Safety of implementing a sleep protocol in hospitalized patients.

BACKGROUND: Although good sleep during hospitalization may promote positive outcomes, some patients and clinicians may have concerns about nursing interventions designed to reduce night-time sleep disturbances. METHODS: A randomized prospective trial of an intervention to promote sleep was conducted with stable, post-operative oncology patients. Eligible patients were randomized to receive usual nursing care overnight or sleep-promoting interventions. RESULTS: All thirty-seven surgeons in the organization agreed to let their qualified patients participate. One hundred and forty-four patients met the study criteria. Of those, 117 (81%) consented to participate, while 27 (19%) declined. The primary reason for non-enrollment was wanting to be checked on throughout the night (n = 21, 78%). There were no adverse events during the study period. Patients' perceptions of pain and nausea control among the two groups were equivalent. CONCLUSION: An intervention to decrease sleep disturbances can be safely executed in a post-operative population while maintaining adequate symptom management.

Deep Q-learning for Predicting Asthma Attack with Considering Personalized Environmental Triggers' Risk Scores.

The purpose of our present study was to develop a forecasting method that would help asthmatic individuals to take evasive action when the probability of an attack was at THEIR PERSONAL THRESHOLD levels. The results are encouraging. Risk factor analysis helps improve the agent's performance (by allowing it to consider personalized risk score of asthma attack triggers while making a decision and being able to ignore the non-triggers), increasing transparency of deep reinforcement learning in medicine applications (by using the results of analyzing risk factors and its association to take actions), and increase accuracy over time since the association risk factor indicators are also changing over time with more accuracy rate. It also brings the possibility of including population-based health in personalized health, which could support a more efficient self-management of chronic diseases.

Personalized Prediction of Asthma Severity and Asthma Attack for a Personalized Treatment Regimen.

Control of asthma is critical for disease management and quality of life. Asthma treatment depends on the patient demographic information (e.g., age), and disease severity, which is determined by: (1) how symptoms affect a patient's daily life, (2) measured lung function, and (3) estimated risk of having an asthma attack. In this paper, we will present the Tensorflow Text Classification (TC) method to classify a patient's asthma severity level. We will also propose a Qlearning method to train an agent through trials and errors to improve the prediction accuracy and create a personalized treatment regimen for asthma patients.

Faster clinical response to the onset of adverse events: A wearable metacognitive attention aid for nurse triage of clinical alarms.

OBJECTIVE: This study evaluates the potential for improving patient safety by introducing a metacognitive attention aid that enables clinicians to more easily access and use existing alarm/alert information. It is hypothesized that this introduction will enable clinicians to easily triage alarm/alert events and quickly recognize emergent opportunities to adapt care delivery. The resulting faster response to clinically important alarms/alerts has the potential to prevent adverse events and reduce healthcare costs. MATERIALS AND METHODS: A randomized within-subjects single-factor clinical experiment was conducted in a high-fidelity 20-bed simulated acute care hospital unit. Sixteen registered nurses, four at a time, cared for five simulated patients each. A two-part highly realistic clinical scenario was used that included representative: tasking; information; and alarms/alerts. The treatment condition introduced an integrated wearable attention aid that leveraged metacognition methods from proven military systems. The primary metric was time for nurses to respond to important alarms/alerts. RESULTS: Use of the wearable attention aid resulted in a median relative within-subject improvement for individual nurses of 118% (W = 183, p = 0.006). The top quarter of relative improvement was 3,303% faster (mean; 17.76 minutes reduced to 1.33). For all unit sessions, there was an overall 148% median faster response time to important alarms (8.12 minutes reduced to 3.27; U = 2.401, p = 0.016), with 153% median improvement in consistency across nurses (F = 11.670, p = 0.001). DISCUSSION AND CONCLUSION: Existing device-centric alarm/alert notification solutions can require too much time and effort for nurses to access and understand. As a result, nurses may ignore alarms/alerts as they focus on other important work. There has been extensive research on reducing alarm frequency in healthcare. However, alarm safety remains a top problem. Empirical observations reported here highlight the potential of improving patient safety by supporting the meta-work of checking alarms.

The Symbolic Functions of Nurses' Cognitive Artifacts on a Medical Oncology Unit.

Acute care nurses continue to rely on personally created paper-based tools-their "paper brains"-to support work during a shift, although standardized handoff tools are recommended. This interpretive descriptive study examines the functions these paper brains serve beyond handoff in the medical oncology unit at a cancer specialty hospital. Thirteen medical oncology nurses were each shadowed for a single shift and interviewed afterward using a semistructured technique. Field notes, transcribed interviews, images of nurses' paper brains, and analytic memos were inductively coded, and analysis revealed paper brains are symbols of patient and nurse identity. Caution is necessary when attempting to standardize nurses' paper brains as nurses may be resistant to such changes due to their pride in constructing personal artifacts to support themselves and their patients.

Microbiology Education in Nursing Practice.

Nurses must have sufficient education and training in microbiology to perform many roles within clinical nursing practice (e.g., administering antibiotics, collecting specimens, preparing specimens for transport and delivery, educating patients and families, communicating results to the healthcare team, and developing care plans based on results of microbiology studies and patient immunological status). It is unclear whether the current microbiology courses required of nursing students in the United States focus on the topics that are most relevant to nursing practice. To gauge the relevance of current microbiology education to nursing practice, we created a confidential, web-based survey that asked nurses about their past microbiology education, the types of microbiology specimens they collect, their duties that require knowledge of microbiology, and how frequently they encounter infectious diseases in practice. We used the survey responses to develop data-driven recommendations for educators who teach microbiology to pre-nursing and nursing students. Two hundred ninety-six Registered Nurses (RNs) completed the survey. The topics they deemed most relevant to current practice were infection control, hospital-acquired infections, disease transmission, and collection and handling of patient specimens. Topics deemed least relevant were the Gram stain procedure and microscope use. In addition, RNs expressed little interest in molecular testing methods. This may reflect a gap in their understanding of the uses of these tests, which could be bridged in a microbiology course. We now have data in support of anecdotal evidence that nurses are most engaged when learning about microbiology topics that have the greatest impact on patient care. Information from this survey will be used to shift the focus of microbiology courses at our university to topics more relevant to nursing practice. Further, these findings may also support an effort to evolve national recommendations for microbiology education in pre-nursing and nursing curricula.

The Hidden Lives of Nurses' Cognitive Artifacts.

BACKGROUND: Standardizing nursing handoffs at shift change is recommended to improve communication, with electronic tools as the primary approach. However, nurses continue to rely on personally created paper-based cognitive artifacts - their "paper brains" - to support handoffs, indicating a deficiency in available electronic versions. OBJECTIVE: The purpose of this qualitative study was to develop a deep understanding of nurses' paper-based cognitive artifacts in the context of a cancer specialty hospital. METHODS: After completing 73 hours of hospital unit field observations, 13 medical oncology nurses were purposively sampled, shadowed for a single shift and interviewed using a semi-structured technique. An interpretive descriptive study design guided analysis of the data corpus of field notes, transcribed interviews, images of nurses' paper-based cognitive artifacts, and analytic memos. RESULTS: Findings suggest nurses' paper brains are personal, dynamic, living objects that undergo a life cycle during each shift and evolve over the course of a nurse's career. The life cycle has four phases: Creation, Application, Reproduction, and Destruction. Evolution in a nurse's individually styled, paper brain is triggered by a change in the nurse's environment that reshapes cognitive needs. If a paper brain no longer provides cognitive support in the new environment, it is modified into (adapted) or abandoned (made extinct) for a different format that will provide the necessary support. CONCLUSIONS: The "hidden lives" - the life cycle and evolution - of paper brains have implications for the design of successful electronic tools to support nursing practice, including handoff. Nurses' paper brains provide cognitive support beyond the context of handoff. Information retrieval during handoff is undoubtedly an important function of nurses' paper brains, but tools designed to standardize handoff communication without accounting for cognitive needs during all phases of the paper brain life cycle or the ability to evolve with changes to those cognitive needs will be underutilized.

Information Content Across Types of Nurse Cognitive Artifacts.

Acute care nurses commonly use personalized cognitive artifacts to organize information during a shift. The purpose of this content analysis is to compare information content across three formats of cognitive artifacts used by acute care nurses in a medical oncology unit: hand-made free-form, preprinted skeleton, and EHR-generated. Information contained in free-form and skeleton artifacts is more tailored to specific patient context than the NSR. Free-form and skeleton artifacts provide a space for synthesizing information to construct a "story of the patient" that is missing in the NSR. Future design of standardized handoff tools will need to take these differences into account for successful adoption by acute care nurses, including tailoring of information by patient, not just unit type, and allowing a space for nurses to construct a narrative describing the patients "story."

Automated pictographic illustration of discharge instructions with Glyph: impact on patient recall and satisfaction.

OBJECTIVES: First, to evaluate the effect of standard vs pictograph-enhanced discharge instructions on patients' immediate and delayed recall of and satisfaction with their discharge instructions. Second, to evaluate the effect of automated pictograph enhancement on patient satisfaction with their discharge instructions. MATERIALS AND METHODS: Glyph, an automated healthcare informatics system, was used to automatically enhance patient discharge instructions with pictographs. Glyph was developed at the University of Utah by our research team. Patients in a cardiovascular medical unit were randomized to receive pictograph-enhanced or standard discharge instructions. Measures of immediate and delayed recall and satisfaction with discharge instructions were compared between two randomized groups: pictograph (n = 71) and standard (n = 73). RESULTS: Study participants who received pictograph-enhanced discharge instructions recalled 35% more of their instructions at discharge than those who received standard discharge instructions. The ratio of instructions at discharge was: standard = 0.04 ± 0.03 and pictograph-enhanced = 0.06 ± 0.03. The ratio of instructions at 1 week post discharge was: standard = 0.04 ± 0.02 and pictograph-enhanced 0.04 ± 0.02. Additionally, study participants who received pictograph-enhanced discharge instructions were more satisfied with the understandability of their instructions at 1 week post-discharge than those who received standard discharge instructions. DISCUSSION: Pictograph-enhanced discharge instructions have the potential to increase patient understanding of and satisfaction with discharge instructions. CONCLUSION: It is feasible to automatically illustrate discharge instructions and provide them to patients in a timely manner without interfering with clinical work. Illustrations in discharge instructions were found to improve patients' short-term recall of discharge instructions and delayed satisfaction (1-week post hospitalization) with the instructions. Therefore, it is likely that patients' understanding of and interaction with their discharge instructions is improved by the addition of illustrations.

Effects of bed height on the biomechanics of hospital bed entry and egress.

BACKGROUND: Although a significant proportion of patient falls in hospitals occur in the vicinity of the hospital bed, little is known about the contribution of bed height to fall risk. OBJECTIVE: To compare lower extremity joint torques and angles during hospital bed entry and egress at two bed heights. METHODS: Twelve adults (age > 55) were purposively selected and had variety of strength and mobility limitations. Biomechanical data for this pilot study were collected with three digital video cameras and processed to obtain estimates for joint torques and included angles. RESULTS: At the low bed height, hip torque for bed entry was significantly higher, and hip, knee, and ankle flexion angles were significantly smaller. The absence of significant differences in knee and ankle torques were the result of a compensation strategy that shifts the center of mass forward by flexing the torso during low bed ingress. Torque data from the egress motion were similar, however 50% of participants were unable to rise from the low bed without assistance. CONCLUSIONS: Healthcare providers should be aware that low bed heights pose safety risks to the population for which they were designed-elderly persons at high risk for falling.

The Safety of Hospital Beds: Ingress, Egress, and In-Bed Mobility.

To explore the safety of the standard and the low hospital bed, we report on a microanalysis of 15 patients' ability to ingress, move about the bed, and egress. The 15 participants were purposefully selected with various disabilities. Bed conditions were randomized with side rails up or down and one low bed with side rails down. We explored the patients' use of the side rails, bed height, ability to lift their legs onto the mattress, and ability to turn, egress, and walk back to the chair. The standard bed was too high for some participants, both for ingress and egress. Side rails were used by most participants when entering, turning in bed, and exiting. We recommend that side rails be reconsidered as a means to facilitate in-bed movement, ingress, and egress. Furthermore, single deck height settings for all patients are not optimal. Low beds as a safety measure must be re-evaluated.

Evaluation of a configural vital signs display for intensive care unit nurses.

OBJECTIVE: The objective was to evaluate a configural vital signs (CVS) display designed to support rapid detection and identification of physiological deterioration by graphically presenting patient vital signs data. BACKGROUND: Current display technology in the intensive care unit (ICU) is not optimized for fast recognition and identification of physiological changes in patients. To support nurses more effectively, graphical or configural vital signs displays need to be developed and evaluated. METHOD: A CVS display was developed based on findings from studies of the cognitive work of ICU nurses during patient monitoring. A total of 42 ICU nurses interpreted data presented either in a traditional, numerical format (n = 21) or on the CVS display (n = 21). Response time and accuracy in clinical data interpretation (i.e., identification of patient status) were assessed across four scenarios. RESULTS: Data interpretation speed and accuracy improved significantly in the CVS display condition; for example, in one scenario nurses required only half of the time for data interpretation and showed up to 1.9 times higher accuracy in identifying the patient state compared to the numerical display condition. CONCLUSION: Providing patient information in a configural display with readily visible trends and data variability can improve the speed and accuracy of data interpretation by ICU nurses. APPLICATION: Although many studies, including this one, support the use of configural displays, the vast majority of ICU monitoring displays still present clinical data in numerical format. The introduction of configural displays in clinical monitoring has potential to improve patient safety.

Collaborative learning using nursing student dyads in the clinical setting.

Formal pairing of student nurses to work collaboratively on one patient assignment is a strategy for improving the quality and efficiency of clinical instruction while better utilizing the limited resources at clinical agencies. The aim of this qualitative study was to explore the student nurse and patient experiences of collaborative learning when peer dyads are used in clinical nursing education. Interviews were conducted with 11 students and 9 patients. Students described the process of collaborative learning as information sharing, cross-checking when making clinical decisions, and group processing when assessing the outcomes of nursing interventions. Positive outcomes reported by students and patients included reduced student anxiety, increased confidence and task efficiency. Students' primary concern was reduced opportunity to perform hands-on skills which had to be negotiated within each dyad. Meeting the present and future challenges of educating nurses will require innovative models of clinical instruction such as collaborative learning using student peer dyads.

Evaluation of an integrated graphical display to promote acute change detection in ICU patients.

OBJECTIVE: The purpose of this study was to evaluate ICU nurses' ability to detect patient change using an integrated graphical information display (IGID) versus a conventional tabular ICU patient information display (i.e. electronic chart). DESIGN: Using participants from two different sites, we conducted a repeated measures simulator-based experiment to assess ICU nurses' ability to detect abnormal patient variables using a novel IGID versus a conventional tabular information display. Patient scenarios and display presentations were fully counterbalanced. MEASUREMENTS: We measured percent correct detection of abnormal patient variables, nurses' perceived workload (NASA-TLX), and display usability ratings. RESULTS: 32 ICU nurses (87% female, median age of 29 years, and median ICU experience of 2.5 years) using the IGID detected more abnormal variables compared to the tabular display [F(1, 119)=13.0, p<0.05]. There was a significant main effect of site [F(1, 119)=14.2], with development site participants doing better. There were no significant differences in nurses' perceived workload. The IGID display was rated as more usable than the conventional display [F(1, 60)=31.7]. CONCLUSION: Overall, nurses reported more important physiological information with the novel IGID than tabular display. Moreover, the finding of site differences may reflect local influences in work practice and involvement in iterative display design methodology. Information displays developed using user-centered design should accommodate the full diversity of the intended user population across use sites.

Graphical arterial blood gas visualization tool supports rapid and accurate data interpretation.

A visualization tool that integrates numeric information from an arterial blood gas report with novel graphics was designed for the purpose of promoting rapid and accurate interpretation of acid-base data. A study compared data interpretation performance when arterial blood gas results were presented in a traditional numerical list versus the graphical visualization tool. Critical-care nurses (n = 15) and nursing students (n = 15) were significantly more accurate identifying acid-base states and assessing trends in acid-base data when using the graphical visualization tool. Critical-care nurses and nursing students using traditional numerical data had an average accuracy of 69% and 74%, respectively. Using the visualization tool, average accuracy improved to 83% for critical-care nurses and 93% for nursing students. Analysis of response times demonstrated that the visualization tool might help nurses overcome the "speed/accuracy trade-off" during high-stress situations when rapid decisions must be rendered. Perceived mental workload was significantly reduced for nursing students when they used the graphical visualization tool. In this study, the effects of implementing the graphical visualization were greater for nursing students than for critical-care nurses, which may indicate that the experienced nurses needed more training and use of the new technology prior to testing to show similar gains. Results of the objective and subjective evaluations support the integration of this graphical visualization tool into clinical environments that require accurate and timely interpretation of arterial blood gas data.

Informing the design of hemodynamic monitoring displays.

In the ICU, an extensive array of variables from the hemodynamic monitoring display is routinely analyzed. However, the development of new display technologies is proceeding without adequate study of the monitoring tasks and behaviors of a primary user group--critical-care nurses. Semistructured interviews focusing on the cognitive aspects of the hemodynamic monitoring task were conducted with 14 critical-care nurses. A systematic content analysis of qualitative data identified cognitive tasks that had applicability to the design of monitoring displays. The cognitive tasks of hemodynamic monitoring were (1) selective data acquisition, (2) applying meaning to the variables and understanding relationships between parameters, (3) controlling hemodynamics by titrating medications and intravenous fluids, and (4) monitoring complex trends of multiple interacting variables and patient response to interventions. Recommendations include designing the monitoring display to match the mental constructs and cognitive tasks of the user by applying conceptual meaning to the variables, highlighting relationships between variables, and presenting a "big picture" view of the patient's condition. Monitoring displays must also present integrated trends that illustrate the dynamic relationship between interventions and patient response.

Graphical arterial blood gas visualization tool supports rapid and accurate data interpretation.

A visualization tool that integrates numeric information from an arterial blood gas report with novel graphics was designed for the purpose of promoting rapid and accurate interpretation of acid-base data. A study compared data interpretation performance when arterial blood gas results were presented in a traditional numerical list versus the graphical visualization tool. Critical-care nurses (n = 15) and nursing students (n = 15) were significantly more accurate identifying acid-base states and assessing trends in acid-base data when using the graphical visualization tool. Critical-care nurses and nursing students using traditional numerical data had an average accuracy of 69% and 74%, respectively. Using the visualization tool, average accuracy improved to 83% for critical-care nurses and 93% for nursing students. Analysis of response times demonstrated that the visualization tool might help nurses overcome the "speed/accuracy trade-off" during high-stress situations when rapid decisions must be rendered. Perceived mental workload was significantly reduced for nursing students when they used the graphical visualization tool. In this study, the effects of implementing the graphical visualization were greater for nursing students than for critical-care nurses, which may indicate that the experienced nurses needed more training and use of the new technology prior to testing to show similar gains. Results of the objective and subjective evaluations support the integration of this graphical visualization tool into clinical environments that require accurate and timely interpretation of arterial blood gas data.

The hazards of using floor mats as a fall protection device at the bedside.

OBJECTIVES: In this study, we evaluated the clinical safety of the floor mat, a device intended to reduce severity of injury in falls from the bed or at the bedside. METHODS: Fifteen participants with a range of gaits and fall risk were video-recorded as they approached and entered a hospital bed and then as they exited and walked away. For 10 participants, a 1-inch-thick floor mat with a beveled edge was used as a fall protection device at the bedside. The videos were coded and analyzed for the purpose of determining the mechanisms by which the floor mat affected balance and gait while participants ambulated to and from the bed. Permission has been received from all patients. RESULTS: The bedside floor mat caused elderly patients with impaired and normal gaits to lose balance and, in some cases, stumble while ambulating onto the floor mat. Eight of 10 patients had difficulty exiting the bed because they placed their heels on the beveled edge of the mat closest to the bed, which shifted their center of gravity back as they were attempting to stand. Furthermore, walkers and mobile intravenous stands maneuvered onto the floor mat were unbalanced and unstable, further jeopardizing patient safety. CONCLUSIONS: The bevel-edged, bedside floor mat is a potential hazard for ambulatory patients, especially those with impaired gaits, using walkers and pushing mobile intravenous stands.

Characteristics of heart period variability in intubated very low birth weight infants with respiratory disease.

BACKGROUND: Heart period variability provides a measure of balance between the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS). Since the PNS develops during the final weeks of gestation, premature infants have an overriding SNS. Spectral power analysis of heart period variability reveals two main frequency regions, the low frequency region (LF) representing primarily SNS activity and the high frequency region (HF) representing PNS activity. OBJECTIVES: To identify the characteristics of heart period power in the LF and HF regions in very low birth weight (VLBW) infants in the neonatal intensive care unit across gestational age groups and between sleep and awake states. METHODS: Data were collected from 16 intubated and mechanically ventilated VLBW infants with respiratory disease. Using spectral analysis techniques, heart period power in the two main frequency regions was extracted. RESULTS: HF power did not improve with gestational age as expected. LF power did increase with age, albeit nonsignificantly. LF and HF power were not significantly different between awake and sleep states. CONCLUSIONS: The results of this preliminary study suggest that PNS tone does not improve with gestational age in VLBW infants with respiratory disease. The intensive care environment may stimulate a sympathetic response in these infants and disrupt normal PNS development.