BACKGROUND As many as 99% of alarm signals may not need any intervention and can result in patients’ deaths. Alarm management is now a Joint Commission National Patient Safety Goal. OBJECTIVES To reduce the number of nuisance electrocardiographic alarm signals in adult patients on the medical cardiovascular care unit. METHODS A quality improvement process was used that included eliminating duplicative alarms, customizing alarms, changing electrocardiography electrodes daily, standardizing skin preparation, and using disposable electrocardiography leads. RESULTS In the cardiovascular care unit, the mean number of electrocardiographic alarm signals per day decreased from 28.5 (baseline) to 3.29, an 88.5% reduction. CONCLUSION Use of a bundled approach to managing alarm signals decreased the mean number of alarm signals in a cardiovascular care unit. (Critical Care Nurse. 2015;35[4]:15–23)

Off-pump bypass grafting is uncommon in patients in the United States who require dialysis. Off- pump bypass grafting provides a morbidity benefit and is associated with a lower risk of death.

Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery, which results in increased morbidity, mortality, length of stay, and hospital costs. We developed and followed a process map to implement a protocol to decrease POAF: (1) identify stakeholders and form a working committee, (2) formal literature and guideline review, (3) retrospective analysis of current institutional data, (4) data modeling to determine expected effects of change, (4) protocol development and implementation into the electronic medical record, and (5) ongoing review of data and protocol adjustment. Retrospective analysis demonstrated that POAF occurred in 29.8% of all cardiovascular surgery cases. Median length of stay was 2 days longer (P<0.001), and median total variable costs $2495 higher (P<0.001) in POAF patients. Modeling predicted that up to 60 cases of POAF and >$200 000 annually could be saved. A clinically based electronic medical record tool was implemented into the electronic medical record to aid preoperative clinic providers in identifying patients eligible for prophylactic amiodarone. Initial results during the 9-month period after implementation demonstrated a reduction in POAF in patients using the protocol, compared with those who qualified but did not receive amiodarone and those not evaluated (11.1% versus 38.7% and 38.8%; P=0.022); however, only 17.3% of patients used the protocol. A standardized methodological approach to quality improvement and electronic medical record integration has potential to significantly decrease the incidence of POAF, length of stay, and total variable cost in patients undergoing elective coronary artery bypass graft and valve surgeries. This framework for quality improvement interventions may be adapted to similar clinical problems beyond POAF.

BACKGROUND Traditionally chest tubes are set to −20 cm H2O wall suctioning until removal to facilitate drainage of blood, fluid, and air from the pleural or mediastinal space in patients after open heart surgery. However, no clear evidence supports using wall suction in these patients. Some studies in patients after pulmonary surgery indicate that using chest tubes with a water seal is safer, because this practice decreases duration of chest tube placement and eliminates air leaks. OBJECTIVE To show that changing chest tubes to a water seal after 12 hours of wall suction (intervention) is a safe alternative to using chest tubes with wall suction until removal of the tubes (usual care) in patients after open heart surgery. METHODS A before-and-after quality improvement design was used to evaluate the differences between the 2 chest tube management approaches in chest tube complications, output, and duration of placement. RESULTS A total of 48 patients received the intervention; 52 received usual care. The 2 groups (intervention vs usual care) did not differ significantly in complications (0 vs 2 events; P = .23), chest tube output (H1 = 0.001, P = .97), or duration of placement (median, 47 hours for both groups). CONCLUSION Changing chest tubes from wall suction to water seal after 12 hours of wall suction is a safe alternative to using wall suctioning until removal of the tubes.