Elizabeth Ely

Systematic Review of Physiologic Monitor Alarm Characteristics and Pragmatic Interventions to Reduce Alarm Frequency

BACKGROUND Alarm fatigue from frequent nonactionable physiologic monitor alarms is frequently named as a threat to patient safety. PURPOSE To critically examine the available literature relevant to alarm fatigue. DATA SOURCES Articles published in English, Spanish, or French between January 1980 and April 2015 indexed in PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Cochrane Library, Google Scholar, and ClinicalTrials.gov. STUDY SELECTION Articles focused on hospital physiologic monitor alarms addressing any of the following: (1) the proportion of alarms that are actionable, (2) the relationship between alarm exposure and nurse response time, and (3) the effectiveness of interventions in reducing alarm frequency. DATA EXTRACTION We extracted data on setting, collection methods, proportion of alarms determined to be actionable, nurse response time, and associations between interventions and alarm rates. DATA SYNTHESIS Our search produced 24 observational studies focused on alarm characteristics and response time and 8 studies evaluating interventions. Actionable alarm proportion ranged from <1% to 36% across a range of hospital settings. Two studies showed relationships between high alarm exposure and longer nurse response time. Most intervention studies included multiple components implemented simultaneously. Although studies varied widely, and many had high risk of bias, promising but still unproven interventions include widening alarm parameters, instituting alarm delays, and using disposable electrocardiographic wires or frequently changed electrocardiographic electrodes. CONCLUSIONS Physiologic monitor alarms are commonly nonactionable, and evidence supporting the concept of alarm fatigue is emerging. Several interventions have the potential to reduce alarms safely, but more rigorously designed studies with attention to possible unintended consequences are needed.

Optimizing the Assessment of Pain in Children Who Are Cognitively Impaired Through the Quality Improvement Process

Pain assessment in children with cognitive impairment (CI) is challenging. A quality improvement (QI) project involving evidence-based review of pain assessment tools, feedback from the Family Advisory Council, trialing of selected tools within clinical settings including obtaining feedback from nurses, and parents caring for nonverbal children with developmental delay was reported. Synthesized evidence supported the adoption of revised Faces, Legs, Activity, Cry, and Consolability pain assessment tool into clinical practice. Results of postimplementation audit and challenges of staff nurse involvement in the QI process were also discussed. The 24-month-long QI process and its impact on changing practice were described in detail.

Polyethylene Glycol Powder Solution Versus Senna for Bowel Preparation for Colonoscopy in Children

Objectives: Safety and effectiveness of large-volume polyethylene glycol-based solution (PEG-ES) have been documented, but the taste and volume can be barriers to successful colonoscopy preparation. Efficacy and safety of small-volume electrolyte-free (PEG-P) preparation (Miralax) for colonoscopy preparation have been rarely studied, although presently used at many pediatric centers. The primary objective of the present study was to determine whether PEG-P results in a more efficacious and safe colonoscopy preparation as compared with senna. Methods: The study design was prospective, randomized, and single-blinded. Patients ages 6 to 21 years were randomized to a 2-day clean-out regimen of PEG-P at a dose of 1.5 g/kg divided twice per day for 2 days versus senna 15 mL daily (ages 6–12) or 30 mL daily (ages 12–21) for 2 days. Both preparations required 1 day of clear liquids whereas senna preparation required an additional day of full liquid diet. A blinded endoscopist graded the quality of preparation with a standardized cleanliness tool (Aronchick scale). Serum chemistry panels were obtained. Patients or parents rated symptoms and ease of preparation. The anticipated number of subjects was 166; however, the interim analysis demonstrated inferiority of senna preparation. Results: Thirty patients were evaluated in the present study. Of the patients in the PEG-P arm, 88% (14/16) received an excellent/good score compared with 29% (4/14), with the senna preparation (P = 0.0022). Both preparations were well-tolerated by patient-graded ease of preparation. Demographics and laboratory values did not differ significantly across the 2 groups. No serious adverse events were noted. Conclusions: PEG-P is an effective colonoscopy preparation whereas senna preparation was insufficient. Both were well-tolerated and appear safe in a pediatric population.

Finding the evidence to change practice for assessing pain in children who are cognitively impaired

We report on a quality improvement project whose purpose was to systematically review behavioral pain assessment tools for children who are cognitively impaired, with the goal of identifying a valid and reliable tool for clinical practice. In addition, we sought to partner with parents and/or caregivers to expand their role in pain assessment. The project team conducted an extensive synthesis of the literature to examine the availability and quality of published pain assessment tools for use with children with cognitive impairment (CI) or developmental disability. Once completed, we identified 2 of the available 10 tools to test in the clinical setting. Data from this quality improvement project provided evidence to support the adoption of the revised Faces, Legs, Activity, Cry, and Consolability pain assessment tool for children with CI into clinical practice.

Measurement of Acute Pain in Infants A Review of Behavioral and Physiological Variables

Background: The use of non-validated pain measurement tools to assess infant pain represents a serious iatrogenic threat to the developing neonatal nervous system. One partial explanation for this practice may be the contradictory empirical data from studies that use newborn pain management tools constructed for infants of different developmental stages or exposed to different environmental stressors. Purpose: The purpose of this review is to evaluate the evidence regarding the physiologic and behavioral variables that accurately assess and measure acute pain response in infants. Methodology: A literature search was conducted using PUBMED and CINAHL and the search terms infant, neonate/neonatal, newborn, pain, assessment, and measurement to identify peer-reviewed studies that examined the validity and reliability of behavioral and physiological variables used for investigation of infant pain. Ten articles were identified for critical review. Principal findings: Strong evidence supports the use of the behavioral variables of facial expressions and body movements and the physiologic variables of heart rate and oxygen saturation to assess acute pain in infants. Conclusion: It is incumbent upon researchers and clinical nurses to ensure the validity, reliability, and feasibility of pain measures, so that the outcomes of their investigations and interventions will be developmentally appropriate and effective pain management therapies.

Pain management for pediatric tonsillectomy: An integrative review through the perioperative and home experience

PURPOSE This integrative review aims to increase our understanding of current pain management care practices for children undergoing tonsillectomy. CONCLUSIONS Synthesis of the literature resulted in four main opportunities for care providers to manage pain: preoperative education and preparation, intraoperative surgical interventions, and postoperative pharmacologic and nonpharmacologic interventions in the post anesthesia care unit and home settings. PRACTICE IMPLICATIONS Nurses have many opportunities to understand pain management practices and intervene to minimize pain experienced in pediatric outpatients undergoing tonsillectomy.

Charting the Course of Pediatric Nursing Research: The SPN Delphi Study

In order to inform the care of children at this pivotal time in the history of healthcare, the Society of Pediatric Nurses (SPN) sought to identify priorities for nursing research and key challenges facing pediatric nursing. A three round Delphi study was conducted electronically with SPN members. The top 10 priorities and challenges were identified and will serve as a valuable guide for pediatric nursing practice, education, policy and administration over the coming decade.

Variation of Opioid Use in Pediatric Inpatients Across Hospitals in the U.S.

CONTEXT Appropriate use of opioids is essential to manage moderate-to-severe pain in children safely and effectively, yet published guidance regarding opioid treatment for pediatric patients is limited, potentially resulting in excessive variation in opioid use in pediatric patients across hospitals in the U.S. OBJECTIVES The aim was to evaluate hospital variation in opioid use in pediatric inpatients. METHODS Using data from the Pediatric Health Information System and the Premier Perspective Database regarding all pediatric inpatients in 626 hospitals, we examined hospital variation in opioid use and the length of opioid use, adjusting for patient demographic and clinical characteristics and for hospital type (childrens vs. general) and hospital patient volume, using multilevel generalized linear regression modeling. RESULTS Overall, 41.2% of all pediatric hospitalizations were exposed to opioids. Among the exposed patients, the mean length of exposure was 4.6 days. Exposure proportion and exposure length varied substantially across hospitals, even after accounting for patient demographic and clinical characteristics, hospital type and hospital patient volume, especially among terminal hospitalizations. For patients discharged alive vs. died, the adjusted exposure percentage for each hospital ranged from 0.7% to 99.1% (interquartile range [IQR]: 35.3%-59.9%) vs. 0.1% to 100.0% (IQR: 29.2%-66.2%), respectively, and the adjusted exposure length ranged from 1.0 to 8.4 days (IQR: 2.2-2.7 days) vs. 0.9 to 35.2 days (IQR: 4.0-7.4 days). CONCLUSION The substantial hospital-level variation in opioid use in pediatric inpatients suggests room for improvement in clinical practice.

Pain management following major intracranial surgery in pediatric patients: A prospective cohort study in three academic children's hospitals

Pain management following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurologic examination. Nevertheless, evidence in adults is accumulating that these patients suffer moderate to severe pain, and this pain is often under‐treated. The purpose of this prospective, clinical observational cohort study was to assess the incidence of pain, prescribed analgesics, methods of analgesic delivery, and patient/parent satisfaction in pediatric patients undergoing cranial surgery at three major university childrens hospitals.

Time Changes for Scheduled Nursing Assessments: Impact on Clinical Decisions and Patient Discharge

Using a shared governance model, a clinical nursing practice change was implemented to increase collaborative decision making among health care providers at morning rounds. The goal of this project was to improve nursing workflow at the beginning of the shift and improve patient flow by discharging patients earlier. By changing the time of morning vital signs and nursing assessments from 0800 to 0600, staff reported increased collaboration among the multidisciplinary team and improved nursing workflow.