EBP Annotated Bibliography

EBP Annotated Bibliography EBP Annotated Bibliography module__3_assignment.docx _s_palchaudhuri__telemetry_monitor EBP Annotated Bibliography. Module 3 Assignment: EBP Annotated Bibliography Feedback Assignment Annotated bibliographies (ABs) help you organize your project’s scholarly information. This writing assignment gives you practice in writing your AB for the EBP class. Directions: Article from EBP (attached) as your source for this assignment. Create an APA bibliographic entry. The annotation consists of two paragraphs using the following parameters: a summary paragraph and an analysis paragraph. This assignment should not exceed one double spaced page. Paragraph 1 (Summary): Briefly summarize the article using complete sentences. The following questions will guide you as you write your summary: • What is the article about? • What kind of study/review was done (i.e., RCT, descriptive, case study, or Systematic Review of similarly designed studies, etc.)? • What is the author’s purpose? • Is the text difficult to read or understand? • Does the author introduce the problem statement? (briefly state) • How and to whom (i.e. population of interest) was the study done? • What main findings are clinically relevant? Paragraph 2 (Analysis): Explain how this article (source) is clinically relevant to your problem statement. How does this article add to the evidence to solve your PICO(T) problem/statement? Background PICO(T) Question: “Does alarm fatigue and desensitization have an impact on critical care patients?” P: I: C: O: Critical Care Nurses Education regarding alarm fatigue n/a Increased awareness on potential harm to patients Rapid #: -14318438 CROSS REF ID: 222228 LENDER: OPEN :: DOIS 092818 BORROWER: FWA :: Pace Library TYPE: Article CC:CCG JOURNAL TITLE: Journal of hospital medicine USER JOURNAL TITLE: Journal of Hospital Medicine ARTICLE TITLE: Telemetry Monitor Watchers Reduce Bedside Nurses’ Exposure to Alarms by Intercepting a High Number of Nonactionable Alarms ARTICLE AUTHOR: Palchaudhuri, Sonali, VOLUME: 12 ISSUE: 6 MONTH: YEAR: 2017 PAGES: 447- ISSN: 1553-5592 OCLC #: Processed by RapidX: 2/14/2019 2:42:31 PM This material may be protected by copyright law (Title 17 U.S. Code) BRIEF REPORT Telemetry Monitor Watchers Reduce Bedside Nurses’ Exposure to Alarms by Intercepting a High Number of Nonactionable Alarms Sonali Palchaudhuri, MD1,2*, Stephanie Chen, MD1-3, Elaine Clayton, MS, RN1, Anthony Accurso, MD2,4, Sammy Zakaria, MD, MPH1,2 1 3 Johns Hopkins Bayview Medical Center, Baltimore, Maryland; 2Providers for Responsible Ordering, Johns Hopkins Medicine, Baltimore, Maryland; Kaiser Permanente San Francisco, San Francisco, California; 4New York University Population Health, New York, New York. Cardiac telemetry, designed to monitor hospitalized patients with active cardiac conditions, is highly utilized outside the intensive care unit but is also resource-intensive and produces many nonactionable alarms. In a hospital setting in which dedicated monitor watchers are set up to be the frst responders to system-generated alerts, we conducted a retrospective study of the alerts produced over a continuous 2-month period to evaluate how many were intercepted before nurse notifcation for being nonactionable, and how many resulted in code team activations. Over the 2-month period, the system gener- ated 20,775 alerts (5.1/patient-day, on average), of which 87% were intercepted by monitor watchers. Module 3 Assignment: EBP Annotated Bibliography EBP Annotated Bibliography. None of the alerts for asystole, ventricular fbrillation, or ventricular tachycardia resulted in a code team activation. Our results highlight the high burden of alerts, the large majority of which are nonactionable, as well as the role of monitor watchers in decreasing the alarm burden on nurses. Measures are needed to decrease telemetry-related alerts in order to reduce alarm-related harms, such as alarm fatigue. Journal of Hospital Medicine 2017;12:447449. © 2017 Society of Hospital Medicine Cardiac telemetry, designed to monitor hospitalized patients with active cardiac conditions, is highly utilized outside the intensive care unit (ICU) and generates a large number of automated alarms. Telemetry is also costly and requires substantial time and attention commitments from nursing and technician staff, who place and maintain the recording devices and address monitoring results.1,2 The staff address and dismiss invalid alarms caused by telemetry artifacts,2 such as the misreporting of patient movement as ventricular tachycardia/fbrillation (VT/VF) or the mimicking of asystole by a lead disconnection. One strategy for addressing telemetry alarms is to have dedicated staff observe telemetry monitors and notify nurses with any events or fndings. Studies conducted in the 1990s showed that dedicated monitor watchers, compared with automatically generated alarms alone, did not affect most outcomes3 but can improve accuracy of arrhythmia detection.4 Since then, given the advances in telemetry detection software, the effect of monitor watchers has not been evaluated. Mindful of the perceived burden of nonactionable telemetry alerts, we wanted to quantify the frequency of automated telemetry alerts in the wards and analyze the proportion of alerts deemed nonactionable by monitor watchers. cases of all non-ICU patients with telemetry monitoring ordered. The telemetry order requires providers specify the indication for monitoring and adjust alert parameters for variables such as heart rate (preset to 60 and 100 beats per minute) and baseline rhythm (preset to normal sinus). Once a telemetry order is received, 5 leads are attached to the patient, and electrocardiographic data begin transmitting to a portable wireless telemetry monitor, or telemeter (Philips Intellispace Telemetry System), which in turn transmits to a central monitoring station in the progressive care unit (PCU; cardiac/pulmonary unit). The majority of patients on telemetry are in the PCU. Telemeters are also located in the general medicine, surgical, and neurologic non-ICU units. Data from a maximum of 96 telemeters in the hospital are simultaneously displayed in the central monitoring station. At all times, two dedicated monitor watchers oversee the central monitoring station. Watchers are certifed medical assistants with extra telemetry-specifc training.Module 3 Assignment: EBP Annotated Bibliography EBP Annotated Bibliography. Each receives a salary of $17 per hour (no benefts), or about $800 per 24hour day for two watchers. Their role is to respond to audiovisual alerts triggered by the monitoring system—they either contact the bedside nurse or intercept the alert if deemed nonactionable. Consistent with the literature,5 nonactionable alerts and alarms were defned as either “invalid” or “nuisance.” Invalid alerts and alarms misrepresent patient status (eg, patient motion is electronically interpreted as VT/VF), and nuisance alerts and alarms do not require clinical intervention (eg, persistent sinus tachycardia has already been communicated to the nurse or provider). Monitor watchers must intercept the alert within a limited amount of time: 15 seconds for suspected lethal alerts (asystole, VT/VF), 30 seconds for extreme tachycardia/bradycardia, and 60 seconds for lead displacement or low battery. If a watcher does not intercept an alert—either intention- METHODS We conducted this retrospective study at a 545-bed urban academic hospital in the United States. We reviewed the *Address for correspondence and reprint requests: Sonali Palchaudhuri, MD, 6th Floor, MFL West, Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Baltimore, MD 21224; Telephone: 410-550-5018; Fax: 410-550-2972; E-mail: [email protected] Received: June 6, 2016; Revised: November 18, 2016; Accepted: November 25, 2016 2017 Society of Hospital Medicine DOI 10.12788/jhm.2754 An Offcial Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 12 | No 6 | June 2017 447 Palchaudhuri et al | Telemetry Monitor Watchers ally or because time ran out—the alert generates an alarm, which automatically sends a text message to the patient’s nurse’s wireless phone. The nurse acknowledges the alarm and decides on further action. If the bedside nurse does not acknowledge the alarm within the same time frames as mentioned, the alarm is escalated, frst to the unit charge nurse and then to the monitoring station charge nurse (Figure). All alerts are available for provider review at the central monitoring station for the duration of the telemetry order, and select telemetry strips are printed and fled in the patient’s paper chart. For this study, we analyzed telemetry system data for all monitored non-ICU ward patients from August 1 through September 30, 2014. We focused on the rate and relevance of alerts (system-generated) and alarms (text message to nurse). As cardiac arrhythmias leading to cardiopulmonary arrest can potentially be detected by telemetry, we also reviewed all code team activations, which are recorded in a separate database that details time of code team activation, to evaluate for correlation with telemetry alerts. etry, and an average of 66.3 patients monitored per day. In addition, the system generated 20,775 alerts, an average of 341 per day, 5.1 per patient-day, 1 every 4 minutes. Module 3 Assignment: EBP Annotated Bibliography ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS EBP Annotated Bibliography. Overall, 18,051 alerts (87%) were intercepted by monitor watchers, preventing nurse text-alarms. Of all alerts, 91% were from patients on medicine services, including pulmonary and cardiology; 6% were from patients on the neurology foor; and 3% were from patients on the surgery foor. Forty percent of all alerts were for heart rates deviating outside the ranges set by the provider; of these, the overwhelming majority were intercepted as nuisance alerts (Table). In addition, 26% of all alerts were for maintenance reasons, including issues with batteries or leads. Finally, 34% (6954) were suspected lethal alerts (asystole, VT/VF); of these, 74% (5170) were intercepted by monitor watchers, suggesting they were deemed invalid. None of the suspected lethal alerts triggered a code team activation, indicating there were no telemetry-documented asystole or VT/VF episodes prompting resuscitative efforts. During the study period, there were 7 code team activations. Of the 7 patients, 2 were on telemetry, and their code team activation was for hypoxia detected by pulse oximetry; the other 5 patients, not on telemetry, were found unresponsive or apneic, and 4 of them had confrmed pulseless electrical activity. RESULTS Within the 2-month study period, there were 1917 admissions to, and 1370 transfers to, non-ICU foors, for a total of 3287 unique patient-admissions and 9704 total patient-days. There were 1199 patient admissions with telemetry orders (36.5% of all admissions), 4044 total patient-days of telem- DISCUSSION In small studies, other investigators have directly observed nurses for hours at a time and assessed their response to telemetry-related alarms.1,2 In the present study, we found a very large number of telemetry-detected alerts over a continuous 2-month period. The large majority (87%) of alerts were manually intercepted by monitor watchers before being communicated to a nurse or provider, indicating these alerts did not affect clinical management and likely were either false positives or nonactionable. It is possible that repeat nonactionable alerts, like continued sinus tachycardia or bradycardia, affect decision making, but this may be outside the role of continuous cardiac telemetry. In addition, it is likely that all the lethal alarms (asystole, VT/VF) forwarded to the nurses were invalid, as none resulted in code team activations. Addressing these alerts is a major issue, as frequent telemetry alarms can lead to alarm fatigue, a widely acknowledged TABLE. Frequency of Alerts by Type and Proportion Being Intercepted by Monitor Watchers Alerts Alert Type Intercepted Alerts n % n % Asystole 2818 14 1945 76 Ventricular tachycardia 3638 18 2849 78 Ventricular fbrillation 498 2 376 77 Tachycardia 7477 36 7215 90 Bradycardia 898 4 881 92 Leads off 5032 24 4537 79 Battery 414 2 248 40 20,775 100 18,051 87 Total System generates an alert Monitor watcher intercepts alert No System texts alarm to RN phone RN acknowledges the alarm No Alarm escalates to CN RN or CN acknowledges the alarm Yes Yes Yes Alert silenced Alarm silenced Alarm silenced No Alarm escalated to CN of the monitoring station FIG. Escalation protocol of telemetry alerts and alarms. Module 3 Assignment: EBP Annotated Bibliography EBP Annotated Bibliography. NOTE: Alert or alarm must be intercepted or acknowledged within described time limits to prevent escalation. Abbreviations: CN, charge registered nurse; RN, registered nurse. 448 An Offcial Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 12 | No 6 | June 2017 Telemetry Monitor Watchers | Palchaudhuri et al safety concern.6 Furthermore, nonactionable alarms are a time sink, diverting nursing attention from other patient care needs. Finally, nonactionable alarms, especially invalid alarms, can lead to adverse patient outcomes. Although we did not specifcally evaluate for harm, an earlier case series found a potential for unnecessary interventions and device implantation as a result of reporting artifactual arrhythmias.7 Our results also highlight the role of monitor watchers in intercepting nonactionable alarms and reducing the alarm burden on nurses. Other investigators have reported on computerized paging systems that directly alert only nurses,8 or on escalated alarm paging systems that let noncrisis alarms self-resolve.9 In contrast, our study used a hybrid 2-step telemetry-monitoring system—an escalated paging system designed to be sensitive and less likely than human monitoring to overlook events, followed by dedicated monitor watchers who are frst-responders for a large number of alarms and who increase the specifcity of alarms by screening for nonactionable alarms, thereby reducing the number of alarms transmitted to nurses. We think that, for most hospitals, monitor watchers are cost-effective, as their hourly wage is lower than that of registered nurses. Furthermore, monitor watchers can screen alerts faster because they are always at the monitoring station. Their presence reduces the amount of time that nurses need to divert from other clinical tasks in order to walk to the monitoring station to evaluate alerts. Nonetheless, there remains a large number of nonactionable alerts forwarded as alarms to nurses, likely because of monitor watchers’ inability to address the multitude of alerts, and perhaps because of alarm fatigue. Although this study showed the utility of monitor watchers in decreasing telemetry alarms to nurses, other steps can be taken to reduce telemetry alarm fatigue. A systematic review of alarm frequency interventions5 noted that detection algorithms can be improved to decrease telemetry alert false positives. Another solution, likely easier to implement, is to encourage appropriate alterations in telemetry alarm parameters, which can decrease the alarm proportion.10 An essential step is to decrease inappropriate telemetry use regarding the indication for and duration of monitoring, as emphasized by the Choosing Wisely campaign championing American Heart Association (AHA) guidelines for appropriate telemetry use.11 At our institution, 20.2% of telemetry orders were for indications outside AHA guidelines, and that percentage likely is an underestimate, as this was required self-reporting on ordering.12 Telemetry may not frequently result in changes in management in the non-ICU setting,13 and may lead to other harms such as worsening delirium,14 so it needs to be evaluated for harm versus beneft per patient before order. Module 3 Assignment: EBP Annotated Bibliography EBP Annotated Bibliography. An Offcial Publication of the Society of Hospital Medicine Cardiac telemetry in the non-ICU setting produces a large number of alerts and alarms. The vast majority are not seen or addressed by nurses or physicians, leading to a negligible impact on patient care decisions. Monitor watchers reduce the nursing burden in dealing with telemetry alerts, but we emphasize the need to take additional measures to reduce telemetry-related alerts and thereby reduce alarm-related harms and alarm fatigue. Acknowledgments The authors thank Torberg Tonnessen, who was instrumental in providing the telemetry and clinical data used in this study, as well as the numerous Johns Hopkins Bayview Medical Center nurses, patient care technicians, and monitor watchers who answered questions about telemetry processes and allowed their work to be observed. Disclosure: Nothing to report. References 1. Gazarian PK. Nurses’ response to frequency and types of electrocardiography alarms in a non-critical care setting: a descriptive study. Int J Nurs Stud. 2014;51(2):190-197. 2. Varpio L, Kuziemsky C, MacDonald C, King WJ. The helpful or hindering effects of in-hospital patient monitor alarms on nurses. Comput Inform Nurs. 2012;30(4):210-217. 3. Funk M, Parkosewich J, Johnson C, Stukshis I. Effect of dedicated monitor watchers on patients’ outcomes. Am J Crit Care. 1997;6(4):318-323. 4. Stukshis I, Funk M, Johnson C, Parkosewich J. Accuracy of detection of clinically important dysrhythmias with and without a dedicated monitor watcher. Am J Crit Care. 1997;6(4):312-317. 5. Paine CW, Goel VV, Ely E, et al. Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency. J Hosp Med. 2016;11(2):136-144. 6. Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission announces 2014 national patient safety goal. Jt Comm Perspect. 2013;33(7):1, 3-4. 7. Knight BP, Pelosi F, Michaud GF, Strickberger SA, Morady F. Clinical consequences of electrocardiographic artifact mimicking ventricular tachycardia. N Engl J Med. 1999;341(17):1270-1274. 8. Zwieg FH, Karfonta TL, Jeske LJ, et al. Arrhythmia detection and response in a monitoring technician and pocket paging system. Prog Cardiovasc Nurs. 1998;13(1):16-22, 33. 9. Cvach MM, Frank RJ, Doyle P, Stevens ZK. Use of pagers with an alarm escalation system to reduce cardiac monitor alarm signals. J Nurs Care Qual. 2013;29(1):9-18. 10. Gross B, Dahl D, Nielsen L. Physiologic monitoring alarm load on medical/ surgical foors of a community hospital. Biomed Instrum Technol. 2011;Spring (suppl):29-36. 11. Drew BJ, Califf RM, Funk M, et al; American Heart Association; Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientifc statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses [published correction appears in Circulation. 2005;111(3):378]. Circulation. 2004;110(17):2721-2746. 12. Chen S, Palchaudhuri S, Johnson A, Trost J, Ponor I, Zakaria S. Does this patient need telemetry? An analysis of telemetry ordering practices at an academic medical center. J Eval Clin Pract. 2017 Jan 27 [Epub ahead of print]. 13. Estrada CA, Rosman HS, Prasad NK, et al. Role of telemetry monitoring in the non-intensive care unit. Am J Cardiol. 1995;76(12):960-965. 14. Chen S, Zakaria S. Behind the monitor—the trouble with telemetry: a teachable moment. JAMA Intern Med. 2015;175(6):894. Journal of Hospital Medicine Vol 12 | No 6 | June 2017 449 …Module 3 Assignment: EBP Annotated Bibliography Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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