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1 Place hospital logo here

2 Quiet ICU Marion Daku, RN, BSN, CCRN Heather Koch, RN Eva Fox, RN, BSN Coach: Carolyn Davidson, RN, PhD, CCRN, ARNP, CPHQ

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5 ICU - MUHLENBERG 20 beds MICU/SICU/CT Surgical (universal unit) Provide care for a diverse population Magnet Designated for Nursing Excellence Driven by a Passion for Better Medicine

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7 Sleeping in a Noisy World

8 Background Primary health effect of noise is disturbed sleep and rest As much as 57% of ICU patient arousals and awakenings are due to noise It can take as little as 24 to 48 hours for the body to react negatively to lack of sleep Some ICU patients are disturbed every 20 minutes while trying to sleep Sleep deprivation has been linked to: patient falls, use of restraints, confusion, and medication Florence Nightingale s Environmental Theory describes noise as: that which damages the patient

9 Project Purpose and Goals

10 Main Why We Heading, Care Calibri 36 pts Bold, Blue Body copy is Calibri, 24 pts black. Single space after period. There should be a hard return between paragraphs and bulleted lists. Keep all line spacing at 1.0. The font sizes recommended are shown on this slide. All text is left justified. Please do not use centered text. When in doubt about spacing, continue content on a second slide.

11 What Contributes to Our Noise? Overhead hallway vent alarm (OFF) 90+ db Linen and food carts 66.9 db Ventilator alarm 64.2 db Portable X-ray machine 80.2 db Pneumatic tube station 67.5 db Loud staff, Patients, visitors 60.7 db Slamming drawers 77.9 db Telephones and pagers 68.2/72.1 Empty room 42.5 db Overhead paging 74.1 db Opening trash bags 69.6 db

12 Project Timeline

13 Key Challenges to the Project Difficulty compiling data due to time constraints Underwhelming interdisciplinary support Lack of reporting of CAM scores at beginning of the project Ability of the group to meet Staff turnover Staff compliance

14 Make It Happen Collaboration between ICU staff members and the multidisciplinary team Initiation of new set quiet times: 1-4 a.m. and 2-4 p.m. Use of better alarm parameters and adjustments Newly developed algorithms for better alarm management Better staff understanding of scores and survey questions

15 Alarm Parameters Algorithms Bradycardia Alarm Assess Patient Yes Is This a New Rhythm? No Consider Treatment No Is this the Patient s Persistent HR? Yes Set Low HR parameter - 5 Beats Under Current Persistent HR

16 During Quiet Time Unit lights dimmed Blinds closed Telephone and television volumes decreased Headsets and earbuds provided Staff interact quietly and remind anyone entering the unit that quiet time is in progress

17 During Quiet Time Staff make every effort to limit nursing activities and not enter patient room unless necessary Patient doors closed if safe to do so Necessary therapeutic interventions performed as quietly as possible Quiet Time door sign

18 Measurement and Evaluation Tools HCAHPS scores Press Ganey scores Staff survey Manual alarm counts Decibel meter readings Cardiac monitor alarm trigger printouts Richards Campbell Sleep Questionnaire (RCSQ)

19 HCAPHS/Press Ganey HCAPHS/Quietness target: Press Ganey: No score if n < 7

20 Staff Survey Pre-Project Launch Rate your impact on the noise level 58% felt that they had no impact on the noise level Satisfaction with noise on the unit 34% of staff are rarely satisfied with the noise level How often do you think patients get > 2 hours uninterrupted rest 39% of staff feel that their patients get 2 hours of uninterrupted rest How often are you distracted by alarms during your shift 53% of staff are always or often distracted by alarms

21 Staff Survey - Post-Project Launch Rate your impact on the noise level 32% felt that they had no impact on the noise level Satisfaction with noise on the unit 3% of staff are rarely satisfied with the noise level How often do you think patients get > 2 hours uninterrupted rest 84% of staff feel that their patients get 2 hours of uninterrupted rest How often are you distracted by alarms during your shift 32% of staff are always or often distracted by alarms

22 Alarm Count Sheet

23 True 50.3 False 49.7 False alarms have decreased 69%. What we have learned True 65.8 False 34.3

24 We have our EKG alarms by 75%. Unfortunately, we have our Pulse ox alarms by 50%.

25 When our unit is loudest/quietest How loud are we Loudest: 10 a.m.-noon (avg. db 53.3) Quietest: 2-4 a.m. (avg. db 45.6)

26 Length of stay (LOS) decreased an average of 0.74 day from July 2013-June July August September October November December January February March April May June

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28 Richards Campbell Sleep Questionnaire Nursing rated patients sleep deeper than patients did by 8% Patients fell asleep faster than nursing thought by 6% Nursing felt patients were awake longer than they were by 6% Nursing felt patients got back to sleep faster by 3.7% Patients rated their night s sleep better than nursing by 13% RCSQ score was higher for nursing than patients by 3.5% Patients slept better than we thought!

29 Richards Campbell Sleep Questionnaire Question 6: Very Quiet Very Noisy Nursing rates the noise level at night: 37 Patients rate the noise level at night: 41 Nursing rates the unit quieter at night than patients do.

30 Unintended Successes Patients are thankful for nap time During Quiet Time, nursing is able to catch up on documentation, chart review, orders, and other tasks Visibility of decibel meter may have influenced awareness Future collaboration with hospital-wide Night Shift Nurse Council working on decreasing noise Opportunity to work with summer research scholar Presentation of project, including to Magnet Champions

31 Projected $avings and Fi$cal Impact CMS Reimbursement LVHN in jeopardy of losing $1.5 million if HCAHPS scores do not reach set benchmarks Muhlenberg responsible for 20% ($300,000) ICUM responsible for 4% ($12,000) Job Retention for RNs Nursing turnover can cost a hospital approximately $88,000 per nurse, when an RN leaves their position

32 Projected Savings and Fiscal Impact LOS LOS in ICU Muhlenberg has decreased 0.74 day The reduction in LOS cannot be attributed solely to the CSI project, because many factors impact LOS, including sleep. Savings of $2590 per patient (based on average cost of $3500 per ICU day) July 2013-July 2014 census was 1948 Projected annual savings of $5,045,320. Patient Safety and Loyalty Unable to place savings on this

33 AACN CSI PROJECT GRANT BUDGET 7% 4% 4% 1% 63% 15% 1% 2% 3% SALARIES DATA COLLECTION MEAL CARDS TRAVEL OFFICE SUPPIES T SHIRTS STAFF FAVORS COMMUNICATION ITEMS FOOD

34 Special Thanks To AACN and the CSI Academy Susan Lacey, RN, PhD, FAAN, CSI Academy Program Director Adrienne Olney, CSI Academy Program Manager Lehigh Valley Hospital ICU Muhlenberg Staff Respiratory Therapy Anne Panik, MS, BSN, RN, NEA-BC (Senior VP, Patient Care Services) Kay Rauchfuss, MSN, RN, CCN (Administrator, Cardiovascular Division) Denise Davis-Maludy, MBA, BSN, RN (Director ICUM/RHCS) Kim Hitchings, MSN, RN, NEA-BC (Manager, Professional Development)

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36 References American Association of Critical-Care Nurses. AACN Practice Alert: Alarm management Accessed August 7, Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med. 2005;33(6): Dennis CM, Lee R, Woodard EK, Szalaj JJ, Walker CA. Benefits of quiet time for neurointensive care patients. J Neurosci Nurs. 2010;42(4): Ganz FD. Sleep and immune function. Crit Care Nurse. 2012;32(2):e19-e25. Gorges M, Markewitz BA, Westenskow DR. Improving alarm performance in the medical intensive care unit using delays and clinical context. Anesth Analg. 2009;108(5): Graham KC, Cvach M. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19(1): Hospital Consumer Assessment of Healthcare Providers and Systems. HCAHPS fact sheet Accessed August 7, 2014.

37 References The Joint Commission. Sentinel Event Alert: Medical device alarm safety in hospitals Accessed August 7, Kamdar BB, King LM, Collop NA, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013;41(3): Lawson N, Thompson K, Saunders G, et al. Sound intensity and noise evaluation in a critical care unit. Am J Crit Care. 2010;19(6): Mazer SE. Creating a culture of safety: reducing hospital noise. Biomed Instrum Technol. 2012;46(5): Press Ganey Accessed August 7, Sendelbach S, Funk M. Alarm fatigue: a patient safety concern. AACN Adv Crit Care. 2013;42(4): Ye L, Keane K, Hutton Johnson S, Dykes PC. How do clinicians assess, communicate about, and manage patient sleep in the hospital? J Nurs Adm. 2013;43(6):

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