Monitoring in ICU BR Bhengu UKZN
What monitoring entails Intermittent (regular or irregular) series of observations Observations are systematic and purposeful Gather information on all aspects of the patient health status or condition Includes: giving feedback/reporting about the progress of the patient to interested parties Multidisciplinary team Family and patient her/himself Recording the observations to : establish patterns/trends Account clinically, professionally and legally Reacting to results especially if adverse
Rationale Monitoring subscribes to needs targeted/driven, problem oriented, context driven and responsive patient care Directs care and treatment Supports ethical obligation to uniqueness of patients and environments Supports sound judgement, adequate knowledge, skills and competencies, critical thinking in patient care/nursing practice Sensitive, relevant & responsive to changes in health care environment and needs
Purpose of monitoring Planning and implementation of care Making decisions for improving patient care, e.g. change treatment, transfer or discharge To show: Extent of compliance with a formulated standard i.e. if on track or Degree of deviation from the expected standard or endpoints or targets Hence the need to define the standards or endpoints or targets
Legal Considerations Based on the provisions of the Nursing Act (Act no. 33 of 2005) and The Charter of Nursing Practice (September 2004): Appropriate and accurate monitoring of clients conditions Accurate and complete recording of observations and care provided Safe application of diagnostic & therapeutic interventions Timeous and appropriate referral of a client OR Consultation of the appropriate multidisciplinary
Legal Considerations Bearing in mind provisions of The old Regulation R387: Acts and Omissions 3 (b) Obligation to protect health status of the patient and physiological response of the body to disease conditions and treatment 4 (f) Responsibility to check diagnostic + therapeutic interventions 5 responsibility to keep clear and accurate records of all actions performed in connection with the patient NOT TO DO SO IS CONSIDERED NEGLIGENCE
What is monitored in ICU Haemodynamic monitoring Vital parameters, including Urine output Neurological function Peripheral circulation Equipment functions and settings Patient condition for progress or deterioration
Principles in monitoring Safe and effective use of monitoring equipment, hence knowledge base and experience Ensure accuracy Monitor context e.g. safety of alarms, patient condition, unit standards Consider trends or pattern rather than isolated observations Know conversion formulae Correlate the observations with the patient condition, e.g. is patient symptomatic Determine frequency according to patient needs
Ensuring Accuracy Appropriate measurement equipment for the size or age of the patient, e.g. BP Cuff Correct siting of line, cuff Phlebostatic axis or Zero point as reference point Correlate zero point of the patient with that of transducer Changing position of transducer with that of patient Therefore importance of a spirit level Calibration or standardization zeroing to atmosphere
Conversions mmhg versus cmh 2 0, e.g. converting cmh 2 0 to mmhg : for example: cmh 2 0 1.36 = mmhg mmhg versus kpa E.g. Converting mmhg to kpa would be: MmHg 0.03 = KPa But not both together
Frequency of Measurements Based on each patient s need rather than specific time intervals or routine Unit or facility standards based on unique patient populations rather than national standards Opportunity for individualization based on a particular patient s situation Avoid unrealistic demands on nurses Recommend AACN Synergy model as framework for determining frequency Schulman & Staul 2010
Framework for Frequency of Assessment (AACN Synergy Model: 2010) Concept from Synergy Model Patient condition More frequent Less frequent Stability Steady state/equilibrium Patient admitted to ICU with severe sepsis requiring multiple bolus of fluids or titration of vaso-active meds to maintain Haemodynamic goals Patient who does not require fluids or vasoactive meds to maintain haemodynamic goals Complexity The intricate entanglement of 2 or more systems Patient in acute renal failure requiring continuous renal replacement therapy Patient with end-stage renal disease who requires haemodialysis every 3 days Predictability A characteristic that allows one to expect a certain course of events or illness Patient after emergent cardiac surgery who is in cardiogenic shock Patient 24 hours after uncomplicated coronary artery bypass graft, no variances on clinical pathway Vulnerability Susceptibility to actual or potential stressors that may adversely affect outcome Patient in acute alcohol withdrawal, exhibiting signs of delirium Patient with history of alcohol use who is alert and oriented several days after admission Resiliency The capacity to return to a restorative level of functioning by using compensatory mechanisms; the ability to bounce back quickly from injury Elderly trauma patient with history of chronic obstructive pulmonary disease and pulmonary contusion Young trauma patient with pulmonary contusion
Frequency of Measurements Allowance for deviation from standard based on the nurse s judgment, However deviation to be documented e.g to much needed sleep Documentation less frequent but both driven by patient condition
Monitoring Environment/Context Regular and preventive maintenance and testing of alarm systems Activated for various reasons, namely Reflection of clinically significant change in patient (true positive); e.g. disconnected ventilator, high airway pressure Clinically insignificant (false positive) ECG Lead off Merely reflection of poorly set monitoring parameters
Alarms Events 2176 Recorded alarm events 68% were false 5,5% were significant 26.5% were induced by interventions Concluded that 94% alarms events were clinically insignificant Chambrin : 2001 Another study only 5.9% of 3166 alarms needed call to a physician
Consequence of false alarm Contribute to inefficiencies in monitoring Take the nurse away from other more essential tasks Lead to staff ignoring alarms assuming is still the false alarm
Assessment patient monitoring equipment Regular and preventive maintenance and testing of alarm systems a collaborative function of nurse and clinical engineer Ensure appropriate settings Sufficiently audible with respect to distance and competing noise within unit Both audible and visible Differentiation of alarm sounds; e.g, airway pressure from disconnected ventilator, etc Stand alone monitoring devices even more important to activate alarms like pulse oximeter equipment, infusion pumps, etc
Assessment Patient Monitoring Equipment Evaluate alarm defaults and configurations: Are they the same for all units? Do they meet patient clinical needs? Does staff know what the default are? Are they customized for each patient based on condition? Determine who is responsible : preventive and maintenance testing audibility testing setting alarm limits responding to the alarm Develop checklist to guide such assessment Presence of other equipment of importance; e.g. patient call lights All alarms should be activated and assessed During the busiest time of the day
Develop protocol for: Alarm Setting alarm setting based on how default and configurations have worked with patients Timing of alarm evaluation e.g. change of caregiver Change of shift Whenever there is a change in patients clinical status Emphasize the importance of keeping the alarm enabled Customize alarms to each individual on the basis of alarm events and clinical status of patient Assure alarm volumes for stand alone monitors
Protocol to include Who will respond to alarm Alarm response How quickly must be the response Hence hierarchy of alarms to: High: e.g. ventilators (electrical or pneumatic failure) death Medium: ventilator disconnect, apnoea, low expiratory minute ventilation, high/low O 2 concentration injury Low: feeding tube minimal adverse effect
Conclusion Vigilance in ICU cannot be over-emphasized Technology does not guarantee safety and accuracy Monitor with purpose Record and Communicate the findings Respond to findings
References Kinney, MR, Dunbar, SB, Brooks-Brunn, Molter N & Vitello-CICCIU, JM 1998 AACN Clinical reference for Critical care Nursing, 4 th edition, Philadelphia: Mosby Phillips J & Barnsteiner JH 2005 Cinical Alarms: Improving Efficiency and effectiveness Critical Care Nursing quaterly/october December Schulman CS & Staul, LS 2010 Standard for frequency of Measurement and documentation of vital signs and physical assessments June Critical care Nurse 30(3), 74-76