There were 138 reported deaths from 2010 to June 2015 due to alarm system failures, according to data from the Joint Commission seen by The Wall Street Journal, which often stemmed from “alarm fatigue,” or medical staff becoming desensitized to alarms and overlooking critical signals. “This is a preventable issue that is killing people, and every year we see the numbers go up because of something related to alarm management,” said Ronald Wyatt, the Joint Commission’s medical director for healthcare improvement, as quoted by the newspaper.
However, hospitals are not wasting any time getting up to speed with the Commission’s calls for improvement. The University of San Francisco (UCSF) piloted a program that adds a delay to finger-clip monitors used to measure the amount of oxygen in patients’ blood, so an alarm only goes off if the changes in oxygen continue for 20 seconds. The technique significantly reduced the number of alarms with no adverse outcomes, so UCSF switched to using the new system at 5 of its intensive care units, UCSF professor of medicine Barbara Drew told the WSJ.
Researchers at Boston Medical Center are taking a similar track. The scientists converted warning alarms for changes in heart rate that were not serious to visual messages sent to nurses, and allowed nurses to tailor alarms to individual patients. Other, more serious alarms for “crisis level” problems sounded in real-time, triggering a faster response from staff. Since the hospital unveiled its approach, heart-related alarms have reduced overall alarms by 60%, Deborah Whalen co-author and clinical service manager of cardiology at Boston Medical Center, told the newspaper.
Pediatric hospitals are also jumping on the innovation bandwagon. The University of Pittsburgh Medical Center’s Children’s Hospital rolled out a software program called the “Rothman Index”, which gathers data in real-time from electronic medical records and gives a score from 1 to 100. Lower scores mean that staff should monitor more closely or immediately help a patient. The system also presents visual graphs on a nursing station screen and sends mobile phone alerts to doctors and nurses when a patient’s condition becomes serious, offering an advantage over alarms which can only be heard if staffers are nearby.
REFERENCE: Fierce Medical Devices; 06 JAN 2016; Emily Wasserman