Ventilator Alarms Research Articles

Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study.

Objectives. Management of mechanically ventilated patients may pose a challenge to novice residents, many of which may not have received formal dedicated critical care instruction prior to starting their residency training. There is a paucity of data regarding simulation and mechanical ventilation training in the medical education literature. The purpose of this study was to develop a curriculum to educate first-year residents on addressing and troubleshooting ventilator alarms. Methods. Prospective evaluation was conducted of seventeen residents undergoing a twelve-hour three-day curriculum. Residents were assessed using a predetermined critical action checklist for each case, as well as pre- and postcurriculum multiple-choice cognitive knowledge questionnaires and confidence surveys. Results. Significant improvements in cognitive knowledge, critical actions, and self-reported confidence were demonstrated. The mean change in test score from before to after intervention was +26.8%, and a median score increase of 25% was noted. The ARDS and the mucus plugging cases had statistically significant improvements in critical actions, p < 0.001. A mean increase in self-reported confidence was realized (1.55 to 3.64), p = 0.049. Conclusions. A three-day simulation curriculum for residents was effective in increasing competency, knowledge, and confidence with ventilator management.

EFFECT OF NEBULIZED COLISTIN ON THE VENTILATOR CIRCUIT: A PROSPECTIVE PILOT CASE-CONTROL STUDY FROM A SINGLE CANCER CENTER

Nebulized colistin (NC) is used for the treatment of pneumonia due to multidrug- resistant Gram-negative bacteria. In this one-year case-control study, our objective was to evaluate the effect of NC on the ventilator circuit (VC) components. The case group consisted of 25 mechanically-ventilated patients who received NC for the treatment of nosocomial pneumonia while the control group was 25 mechanically-ventilated patients who did not receive NC. Respiratory therapists inspected the VC every 4 hrs and whenever a ventilator alarm was reported. The VC component was changed if the alarm did not subside after necessary measures were performed. Patients from both groups were treated at the adult medical/surgical intensive care unit at King Hussein Cancer Center. In the case group, 22 (88%) patients required changing at least one of the circuit components (flow sensor, exhalation membrane, or nebulizer kit). The median number of changes (range) per patient of the flow sensor, exhalation membrane, and nebulizer kit were: 2 (1–3), 2 (1–6), and 1 (1–2), respectively. Large amounts of white crystals, which resembled the colistin powder, were reported on the replaced VC components. The flow sensor was changed in 2 control patients, but white crystals were absent. Crystals obtained from one case subject were confirmed to be colistin by chromatographic mass spectroscopy. Further studies are needed to evaluate the effect of crystal formation on the efficacy of NC and clinical outcomes.

A randomized controlled trial of adaptive support ventilation mode to wean patients after fast-track cardiac valvular surgery.

Adaptive support ventilation can speed weaning after coronary artery surgery compared with protocolized weaning using other modes. There are no data to support this mode of weaning after cardiac valvular surgery. Furthermore, control group weaning times have been long, suggesting that the results may reflect control group protocols that delay weaning rather than a real advantage of adaptive support ventilation. Randomized (computer-generated sequence and sealed opaque envelopes), parallel-arm, unblinded trial of adaptive support ventilation versus physician-directed weaning after adult fast-track cardiac valvular surgery. The primary outcome was duration of mechanical ventilation. Patients aged 18 to 80 yr without significant renal, liver, or lung disease or severe impairment of left ventricular function undergoing uncomplicated elective valve surgery were eligible. Care was standardized, except postoperative ventilation. In the adaptive support ventilation group, target minute ventilation and inspired oxygen concentration were adjusted according to blood gases. A spontaneous breathing trial was carried out when the total inspiratory pressure of 15 cm H2O or less with positive end-expiratory pressure of 5 cm H2O. In the control group, the duty physician made all ventilatory decisions. Median duration of ventilation was statistically significantly shorter (P = 0.013) in the adaptive support ventilation group (205 [141 to 295] min, n = 30) than that in controls (342 [214 to 491] min, n = 31). Manual ventilator changes and alarms were less common in the adaptive support ventilation group, and arterial blood gas estimations were more common. Adaptive support ventilation reduces ventilation time by more than 2 h in patients who have undergone fast-track cardiac valvular surgery while reducing the number of manual ventilator changes and alarms.

Board #108 - Research Abstract Using Reflective Writing to Assess Impact of an Inter-Professional Cardio-Pulmonary Workshop for Medical, Nursing and Respiratory Therapy Students (Submission #8645)

Hypothesis Modern healthcare is delivered in teams; however, healthcare education has lagged behind practice in providing opportunities for students to learn the skills required to function effectively as a member of an inter-professional (IP) team. Educators are challenged to create effective training activities that expose students to communication skills and allow the opportunity to practice these skills. The outcome of these activities should be students who use these skills in the clinical environment to improve patient care. This highlights a second set of challenges – creating training curricula that effectively transfer these skills from the simulation lab into actual clinical practice, and developing metrics to assess the transfer of training.Our hypothesis is that reflective writing can be used to assess the impact of an IP training curriculum on the students’ application of communication skills in the clinical environment. Methods We developed a simulation-based curriculum for nursing, respiratory (RT), and medical (med) students around critical care topics. In one station, students engaged in faculty facilitated group problem-solving for ventilator alarms, exam and transfer of a ventilated patient. The second station involved immersive simulation in which IP student teams assessed and managed a patient with a cardiac arrhythmia. Within the technical skills training, nursing and medical faculty co-led discussion and demonstration of interprofessional team skills including closed-loop communication, flattened hierarchy, anticipatory behavior, role clarity, and shared mental model. Curriculum effectiveness was evaluated through post workshop survey and participant reflective essays addressing an example of how the skills were applied in practice. 3 independent trained reviewers used qualitative content analysis to identify themes in each of the essays. Differences were resolved through discussion and consensus. Results One-hundred nursing, 20 med, and four RT students participated. Fortynine nursing and 17 med students filled out post surveys. One-hundred nursing and 20 med students completed reflective writing. We coded 20 randomly sampled nursing essays and 20 medical student essays. 65/67 students rated the workshop as good or excellent in teaching teamwork skills. Nursing and med student reflective writing themes were similar. We observed different Kirkpatrick levels of impact in the essays, including multiple levels in a single essay. 75% of students described applying at least one new teamwork skill in clinical practice, and 60% of these students observed an improved patient, team or personal outcome as a result of skill use, including improved efficiency and quality of care, fewer errors and increased confidence. 35% observed a teamwork skill in a team member, and 64% described new knowledge or awareness. The dominant skills used or observed were closed-loop communication, role clarity, and flattened hierarchy. Conclusion This IP simulation-based workshop was well rated by students, who felt this format effectively taught teamwork skills. A single exposure to these skills has incomplete transfer into clinical practice for these undergraduate learners. The reflective writing pieces were completed within one month of training, but we expect that if teamwork skills haven’t been practiced by then, they are not likely to be used without additional training or structured opportunities to practice. Additional measures of participants’ teamwork skills in the lab and in practice would help better understand the correlation between self-reflection and actual effectiveness of teamwork skills in an individual. While much of team training research has been focused on practicing providers, interventions at the early clinical or pre-clinical levels may prove more effective. More work is needed to understand the “dosing” and “frequency” required for effective teamwork skills acquisition and transfer to practice. Disclosures None

Audits in real time for safety in critical care: Definition and pilot study

Adverse events significantly impact upon mortality rates and healthcare costs. PurposeTo design a checklist of safety measures based on relevant scientific literature, apply random checklist measures to critically ill patients in real time (safety audits), and determine its utility and feasibility. MethodsA list of safety measures based on scientific literature was drawn up by investigators. Subsequently, a group of selected experts evaluated these measures using the Delphi methodology. Audits were carried out on 14 days over a period of one month. Each day, 50% of the measures were randomly selected and measured in 50% of the randomized patients. Utility was assessed by measuring the changes in clinical performance after audits, using the variable improvement proportion related to audits. Feasibility was determined by the successful completion of auditing on each of the days on which audits were attempted. ResultsThe final verified checklist comprised 37 measures distributed into 10 blocks. The improvement proportion related to audits was reported in 83.78% of the measures. This proportion was over 25% in the following measures: assessment of the alveolar pressure limit, checking of mechanical ventilation alarms, checking of monitor alarms, correct prescription of the daily treatment orders, daily evaluation of the need for catheters, enteral nutrition monitoring, assessment of semi-recumbent position, and checking that patient clinical information is properly organized in the clinical history. Feasibility: rounds were completed on the 14 proposed days. ConclusionsAudits in real time are a useful and feasible tool for modifying clinical actions and minimizing errors.

The effects of different mechanical ventilation flow model on the peak airway pressure during cardiopulmonary resuscitation

To observe the method of mechanical ventilation in the chest compressions during cardiopulmonary resuscitation (CPR), and to explore the influence of the flow pattern selection of square-wave and decelerating-wave on airway pressure of patients. A prospective self-pairing study was conducted. Forty patients undergoing CPR admitted to Department of Emergency of Lishui City Central Hospital from January 2011 to February 2013 were enrolled. Using Respironics Eisprit ventilator, the working mode and parameters of ventilator were set reasonably according to previous research, while the chest compressions was performed in a stable state by the same doctor,. Each patient received different flow, waves, including square-wave and decelerating-wave, and the highest peak airway pressure was recorded as a pair of data when the time-pressure and time-flow waveform were frozen. Two pairs of data by different doctors were collected in each patient. Eighty pairs of data from 40 patients were collected for statistical analysis by paired t test. The highest peak airway pressure of decelerating-wave was (38.15 ± 5.99) cmH₂O (1 cmH₂O=0.098 kPa), which was (5.71 ± 1.98) cmH₂O lower than that of square wave [(43.86 ± 6.68) cmH₂O] with significantly statistical difference (t=22.010, P=0.000). 73.75% patients undergoing square wave with peak airway pressure over 40 cmH₂O were found, but only 45.00% patients were found in decelerating-wave. Because decelerating-wave used in mechanical ventilation during CPR can obviously reduce the peak airway pressure, the occurrence of barotrauma, and the probability of triggering high pressure ventilator alarm, and improve the compliance of ventilator, so decelerating-wave is more reasonable than square-wave.

Preliminary development and evaluation of the support system for care of mechanically ventilated patients

We wanted to demonstrate the feasibility of a novel computer-assisted ventilator alarm system, the support system for care of mechanically ventilated patients (SCMVP), to detect gas leaks and provide graphical information on the site of the leak in a manikin model. We tested six leakage scenarios. Four scenarios were applied to both the respiratory circuits with the SCMVP and without the SCMVP (conventional system), and two scenarios were each specific to one of the systems. Fifteen registered nurses were asked to manage three scenarios each (two mutual and one system-specific scenario). Time to identify the site of the leak was measured and compared between the two systems. The SCMVP showed significantly shorter time for troubleshooting in one of the four mutual scenarios and shorter accumulated time for troubleshooting in the four mutual scenarios [18.0 (range, 14.5-19.5) and 48.5 (9.0-180.0) s, respectively] compared with the conventional system [76.0 (47.0-133.8) and 82.5 (16.0-180.0) s, respectively]. In the mutual scenarios, SCMVP resulted in significantly more frequent incidences of successful troubleshooting within 30 s and less frequent incidences of troubleshooting requiring >180 s [43.3% (13/30) and 6.7% (2/30), respectively] compared with the conventional system [13.3% (4/30) and 30% (9/30), respectively]. The SCMVP can facilitate rapid and successful recognition of the site of leak in a respiratory circuit in a simulation environment.

Enabling speech in ICU patients during mechanical ventilation

Dear Editor, Inability to speak during mechanical ventilation (MV) increases psycho-emotional distress during ICU treatment [1]. Although relevant for all ICU patients, this problem becomes more prominent in patients with a prolonged weaning period. One way to enable speech in tracheotomised patients during the weaning period is to alternate MV with time-limited trials of cuff-deflated spontaneous breathing in combination a speaking valve. However, not all patients tolerate such interruptions of MV [2]. Although not commonly used, MV with deflated cuff in tracheotomised patients may be an alternative approach, and has been provided safely and comfortably in selected groups of non-ICU patients [3]. Its use has been associated with improved swallowing and the possibility to speak [4]. However, in daily clinical ICU practise the use of MV under such conditions is limited by multiple ventilator alarms, as a result of air leakage. Furthermore, optimisation of speech is hampered by loss of airflow during open airway MV. We describe our experiences to improve speech in tracheotomised ICU patients during cuff-deflated MV, in combination with a high flow non-invasive ventilator and a one-way tracheostomy speaking valve. In 2013, 24 patients in our mixed medical-surgical ICU were tracheotomised, using a percutaneous dilatation technique. Five patients were able to wean and speak with progressive periods of spontaneous breathing trials. Five patients were weaned from MV without the ability to speak, one patient died within 2 days after the tracheotomy, and one patient had persistent insufficient air leakage around the cannula, despite reduction in cannula size. Table 1 summarizes the characteristics of the remaining 12 patients. Within 24 h after the tracheotomy procedure air leakage was present after deflation of the cuff. Invasive pressure support ventilation was replaced by a BiPAP mode with a non-invasive ventilator (BiPAP Vision®, Philips, Best, the Netherlands) at equal ventilator settings. A minimum PEEP level of 8 cmH2O was maintained in order to prevent rebreathing of CO2. Furthermore, an increasing level of PEEP has been associated with a prolonged duration and improved quality of speech [5]. In case all expiratory flow passed through the oropharyngeal route, a Passy Muir® speaking valve (Passy Muir Inc., Irvine, USA) was installed in the circuit to enhance speech (Fig. 1). All 12 patients were able to speak in the first day after switching to the BiPAP setting, enabling effective communication with relatives and medical personnel. Quality and duration of speech improved over time. Effective weaning from MV was achieved in all patients by progressive intervals of CPAP. During CPAP the ability to speak was similar to that in the BiPAP mode. Median time from the beginning of speech to the end of MV was 12 ± 6 days. Table 1 Patient characteristics Fig. 1 Ventilator setting; Passy Muir® one-way speaking valve in red circle We conclude that in a selected group of difficult-to-wean tracheotomised ICU patients the ability to speak may effectively be restored by cuff-deflated non-invasive BiPAP ventilation in combination with a one-way speaking valve. We encourage intensive care personnel to develop similar weaning protocols, in an effort to improve well-being of ICU patients.

Examining pediatric emergency home ventilation practices in home health nurses: Opportunities for improved care

To assess the pediatric home health nurses' knowledge in tracheostomy and ventilator emergency care on home mechanical ventilation (HMV). Emergencies are frightening experiences for solo home health nurses and require advanced skills in emergency response and care, especially in pediatric patients who pose unique challenges. Nurses with greater years of nursing experience would perform better on emergency HMV case-based scenarios than nurses with less years of experience. An exploratory online survey was used to evaluate emergency case-based pediatric scenarios. Demographic and professional experiences were profiled. Seventy-nine nurses had an average of 6.73 (SD = 1.41) years in pediatric nursing. Over 70% received their HMV training in their agency, 41% had less than 4 years of experience, and 30.4% had encountered at least one emergency situation at home. The online survey was distributed by managers of 22 home health agencies to nurses providing pediatric HMV care. Nurses scored an average of 4.87 out of 10 possible points. There were no significant differences between nurses with <4 years of experience versus those with more experience on ventilator alarms knowledge or total knowledge. Ninety-seven percent of the nurses favored more training in HMV from a variety of settings (e.g., agency, on-line training). Nurses did not perform well in case-based ventilator alarm scenarios. Length of nursing experience did not differentiate greater knowledge. It is clear that nurses require and want more training in emergency-based HMV. Recommendations for an enhanced curriculum are suggested.

A study of the value of high frequency chest wall oscillation in patients with acute exacerbation of chronic obstructive pulmonary disease

To explore the safety and efficacy of high-frequency chest wall oscillation (HFCWO) in invasive mechanical ventilation patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). A prospective, randomized, controlled trial was conducted. Thirty-five AECOPD patients with invasive mechanical ventilation were included in the intensive care unit of West China Hospital of Sichuan University from February 2012 to February 2013. The patients were randomly allocated into a HFCWO (H) group and a control group using SAS 9.1 software . The control group received routine therapy, while the H group received HFCWO, along with routine therapy. Invasive mechanical ventilation time, noninvasive ventilation time, total mechanical ventilation time, ICU stay time, hospital stay time and pH, oxygen index (OI) during the first 7 days were collected. At the same time, heart rate, blood pressure, respiratory rate, SpO2 and peak airway pressure before, during and after HFCWO and ventilation alarm of the H group were collected. The total mechanical ventilation time of patients in the H group was significantly shorter than that of the control group [(10 ± 6) d and (15 ± 8) d, P < 0.05]. But there were no significant differences between the 2 groups in invasive mechanical ventilation time, noninvasive ventilation time, ICU stay and hospital stay time (P > 0.05). There were no significant differences between the 2 groups in pH and oxygen index during the first 7 days (P > 0.05). There were no change in heart rate, blood pressure, respiratory rate, SpO2 and peak airway pressure before, during and after HFCWO in the H group (P > 0.05). Severe ventilator alarm(level 3) occurred in 3.67% patients, but there was no significant correlation between ventilation alarm and patient prognosis. HFCWO is very safe and comfortable in ventilated patients with AECOPD. It reduces the total mechanical ventilation time, but cannot improve the prognosis.

Audits in real time for safety in critical care: Definition and pilot study

Adverse events significantly impact upon mortality rates and healthcare costs. PurposeTo design a checklist of safety measures based on relevant scientific literature, apply random checklist measures to critically ill patients in real time (safety audits), and determine its utility and feasibility. MethodsA list of safety measures based on scientific literature was drawn up by investigators. Subsequently, a group of selected experts evaluated these measures using the Delphi methodology. Audits were carried out on 14 days over a period of one month. Each day, 50% of the measures were randomly selected and measured in 50% of the randomized patients. Utility was assessed by measuring the changes in clinical performance after audits, using the variable improvement proportion related to audits. Feasibility was determined by the successful completion of auditing on each of the days on which audits were attempted. ResultsThe final verified checklist comprised 37 measures distributed into 10 blocks. The improvement proportion related to audits was reported in 83.78% of the measures. This proportion was over 25% in the following measures: assessment of the alveolar pressure limit, checking of mechanical ventilation alarms, checking of monitor alarms, correct prescription of the daily treatment orders, daily evaluation of the need for catheters, enteral nutrition monitoring, assessment of semi-recumbent position, and checking that patient clinical information is properly organized in the clinical history. Feasibility: rounds were completed on the 14 proposed days. ConclusionsAudits in real time are a useful and feasible tool for modifying clinical actions and minimizing errors.

Pain assessment scales in nonverbal critically ill adult patients: ventilator-related issues

critical points regarding these scales. First, the CPOT and the BPS do not have a specific item for patients who are in a coma (Glasgow Coma Scale ≤8), with artificial airways (eg, tracheostomy tube), who are breathing spontaneously without receiving mechanical ventilation. Other important concerns are items that evaluate patients’ compliance with ventilators. When patients cough we expect to hear the sound of ventilator alarms, which occurs only if alarms have been adequately set up. Consequently, the evaluation of this item is dependent on the variability of clinical settings and health care professionals. Another element that can make it difficult to recognize a patient “fighting with the ventilator” is the use of ventilation modes based on active expiration valves (eg, BIPAP, Drager; DuoPAP, Hamilton; BiVent, Siemens; Bi-Level, Puritan BennettCovidien). These ventilation modes let the patients breathe spontaneously, without activating the ventilator alarms. The identification of patient-ventilator asynchronies is made by the direct observation of patients and the interpretation of ventilator waveforms. A recent European survey has shown a wide variability in ventilator education provided to ICU nurses. Unfortunately we do not know how many nurses are “comfortable” with ventilator graph interpretation, even if 83% consider waveform analysis education “important” or “very important.” Presently, there is a lack of papers published about this issue. Finally, some clinical conditions, not necessarily related to pain, can determine the activation of ventilator alarms due to patients’ dyssynchronies: hiccup and seizures. These conditions can determine false positive results. We hope that our observations can be helpful to improve these pain assessment tools for critically ill patients. CCN

Impact of a continuous education program on the quality of assistance offered by intensive care physiotherapy

ObjectiveTo evaluate the role of quality indicators and adverse events registering in the quality assessment of intensive care physiotherapy and to evaluate the impact of implementing protocolized care and professional training in the quality improvement process.MethodsA prospective before-after study was designed to assess 15 indicators of the quality of care. Baseline compliance and adverse events were collected before and after the implementation of treatment protocols and staff training.ResultsEighty-nine patients admitted, being 48 in the pre-intervention period and 41 in the post-intervention period with a total of 1246 and 1191 observations respectively. Among the indicators related to the global population, there was a significant improvement in chest x-ray control, multidisciplinary rounds and shift changes as well as in compliance with these decisions. Indicators related to the population under mechanical ventilation, obtained by direct observation at bedside, showed a significant improvement in the compliance with the tidal volume of 6-8mL/Kg, plateau pressure <30cmH2O, adequate mechanical ventilation alarm setting, mechanical ventilation humidification control, adequate humidification line exchange and orotracheal tube position. Among the mechanical ventilation indicators collected through the physiotherapy records, there was significantly improved compliance with the predicted tidal volume registry and cuff pressure registry. There was a significant reduction in the number of adverse events. There was no impact on intensive care unit mortality, length of stay, duration of mechanical ventilation and ventilator-free days.ConclusionIt is possible to measure the quality of physiotherapy care using indicators of quality control. The implementation of care protocols and training of the professionals can improve team performance.

Use of filters in anaesthesia: Is it warranted?

Use of filters in anaesthesia: Is it warranted?

Sleep fragmentation and deprivation in critically ill patients – Is noise a factor?

High noise levels disrupt quality and reduce quantity of sleep. Excessive noise may thereby increase the risk of delirium, resulting in increased Medical Intensive Care Unit (MICU) length of stay and possibly increased mortality. The study was conducted in a 24 bed tertiary care academic MICU where Physicians, Nurses, and other allied health care providers were involved. A pre-post intervention design methodology was used for this study. MICU staff responded to an online survey assessing baseline perceptions about patients’ sleep quality and quantity. Data was also gathered on providers’ perception of noise levels in the MICU and factors contributing to high noise levels. In addition, baseline measurements of noise levels (in decibels (dBA) were obtained using a dosimeter. Decibel levels for different noise sources such as ventilator alarms, infusion pumps, telephones, pagers and staff conversations were measured. Multi-pronged interventions involving environmental changes (reducing alarm sound levels, reducing telephone ringer levels etc.), provider education and patient level interventions (use of sleep enhancement order sets, closing room doors at night time to reduce noise exposure) were implemented. A repeat survey was performed post-intervention to re-assess provider perceptions regarding patients’ sleep and noise levels in the MICU. Also, noise levels were re-measured with the dosimeter. Baseline survey data revealed that 88% of the MICU staff agreed that patients slept poorly in the MICU, 69% felt that on an average our patients slept for less than 4 h per day, and more than half (52%) of the interruptions to sleep were secondary to high noise levels. Noise level measurements revealed that alarms (64 dBA), pagers (64 dBA) and staff conversations (60 dBA) were the most significant contributors to noise. Post-intervention, we noted an increase in the proportion of respondents (26% vs 35% p = 0.07) who felt that our patients slept more than 5 h per day. Also, post- intervention, staff continued to perceive that greater than 50% of the interruptions to sleep were secondary to noise. Although mean noise levels were not significantly different pre and post intervention (54.2 dBA vs 53.8 dBA), there was a significant reduction in the number of episodes of peak noise level elevations above 60 dBA (1735 vs 1289, p = <0.00). High noise level in the MICU is a contributing factor to patient’s sleep fragmentation and deprivation in the ICU. Reducing mean and peak noise levels in an ICU proved difficult, and gains may be difficult to sustain over time. In addition to noise reduction, efforts to modify the patient experience of noise, such as provision of hearing protection or white noise, may be more fruitful in reducing influence on sleep. Medical Intensive Care Unit staff at Mayo Clinic, Rochester, MN.

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Introduction: To determine if medical intensive care unit (MICU) noise levels and alarm rates can be reduced using a nighttime noise reduction bundle (NNRB) and a streamlined patient monitoring alarm profile. Methods: This study uses a before and after design to evaluate the combined effect of the bundle and a new alarm profile in a MICU. NNRB elements included posting quiet hours signs, closing patient room doors, reducing IV pump and monitor volumes, modifying workflow to avoid precipitating alarms, turning off TVs and radios, and reducing the volume of staff voices. The new alarm profile was designed to reduce nuisance alarms by applying more stringent alarm criteria. Staff was educated about the interventions before implementation. Number of alarms, compliance with the NNRB, and noise levels were measured for two weeks before and after launch. Alarm number by type was counted every eight hours. Compliance with measurable bundle elements was assessed nightly. Noise was measured in decibels (dB) every one minute at four locations, including inside two patient rooms on opposite sides of the unit and in general care areas at the front and back. Results: Several metrics of noise were significantly reduced, including noise over 24 hours (median 54.3 to 53.0 dB, p<0.0005) and noise at night (median 52.8 to 51.3 dB, p<0.0005). Total alarms, total yellow alarms, and red arrhythmia alarms were all significantly decreased, although red non-arrhythmia alarms increased. This was likely due to the installation of a ventilator update between study phases that was outside the purview of the researchers and that resulted in a concurrent increase in red ventilator alarms. Staff compliance with measurable bundle elements was mixed. Monitor volumes, IV pump volumes, and quiet hour sign use were all significantly improved, but TVs were significantly more likely to be on. There was no change in radio use or door closure. Conclusions: The NNRB and streamlined alarm profile successfully reduced noise and decreased alarms. MICU staff was willing to comply with most requests to change work practices to reduce noise.

Behavior observation of major noise sources in critical care wards

PurposeThis study aimed to investigate the behavior patterns of typical noise sources in critical care wards and relate their patterns to health care environment in which the sources adapt themselves in several different forms. MethodsAn effective observation approach was designed for noise behavior in the critical care environment. Five descriptors have been identified for the behavior observations, namely, interval, frequency, duration, perceived loudness, and location. Both the single-bed and the multiple-bed wards at the selected Critical Care Department were randomly observed for 3 inconsecutive nights, from 11:30 pm to 7:00 am the following morning. The Matlab distribution fitting tool was applied afterward to plot several types of distributions and estimate the corresponding parameters. ResultsThe lognormal distribution was considered the most appropriate statistical distribution for noise behaviors in terms of the interval and duration patterns. The turning of patients by staff was closely related to the increasing occurrences of noises. Among the observed noises, talking was identified with the highest frequency, shortest intervals, and the longest durations, followed by monitor alarms. The perceived loudness of talking in the nighttime wards was classified into 3 levels (raised, normal, and low). Most people engaged in verbal communication in the single-bed wards that occurred around the Entrance Zone, whereas talking in the multiple-bed wards was more likely to be situated in the Staff Work Zone. As expected, more occurrences of noises along with longer duration were observed in multiple-bed wards rather than single-bed wards. “Monitor plus ventilator alarms” was the most commonly observed combination of multiple noises.

Pilot Balloon Malfunction Caused by Endotracheal Tube Bite Blocker

A patient's bite is a frequent cause of endotracheal tube (ETT) obstruction, which affects the volume and pressure delivered by the ventilator. Bite-related ETT obstruction is a frequent cause of ventilator alarm activation, and can cause respiratory failure, negative-pressure pulmonary edema, and

Unexpected death of a ventilator-dependent amyotrophic lateral sclerosis patient

BackgroundAmyotrophic lateral sclerosis (ALS) is a fatal, progressive, neurodegenerative disease and most patients affected die of respiratory compromise and/or pneumonia within 2–3 years of diagnosis. As ALS progresses, ventilator assistance is required. In the end stages of the disease, patients suffer from respiratory failure and may become ventilator-dependent. Deaths due to malfunction of mechanical ventilators are reported but there are very few forensic autopsy records. We report the case of a 69-year-old ALS female ventilator-dependent, trachostomised patient who was found dead by her husband, with the ventilator in “stand-by” mode. MethodA forensic autopsy was performed. Samples of internal organs were taken for histological and toxicological examination. The ventilator internal memory was also analysed and tested in order to find possible malfunction. ResultsGross examination did not reveal any sign of trauma but showed brain and lung congestion. Pulmonary histological examination revealed thickening of peribronchial interstitial space, alveolar over-distension, break of inter-alveolar walls and diffuse alveolar haemorrhages. Focal microhemorrhages were also detected in other organs. Analysis of the ventilator internal memory showed that during the night of death, there had been several voltage drops. Specific tests revealed malfunction of the internal battery which was unable to provide the necessary voltage, as a consequence the ventilator switched off, stopping ventilation. Battery malfunction reduced the volume of the ventilator alarm, which was not heard by the caregiver. ConclusionHistological pattern, with acute pulmonary emphysema and focal polivisceral haemorrhages, is strongly suggestive of a death due to “acute” asphyxia. The authors also discuss the need for strict supervision and follow up of these ventilatory dependent patients and their devices.

Adding Realism: Manipulation of Alarm Settings to Simulate Ventilation in a Scenario

The participant will be able to adjust the ventilator alarm limits and oxygen parameters to allow for ventilation in a scenario while preventing continuous alarm resonation.