Daily Checklist Research Articles

74 Reducing unplanned extubations in a level 3 neonatal intensive care unit - the nuts and bolts of UE bundle implementation

Abstract Background Unplanned extubations (UEs) are preventable adverse events that may lead to short term consequences (e.g. cardiopulmonary collapse) and long term sequelae (e.g. acquired airway injury, brain injury) for patients admitted to the Neonatal Intensive Care Unit (NICU). UE prevention care bundles have been demonstrated to reduce UE rates in NICUs; however, implementation of bundle elements is unit dependent. Objectives To describe the work of a UE Prevention Team in a Level 3 NICU with rising UE rates despite implementation of UE prevention bundle per Children’s Hospital Solutions for Patient Safety (SPS). Design/Methods A neonatologist / respiratory therapist pair was assembled in March 2022 to tackle rising UE rates in a 69 bed NICU. Contributing unit stressors included implementation of a new electronic health record, COVID-19 policies, and nursing shortages. Baseline UE rates were >3x the centerline for SPS network NICUs and likely underreported. Steps undertaken include: 1) daily audit to ensure reporting of all UEs, 2) structured post-event team debriefs, 3) unit education campaign to raise awareness of UE prevention and bundle elements, 4) prominent posting of last UE date and reporting on daily team huddle, 5) rapid UE case reviews and apparent cause analysis with reporting of findings unit-wide, 6) optimize endotracheal tube (ETT) securement methods, 6) enforce T2-T3 ETT tip position, 7) standardize x-ray frequencies and reporting, 8) trial of daily rounds ETT safety checklist. Results From rapid case reviews, apparent causes were determined to be incorrect ETT securement device sizing, taping method prone to loss of tape integrity in high humidity, high ETT positions, and inadequate ETT monitoring during high risk activities other than repositioning (invasive/painful procedures, diaper changes). Post-event structured debriefs and unit-wide vigilance increased reporting of UE events to 100%. UE rates fell from a peak of >4 UEs/month, >2.4/100 ventilation days to 1 UE/month, 0.465/100 ventilation days, a 80% reduction.(Figure 1) Most impactful interventions were standard x-ray reporting template in the electronic health record, reinforcing T2-T3 ETT tip positioning, correcting ETT holder sizing, and change in ETT method (Figure 2). Daily rounds checklist was not effective. UE reductions were achieved without changing patient ratios as nurse staffing shortages continued. Conclusion A nimble systems approach is needed to ensure success in implementation of UE prevention care bundles. Simple changes can be made to decrease UEs, guided by rapid case reviews.

A-186 Patient Safety Rite in Diagnostic Services

Abstract Background Safety rites are well defined in hospitals, but still incipient in diagnostic services. They aim to identify near misses early, promote discussions and improvements with teams related to adverse incidents. This study presents the implementation of the Safety Rite in a large diagnostic service in Brazil, with its challenges and results. Methods Gemba Walk (GW), a practice of the Lean philosophy of checking operation processes, encouraging and collaborating between teams, in addition to identifying opportunities for improvement and enabling immediate decision-making. The laboratory created its own methodology called GW-MDU, which consists of a daily checklist of questions related to processes, efficiency and results. The GW begins with a visit by the leadership, or designated person, to all sectors, answering the checklist and evaluating the need for immediate actions and action plans, with registration in an application (APP). In January 2024, the Patient Quality and Safety System (SGQSP) included questions related to the WHO (World Health Organization) safety goals in the GW: 1. Did patient identification occur without complications/identification failures at all stages of the process? 2. Was there contrast extravasation? 3. Was there allergic reactions? 4. Was there an incorrect or change administration of medication or vaccine? 5. After the end of sedation(anestesia), was there a need to extend the recovery time? 6. Was there a patient fall? 7. Was there a puncture that resulted in a hematoma? 7. Was there an adverse event that required medical action? Every “No” answer to question 1 and “Yes” to questions 2 to 7, the leader must guarantee registration of the QMS, root cause analysis and action plan. After the GW, leadership conducts the Obeya Rite daily, including the Safety Rite, with analysis of the indicators and findings identified during the round.The Safety Rite methodology was tested in a Laboratory Unit where radiology and imaging diagnostic tests, hormonal tests and sample collection for clinical analysis are carried out. After the test, interviews were realized with the leaders to evaluate the application of the Rite. Improvements were implemented and later rolled out to the other Units. Results The Patient Safety Rite was implemented in 646 Laboratory Units, representing 35 brands of the laboratory group. From 12/20/23 to 02/15/24, 18,614 GW were carried out, of this total, for question 1, 82.7% answered “Yes”, 9% answered “No” and 8.3% answered No Applicable. For answers 2 to 7, 1.5% answered “Yes”, 48.2% answered “No” and 50.3% answered Not Applicable. A total of 40.264 incidents were opened in the QMS, 6.4% of which were related to Rite questions. Conclusions The rites consolidate indicators and information, allow the identification of risks and/or events proactively and help define and disseminate corrective actions and improvements in a timely manner to avoid recurrence. However, due to the high rate of “not applicable” responses, we still have challenges and opportunities in implementation, but the correctly used Safety Rite contributes to patient safety.

A Daily Checklist Method Increases Documentation of Code Status in Trauma Patients.

While insufficient code status documentation (CSD) is a longstanding challenge, all patients deserve the opportunity to participate in decision-making regarding code status, especially trauma patients with an unpredictable course. Prior interventions to increase CSD relied on reminder systems. We hypothesize that introducing a daily checklist will increase CSD for patients in the trauma ICU. This quality improvement study examined the efficacy of a twice-daily checklist for improving CSD in trauma patients at a level I trauma center. A pre-intervention (PRE) and post-intervention (POST) daily census characterized the percentage of patients with CSD (primary outcome), time-to-code status (TTCS, secondary outcome) documentation, and information about patients who were discharged with no code status (DNCS, secondary outcome). Of 213 PRE and 207 POST, daily census CSD for all patients increased from a median of 50.0% PRE to 64.4% POST (P < .05). Time-to-code status was halved (PRE: 25.30h, POST: 12.71h, P < .05). Code status documentation within 12h increased from 41.8% PRE to 60.9% POST (P < .05). Overall, the percentage of patients with CSD during their hospitalization increased 20% (PRE: 63.8%, POST: 83.6%, P < .05). Discharged with no code status patients decreased 20% (PRE: 35.2%, POST: 15.5%, P < .05). Including code status in a daily checklist involving key aspects of care for trauma patients is an effective method for improving code status documentation. Capturing code status for more patients in trauma allows us to provide patient-centered, goal-concordant care.

Effects of Viola odorata syrup on hot flashes and night sweats in menopausal women: A randomized, triple-blind, controlled trial

BackgroundHot flashes and night sweats are among the most common and disruptive symptoms in menopausal women. The present study aimed to assess the effects of Viola odorata syrup on hot flashes and night sweats in menopausal women. V. odorata contain flavonoids, saponins, mucilage, alkaloid, vitamin C, magnesium and melatonin. MethodsThis triple-blind, Randomized Controlled Trial was conducted on 84 menopausal women aged 40–65 years referring to the healthcare centers in Mashhad, Iran. Eligible menopausal women received the V. odorata syrup (5 ml) or placebo twice daily for one month. Data were collected before, during, and after the intervention using valid and reliable daily hot flash checklists. Data analysis was performed in SPSS using independent t-test, Mann-Whitney U test, Friedman test, and Chi-square at the significance level of 0.05. ResultsIn the first week (before the intervention), the intervention group (V. odorata syrup) and placebo group (control) were homogenous in terms of the frequency and intensity of hot flashes and night sweats. The Mann-Whitney U test indicated a significant difference in the duration of hot flashes between the two groups. In addition, significant differences were observed between the V. odorata syrup and placebo groups between the mean duration of hot flashes in the second (P = 0.044), third (P = 0.031), fourth (P < 0.001), and fifth weeks (P<0.001), mean frequency of hot flashes in the third, fourth, and fifth weeks (P < 0.001), and mean intensity of hot flashes in the third (P = 0.003), fourth, and fifth weeks (P < 0.001), as well as night sweats in the second week, the mean values of which were significantly lower in the V. odorata group compared to the control group. ConclusionV. odorata syrup could reduce the frequency, intensity, and duration of hot flashes since the second week of the treatment. Therefore, the use of this plant is recommended for the reduction of hot flashes and night sweats in menopausal women.

Providing emotional support and daily emotional well-being among undergraduate students during the COVID-19 pandemic

Receiving emotional support can improve one’s emotional well-being, but findings have been mixed regarding whether providing emotional support to friends and family can also improve the provider’s emotional well-being. Providing emotional support could be impactful during the COVID-19 pandemic, when individuals may be particularly in need of emotional support and social connection. Therefore, the present study assessed whether providing emotional support was related to role fulfillment and enhanced emotional well-being on a day-to-day basis during the COVID-19 pandemic. Participants ( N = 167; Mage = 20.42, SD = 2.30; 73.1% female; 40.1% Asian, 18. 6% Latinx, 16.8% white) completed up to eight daily checklists ( Mchecklists = 6.54, SD = 2.10) in which they reported whether they provided emotional support to their friends and to their parents, their role fulfillment (i.e., the extent to which they felt like a good son/daughter and friend), and the degree of positive and negative emotion they were feeling. Participants reported higher positive emotion and lower negative emotion on days when they provided emotional support to friends, but not to parents, with potentially stronger associations in-person than virtually. Participants also reported higher role fulfillment as a good son/daughter and a good friend on days when they provided emotional support, and role fulfillment significantly mediated associations between providing emotional support and daily emotion. Taken together, results suggested that providing emotional support to friends—particularly in-person—was related to better emotional well-being by promoting a sense of role fulfillment as a good friend. Providing emotional support may provide one means for reinforcing social relationships and promoting emotional well-being during times of social isolation.

Improving Safety Culture by Establishing Alarm Fatigue Performance in The Adult Intensive Care Unit, Dammam Hospital

Alarm fatigue is becoming a more significant global public health issue that compromises patient safety. Alarm fatigue is especially common among critical care nurses, who are the frontline healthcare providers that provide patients with the most direct care and round-the-clock patient monitoring. An excessive number of alerts, together with erroneous and ineffective alerts, can cause alarm fatigue and negatively impact the psychological well-being of nurses and patients during their recovery process. To find a way to lower the number of false alarms and assess the effectiveness of the measures put in place, a quantitative, descriptive cross-sectional approach was employed. In the adult ICU at NGHA Dammam, this pilot project was carried out from June 2019 to November 2020. In order to identify true alarms and false alarms, the Central Monitor Nurse Daily Checklist was utilized as a data collection tool in conjunction with education training and departmental policies and procedures. There are about 820 alerts per patient each day, including 104 telemetry and 716 bedside alarms. Three months into the project, the project's top alarm measurement was 1503 alarms per patient per day. The project has shown a constant trend in alarm declinations after this peak, largely as a result of project improvement activities. The lowest recorded alarm count in November 2020 was 226 alerts, a 72% decrease from the initial 820 alarms. Nonetheless, the declining trend over the previous three months showed a 22%, 42%, and 48% drop in the overall number of alarms. This study found that alarm fatigue, which is influenced by a number of variables, including safety culture practices, was more common among critical care nurses working in the Intensive Care Unit at NGHA Dammam. Overall, during the first two months of its deployment, this study effectively met its aim and had a considerable impact on the reduction of "false alarms". The results of this study, taken together with improved psychological health for nurses and the provision of a therapeutic environment for patients, offer crucial direction for future intervention programs aimed at reducing alarm fatigue among critical care nurses. Future studies should concentrate on the traits of adherence and management, as well as the obstacles that prevent ICU staff from continuing to implement interventions and false alarm reduction strategies.

Standardized Treatment andDiagnostic Approach to Reduce Disease burden in the early postoperative phase in children with congenital heart defects—STANDARD study: a pilot randomized controlled trial

To explore the effect of a daily goal checklist on pediatric cardiac intensive care unit (PCICU) length of stay (LOS) after congenital heart surgery. This study is a prospective randomized single-center study. Group characteristics were as follows: STANDARD group: n = 30, 36.7% female, median age 0.9 years; control group: n = 33, 36.4% female, median age 1.1 years. Invasive ventilation time, STAT categories, mean vasoactive-inotropic score (VIS)24h, maximal (max.) VIS24h, mean VIS24–48h, max. VIS24–48h, VIS category, number of sedatives, analgesics, diuretics, number of deployed diagnostic modalities, morbidities, and mortality did not differ between both groups. Median PCICU LOS was 96.0 h (STANDARD group) versus 101.5 h (control group) (p = 0.63). In the overall cohort, univariate regression analysis identified age at surgery (b = −0.02), STAT category (b = 18.3), severity of CHD (b = 40.6), mean VIS24h (b = 3.5), max. VIS24h (b = 2.2), mean VIS24–48h (b = 6.5), and VIS category (b = 13.8) as significant parameters for prolonged PCICU LOS. In multivariate regression analysis, age at surgery (b = −0.2), severity of CHD (b = 44.0), and mean VIS24h (b = 6.7) were of significance. Within the STANDARD sub-group, univariate regression analysis determined STAT category (b = 32.3), severity of CHD (b = 70.0), mean VIS24h (b = 5.0), mean VIS24–48h (b = 5.9), number of defined goals (b = 2.6), number of achieved goals (b = 3.3), number of not achieved goals (b = 10.8), and number of unevaluated goals (b = 7.0) as significant parameters for prolonged PCICU LOS. Multivariate regression analysis identified the number of defined goals (b = 2.5) and the number of unevaluated goals (b = −3.0) to be significant parameters. Conclusion: The structured realization and recording of daily goals is of advantage in patients following pediatric cardiac surgery by reducing PCICU LOS.What is known:• Communication errors are the most frequent reasons for adverse events in intensive care unit patients.• Improved communication can be achieved by discussion and documentation of the patients’ goals during daily rounds.What is new:• In the overall cohort age at surgery, severity of congenital heart defect and mean vasoactive inotropic score within the first 24 hours had significant impact on pediatric cardiac intensive care unit (PCICU) length of stay (LOS).• In the intervention group, the number of defined goals and the number of unevaluated goals were significant parameters for prolonged PCICU LOS.

Reducing Postoperative Length of Stay for Idiopathic Scoliosis Patients using Quality Improvement Methodology.

The aim was to increase the percentage of idiopathic scoliosis patients with a procedure to discharge LOS of less than or equal to 4 days after posterior spinal fusion from 39.13% to 90%. Interventions included implementing a new pain management protocol, a daily checklist, education on expectations of postoperative pain, and updated order sets. Interventions improved patients discharged in less than 4 days from 39.13% to 93.48% (P ≤ 0.001), reducing the average postprocedure LOS from 4.93 to 2.59 (P ≤ 0.001) days. A key process measure tracked was the percentage of patients off the patient-control analgesia pump by postoperative day 2, which increased from 13% to 97.75% (P ≤ 0.001). These improvements did not affect the balancing measure of readmissions or Emergency Department visits for pain. By implementing a more standardized pathway, including a patient-focused daily checklist for providers and families, we established expectations for LOS and pain. This checklist and updates to the pain management protocol successfully reduced the length of stay in idiopathic scoliosis patients after posterior spinal fusion.

COVID-19 Symptom Reporting Compliance Rates Among University Performing Arts Majors.

The COVID-19 pandemic negatively affected the performing arts sector by temporarily closing venues. As venues reopened, COVID-19 symptom self-reporting and monitoring were one tool to identify potentially symptomatic cast and crew, who would then undergo contact tracing, testing, or isolation to prevent spreading COVID-19. However, the compliance rates for submitting a COVID-19 self-monitoring checklist among undergraduate performing art majors remain unknown. This retrospective medical chart review investigated 282 cast and crew (68 males and 214 females) regarding their daily COVID-19 symptom report documents across the genres of dance, musical theater, and vocal performance throughout the production runs of 11 performances at a midwestern United States university's integrated performing arts campus. Compliance regarding the completion of the COVID-19 symptom checklist was compared between gender identity, performance semester, and performance type throughout the 2020-2021 academic year. There was no statistically significant difference on masking compliance when comparing males (mean 73.6%) and females (73.8%). The completion of the symptom self-reporting during the fall 2020 semester was statistically significantly higher than in the spring 2021 semester (F = 6.065, t = 4.485, df = 229.661, p = 0.014, d = 0.52). Additionally, those participating in musical theater were more compliant than those in vocal performance (F(2,280) = 4.410, p = 0.013, d = 0.031). There was no statistically significant difference between dance and musical theater or vocal performance and dance genres regarding overall compliance. These findings can help understand the groups of performing artists who would comply with the public health measure of completing a daily symptom checklist for COVID-19 or similar communicable diseases.

P99: Progressive Mobilization Protocol for Patients Supported on ECMO Via Multidisciplinary Culture Change

Our project was aimed at changing the culture surrounding mobilization of the patient supported on ECMO. Due to the critical nature of patients supported on ECMO a multidisciplinary approach of ECMO trained staff members is essential. It is known that critically ill patients benefit from early mobilization. Culture around mobilizing patients supported on ECMO at our facility has been historically conservative and progressive mobility was met with resistance. Our goal was to initiate culture change to one in which progressive mobility is an expectation for the critically ill while designing and implementing a standardized formal protocol for mobilization of patients supported on VA/VV ECMO. This initiative required a multidisciplinary team of stakeholders and influencers to promote acceptance and willingness from nursing, perfusion, pulmonary critical care team and ICU lead physicians. Our team created a protocol with the following goals: 1) increase early and progressive mobilization of patients supported on ECMO 2) decrease time of eligibility to transplant listing of patients supported on ECMO 3) improve outcomes of patients supported on ECMO to include; earlier decannulation, decreased hospital length of stay and discharge to home or rehab vs skilled nursing facility or LTACH 4) change nursing culture to one where early and progressive mobilization is the expectation for patients supported on ECMO 5) increase confidence among healthcare staff regarding early and progressive mobility of the critically ill patient. For every ECMO patient on our unit, bedside nursing staff completes a daily checklist. The purpose of this list was to create ownership from nursing to allow them stake in the process. Checklist was created and vetted by all teams to allow input and to cultivate a multidisciplinary approach. The bedside nurse and physical therapist reviewed the patients’ case daily. Once the patient passes the suggested guidelines for mobility the multidisciplinary team, led by the physical therapist and consisting of the bedside nurse, perfusionist and respiratory therapist, initiates mobility per physical therapy protocol. If patients do not pass the safety checklist by nursing, a multidisciplinary conversation occurs to determine the appropriateness (risk/benefit) of mobilizing the patient, and session is either initiated or deferred. A specialized team and protocol are imperative to successful mobility for this patient population. This initiative created influencers who consisted of team leads targeted to implement change. Culture change has occurred and patients receiving ECMO support are mobilized daily without hesitation. Our future plans include modification of nursing checklists and physical therapy protocol, creation of post mobilization procedures to collect and analyze data, and the development and implementation of an ECMO competency for our PT/OT rehabilitation staff to ensure a high level of training and clinical competence.

Strengthening Youths’ Morals Through Character School

This study investigates the effectiveness of character schools (known as "sekolah karakter or sekuter") in instilling moral values in adolescents, particularly in the context of today's technology-driven world where children can easily access information independently, including content that may not be suitable for their age. Iqro Club is an institution dedicated to religious and social activities, providing a platform for positive engagement, skill development, and the cultivation of a respectful and virtuous Muslim identity among adolescents. The research problem addressed in this study revolves around understanding how character schools (sekuter) contribute to moral reinforcement in adolescents. The primary objective is to assess the practical implementation of moral strengthening through character schools (sekuter). This research adopts a qualitative approach, employing a case study research design, and is conducted at Iqro Club in Pekalongan Regency. Data collection methods encompass observation, interviews, and document analysis, while data analysis involves data reduction, presentation, and drawing conclusions. The study findings reveal three key stages: planning, implementation, and evaluation. During the planning phase, Iqro Club formulates a tailored lesson plan and curriculum that align with the specific needs of adolescents. The implementation phase adheres to established standards, including opening procedures, Quran recitation, content delivery, discussions, and concluding activities. Importantly, the content and discussions are strategically designed to address moral indicators. Finally, in the evaluation phase, participants are required to complete a daily checklist to assess their progress and engagement in the character school program.

Through the Looking-Glass Door*

In Lewis Carroll’s Alice in Wonderland sequel, Through the Looking-Glass, Alice again enters a mythical world but this time by climbing through a mirror rather than falling into the rabbit’s hole (1). Within the world, she finds a book of poetry with the words written backward so that it can only be read by holding it up to the mirror. Alice wanders through a chaotic world of Queens and characters, narrowly escaping with her life only to awaken back in her armchair, safe in her own house, unclear if the adventures were dreams or reality. Alice’s journey is not unlike those of our patients as they enter the PICU. “Why, it’s a looking-glass book, of course! And if I hold it up to a glass, the words will all go the right way again.” (1) In this issue of Pediatric Critical Care Medicine, Jones et al (2) describe the implementation of a tool to facilitate team collaboration and communication as part of a larger study with a global aim to improve outcomes for critically ill children (2). Modeled after a paper Daily Goals Checklist, daily goals are written on the patient room glass door to prompt and support shared understanding of goal-directed care (3). For patients, the Liber8 Glass Door is their own looking-glass with the information appearing backward to those inside the room. Yet, it is a guide to the chaotic world of pediatric critical care that will help the patient to survive and end up safely home through supporting ICU best practices (4). “‘You couldn’t have it if you did want it,’ the Queen said. ‘The rule is, jam to-morrow and jam yesterday-but never jam to-day.’”(1) Despite knowledge that ICU care bundles similar to PICU Liber8 bundle can hasten liberation from mechanical ventilation and the ICU while improving patient outcomes (5–7), implementation in PICUs remain variable. National guidelines recommend implementing such bundles (8), yet, significant barriers derail successful implementation and/or sustainability, even for those who want it (9). The key strength of the work by Jones et al (2) is their low cost, simple, effective, and feasible tool, which could be adapted for all care settings, coupled with the “how” of implementation (paper reference). Using a straightforward implementation strategy, Pronovost’s 4Es of engagement, education, execution, and evaluation (10), they create an implementation roadmap for any team looking to employ a similar quality improvement intervention. Most remarkably, their solution masterfully maximizes the concept of visibility to all team members, including the family. The goals are shared, standardized, and no one involved in the patient’s care could claim difficulty finding them. “The Red Queen shook her head. ‘You may call it “nonsense” if you like,’ she said, ‘but I’ve heard nonsense, compared with which that would be as sensible as a dictionary!’ (1)” Plenty of pediatric critical care colleagues will, unfortunately, discount sensible projects such as the Liber8 Glass Door, citing a lack of rigorous evaluation, privacy concerns, or believing technological solutions would be better. However, as Red Queens ourselves in pediatric critical care, we stand alongside Jones et al (2) to say that sensible science is exactly what we should be leading, presenting, publishing, and sharing as a scientific community to improve patient care today. The authors outline the limits of their work and address privacy concerns on both institutional and patient levels that would be feasible within many countries including the United States. This article joins numerous others in the pediatric critical care quality improvement and implementation science realm presenting readers with a guide for leading change. Importantly but not surprisingly, like other clinical decision support interventions (11), translating this work to the electronic health record did not improve communication or compliance. “Alice laughed. ‘There’s no use trying,’ she said: ‘one can’t believe impossible things.’ ‘I daresay you haven’t had much practice,’ said the Queen. ‘When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.’ (1)” To accomplish impossible things in pediatric critical care, we need to believe impossible things and realize sometimes it merely takes several simple things all put together to achieve the impossible. Then by utilizing a pragmatic approach based in implementation science, we can accomplish our goals. Engaging families and stakeholders, applying implementation methodology, and measuring our impact and outcomes is necessary to drive ongoing transformation. Studies like those of Jones et al (2) give us roadmaps for implementing change locally. We must also continue our larger learning health networks to examine generalizability of such interventions more broadly, and this collaborative science will allow us to accomplish as many as six impossible things before breakfast.

Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project.

To develop and implement a tool to improve daily patient goal setting, team collaboration and communication. Quality improvement implementation project. Tertiary-level PICU. Inpatient children less than 18 years old requiring ICU level care. A "Glass Door" daily goals communication tool located in the door front of each patient room. We used Pronovost's 4 E's model to implement the Glass Door. Primary outcomes were uptake of goal setting, healthcare team discussion rate around goals, rounding efficiency, acceptability and sustainability of the Glass Door. The total implementation duration from engagement to evaluation of sustainability was 24 months. Goal setting increased significantly from 22.9% to 90.7% ( p < 0.01) patient-days using the Glass Door compared to a paper-based daily goals checklist (DGC). One-year post implementation, the uptake was sustained at 93.1% ( p = 0.04). Rounding time decreased from a median of 11.7 minutes (95% CI, 10.9-12.4 min) to 7.5 minutes (95% CI, 6.9-7.9 min) per patient post-implementation ( p < 0.01). Goal discussions on ward rounds increased overall from 40.1% to 58.5% ( p < 0.01). Ninety-one percent of team members perceive that the Glass Door improves communication for patient care, and 80% preferred the Glass Door to the DGC for communicating patient goals with other team members. Sixty-six percent of family members found the Glass Door helpful in understanding the daily plan and 83% found it helpful in ensuring thorough discussion among the PICU team. The Glass Door is a highly visible tool that can improve patient goal setting and collaborative team discussion with good uptake and acceptability among healthcare team members and patient families.

Curious case of a spurious medical gas cylinder.

INTRODUCTION Anaesthesia machines are supplied through a central medical gas pipeline system (MGPS) or cylinders. Type E cylinders are used as backup when the pipeline system fails.[1,2] Ensuring a filled type E oxygen cylinder attached to the anaesthesia machine is an element of the pre-use daily equipment checklist in the operating rooms (ORs).[3] Various safety features ensure that correct gas is delivered to the patient through the cylinders, namely colour coding and label, pin index system, etc. Pin index is unique to each gas and prevents connection of wrong cylinder to the anaesthesia machine.[4] We report our recent encounter with a cylinder, colour coded (black body and white shoulder) and labelled for oxygen but with a pin index and label on valve for nitrous oxide (N2O). CASE REPORT In an OR, the backup oxygen cylinder was empty. Hence, another oxygen cylinder (as identified by ‘O2’ marking and colour coding) was attempted to attach to the hanger yoke assembly. However, it could not be attached. Upon close inspection of the cylinder, the holes on the cylinder corresponded to pin index of N2O, (3,5) and N2O was engraved on the valve [Figure 1a and b]. This cylinder could be successfully attached to the nitrous oxide hanger yoke assembly without any leak [Figure 1c]. Also, there was doubt regarding the actual contents of the cylinder. The anaesthetic gas monitor (AGM) of the anaesthesia workstation (Datex Ohmeda 9100c NXT, GE Healthcare, United Kingdom) was utilized after disconnecting the N2O and air pipelines. The oxygen pipeline was not disconnected since N2O cannot be turned on without oxygen. A test lung was connected to the breathing circuit, and gas flow was turned on (O2:N2O 50:50; 5 L/min each). The N2O flowmeter was supplied by the spurious cylinder and oxygen flowmeter by the pipeline. As depicted by the AGM, both the inspiratory and expiratory gases had just oxygen and no N2O, indicating that the actual content of the cylinder in question was oxygen. The faulty oxygen cylinder was labelled appropriately for caution and segregated, and another oxygen cylinder was attached as backup for the day. The event was reported to the hospital authorities for suitable action towards the supplier/manufacturer.Figure 1: (a) Cylinder, colour coded for oxygen (black body and white shoulders) with N2O engraved over the valve (black arrow); (b) Pin holes corresponding to pin index of nitrous oxide (white arrow); and (c) The spurious cylinder attached to nitrous oxide hanger yoke, since it could not be attached to the oxygen hanger yokeDISCUSSION Despite the technical advances and incorporation of safety features, potentially catastrophic events continue to happen every now and then. Pauling and Ball reviewed case reports pertaining to the delivery of anoxic gas mixtures to the patients, both prior to and after the obligatory safety checklist.[5] The safety features are prone to disregard which may arise out of unawareness, disinterest or accident. This can occur at any point in the process, manufacturer, supplier or end user. Pin index system has been instrumental in preventing erroneous connection of cylinder. The pin index system is also used to fill the correct gas in the cylinder.[6] However, this system is not infallible. It can be bypassed by using an adapter while filling the gas or using multiple washers (Bodok seal) while attaching to the hanger yoke assembly of anaesthesia machine. The same seemed to have happened in our case as well, where oxygen was filled in the cylinder through a N2O valve. Had it been the other way around with N2O filled in an oxygen cylinder, the outcome could have been catastrophic. Ours was a clear instance of threading a N2O valve onto a shoulder and body which was colour coded and labelled for oxygen. This could have been the result of amateurish work in an unsupervised environment at the point of manufacturing. Sensitization, upskilling, training and reeducating at this level of the supply chain are mandatory to avoid such mishaps. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Fitness checklist model for spontaneous breathing tests in pediatrics.

To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

Modelo de checklist de aptidão para teste de respiração espontânea em pediatria

OBJECTIVE: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. METHODS: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. RESULTS: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. CONCLUSION: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

Intensive care nurses' knowledge and use of a nursing checklist: A cross-sectional survey.

This descriptive study was conducted to determine the awareness of nurses working in intensive care units about the daily patient checklist. Checklists are used in the daily follow-up and evaluation of patients admitted to the intensive care unit. The research was carried out with 180 nurses through the social media account of the Turkish Intensive Care Specialists Association Nurse Commission between July 2021 and March 2022. Data were collected with a descriptive information form and intensive care unit daily patient checklist. Necessary permissions were obtained before the study. Among nurses, 45.0% of them got 15 full points from the Checklist. Moreover, 81.1% of the nurses stated that they knew that a checklist should be used to help eliminate the deficiencies of daily care and treatment in the intensive care unit, while 66.7% stated that they used a checklist. It was determined that nurses knew the most about parameters 'Check the daily infection parameters', 'Glycaemic control', 'Therapy', and the least about parameters 'Thromboprophylaxis', 'Ulcer prevention', 'Hypo-hyper delirium' and 'Use a daily checklist'. It was determined that the level of awareness of intensive care unit nurses about some parameters that should be followed daily for patient care was low. Checklists can be used as a guide for health care professionals in the routine daily evaluation of intensive care unit patients. It is thought that these reminder abbreviations will provide efficiency in preventing the disruption of applications, reducing medical errors, reducing mortality and morbidity, and cost.

Discussion Guide for the Alves Article.

Discussion Guide for the Alves Article.

Managing Thirst in the Critically Ill.

Managing Thirst in the Critically Ill.

Pembuktian Isu Kehilangan BBM Head Truck Depo Transhipment Pada PT. Berkah Multi Cargo Logistic

Head truck activities at PT. BMC Logistics is currently experiencing the issue of fuel consumption which is considered too wasteful, therefore it is suspected that there is a theft of fuel in the fuel tank. This study aims to prove the issue of fuel loss caused by theft by calculating the average fuel consumption (liters / hour) on each head truck every day with a sample of 15 head truck units located at the transshipment depot of PT. BMC Logistics which is located on Jalan Perak Utara, Pabean Cantian, Surabaya, East Java 60165. The research uses quantitative methods by collecting data based on a daily head truck checklist data sample from July 2021 to October 2021, then an average consumption of Liters per hour is made from the initial fuel filling to the next fuel filling, then a normality test is carried out to find out whether H0 (theft did not occur) is accepted or rejected. From the results of the study it was found that the test data were normally distributed. which means that the issue of fuel theft really didn't happen.