Lynzy Elzinga, Deirdre McNally, and Eddie Montes
The ABCDEF Bundle (2017) is an evidence-based guide for clinicians working with critically ill patients to coordinate multidisciplinary care in the intensive care unit. The “B” of the ABCDEF Bundle represents both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs). During an SAT, patients are slowly weaned off sedation to determine if they are capable of tolerating a smaller amount of sedating medications. In an SBT, ventilator settings are weaned on qualifying patients to determine readiness to extubate. A pairing of these trials is now the standard of care. Other bundle topics include: adequate pain control, properly choosing analgesia and sedation, monitoring and managing delirium, early mobility, and family engagement (Marra, Ely, Pandharipande, et al., 2017). Nearly all patients who are mechanically ventilated receive continuous intravenous sedation. In one study, researchers demonstrated that daily interruption of sedation shortened the duration of mechanical ventilation by over 2 days and ICU length of stay by 3.5 days (Kress, Pohlman, O’Conner, et al., 2000). There is still discussion on the best way to perform paired awakening and breathing trials, both within our unit and the academic community. Although our institution has parameters a patient must meet to qualify for a paired SAT/SBT, the spontaneous awakening portion of the trial is at the discretion of the patient’s nurse.
The purpose of this pilot project was to investigate if the protocolization and standardization of our spontaneous awakening and brieathing trials, as supported by an audit tool, will decrease the number of days a patient spends on mechanical ventilation.
The Institutional Review Board (IRB) waived approval for this evidence based project as no changes to the standard of care were implemented. All patients were sourced from the Providence Portland Intensive Care Unit between July and August of 2020. Prior to the implementation phase, staff nurses in the ICU were educated on proper use of spontaneous awakening and breathing trials. Education included information on the signs and symptoms that indicate a “fail” or a “pass” on the trials (Girard, Kress, Fuchs, et al., 2008). The flowchart below was edited based on the recommendations of pulmonologists in the PPMC critical care unit. Patients who qualified for a stand-alone SAT or combined SAT/SBT were identified by the pulmonologist on service during medical rounds. Eligible individuals included mechanically ventilated patients ages 18 and over, exclusive of tracheostomy patients. Nurses with a qualifying mechanically ventilated patient completed an audit form in order to ensure protocol adherence. It was assumed patients did not have an SBT, SAT, NMB, sedation, or were proned if an audit sheet was not collected demonstrating this. Study groups were compared using the two-sample t-test assuming unequal variances.
163 audit sheets were turned during the data collection phase. 15 of these sheets were unusable because they lacked patient labels. The remaining 149 audit sheets represented 36 discrete patients. Analysis of the data demonstrated that patients with less ventilator hours are less likely to: Need a neuromuscular blockade (NMB) Be proned Need an SBT Or need an SAT, t(35) = 4.35, p<.05. Additionally, there was a significant relationship between age and length of stay.
This data appears to represent the population of patients who are mechanically ventilated in our ICU. A major limitation of this pilot project is that audit sheets demonstrating an SBT, SAT, proning, NMB, or use of sedation may not have been turned in. Furthermore, the number of audit sheets did not match the number of shifts each of these patients was ventilated. Audit sheets demonstrated a great variability in knowledge surrounding spontaneous awakening and breathing trials in our unit. Education on this topic, as well as updates in Epic, would be helpful in addressing issues with the audit forms. In the future, we plan to simplify the audit form and collect data only related to the project at hand. This may eliminate the number of incomplete audit forms we receive. Future iterations of this project could involve a control and test group to evaluate whether changes to our SAT/SBT protocol decreases ventilator time.
Amanda Grimes and Rebecca Choma
Nurses are required to reposition patients at risk for HAPI every 2 hours, however finding timely assistance can be challenging, leading to increased length of time between, or missed turns. Previous studies have found that structured Turn Team assignments reduced HAPI rates up to 75%.
The purpose of this study is to investigate the implications of a team-initiated turning and repositioning technique every two hours. The study question was, “Does two-hour team nurse turning and repositioning rounds reduce incidence of HAPI in adult medical-surgical patients as compared to primary nurse initiated turning and repositioning?” This QI Project was exempt from IRB approval.
A Quality Improvement project using a convenience sample was conducted. An EPIC chart review was completed following the intervention period to assess HAPI incidence and charting compliance. Who was included? Adult 4G/4R patients with a Braden score of less than 18 and inability to independently reposition in bed. The primary care nurse is responsible for adding patients / updating the charge nurse on patient appropriateness for the turn team assignments each shift. What is the turn team? On the odd hours two assigned caregivers round on each assigned patient. They provide incontinence care, reposition the patient to their opposite side, then document cares and patient position in real time through EPIC “Quickchart flowsheet, Positioning tab”. Ideally, each caregiver is assigned one time slot per shift, with all other turns being consistently provided by other members of the team. Who assigns caregivers to the turn team? The charge nurse is responsible for making turn team assignments along with the upcoming shift assignment, and posts where most visible for the care team to see.
The turn team initiative greatly reduced the incidence of HAPIs. Since concluding the study, the unit has permanently adopted the intervention into their unit practices. This cost-neutral nursing intervention can be easily applied to all medical surgical units. Limitations: Conducting study at the start of the COVID-19 pandemic, which could have impacted average patient acuity, as well as overall unit census. Inconsistency in reporting HAPI’s via Datix Reporting System.
The Effects of Music Intervention on Pain and Anxiety in the Immediate Postoperative Period in Adults Undergoing Total Knee Arthroplasty and Total Hip Arthroplasty
Peggy Olsen and Mary Waldo
With the current opioid crisis in the United States, examining adjunct therapies for pain control is an important focus for nursing.
Music has demonstrated its value in treatment of pain in multiple settings including psychiatric medicine, palliative care, neurology and intensive care. Meta-analyses can be found supporting music intervention in reducing patients’ pain and anxiety.
“The Effects of Music Intervention in the Management of Chronic Pain, A Single-Blind, Randomized, Controlled Trial” (Clin J Pain, Vol 00, Number 00, 2011) details the study of Music Care in treating chronic pain patients and states that Music Care as an intervention “appears to be useful in managing chronic pain as it enables a significant reduction in the consumption of medication.”
“Music could be offered as a way to help patients reduce pain and anxiety during the postoperative period.” A meta-analysis highlights that “music reduced postoperative pain, anxiety and analgesia use and increased patient satisfaction, and that music was effective even when patients were under general anesthetic.” (The Lancet, Vol 386, October 24, 2015)
Music Care has developed a software program standardizing a music intervention, thus enabling more methodological rigor in studying music’s effects.
This study focused on assessing the effects of using music with elective joint replacement patients in the Post Anesthesia Care Unit (PACU) of Providence Portland Medical Center.
The study used a standardized music intervention throughout the immediate postoperative period to assess its usefulness in reducing acute and/or acute on chronic pain and anxiety.
An IRB-approved correlational study using prospective and historical data was conducted.
Study participants included orthopedic surgery patients of Dr. John O’Shea and Dr. Richard Rubinstein who underwent elective knee replacement and patients of Dr. Gustav Fischer who underwent elective knee and hip replacement surgery in the months November and December 2019 and January 2020 through March 2020 at Providence Portland Medical Center.
Historical data was gathered from orthopedic patients of these physicians undergoing elective joint replacements during January, February, March, April and May 2019 at Providence Portland Medical Center.
Historical data from patients was compared with the interventional arm consisting of patients who underwent the same procedures. The music intervention was initiated upon admission to the PACU (Phase 1 of recovery) and discontinued when patients entered Phase 2 of recovery.
Data collected from electronic health records included: vital signs, Pasero Opioid Induced Sedation Scale (POSS), narcotics and benzodiazepines administered and pain ratings. Data was collected throughout the perioperative period, including the preop, intraop and postop Phase 1 and Phase 2 periods.
There was a statistically significant decrease in the amount of Dilaudid administered in the study participants, with a p value of 0.03, as well as statistically significant decrease in heart rate (p value 0.006), respiratory rate (p value 0.05) and POSS (p value 0.05). There was no statistically significant difference in the administration of Fentanyl, Oxycodone or Versed, nor in the subjective rating of pain in comparing the 2 groups.
Music has proven to be a valuable adjunct in managing pain and anxiety in multiple settings. This study showed a statistically significant reduction of Dilaudid administration in patients who had the music intervention during the immediate postoperative period. The study also showed a decrease in heart rate, blood pressure, respiratory rate and POSS with the music intervention.
These findings are important in supporting the use of adjunct therapies for pain control thus decreasing the use of narcotics and their untoward side effects (e.g., decreased respiratory rate, sedation) and related sequelae (e.g., delay in mobility, constipation). A lower POSS and decreased narcotic use may promote early mobility and discharge.
Anecdotally, several patients commented on the comfort of listening to music with noise-cancelling headphones in the PACU. Implications for nursing may include providing soothing background music or other distractions that may help patients relax in a noisy PACU. Of the 50 study participants, 10 requested their own music for the intervention. This implies patients are interested in using a music intervention, but would like more independence in the choice of music.
This study’s limitations included the restrictions of music choice and duration as determined by the software from Music Care, as well as the limited recruitment of patients due to the outbreak of Covid19. The study was terminated in March 2020 due to the postponement of elective surgeries and the additional burden to caregivers during the pandemic.
Further research in the use of music throughout the operative experience, including all phases of care, and the use of personal music may be of interest.
Assessing Time from Door-to-Antibiotic Administration for Adult Cancer Patients with Neutropenic Fever in the Emergency Department
Sarah Roy and Tina Magsarili
Infection, related to febrile neutropenia, in patients receiving chemotherapy for cancer remains a common complication and is a medical emergency. Fever is often the only sign of severe underlying infection in neutropenic patients due to the patient’s immunosuppressed state (Butts, et.al, 2017). Vigilant nursing assessment and immediate medical attention for neutropenic fever (NF) is imperative because the rate of major organ complication and mortality is as high as 30% and 11% respectively (Freifield et.al, 2011 & Taplitz et.al, 2018). In the setting of severe sepsis or septic shock the mortality rate may be as high as 50% (Taplitz et.al, 2018). Reduced time to antibiotics has been shown to improve outcomes in patients with sepsis (Fletcher et.al, 2013). Despite controversial outcomes related to door to antibiotic times in NF patients, the expert recommendation and current standard of practice uphold that initiation of antibiotics be administered within 60 minutes (Taplitz et.al, 2018 & Flowers et.al, 2013). NF patients frequently present to Emergency Department (ED) settings for evaluation and treatment ( Bow et.al, 2019). Studies confirm significant delays in antibiotic administration, associated with NF patients, occur in the ED setting (Koenig et.al, 2019). As a result, increased length of stay, increased risk for adverse events, sepsis and even death can occur (Koenig et.al, 2019). Providence Portland Medical Center’s (PPMC) 46-bed ED is where cancer patients commonly present with NF and are provided nursing and medical care.
The purpose of this study is to assess the door to antibiotic times, based on current standards of care of a 60-minute time frame, for cancer patients presenting with NF who are admitted through PPMC’s ED.
The Providence Oregon Regional Institutional Review Board approved this project. This was a retrospective chart review of adult cancer patients admitted with NF from PPMC’s ED to inpatient units between January 1st, 2018 to December 31st, 2019. Inclusion criteria used to define the study population consisted of: age of at least 18 years old, active cancer diagnosis, received chemotherapy within 14 days of presentation to the ED, absolute neutrophil count (ANC) of less than or equal to 1,000pu/L, and an oral temperature of equal to or greater than 38.1 C. Data points included door to antibiotic (DTA) times, early identification of risk factors in triage note, demographics, vital signs, triage acuity using Emergency Severity Index (ESI) with 1 being higher acuity than 5, types of venous access, and times of blood draws, and antibiotic orders.
21 patients met inclusion criteria for this project. The average DTA time was 152 minutes with a range between 72 and 260 minutes (Figure 1). The 2 outliers with the longest DTA times were mis-triaged at a lower acuity of ESI-3. On arrival to the ED, patients self identified a risk factor of cancer, chemotherapy, or fever between 67 – 95% of the time. There were no significant DTA discrepancies between select populations except for ESI acuity (Figure 4). Delays were spread evenly between blood draw, ANC result, antibiotic order, and antibiotic delivery (Figure 2).
Lengthy DTA times suggest interventions are needed to address delays. A key limitation was the small sample size of 21 patients. Assigning an ESI-2 triage acuity is recommended as lengthy delays were noted with ESI-3 patients (Figure 4). Time delays are spread throughout the DTA timeline suggesting that multiple workflow barriers exist throughout the ED encounter (Figure 2). Future projects should focus on process improvement towards rapid identification of febrile neutropenia, timely antibiotic orders and delivery as well as nursing education.