Alarm Fatigue

The Case for Continuous Surveillance Monitoring and Real-Time Analytics

In this article which was published in Healthcare Business Today, Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety) makes the case for continuous surveillance monitoring and real-time analytics.

The successful implementation of continuous surveillance monitoring may have substantial patient benefits. Unfortunately, analyzing notifications from individual medical devices, reliance on physical spot checks of patients, and the lack of rules-based advanced analytics to assess a patient’s current condition in real-time or to identify signs of deterioration is a goal that many hospitals and health systems still have not attained.

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Alarm Fatigue

Maria Cvach’s 6 Steps for Improving Alarm Management The Experience of John Hopkins Hospital in Reducing Alarm Fatigue

Maria Cvach, DNP, RN, FAAN, who is director of policy management and integration for Johns Hopkins Health System, recently spoke with the Physician-Patient Alliance for Health & Safety (PPAHS) about the experience of John Hopkins Hospital in improving patient safety and reducing alarm fatigue.

Clinical Education Podcast Features Maria Cvach on Reducing Alarm Fatigue

Maria Cvach

In a clinical education podcast that was released on PPAHS’s YouTube Channel, Ms. Cvach discussed how John Hopkins Hospital was ahead of the curve in managing alarm fatigue, which became The Joint Commission proclaimed as a national patient safety goal in 2014. Johns Hopkins Hospital had formed an alarm management committee in 2006:

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Alarm Fatigue

ECRI’s Advice on Alarm Management Ensure proper settings of secondary notifications

ECRI Institute’s Marc Schlessinger, RRT, MBA, FACHE, who is senior associate at their applied solutions group, recently spoke with the Physician-Patient Alliance for Health & Safety (PPAHS) on how to improve alarm management. The interview can be heard on the clinical education podcast, “Improving Patient Safety and Reducing Alarm Fatigue: The Right and Wrong Way to Use Continuous Surveillance Monitoring.”

Michael Wong, JD (Founder/Executive Director, PPAHS) noted the work that ECRI has done to help improve patient safety and reduce alarm fatigue citing ECRI’s recent “Top 10 Health Technology Hazards for 2018:”

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Alarm Fatigue

ECRI’s Top Ten Technology Hazards for 2018 Middleware Technology Must be Configured Appropriately to Reduce Alarm Fatigue

Recently, ECRI Institute released its Top Ten Technology Hazards for 2018. The purpose behind ECRI’s yearly list is to promote the safer use of technology:

The safe use of health technology—from beds and stretchers to large, complex imaging systems—requires identifying possible sources of danger or difficulty with those technologies and taking steps to minimize the likelihood that adverse events will occur. This list will help healthcare facilities do that.

Number 4 on this list deals with how Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems:

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Alarm Fatigue, Hospital Acquired Conditions

Advances in Alarm Management and Surveillance Monitoring

Written by James Welch, CEO Arc Biomedical Consultants (jwelch@arcbiomed.com)

james-welch

Mr. Welch is a Clinical Engineer with 17 yrs experience in hospitals and over 24 yrs as an executive in the medical device industry. His focus has been on applying technologies to improve patient safety through continuous surveillance monitoring. Mr. Welch has ten patents and articles in the field of wireless physiologic monitoring, surveillance systems and alarm management. He regularly contributes to the AAMI Foundation on alarm safety and is a voting member on a number of International Standards committees.

Early detection of physiologic deterioration is essential in improving patient safety in acute care hospital settings.  Patients in non-ICU settings who are recovering from surgery or special procedures are especially vulnerable because of private or semi-private room settings prevents direct observation and nurse to patient ratios are often 1:6. Experts in Rapid Response Systems (RRS) have arrived at a consensus that strengthening early detection through continuous monitoring is essential in improving the effectiveness of RRS but only if such systems do not impose a burden on the clinical staff. The high incidence of nuisance alarms and cost are two of the major barriers preventing broader adoption of continuous monitoring on the general care floor. Read More

Opioid Safety, Patient Safety, Practices & Tips, Respiratory Compromise

The Vital Role Nurses Play in Patient Care

Written by Michael Wong, JD, Founder & Executive Director of PPAHS

As founder and executive director PPAHS, when I speak at conferences about the Physician-Patient Alliance for Health & Safety support for continuous electronic monitoring of patients receiving opioids, I am often asked two questions:

  • Is PPAHS suggesting or recommending that technology replace nurses?
  • Why has continuous monitoring been so slow to be adopted by hospitals?

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Must Reads

Patient Safety Weekly Must Reads (April 15, 2017)

Great news–our video last week was watched over 25,000 times! Let’s keep working to transform that awareness into progress for patient safety.

This week in #patientsafety, PPAHS Founder and Executive Director Michael Wong, JD, penned an article for Healthcare Business Today on what makes “good” hospital leadership. From around the web, a study looks at the relationship between readmission rates and caregiver involvement in discharge discussions. Another study looks at factors associated with alarm response time. And a doctor asks if her peers have noticed an increase in inquiries about NSAIDs with growing awareness of the opioid epidemic.

From PPAHS:

“Good” Hospitals Require Real Leaders. How can you tell the difference between a “good” hospital and a “bad” one?

From Around the Web:

Study: To reduce readmissions, involve caregivers in discharge planning. A study finds that involving caregivers in discharge discussions was associated with a 25% reduction in the likelihood of an elderly patient being readmitted to the hospital within 90 days of discharge.

Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children’s Hospital. Nurses who responded faster included those who were earlier in their shifts, had less than 1 year of experience, previously responded to an alarm requiring intervention, were caring for only 1 patient, and were responding to an alarm for lethal arrhythmia.

More information on NSAIDs & CV risk. A doctor looks at research on the cardiovascular risks of NSAIDs as patients appear to ask about them more frequently.

Must Reads

Patient Safety Weekly Must Reads (April 8, 2017)

This week in #patientsafety, we released a video that summarizes experiences of clinicians in improving opioid safety in their hospital or healthcare facility, and reminds us of the tragic consequences of adverse events and deaths that may ensue if clinicians and healthcare executives are not proactive in promoting safety. From around the web, a look at alarm fatigue, pre-surgical counselling on opioid use, and reactions to a sepsis awareness campaign.

From PPAHS:

Nine Minutes to Improving Opioid Safety: PPAHS Releases Patient Safety Video. Over 10 hours of in-depth interviews released by PPAHS in 2016 distilled into 9 minutes.

From Around the Web:

How Redesigning The Abrasive Alarms Of Hospital Soundscapes Can Save Lives. Alarm fatigue continues to be a problem at hospitals.

Here’s something that curbs opioid use: Pre-surgical counseling. This surgeon shows a video on opioid safety to patients before undergoing surgery, and says it works at reducing opioid use.

Sepsis awareness campaigner reacts to health board responses. Health boards in the UK are working on reducing sepsis, but some are wary of a widower’s awareness campaign.

Must Reads

Patient Safety Weekly Must Reads (March 4, 2017)

This week in #patientsafety, we shared an article on opioids in dentistry by Bradley Truax, MD. Outpatient Surgery covered our position statement on patient ambulation. From around the web, NPR wrote about dentists working to use fewer opioids, a hospital reduced nuisance alarms by 30%, and The Joint Commission issued a new Sentinel Event Alert on developing a culture of safety.

From PPAHS:

Patient Safety Tip of the Week: Dental Patient Safety. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted an article on dental patient safety (with permission).

Push to Make Ambulation a Key Patient Recovery Metric. Outpatient Surgery covered our position statement on patient ambulation.

From Around the Web:

Dentists Work To Ease Patients’ Pain With Fewer Opioids. Dr. Joel Funari performs some 300 tooth extractions annually at his private practice in Devon, Pa. He’s part of a group of dentists reassessing opioid prescribing guidelines in the state.

Hospital’s program reduces nuisance alarms 30 percent. Nurses at Palomar Health in California were part of a study designed to reduce alarm fatigue. The health system decreased its alarms by nearly 30 percent.

Sentinel Event Alert 57: The essential role of leadership in developing a safety culture. “Competent and thoughtful leaders contribute to improvements in safety and organizational culture,” says The Joint Commission.

Patient Safety

Top 10 Articles of 2016

Happy Holidays!

We’d like to wish you a safe and healthy 2017.

As we prepare for 2017, we reflect back on the top 10 articles from 2016.

Opioid Safety

  1. Physicians on Surgeon General’s Letter on Opioid Epidemic: Survey Results. The Surgeon General issued an Open Letter on the Opioid Epidemic. We looked into how clinicians and other patient safety experts felt about it.
  2. The U.S. Opioid Epidemic In Numbers. Related, Advance for Nurses generated an infographic summarizing your responses.
  3. 12 Years of Event-Free Opioid Use. In 2016, St. Joseph’s/Candler Health System celebrated 12 years free from Serious Adverse Events related to Opioid-Induced Respiratory Depression since the implementation of its continuous monitoring program.

Alarm Safety

  1. 3 Ways to Make Opioids Safer. Peggy Lange, RT, Director of the Respiratory Care Department at St. Cloud Hospital, discussed the importance of setting alarm thresholds for each patient in this podcast.
  2. Drawn Curtains, Muted Alarms, And Diverted Attention Lead To Tragedy In The Postanesthesia Care Unit. Sadly, alarms on the monitoring equipment used to alert healthcare professionals to changes in the patient’s cardiac and respiratory status were muted in one tragic death of a 17-year-old.
  3. A New Tool to Predict Respiratory Failure: An Interview with Hiroshi Morimatsu, MD, Ph.D. Could this multi-parameter indicator help counter alarm fatigue?

Bloot Clots Safety

  1. New PPAHS Campaign Targeting Orthopedic Venous Thromboembolism. VTE is the third-most prevalent reason for readmission after surgery, and about 1 million hip and knee replacement surgeries happen each year in the U.S.
  2. Physician-Patient Alliance Partners with World Thrombosis Day. As part of our new campaign, we partnered with World Thrombosis Day in 2016. Looking forward to working together in 2017.
  3. Why Bundled Payments for Joint Replacement May Be Risky for Patients. We took a look at whether patients are receiving evidence-based or reimbursement-based care under the Bundled Payments model.

Special Mention

  1. Why All Medical Schools Must Incorporate Quality Improvement and Patient Safety into Their Curriculums. This position by Molly Siegel generated plenty of engagement on the Twittersphere and is a theme that cuts across all of our priority areas.