COMBINED (P.G.

) INSTITUTE OF MEDICAL SCIENCES &

RESEARCH
DEHRADUN, UTTARAKHAND

Medical Surgical Nursing

Procedure
On
Intra-Aortic Balloon Pump Insertion (IABP)

Submitted To Submitted By
Mohamad Dildar
M.Sc Nursing 1st Year
 Intra-aortic balloon, fiber-optic, insertion, assisting

Introduction

An intra-aortic balloon pump (IABP) is a short-term-use cardiac device that provides stability to
a failing myocardium. It helps treat patients who have hemodynamic instability and patients
undergoing high-risk procedures in a cardiac catheterization laboratory. An intra-aortic balloon
(IAB) is a cardiac assist device attached to an external pump console that inflates and deflates
in synchrony with the cardiac cycle. This counterpulsation increases myocardial oxygen supply

and cardiac output while decreasing the myocardial oxygen demand. 1

The latest IAB technology features a flexible balloon catheter with a fiber-optic sensor that
automatically calibrates in vivo, allowing faster initiation of therapy, faster signal acquisition,
and faster adaptation to rate and rhythm changes than does a conventional IAB catheter. The
fiber-optic balloon catheter has one lumen for pressure monitoring and a second lumen that

permits periodic delivery and removal of helium gas to a closed balloon. 2

The IAB is inflated with helium, an inert gas with a lower molecular weight than that of room
air. This lighter weight produces faster inflation and deflation times than is possible with

conventional room air. 1

The practitioner typically inserts a fiber-optic IAB catheter percutaneously using a femoral
artery approach, but may also insert it using a brachial or subclavian artery if the femoral

approach is contraindicated. 1 The practitioner advances the fiber-optic IAB catheter into the
proper position in the descending thoracic aorta under fluoroscopy, leaving the IAB catheter tip
just distal (about 3/4" [2 cm]) to the left subclavian artery. An X-ray must confirm placement if
the practitioner doesn't use fluoroscopic guidance for insertion. Make sure that the pump is in
standby mode while obtaining the X-ray.

Hospital-acquired condition alert: Keep in mind that the Centers for Medicare and Medicaid
Services considers vascular catheter–associated infection a hospital-acquired condition because
it can be reasonably prevented using a variety of best practices. Make sure to follow evidence-
based infection prevention practices, such as performing hand hygiene, using maximal barrier
precautions, following sterile no-touch technique, and preparing the insertion site properly for

IAB catheter insertion, to reduce the risk of vascular catheter–associated infections. 3 4 5 6 7 8

The other end of the balloon catheter is attached to a mobile console that contains the system

for helium transfer and a computer that controls inflation and deflation. 2 The primary goals of
the IABP are to increase the myocardial oxygen supply and decrease the myocardial oxygen
demand. These goals are accomplished through the process of timing. The balloon pump
console uses data from the aortic pressure readings and the electrocardiogram (ECG) tracing to
determine the periods during the cardiac cycle when the balloon should inflate, the duration of

time it should remain inflated, and the timing for deflation. 2 The IABP bases its timing on the
arterial waveform. The IABP inflates at the closure of the aortic valve, which appears on the
arterial waveform as the dicrotic notch. As the balloon inflates at the onset of diastole, the
displaced blood causes an increase in aortic pressure through retrograde flow, thus increasing
coronary artery perfusion and mean arterial pressure. Balloon deflation is timed to occur with
the onset of systole. The balloon deflates immediately before systolic ejection, creating a
vacuum that results in a rapid decrease in aortic pressure, thus decreasing afterload and
increasing cardiac output.

Fiber-optic IABP is indicated for various low-cardiac-output disorders and cardiac instability.

INDICATIONS AND CONTRAINDICATIONS FOR FIBER-OPTIC IABP THERAPY

Various indications and contraindications exist for fiber-optic intra-aortic balloon pump (IABP) therapy, including
those listed here.

Indications1 2

1) Refractory unstable angina

2) Impending myocardial infarction (MI)

3) Acute MI

4) Refractory ventricular failure Acute mitral regurgitation Ventricular septal defect Papillary muscle rupture

5) Cardiogenic shock

6) Support for diagnostic procedures, percutaneous revascularization, and interventional procedures

 7) Ischemia related to intractable ventricular arrhythmias

8) Septic shock

9) Inoperative pulsatile flow generation

10) Weaning from cardiopulmonary bypass Cardiac support for noncardiac surgery

11) Prophylactic support to prepare for cardiac surgery, particularly in a patient with left main coronary artery
stenosis

12) Postoperative myocardial dysfunction

13) Myocardial contusion

14) Mechanical bridge to another assist device

15) Cardiac support after correction of anatomic defects

16) Low cardiac output after coronary artery bypass graft surgery

2
Absolute contraindications

 Significant aortic regurgitation

 Aortic dissection or significant aortic aneurysm Uncontrolled sepsis

2
Relative contraindications

 Uncontrolled bleeding disorder

 Aortic atheroma or severe atherosclerosis

 Severe peripheral artery disease that can't be treated with a stenting procedure Left ventricular outflow
tract obstruction

 Inability to achieve adequate IABP inflation and deflation timing due to arrhythmias

Equipment

1) 500-mL normal saline solution Pressure infuser bag

2) IV pole
 3) Single transducer system IABP console and cables Helium gas supply

4) Cardiac monitor with leads and electrodes Pulse oximeter and probe

5) Automated blood pressure cuff Hemodynamic monitoring device Capnography device

6) ECG electrodes

7) Prescribed sedative or analgesic

8) IAB insertion kit with appropriately sized IAB catheter Caps

9) Masks and goggles or masks with face shields Antiseptic solution

10) Sterile drapes

11) Sterile gloves

12) Sterile gowns

13) Sterile occlusive dressing Securement device Insertion checklist Labels

14) Emergency equipment (code cart with emergency medications, defibrillator, handheld
resuscitation bag with mask, and intubation equipment)

Optional: supplemental oxygen and administration equipment, single patient–use scissors or

disposable-head surgical clippers, soap, water, prescribed heparin bolus, prescribed IV fluids, IV
catheter insertion equipment, central venous access catheter insertion equipment, arterial catheter
insertion equipment, pulmonary artery catheter insertion equipment, additional set of ECG
electrodes, gloves, gown

Preparation of Equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised
integrity, remove it from patient use, label it as expired or defective, and report the expiration or
defect as directed by your facility.

Prepare the transducer system setup (see the "Transducer system setup" procedure) and hang a
bag of normal saline solution with the pressure infuser bag attached on an IV pole so that it's at
least 3' (0.9 m) above the transducer. Ensure that the transducer system is primed and has no air
bubbles to prevent air embolism. Make sure that the pressure infuser bag is inflated to 300 mm Hg.
Set up the balloon pump console following the manufacturer's instructions. Then plug it into an
outlet with generator backup and turn it on.

Make sure that emergency equipment is functioning properly and readily available.

Implementation

 Verify the practitioner's order.

 Review the patient's medical record for history of aortic valve competency, aortic disease,
and peripheral vascular disease to identify contraindications to IAB therapy. 1 Also review
the patient's history for an allergy to latex or local anesthetics.

 Gather and prepare the necessary equipment and supplies.

 If required by your facility, confirm that informed consent has been obtained and that the
signed consent form is in the patient's medical record.9 10 11 12

 Conduct a preprocedure verification to make sure that all relevant documentation, related
information, and equipment are available and correctly identified to the patient's
identifiers.13 14

 Verify that a complete blood count, coagulation studies, and other ordered studies are
complete to check for conditions that increase the risk of bleeding and that the results are in
the patient's medical record. Notify the practitioner of any unexpected results. 1

 Performhandhygiene.15 16 17 18 19 20 Confirm the patient's identity using atleast two

patient identifiers.13 21 Provide privacy.22 23 24 25

 Reinforce the practitioner's explanation of the procedure, explaining that the practitioner will
insert a special balloon catheter into the aorta to increase the oxygen supply to the heart,
decrease the heart's workload, and increase the cardiac output and perfusion of vital organs.
10 11 12 26 (See How an intra-aortic balloon pump works.) Briefly describe the insertion
procedure and mention that the catheter will be connected to a console next to the bed. Let
the patient know that IAB removal will occur after the patient's heart can resume an
adequate workload.

EQUIPMENT

HOW AN INTRA-AORTIC BALLOON PUMP WORKS

A fiber-optic intra-aortic balloon is attached to an external pump console by a catheter. These
illustrations show the direction of blood flow when the pump inflates and deflates the balloon.

Balloon inflation

The balloon inflates as the aortic valve closes and diastole begins. Balloon inflation displaces blood
superiorly (as shown below), which in turn augments coronary artery blood flow.

Balloon deflation

1) The balloon deflates before ventricular ejection, when the aortic valve opens (as shown
below). Balloon deflation permits rapid ejection of blood from the left ventricle against a
lowered resistance. As a result, aortic end- diastolic pressure and afterload decrease and
cardiac output rises.

2) Raise the bed to waist level before providing care to prevent caregiver back strain. 27
Performhandhygiene.15 16 17 18 19 20

3) Put on gloves and other personal protective equipment, as needed, to comply with
standard precautions.28 29 30

4) Make sure that the patient has adequate IV access via a peripheral IV catheter or
central venous access device, as prescribed, to administer prescribed medication and IV
 fluids, as needed. 1 (See the "IV catheter insertion" or "Central venous access catheter
insertion, assisting" procedure.)

5) Make sure that the patient is attached properly to all monitoring equipment, including
the cardiac monitor, pulse oximeter, automated blood pressure cuff, hemodynamic
monitoring device, and capnography device, as indicated. Make sure that alarm limits
are set appropriately for the patient's current condition and that
alarmsareturnedon,functioningproperly,andaudibletostaff.31 32 33 34

6) Attach another set of ECG electrodes to the patient, unless another cable is transmitting
the ECG pattern from the patient's bedside monitor to the balloon pump console.

7) Obtain an ECG tracing with an optimal R wave because the R wave is the preferred
signal from which the IABP determines systole and diastole to trigger inflation and
deflation. 1

8) Administer supplemental oxygen, as needed and ordered.

9) If indicated, ordered, and not already in place, assist with insertion of hemodynamic
monitoring devices, such as an arterial catheter or pulmonary artery catheter. (See the
"Arterial catheter insertion, assisting" or "Pulmonary artery catheter insertion, assisting"
procedure.) 1

10) Assess and record the patient's peripheral leg pulses and document sensation,
movement, color, and temperature of the legs to help determine the best insertion site.

11) Position the patient supine to facilitate access to the insertion site. 1

12) Remove excess hair from the intended insertion site, if needed, using single patient–use
scissors or disposable-head surgical clippers, to facilitate dressing application. 35

13) If the intended insertion site is visibly soiled, clean the area with soap and water. 35

14) Administer a sedative or an analgesic, as ordered, following safe medication

administration practices.36 37 38 39

15) Remove and discard your gloves and other personal protective equipment, if worn. 30
Performhandhygiene.15 16 17 18 19 20

16) Put on a cap and a mask and goggles or a mask with a face shield. 1

17) Perform hand hygiene.15 16 17 18 19 20

18) Prepare the sterile field. 1

 19) Place the catheter, insertion kit, and other supplies on the sterile field, as indicated. 1

20) Label all medications, medication containers, and other solutions on and off the sterile
field. 40

21) Put on a sterile gown and sterile gloves to comply with maximal barrier precautions. 5

22) Before inserting the balloon, the practitioner puts on a cap and a mask and goggles or a
mask with a face shield, performs hand hygiene, and puts on a sterile gown and sterile
gloves. 1 Then the practitioner cleans the insertion site with antiseptic solution, lets it
dry completely, and drapes the patient using a sterile drape and observing maximal
barrier precautions. 5

23) Conduct a time-out immediately before starting the procedure to perform a final
assessment that the correct patient, site, positioning, and procedure are identified and,
as applicable, that all relevant information and necessaryequipmentareavailable. 13 41

24) Administer a heparin bolus,if prescribed,following safe medication administration

practices.1 36 37 38 39

Clinical alert: Heparin is considered a high-alert medication because it can cause significant
patient harm when used in error. 42

o If required by your facility, before administering heparin, have another nurse perform an
independent double-check to verify the patient's identity and make sure that you have
the correct medication in the prescribed concentration, the medication's indication
corresponds with the patient's diagnosis, the dosage calculations are correct and the
dosing formula used to derive the final dose is correct, the prescribed route of
administration is safe and proper for the patient, the prescribed time and frequency of
administration are safe and proper for the patient, the pump settings are correct, and
the infusion line is attached to the correct port. 43

o After comparing the results of the independent double-check with the other nurse (if
required), administer the medication if no discrepancies exist. If discrepancies exist,
rectify them before administering the medication. 43

o During the procedure, make sure that the health care team follows infection prevention
practices. Use an insertion checklist to guide the insertion process to reduce the risk of
infection. 3

o Assist the practitioner with the procedure, as needed:

o After attaching a one-way valve to the male luer fitting of the IAB catheter, the
practitioner applies a 30-mL vacuum using a 30-mL syringe. Then the practitioner
removes the syringe while keeping the one-way valve attached to the IAB catheter.

o The practitioner accesses the femoral artery by inserting a needle at a 45-degree angle
and removing the inner stylet.

o The practitioner advances the guidewire through the needle and removes the needle.

o After making a small incision at the exit of the guidewire, the practitioner inserts the
vessel dilator over the guidewire, tapered end first.

o The practitioner inserts the introducer into the sheath hub and secures it.

o The practitioner advances the sheath over the guidewire into the artery and withdraws
the introducer dilator, leaving the sheath in place.

o The practitioner prepares the IAB catheter and advances it in short (1" [2.5-cm]) strokes
through the sheath into the artery until placement is correct.

o The practitioner pushes the sheath seal into the hub of the sheath and secures the
catheter to the patient's leg.

o The practitioner removes the guidewire, aspirates 3 mL of blood from the inner lumen,
and then flushes the inner lumen with 3 to 5 mL of flush solution.

o Attachthetransducersystempressuretubingtothepropercatheterport. 1 44

o Assist with removal of the one-way valve from the IAB catheter to release the vacuum
and prepare for therapy. 1

o Connect the IAB catheter's male luer fitting to the female luer fitting of the catheter
extender, connect the male luer fitting of the catheter extender to the safety disk, and
then insert the fiber-optic sensor connector in the IABP's sensor input receptacle.

o Connect the male luer fitting of the catheter extender to the pneumatic module on the
console and then insert the fiber-optic sensor connector into the IABP's sensor input
receptacle.

o Trace the tubing from the patient to the point of origin to make sure that you're
connecting the tubing to the proper port and to prevent dangerous misconnections. 44
45

o Route the tubing in a standardized direction if the patient has other tubing and catheters
with different purposes. Label the tubing as IAB CATHETER at both the distal (near the
 patient connection) and proximal (near the source container) ends to reduce the risk of
misconnections if multiple lines will be used. 44

o Apply a sterile occlusive dressing to the insertion site. Label the dressing with the date,
the time, and your initials. 5

o Set the operation mode, as ordered, following the manufacturer's instructions. The
automatic mode provides automatic lead and trigger selection; the semi-automatic mode
allows the user to select the most appropriate lead and triggering source. Make sure
that alarm limits are set appropriately for the patient's
currentconditionandthatalarmsareturnedon,functioningproperly,andaudibletostaff. 31 32
33 34

o Arrange for a chest X-ray, as needed and ordered, to confirm IAB placement. 1

o Interpret waveforms, monitor balloon function, and maintain accurate IABP timing
according to waveform interpretation. Proper IABP inflation and deflation balance the
oxygen supply and demand, reducing the risk of further ischemia and compromised
contractility. 46 (See Interpreting intra-aortic balloon waveforms.)
INTERPRETING INTRA-AORTIC BALLOON WAVEFORMS

For an intra-aortic balloon pump (IABP) to function properly, the practitioner must synchronize
the device's inflation-deflation cycle to appropriate events in the patient's cardiac cycle. During
intra-aortic balloon therapy, you can use electrocardiogram (ECG) and arterial pressure
waveforms to determine whether the IABP is functioning properly. The central lumen of the
double-lumen intra-aortic balloon catheter allows monitoring of the pressure in the descending
aorta during the cardiac cycle. This arterial line provides data to the IABP
console.ThepractitionerusesthearterialwaveformasaguidewhentimingtheIABP. 1 47

Many IABC models automatically adjust timing settings to accommodate changes in the heart
rate and ECG tracing. Knowing the individual patient's goals of therapy and the available trigger
options for a particular system helpsoptimizetherapy. 1 2

Normal inflation-deflation timing

The balloon inflates after aortic valve closure; it deflates during isovolumetric contraction, just
before the aortic valve opens. In a properly timed waveform (shown below), the inflation point
lies at or slightly above the dicrotic notch. Inflation and deflation cause a sharp V shape. The
peak diastolic pressure exceeds the peak systolic pressure, and the peak systolic pressure
exceeds the assisted peak systolic pressure.
Early inflation

With early inflation, the inflation point lies before the dicrotic notch (shown below). Early
inflation dangerously increases myocardial stress and decreases the cardiac output.

Early deflation

Early deflation results in a U shape on the arterial waveform (shown below). The peak systolic
pressure is less than or equal to the assisted peak systolic pressure. Early deflation doesn't help
decrease afterload or myocardial oxygen consumption.
Late inflation

With late inflation, the dicrotic notch precedes the inflation point, and the notch and the
inflation point create a W shape (shown below). Late inflation can lead to a reduction in the
peak diastolic pressure, coronary and systemic perfusion augmentation time, and augmented
coronary perfusion pressure.

Late deflation

With late deflation, the peak systolic pressure exceeds the assisted peak systolic pressure
(shown below). This event threatens the patient by increasing afterload, myocardial oxygen
consumption, cardiac workload, and preload. It occurs when the balloon has been inflated for
too long or fails to receive the input signal from the ECG, indicating the start of systole (QRS
complex).

Monitor the IABP console to make sure that it's functioning properly.
Clinical alert: If a pump console malfunctions or becomes inoperable, don't let the balloon
catheter remain dormant for longer than 30 minutes or for the length of time determined by the
manufacturer. Obtain another pump console, attach it to the balloon, and then resume
pumping. In the meantime, inflate and deflate the balloon manually, according to the
manufacturer's instructions, once every 5 minutes to prevent thrombus formation in the
catheter. Never manually inflate the balloon if you suspect rupture. 1

Monitor the patient's vital signs, hemodynamic parameters, and clinical status at a frequency
determined by your facility and the patient's condition. 1 47 (See the "Intra-aortic balloon
management" procedure.)

Return the bed to the lowest position to prevent falls and maintain the patient's safety. 48
Discard used supplies in appropriate receptacles. 30
Remove and discard your personal protective equipment. 30
Performhandhygiene.15 16 17 18 19 20

Document the procedure.49 50 51 52

Complications

Complication sassociated with fiber-optic IAB insertion may include:1 2

1) Balloon membrane perforation vascular laceration

2) Limb ischemia

3) Visceral ischemia

4) Spinal cord ischemia peripheral neuropathy bleeding at the insertion site infection

5) Thrombocytopenia hemolysis

6) Aortic dissection thrombosis

7) Cholesterol embolization stroke.

References

(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)

1. Wiegand, D. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.).
Elsevier.

2. Laham, R. J., & Pinto, D. S. (2022). Intraaortic balloon pump counterpulsation. In: UpToDate, Gersh, B. J.,
& Cutlip, D. (Eds.).
UpToDate Full Text

3. 3. Buetti, N., et al. (2022). SHEA/IDSA/APIC practice recommendation: Strategies to prevent central line-
associated bloodstream infections in acute care hospitals. Infection Control & Hospital Epidemiology, 43(5),
553–569. Retrieved July 2022 from https://doi.org/10.1017/ice.2022.87 (Level I)

4. Jarrett, N., & Callaham, M. (2016). Evidence-based guidelines for selected hospital-acquired conditions:
Final report. Retrieved July 2022 from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalAcqCond/Downloads/2016-HAC-Report.pdf

5. Centers for Disease Control and Prevention. (2011, revised 2017). Guidelines for the prevention of
intravascular catheter–related infections. Retrieved July 2022 from
https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html (Level I)

6. Standard 50. Infection. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing,
44(Suppl. 1), S153–S157. Retrieved July 2022 from https://doi.org/10.1097/NAN.0000000000000396 (Level
VII)

7. Association of Professionals in Infection Control and Epidemiology. (2015). Guide to preventing central line–
associated bloodstream infections. Retrieved July 2022 from
http://apic.org/Resource_/TinyMceFileManager/2015/APIC_CLABSI_WEB.pdf (Level IV)

8. Standard 18. Aseptic Non Touch Technique (ANTT®). Infusion therapy standards of practice (8th ed.).
(2021). Journal of Infusion Nursing, 44(Suppl. 1), S56–S58. Retrieved July 2022 from
https://doi.org/10.1097/NAN.0000000000000396 (Level VII)

9. Accreditation Commission for Health Care. (2021). Standard 30.01.11. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

10. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.3. NIAHO® accreditation requirements, interpretive
guidelines and surveyor guidance – revision 20-1. (Level VII)

11. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Patient's rights. 42 C.F.R. §
482.13(b)(2).
12. The Joint Commission. (2022). Standard RI.01.03.01. Comprehensive accreditation manual for hospitals.
(Level VII)

13. Accreditation Commission for Health Care. (2021). Standard 30.00.14. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

14. The Joint Commission. (2022). Standard UP.01.01.01. Comprehensive accreditation manual for hospitals.
(Level VII)

15. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16), 1–
45. Retrieved July 2022 from https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)

16. World Health Organization (WHO). (2009). WHO guidelines on hand hygiene in health care: First global
patient safety challenge, clean care is safer care. Retrieved July 2022 from
https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)

17. The Joint Commission. (2022). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals.
(Level VII)

18. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Infection control. 42 C.F.R. §
482.42.

19. Accreditation Commission for Health Care. (2021). Standard 07.01.21. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

20. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance – revision 20-1. (Level VII)

21. The Joint Commission. (2022). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals.
(Level VII)

22. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO® accreditation requirements, interpretive
guidelines and surveyor guidance – revision 20-1. (Level VII)

23. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Patient's rights. 42 C.F.R. §
482.13(c)(1).

24. The Joint Commission. (2022). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals.
(Level VII)

25. Accreditation Commission for Health Care. (2021). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

26. Accreditation Commission for Health Care. (2021). Standard 15.01.11. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

27. Waters, T. R., et al. (2009). Safe patient handling training for schools of nursing. Retrieved July 2022 from
https://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf (Level VII)

28. Siegel, J. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of
infectious agents in healthcare settings. Retrieved July 2022 from
https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
29. Accreditation Commission for Health Care. (2021). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

30. Occupational Safety and Health Administration. (2019). Bloodborne pathogens, standard number
1910.1030. Retrieved July 2022 from
https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030 (Level VII)

31. The Joint Commission. (2022). Standard NSPG.06.01.01. Comprehensive accreditation manual for hospitals.
(Level VII)

32. The Joint Commission. (2013). Sentinel event alert 50: Medical device alarm safety in hospitals. Retrieved
July 2022 from https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-
topics/sentinel-event/sea_50_alarms_4_26_16.pdf (Level VII)

33. American Association of Critical-Care Nurses (AACN). (2018). AACN practice alert: Managing alarms in acute
care across the life span: Electrocardiography and pulse oximetry. Retrieved July 2022 from
https://www.aacn.org/clinical-resources/practice-alerts/managing-alarms-in-acute-care-across-the-life-span
(Level VII)

34. Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and
decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28–37. Retrieved July 2022 from
https://doi.org/10.4037/ajcc2010651
Abstract | Complete Reference | Full Text

35. Standard 33. Vascular access site preparation and skin antisepsis. Infusion therapy standards of practice
(8th ed.). (2021). Journal of Infusion Nursing, 44(Suppl. 1), S96. Retrieved July 2022 from
https://doi.org/10.1097/NAN.0000000000000396 (Level VII)

36. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Nursing services. 42 C.F.R. §
482.23(c).

37. Accreditation Commission for Health Care. (2021). Standard 16.01.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

38. DNV GL-Healthcare USA, Inc. (2020). MM.1.SR.3. NIAHO® accreditation requirements, interpretive
guidelines and surveyor guidance – revision 20-1. (Level VII)

39. The Joint Commission. (2022). Standard MM.06.01.01. Comprehensive accreditation manual for hospitals.
(Level VII)

40. Accreditation Commission for Health Care. (2021). Standard 25.01.27. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

41. The Joint Commission. (2022). Standard UP.01.03.01. Comprehensive accreditation manual for hospitals.
(Level VII)

42. Institute for Safe Medication Practices (ISMP). (2018). ISMP list of high-alert medications in acute care
settings. Retrieved July 2022 from https://www.ismp.org/sites/default/files/attachments/2018-
08/highAlert2018-Acute-Final.pdf

43. Institute for Safe Medication Practices. (2019). Independent double checks: Worth the effort if used
judiciously and properly. Retrieved July 2022 from https://www.ismp.org/resources/independent-double-
checks-worth-effort-if-used-judiciously-and-properly (Level VII)
44. The Joint Commission. (2014). Sentinel event alert 53: Managing risk during transition to new ISO tubing
connector standards. Retrieved July 2022 from https://www.jointcommission.org/-
/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_53_connectors_8_19_14_final.pdf
(Level VII)

45. U.S. Food and Drug Administration. (2021). Examples of medical device misconnections. Retrieved July
2022 from https://www.fda.gov/medical-devices/medical-device-connectors/examples-medical-device-
misconnections

46. Hanlon-Pena, P. M., & Quaal, S. J. (2011). Intra-aortic balloon pump timing: Review of evidence supporting
current practice. American Journal of Critical Care, 20(4), 323–333. Retrieved July 2022 from

47. Goldich, G. (2011). Getting in sync with intra-aortic balloon pump therapy. Nursing, 41(Suppl. 1), 10–13.
Retrieved July 2022 from https://doi.org/10.1097/01.nurse.0000406632.71036.e0 (Level VII)
Abstract | Complete Reference

48. Ganz, D. A., et al. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ
Publication No. 13-0015-EF). Agency for Healthcare Research and Quality. Retrieved July 2022 from
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html (Level VII)

49. The Joint Commission. (2022). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals.
(Level VII)

50. Accreditation Commission for Health Care. (2021). Standard 10.00.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

51. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Medical record services. 42
C.F.R. § 482.24(b).

52. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive
guidelines and surveyor guidance – revision 20-1. (Level VII)