Nurse attitudes to automatic computer control of arterial pressure

Nurse attitudes to automatic control of arterial pressure C. J. Murchie

computer

and G. N. C. Kenny

Patients who have undergone cardiac bypass surgery require frequent administration ofvaso-dilators in the immediate post-operative period. A computer system has been

developed in Glasgow Royal Infirmary which controls automatically the delivery of sodium nitroprusside in these patients. Seventeen nurses completed a questionnaire to determine nurse attitudes to this system. The results showed that all the nurses found the system helpful but 59% noted certain disadvantages. The principal benefit was the saving of nurse time since adjustment of the infusion pump was not necessary and more time was available to undertake other aspects of patient care. Some of the nurses (5 1%) preferred computer rather than manual control but there was concern over the speed of response of the computer control system and lack of instruction provided.

In an attempt to improve blood pressure con-

INTRODUCTION

trol and to relieve nursing staff of this problem,

Hypertension occurs commonly during the immediate post-operative period in patients who have undergone cardiac surgery and the increase in blood pressure and therefore in cardiac work

an automatic

closed loop system based on an

Apple IIe microcomputer

has been developed in

Glasgow Royal

for use in the Cardiac

Intensive

Infirmary

Care Unit. The computer

associated

with this rise can cause myocardial

trols the administration

ischaemia.

Blood pressure control often involves

Apple

the use of vasodilator

drugs such as sodium nitro-

prusside (SNP). Accurate delivery, by altering the infusion pump rate to maintain the blood pressure within a prescribed

range, can be diffi-

system con-

of SNP and consists of an

IIe microcomputer

with colour

monitor

and disk drive, an Imed 929 or Braun Infusomat computer

controlled

cardiovascular

volumetric

pump

and

a

monitor.

The computer

is programmed

to analyse the

cult for nursing staff to achieve due to variations

blood pressure waveform obtained from an intra-

in sensitivity

arterial

to the drug between

patients

and

cannula

and then instruct

the infusion

within patients as they recover from surgery.

pump to deliver the appropriate

C. Joyce

the patient. To run the system it is necessary to supply certain data such as patient weight, target blood pressure and concentration of SNP to be

Murchie, BN, RGN, SCM, Research Fellow Gavin N. C. Kenny, BSc(Hons), MD, FFARCS, Senior Lecturer, University Department of Anaesthasia, Glasgow Royal Infirmary, &16 Alexandra Parade, Glasgow G31 2ER (Correspondence to GNCK) Manuscript

112

accepted

7 June

1988

rate of SNP to

used. The computer is programmed to prompt the user to enter this information through a series of screen displays. Once the necessary data have been entered, the computer obtains the blood

INTENSIVE

pressure and

values

blood

from

the cardiovascular

pressure

control

monitor

is commenced

system

when

the user required. During

gery.

the

make

changes

gram

provides

example,

infusion

it may

to the original a menu

the

concentration pressure

is running,

a graphical

actual

blood

blood

pressure

livered

to the

SNP

evaluated

the

dose blood

arterial

undergone

and

who

(1987)

Their

control

manual

control

patient.

However,

how

control

of who

METHOD

The research survey

systems

ing and analysis

hospitals

and

Population

work

there.

areas

has

Their been

tion of 50 qualified

the

to the

and

system

worked

therapy.

patients

in the ICU

by the professionals

in who

into patient there

care are

a

are

1984). As a result,

becoming

puter

increasingly

technology

nursing

order

1982).

have

been

prove completeness, accuracy nursing records and perhaps care (Henney, In intensive puters from

to collect patient

valuable undertake B

at ward

involved

(Cook, systems

nurses

with

the

ability

equipment

experience rotated

nurses

had

ward

and

cared

for

who were receiving

controlled

closed

who

between

SNP via

loop

system.

care course

permanently

in

the

and

wards

were not included. A letter charge

was

of the

and requesting When

sent

Nursing

to carry

the

duty

rota

the

in aims

out the study.

had been granted,

from

Officer

explaining

permission

permission

obtained

to the

department

names

and,

to

were obtain

level

opinions

from a cross-section

of staff,

com-

tied into

3 groups

to grade:-

Nursing

Enrolled

Nurses.

to im-

and legibility of improve nursing

information

a populastaff, male

post-operative of

worked

shown

store

monitoring

who

Twelve

areas

and

on the post basic intensive

Computerised

and

group

computer

Officers/Sisters,

1984). care

duty

ward,

This

but

or

record-

from

nursing

age and

or night

CICU.

number of systems being used to collect, store and reproduce patient information (Kenny & Madsen,

of varying

day

for ensuring

used increasingly

slow

were chosen permanent

the pre-operative

from the nursing

introduction

subjects

female,

those

relatively

the collection,

and sample size

than

Nurses

therefore

was of the descriptive

of data.

accurate

are being

DESIGN

involved

more

of benefit

post-

OF STUDY

Computer

of view.

conducted

type and

The survey

the correct

Infirmary

of such a sys-

Type of research

that

receive

point

AND

concluded

responsible

in the Cardiac Royal

to assess the acceptability

tem from a nursing

the

AIM

system

of Glasgow

the

staff using

surgery

early

that

was to obtain

loop computer Care Unit

results

not take over completely

that their patients

they

loop sys-

bypass

study

to

may be to the

of the nursing

the

stated

staff who are ultimately

of

heart

in 60 patients

therefore they

the closed

of sur-

documented

opinions

during

was and

rate

of the closed

SNP

and

cardiac

de-

the graph.

described

pressure

attitudes

in order

and

been

in their use.

staff involved

The aim of the present

target and

has

nursing

with

being

little

the control

following

such systems

Intensive

pressure,

cardiopulmonary

period.

computer

the

nurse and computer blood

required

operative

While

However,

shows

pressure

in text beneath

Kenny

had

be

to improve

pressure

show how acceptable

For

may

blood

display

of SNP

Target

actual

tem by comparing

should

changed.

the performance

systolic

SNP

compared

patient.

rate are displayed and

the pro-

on the top half of the screen half,

infusion,

Reid

to

purpose.

of

or the target

pressure

and

this

altered

lower

be necessary

data

for

system

on the

has been shown

patients

113

CARE NURSING

of comdirectly

has proved

because the nursing staff are free to other tasks. The closed loop computer

using sample

subjects random

according Staff were

number

chosen tables

from

each

group

and

the

survey

size was 36.

Collection of data A questionnaire was This

Nurses,

were classi-

was distributed

used

for data

collection.

to the staff concerned

and

was accompanied by a covering letter and an addressed envelope for its return. The letter

114

INTENSIVE

explained total

the

aims

of the

confidentiality.

designed

using

choice sibility

because

questions were

the system

would

to ascertain the

responses. in total.

The

first

if the nurse

had

used

Questions

2 and 3

advantages

1. advantages/disadvantages pressure

using

the pos-

and

advantages of the system respectively each divided into 3 sections:

dis-

and

the CLCS was used by the

Number of times used

Number of nurses

Percent used

l-9 10-19 20-29 30-39 4049 50-59

5 7 1 1 1 1

29 41 6 6 6 6

regarding

were

All the nurses

blood

control

2. advantages/disadvantages

Table 1 The number of timw nurses. (n=17)

This

introduce

and if so, how often. with

was

questions.

important

concerned

ensured

it was felt that

five questions

was designed

and

questionnaire

open-ended

of omitting

There

survey

The

was made

closed-ended

were

CARE NURSING

for the nurses

per-

sonally

control

59%

noted

disadvantages

system

advantages/disadvantages

4 involved

ence

for either

blood

pressure

any further

the nurses

manual and

whereas

the final

of organisation

Organisation

and

proved

difficult

more

of questionnaire, produced

control

of

asked

for

question

a large

variety

in turn

rived into which

and analysis of the data

than

using

responses

question

analysis

collected

envisaged.

The

style

open-ended

questions,

of individual

responses.

were

studied

and

a number

carefully be placed.

a response made two or more points, allocated to more than one category.

these

deWhen were

Question

that

Of the 36 questionnaires

issued 2 1 were returned,

a response

Four

system tinue

(CLCS) to complete

of times

each

respondents

out of

with the closed loop computer

con-

had

5 made what

somewhat

ambivalent

comments

that

in straightforward

The number

as the manual

system’.

The comments verse comments

able to

10,3 gave no

referring

to dis-

a statement

did and one made

the

reply:

the questionnaire.

worked with the system varied. Table 1 shows the frequency distribution obtained when each nurse was asked how often she had actually used the system. Of all nurses 41% had used the system between 10 and 19 times. The majority, 70%, had used the system less than 20 times while 24:/b had used the system between 20 and 59 times.

found

7 were

one made

the system

the system

had

only

remaining

of the system,

reiterating

‘Only

helped,

why. Ofthe

was unstable,

nurses

100 59 59 29 12

if the nurses

did not con-

17 remaining

manual

rates (%)

at all and therefore of the

2).

the computer

only 29% favoured

(2a) asked

the system

advantages

of 58%.

but

(Table

using the system helped in the control of blood pressure. Whereas all 17 of the nurses indicated

comment,

rate

using

they

Computer system helpful Disadvantages in computer system Preference for computer control Preference for manual control No preference for either system

say precisely

RESULTS

21 had not worked

preferred

that helpful

2).

Table 2 Overall response

for each

of categories

each one could

system

a prefer-

or computer

comments.

Methods

These

stating

certain percent

trol (Table Question

reported

the computer

Fifty-nine

3. any other

who replied

found

cases.

If the patient

is not as controllable

made are shown in Table 3. Adrefers to statements interpreted

as criticisms. One nurse commented on specific advantages regarding the control of BP in answer to a later question stating: ‘It enables accurate administration control of blood pressure.’

of SNP in

INTENSIVE

Table 3 Reasons offered by nurses to explain why the CLCS assisted with the control of blood pressure

CARE

NURSING

i 15

Table 5 Other reasons offered by nurses to explain why the system was helpful

(SW

scribed

further

are shown The

apparent

difficulty

in answering

tion may have been caused equally

it might

assessing

in

derive

an

this ques-

by poor wording,

from

abstract

a basic

way

but

problem

how

the

in

system

helped. found

(2b)

that

Sixteen

Fifteen answer

nurses

helped

resulted

in a much

of the 17 nurses helped

remaining

the

the system

This question had

asked

while

one

‘particularly

if

had

personally.

better

response.

that the system

unfortunately,

one did not answer

of the nurses

them

indicated

personally,

if they

could nurse

the

the question

give a reason gave

the

at all. for their

ambivalent

advantages

in Table

pressure

more

saving

feature

of the

reasons

given

to explain

automatic

control

the CLCS

CLCS

unfavourable.

pump

indicated

time of the

if they thought

in Table

tional

disadvantages

in the control

they had found Two

problems system.

shown another

the

principal

the advantages the nurses

tain points of the

1

to control

the

any disadvantages

nurses

ages

1

comments

and are

2

system.

of BP. Ten infusion

their

the ability

accurately

(3a) asked had

and

5. Thus

blood

Question

Question

2

Removes worry from junior staff Eliminates risk of mistakes because of ignorance of drug action Don’t need to keep asking if rate should be altered More reliable than inexperienced staff

More accurate control of BP Visual display of BP trend provided Adverse comments No comment Other

of these

rather

The

6. Two

than

other

cer-

reported

disadvant-

comments

of the nurses

of the system

are

gave

addi-

in answer

to

question:

reply:

‘ Nipride

for a relatively

The comments nurse

patient

stated

made

on

high

doses

of

long period.’

are shown

one further

4. One

in answer

to a

‘ I it allows me to observe monitor

(colour

trend

graph)

via the

attached

in this group

if they

had

found

any

CLCS

had

helped.

other

Only

asked

ways

tne nurses

in which

the

four of the nurses

de-

high swings member

conthan

so long

to deliver

dose’.

obviously

takes

of blood

pressure

of staff turning

longer

to

than

an

the rate

up.’ Of the 7 nurses

who indicated

disadvantages,

2 stated

answer

question:

‘On occasions,

I found

‘ Table 4 Reasons offered by nurses to explain why the CLCS had helped them 10 3 1 1 1 1 1 1

to sudden

that they found

unfavourable

to another

respond

Time saving Eliminates risk of overdose Removes decisions on BP control More reliable than inexperienced staff Quicker in reaction than inexperienced staff Less worry than with inexperienced staff Provided visual display of SNP administered Other

the required

a nurse effective

to

computer.’ The tinal question

more

it takes

‘. . . the computer

experienced any change

procedures

is often

because

and increase control

later question:

nursing

the SNP

the CLCS

in Table

comment

during

trolling

the computer

changes

I find that the computer

in blood

no

points

in

slow to pressure.’

is sometimes

slow

Table 6 Reasons offered by the nurses to explain the disadvantages of the CLCS in the control of BP Slow to react to BP changes Continues to infuse 1 ml of SNP even when BP low Does not register I.V. line disconnection Alarms when blood taken from arterial line Technical problem when putting up a new bag of SNP Other

5 2 2 1 1 2

116

INTENSIVE

CARE NURSING

Table 9 Reasons offered by the nurses to explain why they preferred computer control of BP

Table 7 Reasons offered by nurses to explain why the CLCS was of disadvantage to them personally 5 5 1 1 1

Lack of instruction Lack of ‘hands on’ experience Did not feel in control of computer Equipment bulky Other -

Table 8 Other disadvantages nurses

of the CLCS offered

by the

Table 10 Reasons offered by the nurses to explain why they preferred manual control BP

Lack of ‘hands on’ experience Lack of knowledge of the system Other

in responding

3 2 1

to sudden

changes

in

More accurate control of BP Time saving Safer than inexperienced nurses Safer with low staffing levels Provides visual aid Knowledge of good BP control No comment

3 1 1

Ignorance of CLCS Experienced staff better at controlling unstable BP Infrequent use of the system

blood

pressure.’ Question found them

(3b)

that

the CLCS

personally.

found

certain

Ten

a comment

Other

responses

The of the

final CLCS.

Thus reason

nurses

question Four

points.

the in given

disadvantages

slow blood

if they

indicated

regarding are shown

regarding blood sponses are shown changes

nurses

unfavourable.

had

they

a pump

had 1

asked

the

disadvantages

offered

further

pressure in Table

control. 8. of

by the nursing

Other

the the

re-

CLCS

to

principal

staff to explain

of the system.

the

It is also apparent

that lack of instruction and ‘hands on’ experience, although not actually faults of the system itself, were a major Question for either pressure

drawback

to the nursing

staff.

4 asked if the nurse had a preference computer

and

or manual

if so, why.

Ten

control nurses

of blood stated

they preferred computer control, of these no reason for their answer. The comments

manual

un-

one gave a comment

was

by the nurses 4 1

In-service training required Only usage will encourage acceptance

and computer

give a reason

Of these

reaction

offered

problem.

group

pressure

Table 11 Other comments

7.

any other

nurses

for

Of these,

in Table

in this

if they had found

favourable

the

had any disadvantages

points

gave

nurses

asked

that 3 gave made

by the remaining 7 are shown in Table 9. Five nurses preferred manual control of blood pressure and the reasons are shown in Table 10. Two nurses expressed no preference between

‘In fairly

of BP. One did not stated:

stable

computer

patients,

best for patients patients

control

while the other

I

control

is

and staff, but in very unstable

think

manual

control

has

the

for

any

advantage.’ The further points

final

question

relevant

asked

the

comments.

nurses

Five

to add and these are shown

had

further

in Table

11.

DISCUSSION Reid CLCS sure

and does control

Kenny provide than

(1987) more manual

fusion pump. Myocardial caused by increased or arterial pressure. Therefore, infusion of vasodilators is this danger to post-cardiac However, they do point

have

shown

accurate adjustment

that

blood

the pres-

of an in-

ischaemia may be excessively decreased close control of the essential to minimise bypass patients. out that it should not

INTENSIVE

take over complete ing staff. They

responsibility

viewed

tern as a tool to be used produce trol

achieved

by using

compared

with

ministration nurses

pressure

is required

and would

is

infusion

ad-

important

that

fully acceptable

system

in this study

closed

loop

nurses

did not find the system

to them. 59%

completely

preferred

preferred

the

The results

con-

system

using the computer

suggest

of the infusion time patient

pump

was available care.

and

system

over

advantage

factor.

of

Adjustment

was not necessary to carry

Although

their prefence manual control, cern

that the main

was its time saving

out other

and more aspects

59?/, of the nurses

of

stated

for computer compared with it is evident that there was con-

the lack of instruction

given

encourage

that inof the greater

of the closed

by those so closely involved

loop

in its use.

Acknowledgements C. Joyce Murchies held a Research Fellowship in Computing Experience granted by the Scottish Home and Health Department.

of the

in spite of some reservations. the system

and acceptance

four

17

accept-

manual

to the automatic

understanding system

by

1

pump

reported

to be helpful,

only 29%

trol of SNP infusion the majority

nurses,

intravenous

all the nurses

able. However,

to

standard

find the CLCS

While

as suggested

which

NlJRSING

It is possible

training,

a volumetric It is therefore

experience.

service

of con-

to that

lack ofhands-on

sys-

staff

in the quality similar

the

set.

the nurs-

control

by the nursing

an improvement

of blood

from

the automatic

CARE

and

the

References Reid J A, Kenny G N C 1987 Evaluation of closed-loop control of arterial pressure after cardiopulmonary bypass. Br J Anaesth 59: 247-255 Kenny G N C, Madsen S 1985 Patient monitoring in intensive care. In-Computer Techniques in Clinical Medicine, ed. P W Macfarlane. London: Butterworths 222-233 Cook M 1984 Using computers to enhance professional practice. Nursing Times 78: 1542-1545 Henney C 1984 The use ofcomputers for improvement and measurement of nursing Carl. In-Recent Advances in Nursing I&Measuring the Quality of Care. ed. L Willis and M Linwood. Edinburgh: Churchill Livingstone 174-188