Point, Eastern Health, Melbourne, VIC, Australia
| | - Alan C Young
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, VIC, Australia. .,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia. .,Department of Respiratory & Sleep Medicine, Box Hill Hospital, Eastern Health and Monash University, Box Hill, VIC, 3128, Australia.
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18
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Management of atopic dermatitis in the inpatient setting. CURRENT DERMATOLOGY REPORTS 2021. [DOI: 10.1007/s13671-021-00332-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Sleeping Safely! A Quality Improvement Project to Minimize Nighttime Interruptions without Compromising Patient Care. Pediatr Qual Saf 2021; 6:e404. [PMID: 33977192 PMCID: PMC8104151 DOI: 10.1097/pq9.0000000000000404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/29/2020] [Indexed: 12/30/2022] Open
Abstract
Sleep is crucial for patients' health but is often disrupted, slowing recovery and resulting in adverse health effects. This study identified whether passive vital sign checks (heart rate, respiratory rate, and pulse oximetry) and delayed routine morning laboratories in clinically stable pediatric patients minimized nighttime interruptions without compromising patient safety. Methods After developing the inclusion criteria using the Pediatric Early Warning Score, we enrolled eligible patients for the intervention. We assessed physician compliance through order entry and nursing compliance through recorded vital signs and timing of blood draws. Eligible patients received passive vital sign checks at 4 am with routine morning laboratories drawn at midnight or 6 am, instead of 4 am, to minimize patients' nighttime interruptions. All other nursing duties continued with the institution's patient care policies. Finally, retrospective chart reviews were performed to determine whether the intervention resulted in the escalation of care, our primary outcome. Results We collected 2,138 individual data points, which represented approximately 420 patients. Over the intervention period, high compliance rates with physician order placement, nurse performing passive vital signs, and delayed blood draws were maintained. On eligible patients, there was no escalation of care or rapid response team involvement. Conclusions The use of passive vital sign checks on eligible pediatric patients was generally well-received and had high compliance during the intervention period. There were no negative patient care consequences, supporting the feasibility of this program. Further studies are needed to determine sleep quality and patient satisfaction.
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20
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Abstract
BACKGROUND AND PURPOSE Daily chest radiographs (CXRs) have long been a routine part of care. However, evidence as well as changing technology has promoted on-demand CXRs as beneficial to patient care. We found that a substantial number of routine daily CXRs were being ordered, with some of the orders staying active even after extubation. METHODS Within a 19-bed adult medical ICU, we prospectively utilized 3 intervention phases from October 1, 2014, to February 28, 2018, to reduce routine CXRs. Nurse Practitioners (NP) initiated this quality improvement (QI) project, aiming to reduce the number of unnecessary of CXRs. Interventions included staff survey, routine CXR order removal, duplicate alerts, visual reminders, and an electronic clinical decision support tool. Monthly education of appropriate CXRs and bedside ultrasound were facilitated by NPs. The outcome measures of interest include: the number of CXRs per patient-day, the number of routine and on-demand CXRs, mortality rate, ICU length of stay, and ventilator days, radiation and cost. CONCLUSIONS Total number of CXRs per patient-day decreased by 36.1%. The proportion of routine CXRs decreased from 55.37% to 13.18%; on-demand orders increased, from 44.63% to 86.82%; and calculated radiation-exposure per census decreased, from 0.011 to 0.008 mSv. In addition, charges to patients for CXRs decreased by $7,750/month. ICU mortality and ventilator days per census remained stable. IMPLICATIONS FOR PRACTICE By an orchestrated process that included creating awareness and desire to change CXR ordering practices, we were able to decrease routine CXRs and increase on-demand utilization while maintaining counterbalance measures.
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21
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Kostakis I, Smith GB, Prytherch D, Meredith P, Price C, Chauhan A. Impact of the coronavirus pandemic on the patterns of vital signs recording and staff compliance with expected monitoring schedules on general wards. Resuscitation 2020; 158:30-38. [PMID: 33221355 PMCID: PMC7676313 DOI: 10.1016/j.resuscitation.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/19/2020] [Accepted: 11/09/2020] [Indexed: 11/23/2022]
Abstract
Introduction Coronavirus disease 2019 (COVID-19) placed increased burdens on National Health Service hospitals and necessitated significant adjustments to their structures and processes. This research investigated if and how these changes affected the patterns of vital sign recording and staff compliance with expected monitoring schedules on general wards. Methods We compared the pattern of vital signs and early warning score (EWS) data collected from admissions to a single hospital during the initial phase of the COVID-19 pandemic with those in three control periods from 2018, 2019 and 2020. Main outcome measures were weekly and monthly hospital admissions; daily and hourly patterns of recorded vital signs and EWS values; time to next observation and; proportions of ‘on time’, ‘late’ and ‘missed’ vital signs observations sets. Results There were large falls in admissions at the beginning of the COVID-19 era. Admissions were older, more unwell on admission and throughout their stay, more often required supplementary oxygen, spent longer in hospital and had a higher in-hospital mortality compared to one or more of the control periods. More daily observation sets were performed during the COVID-19 era than in the control periods. However, there was no clear evidence that COVID-19 affected the pattern of vital signs collection across the 24-h period or the week. Conclusions The increased burdens of the COVID-19 pandemic, and the alterations in healthcare structures and processes necessary to respond to it, did not adversely affect the hospitals’ ability to monitor patients under its care and to comply with expected monitoring schedules.
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Affiliation(s)
- Ina Kostakis
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education (CoPMRE), Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK.
| | - David Prytherch
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Meredith
- Research & Innovation Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Connor Price
- Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, UK
| | - Anoop Chauhan
- Director of Research and Innovation and Consultant Respiratory Physician, Portsmouth Hospitals University NHS Trust, Professor of Respiratory Medicine, University of Portsmouth, Portsmouth, UK
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22
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Tóth V, Meytlis M, Barnaby DP, Bock KR, Oppenheim MI, Al-Abed Y, McGinn T, Davidson KW, Becker LB, Hirsch JS, Zanos TP. Let Sleeping Patients Lie, avoiding unnecessary overnight vitals monitoring using a clinically based deep-learning model. NPJ Digit Med 2020; 3:149. [PMID: 33299116 PMCID: PMC7666176 DOI: 10.1038/s41746-020-00355-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/20/2020] [Indexed: 12/23/2022] Open
Abstract
Impaired sleep for hospital patients is an all too common reality. Sleep disruptions due to unnecessary overnight vital sign monitoring are associated with delirium, cognitive impairment, weakened immunity, hypertension, increased stress, and mortality. It is also one of the most common complaints of hospital patients while imposing additional burdens on healthcare providers. Previous efforts to forgo overnight vital sign measurements and improve patient sleep used providers’ subjective stability assessment or utilized an expanded, thus harder to retrieve, set of vitals and laboratory results to predict overnight clinical risk. Here, we present a model that incorporates past values of a small set of vital signs and predicts overnight stability for any given patient-night. Using data obtained from a multi-hospital health system between 2012 and 2019, a recurrent deep neural network was trained and evaluated using ~2.3 million admissions and 26 million vital sign assessments. The algorithm is agnostic to patient location, condition, and demographics, and relies only on sequences of five vital sign measurements, a calculated Modified Early Warning Score, and patient age. We achieved an area under the receiver operating characteristic curve of 0.966 (95% confidence interval [CI] 0.956–0.967) on the retrospective testing set, and 0.971 (95% CI 0.965–0.974) on the prospective set to predict overnight patient stability. The model enables safe avoidance of overnight monitoring for ~50% of patient-nights, while only misclassifying 2 out of 10,000 patient-nights as stable. Our approach is straightforward to deploy, only requires regularly obtained vital signs, and delivers easily actionable clinical predictions for a peaceful sleep in hospitals.
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Affiliation(s)
- Viktor Tóth
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Marsha Meytlis
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA
| | - Douglas P Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kevin R Bock
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Michael I Oppenheim
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Yousef Al-Abed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Karina W Davidson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Lance B Becker
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jamie S Hirsch
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Theodoros P Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA. .,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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23
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Gross O, Agostini B, Belleval P, Cavé I, Citrini M, Fernandes S, Ghadi M, Graeve N, Gagnayre R. [Health care safety: The discrepancies between experience and degree of satisfaction of hospitalized patients observed in interviews performed by user representatives]. Rev Epidemiol Sante Publique 2020; 68:337-346. [PMID: 33162268 DOI: 10.1016/j.respe.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 05/18/2020] [Accepted: 10/10/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The purpose of this article is to present the results of a qualitative survey conducted by user representatives (URs) focusing on the health care safety experience of hospitalized patients. The authors wished to identify factors associated with safety of care and, more specifically, with the possibly ominous medical events reported by patients. METHODS After being trained with these objectives in mind, eight URs conducted semi-directive interviews with fourteen patients hospitalized in eleven separate hospital units in nine different hospitals. RESULTS Eight types of factors consisting in 30 contributing factors liable to be reported by patients were identified: 1) factors related to patients' basic needs; 2) personalization of care; 3) professional factors; 4) organizational factors; 5) communication factors; 6) caregiver responsiveness; 7) infectious risks; 8) continuity of care. Patients' overall feelings about their hospitalization remained excellent notwithstanding more tempered, even negative experiences. CONCLUSION This paradoxical result shows that the patients' actual experience is far more instructive than their degree of satisfaction. In light of this study, the acceptability of this type of research (i.e. research conducted by URs) is excellent and it also appears highly feasible, whatever the limitations imposed by organizational considerations.
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Affiliation(s)
- O Gross
- Laboratoire Éducations et pratiques de Santé (UR3412), Université Sorbonne Paris Nord, Paris, 74, rue Marcel-Cachin, 93017 Bobigny, France; Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France.
| | - B Agostini
- Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France
| | - P Belleval
- Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France
| | - I Cavé
- Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France
| | - M Citrini
- Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France
| | - S Fernandes
- Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France
| | - M Ghadi
- Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France
| | - N Graeve
- Représentants d'usagers à l'Assistance publique-Hôpitaux de Paris, Paris, France
| | - R Gagnayre
- Laboratoire Éducations et pratiques de Santé (UR3412), Université Sorbonne Paris Nord, Paris, 74, rue Marcel-Cachin, 93017 Bobigny, France
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24
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Locihová H, Axmann K, Žiaková K. Sleep-disrupting effects of nocturnal nursing interventions in intensive care unit patients: A systematic review. J Sleep Res 2020; 30:e13223. [PMID: 33128479 DOI: 10.1111/jsr.13223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/17/2020] [Accepted: 10/02/2020] [Indexed: 12/17/2022]
Abstract
Patients staying in the intensive care unit (ICU) require constant monitoring and numerous nursing interventions performed as needed, irrespective of daytime or night-time. The disturbing effect of nocturnal nursing interventions and their contribution to sleep disruptions are unclear. The review analysed nocturnal nursing interventions, and their character, frequency and effects on sleep quality. The databases CINAHL, PubMed and Scopus were searched to identify and subsequently evaluate 19 studies (1,531 patients) meeting the algorithm used. Although nocturnal nursing interventions provided to ICU patients were frequent and varied, they were responsible for only a minority of observed sleep disruptions. The most frequent nocturnal intervention was Vital signs monitoring (Nursing Interventions Classification, 6,680). Implementation of sleep protocols, of which an integral part is clustering and planning of nocturnal interventions, appears to be effective. The review suggests that nursing interventions are not the main cause of sleep disruptions in the ICU. In an effort to improve the quality of sleep in ICU patients, other factors causing disturbance need to be addressed as well. The current trend is more careful planning of nursing care, clustering of interventions and minimizing nocturnal disruptions to allow patients at least one uninterrupted sleep cycle (90 min).
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Affiliation(s)
- Hana Locihová
- AGEL Research and Training Institute, Prostějov, AGEL Nemocnice Valašské Meziříčí, AGEL Střední zdravotnická škola, Ostrava, Czech Republic
| | - Karel Axmann
- Fakultní nemocnice Olomouc, Palacky University in Olomouc, Faculty of Medicine and Dentistry, Olomouc, Czech Republic
| | - Katarína Žiaková
- Comenius University in Bratislava Jessenius Faculty of Nursing in Martin, Martin, Slovakia
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Cook DJ, Arora VM, Chamberlain M, Anderson S, Peirce L, Erondu A, Ahmed F, Kilaru M, Edstrom E, Gonzalez M, Ridgeway R, Stanly S, LaFond C, Fromme HB, Clardy C, Orlov NM. Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring. Pediatrics 2020; 146:peds.2019-2217. [PMID: 32817268 PMCID: PMC7461242 DOI: 10.1542/peds.2019-2217] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.
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Affiliation(s)
- David J. Cook
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; and
| | - Vineet M. Arora
- Departments of Medicine and,Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; and
| | - Michael Chamberlain
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; and
| | | | - Leah Peirce
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; and
| | - Amarachi Erondu
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; and
| | - Farah Ahmed
- Center for Healthcare Delivery Sciences and Innovation and
| | - Megha Kilaru
- Center for Healthcare Delivery Sciences and Innovation and
| | - Eve Edstrom
- Center for Healthcare Delivery Sciences and Innovation and
| | - Monica Gonzalez
- Comer Children’s Hospital, University of Chicago Medicine, Chicago, Illinois
| | - Rachel Ridgeway
- Comer Children’s Hospital, University of Chicago Medicine, Chicago, Illinois
| | - Suja Stanly
- Comer Children’s Hospital, University of Chicago Medicine, Chicago, Illinois
| | - Cynthia LaFond
- Pediatrics and,Center for Healthcare Delivery Sciences and Innovation and
| | - H. Barrett Fromme
- Pediatrics and,Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; and
| | | | - Nicola M. Orlov
- Pediatrics and,Pritzker School of Medicine, The University of Chicago, Chicago, Illinois; and
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26
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Ueno R, Xu L, Uegami W, Matsui H, Okui J, Hayashi H, Miyajima T, Hayashi Y, Pilcher D, Jones D. Value of laboratory results in addition to vital signs in a machine learning algorithm to predict in-hospital cardiac arrest: A single-center retrospective cohort study. PLoS One 2020; 15:e0235835. [PMID: 32658901 PMCID: PMC7357766 DOI: 10.1371/journal.pone.0235835] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/23/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although machine learning-based prediction models for in-hospital cardiac arrest (IHCA) have been widely investigated, it is unknown whether a model based on vital signs alone (Vitals-Only model) can perform similarly to a model that considers both vital signs and laboratory results (Vitals+Labs model). METHODS All adult patients hospitalized in a tertiary care hospital in Japan between October 2011 and October 2018 were included in this study. Random forest models with/without laboratory results (Vitals+Labs model and Vitals-Only model, respectively) were trained and tested using chronologically divided datasets. Both models use patient demographics and eight-hourly vital signs collected within the previous 48 hours. The primary and secondary outcomes were the occurrence of IHCA in the next 8 and 24 hours, respectively. The area under the receiver operating characteristic curve (AUC) was used as a comparative measure. Sensitivity analyses were performed under multiple statistical assumptions. RESULTS Of 141,111 admitted patients (training data: 83,064, test data: 58,047), 338 had an IHCA (training data: 217, test data: 121) during the study period. The Vitals-Only model and Vitals+Labs model performed comparably when predicting IHCA within the next 8 hours (Vitals-Only model vs Vitals+Labs model, AUC = 0.862 [95% confidence interval (CI): 0.855-0.868] vs 0.872 [95% CI: 0.867-0.878]) and 24 hours (Vitals-Only model vs Vitals+Labs model, AUC = 0.830 [95% CI: 0.825-0.835] vs 0.837 [95% CI: 0.830-0.844]). Both models performed similarly well on medical, surgical, and ward patient data, but did not perform well for intensive care unit patients. CONCLUSIONS In this single-center study, the machine learning model predicted IHCAs with good discrimination. The addition of laboratory values to vital signs did not significantly improve its overall performance.
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Affiliation(s)
- Ryo Ueno
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- * E-mail:
| | - Liyuan Xu
- Department of Computer Science, Graduate School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Wataru Uegami
- Anatomical Pathology, Kameda Medical Center, Chiba, Japan
| | - Hiroki Matsui
- Clinical Research Support Division, Kameda Medical Center, Chiba, Japan
| | - Jun Okui
- Post-Graduate Education Center, Kameda Medical Center, Chiba, Japan
| | - Hiroshi Hayashi
- Post-Graduate Education Center, Kameda Medical Center, Chiba, Japan
| | - Toru Miyajima
- Post-Graduate Education Center, Kameda Medical Center, Chiba, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Daryl Jones
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
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Tham SM, Kasinathan S, Lui PL, Lim BK, Yap RAP, Montanez FB, Ow SGW. Nurse-Led Vital Signs Monitoring Can Safely Identify Low-Risk Hematology-Oncology Patients For De-Escalation. JCO Oncol Pract 2020; 16:e1222-e1231. [PMID: 32574136 DOI: 10.1200/jop.19.00636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE It is routine practice for patients to be on vital signs monitoring (VSM) once every 4 hours, which is laborious and disruptive. VSM de-escalation has been demonstrated to be safe in low-risk (LR) patients, but it has not been well studied in the hematology-oncology setting. METHODS A quality improvement project was conducted in 3 hematology-oncology inpatient wards within a comprehensive cancer center, from March 2017 to July 2017 (pilot phase) and from October 2017 to Sept 2018 (maintenance phase). Root causes for frequent VSM identified via problem analysis include (1) perception of VSM, (2) lack of concise clinical guidelines, and (3) lack of nurse empowerment. Consensus criteria to define suitable LR patients and a nurse-led VSM de-escalation protocol were formulated. RESULTS Of 1,065 patients who underwent nurse-led VSM de-escalation, there was a 50% reduction in the mean number of nurse encounters (NE) per month (P < .01), with total savings of 2,731.5 NE-minutes per month. VSM re-escalation was required by 10.1% of patients; all were deemed unpreventable with more frequent VSM and none resulted in severe adverse outcomes. With additional interventions such as spot audits and retraining, recruitment for de-escalation improved from 51.7% of LR admissions in the pilot phase to 93.8% in the maintenance phase (P < .01). The time saved was used to enhance other aspects of patient care, such as patient education. One hundred thirty-nine of 169 doctors and nurses surveyed after implementation (96.5%) supported continuing this protocol. CONCLUSION A well-defined protocol allows safe nurse-led de-escalation of VSM for LR patients without adverse outcomes and was shown to be sustainable in this cohort of hematology-oncology patients.
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Affiliation(s)
- Sai Meng Tham
- Department of Medicine, National University Health System, Singapore
| | | | - Pak Ling Lui
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Bee Kuan Lim
- Division of Oncology Nursing, National University Cancer Institute, Singapore
| | | | | | - Samuel G W Ow
- Department of Hematology-Oncology, National University Cancer Institute, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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28
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Orlov NM, Arora VM. Things We Do For No Reason™: Routine Overnight Vital Sign Checks. J Hosp Med 2020; 15:272-274. [PMID: 32379025 PMCID: PMC7204996 DOI: 10.12788/jhm.3442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 04/07/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Nicola M Orlov
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
- Section of Pediatric Hospital Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Vineet M Arora
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
- Section of General Internal Medicine, University of Chicago Medical Center, Chicago, Illinois
- Corresponding Author: Vineet M Arora, MD, MAPP; ; Telephone: 773-702-8157; Twitter: @FutureDocs
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29
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Mizrahi J, Kott J, Taub E, Goolsarran N. Low daily MEWS scores as predictors of low-risk hospitalized patients. QJM 2020; 113:20-24. [PMID: 31411326 DOI: 10.1093/qjmed/hcz213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/07/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Modified Early Warning System (MEWS) is a well-validated tool used by hospitals to identify patients at high risk for an adverse event to occur. However, there has been little evaluation into whether a low MEWS score can be predictive of patients with a low likelihood of an adverse event. AIM The present study aims to evaluate the MEWS score as a method of identifying patients at low risk for adverse events. DESIGN Retrospective cohort study of 5676 patient days and analysis of associated MEWS scores, medical comorbidities and adverse events. The primary outcome was the association of average daily MEWS scores in those who had an adverse event compared with those who did not. RESULTS Those with an average MEWS score of >2 were over 9 times more likely to have an adverse event compared with those with an average MEWS score of 1-2, and over 15 times more likely to have an adverse event compared to those with an average MEWS score of <1. CONCLUSIONS Our study shows that those with average daily MEWS scores <2 are at a significantly lower likelihood of having an adverse event compared with a score of >2, deeming them 'low-risk patients'. Formal recognition of such patients can have major implications in a hospital setting, including more efficient resource allocation in hospitals and better patient satisfaction and safety by adjusting patient monitoring according to their individual risk profile.
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Affiliation(s)
- J Mizrahi
- Department of Medicine at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
| | - J Kott
- Department of Medicine at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
| | - E Taub
- Department of Biostatistics at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
| | - N Goolsarran
- Department of Medicine at Stony Brook University Hospital at Stony Brook, Stony Brook, NY, USA
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30
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Insights into postoperative respiration by using continuous wireless monitoring of respiratory rate on the postoperative ward: a cohort study. J Clin Monit Comput 2019; 34:1285-1293. [PMID: 31722079 PMCID: PMC7548277 DOI: 10.1007/s10877-019-00419-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/03/2019] [Indexed: 11/09/2022]
Abstract
Change of respiratory rate (RespR) is the most powerful predictor of clinical deterioration. Brady- (RespR ≤ 8) and tachypnea (RespR ≥ 31) are associated with serious adverse events. Simultaneously, RespR is the least accurately measured vital parameter. We investigated the feasibility of continuously measuring RespR on the ward using wireless monitoring equipment, without impeding mobilization. Continuous monitoring of vital parameters using a wireless SensiumVitals® patch was installed and RespR was measured every 2 mins. We defined feasibility of adequate RespR monitoring if the system reports valid RespR measurements in at least 50% of time-points in more than 80% of patients during day- and night-time, respectively. Data from 119 patients were analysed. The patch detected in 171,151 of 227,587 measurements valid data for RespR (75.2%). During postoperative day and night four, the system still registered 68% and 78% valid measurements, respectively. 88% of the patients had more than 67% of valid RespR measurements. The RespR’s most frequently measured were 13–15; median RespR was 15 (mean 16, 25th- and 75th percentile 13 and 19). No serious complications or side effects were observed. We successfully measured electronically RespR on a surgical ward in postoperative patients continuously for up to 4 days post-operatively using a wireless monitoring system. While previous studies mentioned a digit preference of 18–22 for RespR, the most frequently measured RespR were 13–16. However, in the present study we did not validate the measurements against a reference method. Rather, we attempted to demonstrate the feasibility of achieving continuous wireless measurement in patients on surgical postoperative wards. As the technology used is based on impedance pneumography, obstructive apnoea might have been missed, namely in those patients receiving opioids post-operatively.
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31
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Mann DL. Q4 Vital Signs: Can Machine Learning Protect Patients From the Machinery of Modern Medicine? JACC Basic Transl Sci 2019; 4:468-469. [PMID: 31312769 PMCID: PMC6609994 DOI: 10.1016/j.jacbts.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Douglas L. Mann
- Address for correspondence: Dr. Douglas L. Mann, Editor-in-Chief, JACC: Basic to Translational Science, American College of Cardiology, Heart House, 2400 N Street NW, Washington, DC 20037.
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32
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Kellett J, Wasingya-Kasereka L, Brabrand M. Are changes in objective observations or the patient’s subjective feelings the day after admission the best predictors of in-hospital mortality? An observational study in a low-resource sub-Saharan hospital. Resuscitation 2019; 135:130-136. [DOI: 10.1016/j.resuscitation.2018.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/17/2018] [Accepted: 10/25/2018] [Indexed: 12/21/2022]
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Brekke IJ, Puntervoll LH, Pedersen PB, Kellett J, Brabrand M. The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PLoS One 2019; 14:e0210875. [PMID: 30645637 PMCID: PMC6333367 DOI: 10.1371/journal.pone.0210875] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/03/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Vital signs, i.e. respiratory rate, oxygen saturation, pulse, blood pressure and temperature, are regarded as an essential part of monitoring hospitalized patients. Changes in vital signs prior to clinical deterioration are well documented and early detection of preventable outcomes is key to timely intervention. Despite their role in clinical practice, how to best monitor and interpret them is still unclear. OBJECTIVE To evaluate the ability of vital sign trends to predict clinical deterioration in patients hospitalized with acute illness. DATA SOURCES PubMed, Embase, Cochrane Library and CINAHL were searched in December 2017. STUDY SELECTION Studies examining intermittently monitored vital sign trends in acutely ill adult patients on hospital wards and in emergency departments. Outcomes representing clinical deterioration were of interest. DATA EXTRACTION Performed separately by two authors using a preformed extraction sheet. RESULTS Of 7,366 references screened, only two were eligible for inclusion. Both were retrospective cohort studies without controls. One examined the accuracy of different vital sign trend models using discrete-time survival analysis in 269,999 admissions. One included 44,531 medical admissions examining trend in Vitalpac Early Warning Score weighted vital signs. They stated that vital sign trends increased detection of clinical deterioration. Critical appraisal was performed using evaluation tools. The studies had moderate risk of bias, and a low certainty of evidence. Additionally, four studies examining trends in early warning scores, otherwise eligible for inclusion, were evaluated. CONCLUSIONS This review illustrates a lack of research in intermittently monitored vital sign trends. The included studies, although heterogeneous and imprecise, indicates an added value of trend analysis. This highlights the need for well-controlled trials to thoroughly assess the research question.
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Affiliation(s)
- Idar Johan Brekke
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Peter Bank Pedersen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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34
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Arora VM, Machado N, Anderson SL, Desai N, Marsack W, Blossomgame S, Tuvilleja A, Ramos J, Francisco MA, LaFond C, Leung EK, Valencia A, Martin SK, Meltzer DO, Farnan JM, Balachandran J, Knutson KL, Mokhlesi B. Effectiveness of SIESTA on Objective and Subjective Metrics of Nighttime Hospital Sleep Disruptors. J Hosp Med 2019; 14:38-41. [PMID: 30667409 DOI: 10.12788/jhm.3091] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We created Sleep for Inpatients: Empowering Staff to Act (SIESTA), which combines electronic "nudges" to forgo nocturnal vitals and medications with interprofessional education on improving patient sleep. In one "SIESTAenhanced unit," nurses received coaching and integrated SIESTA into daily huddles; a standard unit did not. Six months pre- and post-SIESTA, sleep-friendly orders rose in both units (foregoing vital signs: SIESTA unit, 4% to 34%; standard, 3% to 22%, P < .001 both; sleeppromoting VTE prophylaxis: SIESTA, 15% to 42%; standard, 12% to 28%, P < .001 both). In the SIESTAenhanced unit, nighttime room entries dropped by 44% (-6.3 disruptions/room, P < .001), and patients were more likely to report no disruptions for nighttime vital signs (70% vs 41%, P = .05) or medications (84% vs 57%, P = .031) than those in the standard unit. The standard unit was not changed. Although sleep-friendly orders were adopted in both units, a unit-based nursing empowerment approach was associated with fewer nighttime room entries and improved patient experience.
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Affiliation(s)
| | | | | | - Nimit Desai
- University of Chicago Medicine, Chicago, Illinois, USA
| | | | | | | | | | | | - Cynthia LaFond
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Edward Ky Leung
- Children's Hospital Los Angeles, Los Angeles, California, USA
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Recio‐Saucedo A, Maruotti A, Griffiths P, Smith GB, Meredith P, Westwood G, Fogg C, Schmidt P. Relationships between healthcare staff characteristics and the conduct of vital signs observations at night: Results of a survey and factor analysis. Nurs Open 2018; 5:621-633. [PMID: 30338108 PMCID: PMC6177549 DOI: 10.1002/nop2.179] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/29/2018] [Indexed: 12/01/2022] Open
Abstract
AIM To explore the association of healthcare staff with factors relevant to completing observations at night. DESIGN Online survey conducted with registered nurses, midwives, healthcare support staff and student nurses who had worked at least one night shift in a National Health Service hospital in England. METHODS Exploratory factor analysis and mixed effects regression model adjusting for role, number of night shifts worked, experience and shift patterns. RESULTS Survey items were summarized into four factors: (a) workload and resources; (b) prioritization; (c) safety culture; (d) responsibility and control. Staff experience and role were associated with conducting surveillance tasks. Nurses with greater experience associated workload and resources with capacity to complete work at night. Responses of student nurses and midwives showed higher propensity to follow the protocol for conducting observations. Respondents working night shifts either exclusively or occasionally perceived that professional knowledge rather than protocol guided care tasks during night shifts.
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Affiliation(s)
- Alejandra Recio‐Saucedo
- University of SouthamptonCentre for Innovation and Leadership in Health SciencesSouthamptonUK
- Acute Medicine UnitPortsmouth Hospitals NHS TrustQueen Alexandra HospitalPortsmouthUK
| | - Antonello Maruotti
- University of SouthamptonCentre for Innovation and Leadership in Health SciencesSouthamptonUK
- Dipartimento di Scienze EconomichePolitiche e delle Lingue Moderne – Libera Università Maria Ss AssuntaRomaItaly
| | - Peter Griffiths
- University of SouthamptonCentre for Innovation and Leadership in Health SciencesSouthamptonUK
- Acute Medicine UnitPortsmouth Hospitals NHS TrustQueen Alexandra HospitalPortsmouthUK
| | - Gary B Smith
- Faculty of Health and Social SciencesUniversity of BournemouthBournemouthUK
| | - Paul Meredith
- Portsmouth Hospitals NHS TrustQueen Alexandra HospitalTEAMS CentrePortsmouthUK
| | - Greta Westwood
- University of SouthamptonCentre for Innovation and Leadership in Health SciencesSouthamptonUK
- Portsmouth Hospitals NHS TrustPortsmouthUK
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) WessexUK
| | - Carole Fogg
- Portsmouth Hospitals NHS TrustPortsmouthUK
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) WessexUK
- University of Portsmouth – School of Health Sciences and Social WorkPortsmouthUK
| | - Paul Schmidt
- University of Portsmouth – School of Health Sciences and Social WorkPortsmouthUK
- Acute Medicine UnitPortsmouth Hospitals NHS TrustQueen Alexandra HospitalPortsmouthUK
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Melatonin and Sleep in Preventing Hospitalized Delirium: A Randomized Clinical Trial. Am J Med 2018; 131:1110-1117.e4. [PMID: 29729237 PMCID: PMC6163056 DOI: 10.1016/j.amjmed.2018.04.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/07/2018] [Accepted: 04/19/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Studies suggest that melatonin may prevent delirium, a condition of acute brain dysfunction occurring in 20%-30% of hospitalized older adults that is associated with increased morbidity and mortality. We examined the effect of melatonin on delirium prevention in hospitalized older adults while measuring sleep parameters as a possible underlying mechanism. METHODS This was a randomized clinical trial measuring the impact of 3 mg of melatonin nightly on incident delirium and both objective and subjective sleep in inpatients age ≥65 years, admitted to internal medicine wards (non-intensive care units). Delirium incidence was measured by bedside nurses using the confusion assessment method. Objective sleep measurements (nighttime sleep duration, total sleep time per 24 hours, and sleep fragmentation as determined by average sleep bout length) were obtained via actigraphy. Subjective sleep quality was measured using the Richards Campbell Sleep Questionnaire. RESULTS Delirium occurred in 22.2% (8/36) of subjects who received melatonin vs in 9.1% (3/33) who received placebo (P = .19). Melatonin did not significantly change objective or subjective sleep measurements. Nighttime sleep duration and total sleep time did not differ between subjects who became delirious vs those who did not, but delirious subjects had more sleep fragmentation (sleep bout length 7.0 ± 3.0 vs 9.5 ± 5.3 min; P = .03). CONCLUSIONS Melatonin given as a nightly dose of 3 mg did not prevent delirium in non-intensive care unit hospitalized patients or improve subjective or objective sleep.
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Tan X, van Egmond L, Partinen M, Lange T, Benedict C. A narrative review of interventions for improving sleep and reducing circadian disruption in medical inpatients. Sleep Med 2018; 59:42-50. [PMID: 30415906 DOI: 10.1016/j.sleep.2018.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 12/28/2022]
Abstract
Sleep and circadian disruptions are frequently observed in patients across hospital wards. This is alarming, since impaired nocturnal sleep and disruption of a normal circadian rhythm can compromise health and disturb processes involved in recovery from illness (eg, immune functions). With this in mind, the present narrative review discusses how patient characteristics (sleep disorders, anxiety, stress, chronotype, and disease), hospital routines (pain management, timing of medication, nocturnal vital sign monitoring, and physical inactivity), and hospital environment (light and noise) may all contribute to sleep disturbances and circadian misalignment in patients. We also propose hospital-based strategies that may help reduce sleep and circadian disruptions in patients admitted to the hospital.
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Affiliation(s)
- Xiao Tan
- Department of Neuroscience, Sleep Research Laboratory, Uppsala University, Uppsala, Sweden.
| | - Lieve van Egmond
- Department of Neuroscience, Sleep Research Laboratory, Uppsala University, Uppsala, Sweden
| | - Markku Partinen
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland; VitalMed Research Center, Helsinki Sleep Clinic, Helsinki, Finland
| | - Tanja Lange
- Department of Rheumatology & Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Christian Benedict
- Department of Neuroscience, Sleep Research Laboratory, Uppsala University, Uppsala, Sweden.
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Lyons PG, Edelson DP, Churpek MM. Rapid response systems. Resuscitation 2018; 128:191-197. [PMID: 29777740 DOI: 10.1016/j.resuscitation.2018.05.013] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/20/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Rapid response systems are commonly employed by hospitals to identify and respond to deteriorating patients outside of the intensive care unit. Controversy exists about the benefits of rapid response systems. AIMS We aimed to review the current state of the rapid response literature, including evolving aspects of afferent (risk detection) and efferent (intervention) arms, outcome measurement, process improvement, and implementation. DATA SOURCES Articles written in English and published in PubMed. RESULTS Rapid response systems are heterogeneous, with important differences among afferent and efferent arms. Clinically meaningful outcomes may include unexpected mortality, in-hospital cardiac arrest, length of stay, cost, and processes of care at end of life. Both positive and negative interventional studies have been published, although the two largest randomized trials involving rapid response systems - the Medical Early Response and Intervention Trial (MERIT) and the Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients (EPOCH) trial - did not find a mortality benefit with these systems, albeit with important limitations. Advances in monitoring technologies, risk assessment strategies, and behavioral ergonomics may offer opportunities for improvement. CONCLUSIONS Rapid responses may improve some meaningful outcomes, although these findings remain controversial. These systems may also improve care for patients at the end of life. Rapid response systems are expected to continue evolving with novel developments in monitoring technologies, risk prediction informatics, and work in human factors.
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Affiliation(s)
- Patrick G Lyons
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Dana P Edelson
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Matthew M Churpek
- Department of Medicine, University of Chicago, Chicago, IL, United States.
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Melville S, Teskey R, Philip S, Simpson JA, Lutchmedial S, Brunt KR. A Comparison and Calibration of a Wrist-Worn Blood Pressure Monitor for Patient Management: Assessing the Reliability of Innovative Blood Pressure Devices. J Med Internet Res 2018; 20:e111. [PMID: 29695375 PMCID: PMC5943631 DOI: 10.2196/jmir.8009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 11/10/2017] [Accepted: 11/16/2017] [Indexed: 01/09/2023] Open
Abstract
Background Clinical guidelines recommend monitoring of blood pressure at home using an automatic blood pressure device for the management of hypertension. Devices are not often calibrated against direct blood pressure measures, leaving health care providers and patients with less reliable information than is possible with current technology. Rigorous assessments of medical devices are necessary for establishing clinical utility. Objective The purpose of our study was 2-fold: (1) to assess the validity and perform iterative calibration of indirect blood pressure measurements by a noninvasive wrist cuff blood pressure device in direct comparison with simultaneously recorded peripheral and central intra-arterial blood pressure measurements and (2) to assess the validity of the measurements thereafter of the noninvasive wrist cuff blood pressure device in comparison with measurements by a noninvasive upper arm blood pressure device to the Canadian hypertension guidelines. Methods The cloud-based blood pressure algorithms for an oscillometric wrist cuff device were iteratively calibrated to direct pressure measures in 20 consented patient participants. We then assessed measurement validity of the device, using Bland-Altman analysis during routine cardiovascular catheterization. Results The precalibrated absolute mean difference between direct intra-arterial to wrist cuff pressure measurements were 10.8 (SD 9.7) for systolic and 16.1 (SD 6.3) for diastolic. The postcalibrated absolute mean difference was 7.2 (SD 5.1) for systolic and 4.3 (SD 3.3) for diastolic pressures. This is an improvement in accuracy of 33% systolic and 73% diastolic with a 48% reduction in the variability for both measures. Furthermore, the wrist cuff device demonstrated similar sensitivity in measuring high blood pressure compared with the direct intra-arterial method. The device, when calibrated to direct aortic pressures, demonstrated the potential to reduce a treatment gap in high blood pressure measurements. Conclusions The systolic pressure measurements of the wrist cuff have been iteratively calibrated using gold standard central (ascending aortic) pressure. This improves the accuracy of the indirect measures and potentially reduces the treatment gap. Devices that undergo auscultatory (indirect) calibration for licensing can be greatly improved by additional iterative calibration via intra-arterial (direct) measures of blood pressure. Further clinical trials with repeated use of the device over time are needed to assess the reliability of the device in accordance with current and evolving guidelines for informed decision making in the management of hypertension. Trial Registration ClinicalTrials.gov NCT03015363; https://clinicaltrials.gov/ct2/show/NCT03015363 (Archived by WebCite at http://www.webcitation.org/6xPZgseYS)
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Affiliation(s)
- Sarah Melville
- Department of Pharmacology, Dalhousie Medicine New Brunswick, Saint John, NB, Canada.,Cardiovascular Research New Brunswick, New Brunswick Heart Centre, Saint John, NB, Canada
| | - Robert Teskey
- Cardiovascular Research New Brunswick, New Brunswick Heart Centre, Saint John, NB, Canada.,Department of Cardiology, Saint John Regional Hospital, Horizon Health Network, Saint John, NB, Canada
| | - Shona Philip
- Department of Pharmacology, Dalhousie Medicine New Brunswick, Saint John, NB, Canada.,Cardiovascular Research New Brunswick, New Brunswick Heart Centre, Saint John, NB, Canada
| | - Jeremy A Simpson
- Department of Human Health Nutritional Sciences, University of Guelph, Guelph, ON, Canada
| | - Sohrab Lutchmedial
- Cardiovascular Research New Brunswick, New Brunswick Heart Centre, Saint John, NB, Canada.,Department of Cardiology, Saint John Regional Hospital, Horizon Health Network, Saint John, NB, Canada
| | - Keith R Brunt
- Department of Pharmacology, Dalhousie Medicine New Brunswick, Saint John, NB, Canada.,Cardiovascular Research New Brunswick, New Brunswick Heart Centre, Saint John, NB, Canada.,Department of Cardiology, Saint John Regional Hospital, Horizon Health Network, Saint John, NB, Canada
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Hope J, Recio-Saucedo A, Fogg C, Griffiths P, Smith GB, Westwood G, Schmidt PE. A fundamental conflict of care: Nurses' accounts of balancing patients' sleep with taking vital sign observations at night. J Clin Nurs 2018; 27:1860-1871. [PMID: 29266489 PMCID: PMC6001445 DOI: 10.1111/jocn.14234] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 11/29/2022]
Abstract
Aims and objectives To explore why adherence to vital sign observations scheduled by an early warning score protocol reduces at night. Background Regular vital sign observations can reduce avoidable deterioration in hospital. early warning score protocols set the frequency of these observations by the severity of a patient's condition. Vital sign observations are taken less frequently at night, even with an early warning score in place, but no literature has explored why. Design A qualitative interpretative design informed this study. Methods Seventeen semi‐structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital sign observations. A thematic analysis approach was used. Results At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital sign observations. The night‐time frequency of these observations was determined by clinical judgement, ward‐level expectations of observation timing and the risk of disturbing other patients. Patients with COPD or dementia could be under‐monitored, while patients nearing the end of life could be over‐monitored. Conclusion In this study, we found an early warning score algorithm focused on deterioration prevention did not account for long‐term management or palliative care trajectories. Nurses were therefore less inclined to wake such patients to take vital sign observations at night. However, the perception of widespread exceptions and lack of evidence regarding optimum frequency risks delegitimising the early warning score approach. This may pose a risk to patient safety, particularly patients with dementia or chronic conditions. Relevance to clinical practice Nurses should document exceptions and discuss these with the wider team. Hospitals should monitor why vital sign observations are missed at night, identify which groups are under‐monitored and provide guidance on prioritising competing expectations. early warning score protocols should take account of different care trajectories.
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Affiliation(s)
- Joanna Hope
- Faculty of Health Sciences, University of Southampton, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Alejandra Recio-Saucedo
- Faculty of Health Sciences, University of Southampton, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Carole Fogg
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK.,Portsmouth Hospitals NHS Trust, Research and Innovation, Queen Alexandra Hospital, Cosham, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education (CoPMRE), Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Greta Westwood
- Faculty of Health Sciences, Clinical Academic Facility, The QUaD Building, Queen Alexandra Hospital, University of Southampton, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
| | - Paul E Schmidt
- Medical Assessment Unit, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
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Innovations in Insomnia Management: A Review of Current Approaches and Novel Targets Including Orexin Receptor Antagonists. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Hospitalization is a period of acute sleep deprivation for older adults owing to environmental, medical, and patient factors. Although hospitalized patients are in need of adequate rest and recovery during acute illness, older patients face unique risks owing to acute sleep loss during hospitalization. Sleep loss in the hospital is associated with worse health outcomes, including cardiometabolic derangements and an increased risk of delirium. Because older patients are at risk of polypharmacy and medication side effects, a variety of nonpharmacologic interventions are recommended first to improve sleep loss for hospitalized older adults.
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Affiliation(s)
- Nancy H Stewart
- Creighton University Medical Center, 7500 Mercy Road, Omaha, NE 68124, USA
| | - Vineet M Arora
- Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007 AMB W216, Chicago, IL 60637, USA.
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Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry. Crit Care Med 2017; 45:1677-1682. [PMID: 28742548 DOI: 10.1097/ccm.0000000000002620] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes. DESIGN Retrospective analysis of a prospectively collected registry database. SETTING National registry database of inpatient rapid response team calls. PATIENTS Index rapid response team calls occurring on the general wards in the American Heart Association Get With The Guidelines-Medical Emergency Team database between 2005 and 2015 were analyzed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was inhospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models adjusting for patient characteristics were fit. A total of 282,710 rapid response team calls from 274 hospitals were included. The lowest frequency of calls occurred in the consecutive 1 AM to 6:59 AM period, with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 AM hour and lowest during the noon hour (18.8% vs 13.8%; adjusted odds ratio, 1.41 [1.31-1.52]; p < 0.001). Compared with calls at the noon hour, those during the 7 AM hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers. CONCLUSIONS Rapid response team activation is less frequent during the early morning and is followed by a spike in mortality in the 7 AM hour. These findings suggest that failure to rescue deteriorating patients is more common overnight. Strategies aimed at improving rapid response team utilization during these vulnerable hours may improve patient outcomes.
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The measurement frequency and completeness of vital signs in general hospital wards: An evidence free zone? Int J Nurs Stud 2017; 74:A1-A4. [PMID: 28701265 DOI: 10.1016/j.ijnurstu.2017.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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45
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Han MK, Martinez CH, Au DH, Bourbeau J, Boyd CM, Branson R, Criner GJ, Kalhan R, Kallstrom TJ, King A, Krishnan JA, Lareau SC, Lee TA, Lindell K, Mannino DM, Martinez FJ, Meldrum C, Press VG, Thomashow B, Tycon L, Sullivan JL, Walsh J, Wilson KC, Wright J, Yawn B, Zueger PM, Bhatt SP, Dransfield MT. Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective. THE LANCET RESPIRATORY MEDICINE 2016; 4:473-526. [PMID: 27185520 DOI: 10.1016/s2213-2600(16)00094-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 12/21/2022]
Abstract
The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.
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Affiliation(s)
- MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Carlos H Martinez
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - David H Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, and VA Puget Sound Health Care System, US Department of Veteran Affairs, Seattle, WA, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Jean Bourbeau
- McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard Branson
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital & Health Sciences System, University of Illinois, Chicago, IL, USA
| | - Suzanne C Lareau
- University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL, USA
| | | | - David M Mannino
- Department of Preventive Medicine and Environmental Health, University of Kentucky, Lexington, KY, USA
| | - Fernando J Martinez
- Department of Internal Medicine, Weill Cornell School of Medicine, New York, NY, USA
| | - Catherine Meldrum
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Byron Thomashow
- Division of Pulmonary, Critical Care and Sleep Medicine, Columbia University Medical Center, New York, NY, USA
| | - Laura Tycon
- Palliative and Supportive Institute, Pittsburgh, PA, USA
| | | | | | - Kevin C Wilson
- Boston University School of Medicine, Boston, MA, USA; American Thoracic Society, New York, NY, USA
| | - Jean Wright
- Carolinas HealthCare System, Charlotte, NC, USA
| | - Barbara Yawn
- Family and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Patrick M Zueger
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
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46
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Behavioral economics strategies for promoting adherence to sleep interventions. Sleep Med Rev 2015; 23:20-7. [DOI: 10.1016/j.smrv.2014.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 11/04/2014] [Accepted: 11/11/2014] [Indexed: 12/28/2022]
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47
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Xu T, Wick EC, Makary MA. Sleep deprivation and starvation in hospitalised patients: how medical care can harm patients. BMJ Qual Saf 2015; 25:311-4. [PMID: 26350065 PMCID: PMC4853558 DOI: 10.1136/bmjqs-2015-004395] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/17/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Tim Xu
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth C Wick
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Martin A Makary
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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