Alarms at Mass Gen­eral /

Mass. in­ci­dent high­lights need for pro­to­cols check

Modern Healthcare - - Front Page - Mau­reen McKin­ney

Af­ter a re­cent CMS re­port ruled that nurses’ de­sen­si­ti­za­tion to mon­i­tor alarms played a role in the death of a car­diac pa­tient, more hos­pi­tals are tak­ing heed and ex­am­in­ing the prob­lem, known as alarm fa­tigue, in their own or­ga­ni­za­tions.

The in­ci­dent occurred on an early Jan­uary morn­ing at 907-bed Mas­sachusetts Gen­eral Hospi­tal, Bos­ton. The pa­tient was one of 31 oth­ers on a sur­gi­cal floor staffed by 10 nurses, ac­cord­ing to the April 2 re­port. A re­view of car­diac mon­i­tor logs showed that dur­ing a 20minute pe­riod, the pa­tient’s heart rate dropped rapidly and even­tu­ally stopped, and sub­se­quent re­sus­ci­ta­tion ef­forts were un­suc­cess­ful.

Nurses did not re­port hear­ing re­peated warn­ing alarms, and the vol­ume on the pa­tient’s bed­side cri­sis alarm, which alerts staff to an ar­rhyth­mia, was in the “off” set­ting, said Gregg Meyer, Mas­sachusetts Gen­eral’s se­nior vice pres­i­dent for qual­ity and safety.

The event high­lighted a num­ber of sig­nif­i­cant prob­lems, in­clud­ing the dis­cov­ery that scrolled vol­ume func­tions on bed­side alarms had an off set­ting that could be ap­plied eas­ily and in­ad­ver­tently—some­thing that was not well-known among staff, Meyer said.

De­spite the tragedy, Meyer said he was pleased the staff had fol­lowed proper pro­to­col for a se­ri­ous safety event. Nurses on the floor im­me­di­ately com­pleted a re­port and no­ti­fied ad­min­is­tra­tors, who then alerted the state’s pub­lic health depart­ment.

Of­fi­cials from the CMS knew of the event al­ready when they ar­rived at Mas­sachusetts Gen­eral in Fe­bru­ary for a ran­dom val­i­da­tion sur­vey, and they were able to ex­am­ine the in­ci­dent in de­tail while at the hospi­tal, said Roseanne Paw­elec, spokes­woman for the CMS’ re­gional of­fice.

“CMS did not un­cover a rock dur­ing their sur­vey,” Meyer said. “We had al­ready shared this openly.”

Since the in­ci­dent, the staff at Mas­sachusetts Gen­eral has dis­abled the off set­ting on more than 1,100 mon­i­tors, in­stalled dis­trib­uted speak­ers so vol­ume set­tings on alarms do not have to be turned up so high, stan­dard­ized alarm vol­umes, and in­sti­tuted a re­view process for any changes to de­fault set­tings. Ad­di­tion­ally, the staff has cre­ated a train­ing pro­gram that re­views mon­i­tor tech­nol­ogy, and has formed a com­mit­tee charged with cre­at­ing best prac­tices and stan­dards for alarm use, said Jeanette Ives Erick­son, se­nior vice pres­i­dent for pa­tient care and chief nurse at the hospi­tal.

“The team is re­view­ing stan­dards to see which pa­tients re­ally need to be on mon­i­tors,” Meyer said. “We have im­me­di­ately seen more dis­cus­sion at the unit level, and we’ve dis­cov­ered it’s a topic that needs to be part of shiftto-shift hand­off con­ver­sa­tions.”

Alarm fa­tigue is not unique to Mas­sachusetts Gen­eral. Sev­eral years ago, prompted by a fear that ex­ces­sive alarms had de­sen­si­tized nurs­ing staff, 925-bed Johns Hop­kins Hospi­tal, Bal­ti­more, be­gan a qual­ity im­prove­ment project, the re­sults of which were pub­lished in the Jan­uary is­sue of the Amer­i­can Jour­nal of Crit­i­cal Care.

The find­ings were eye-open­ing, said Maria Cvach, as­sis­tant di­rec­tor of nurs­ing, clin­i­cal stan­dards, and co-au­thor of the ar­ti­cle. The hospi­tal’s med­i­cal pro­gres­sive care unit had a stag­ger­ing 500 alarms per pa­tient per day—most of which were low-pri­or­ity and re­quired no in­ter­ven­tion, but made for a very noisy en­vi­ron­ment, she said. Through the im­prove­ment pro­gram, the hospi­tal was able to re­duce that num­ber to 200.

The key, said Cvach, is set­ting re­al­is­tic, ac­tion­able alarm pa­ram­e­ters based on your pa­tient pop­u­la­tion. For in­stance, if a unit has a large num­ber of res­pi­ra­tory pa­tients with chronic lung dis­ease, it’s not pro­duc­tive to set alarms on pulse oxy­gena­tion mon­i­tors based on nor­mal lung-func­tion val­ues.

Cvach also ad­vised cre­at­ing some kind of backup sys­tem to pro­vide a safe­guard against er­rors. Some hos­pi­tals de­liver an ad­di­tional no­ti­fi­ca­tion via pager, cell phone or mar­quee sign. Oth­ers have taken an ex­tra step and added a mon­i­tor tech­ni­cian whose job is to serve as an ex­tra pair of eyes and make sure lethal rhythms or de­te­ri­o­rat­ing sta­tus do not go un­no­ticed.

The in­creas­ing fo­cus on alarm fa­tigue is just one part of a larger trend of pa­tient-safety aware­ness, said An­drea Kline, pe­di­atric nurse prac­ti­tioner at Ri­ley Hospi­tal for Chil­dren, part of 1,385-bed Clar­ian Health Part­ners, Indianapolis. Ear­lier this year, while work­ing at 247-bed Chil­dren’s Memo­rial Hospi­tal, Chicago, Kline de­vel­oped a 24-ques­tion sur­vey on alarm fa­tigue, sent it to 300 crit­i­cal-care nurses at 681-bed Rush Uni­ver­sity Med­i­cal Cen­ter, Chicago, and pre­sented re­sults from the 94 re­sponses she re­ceived at the So­ci­ety of Crit­i­cal Care Medicine’s an­nual Crit­i­cal Care Congress in Jan­uary.

The sur­vey in­di­cated that alarms were of­ten not set ap­pro­pri­ately for pa­tients, and nurses of­ten wor­ried about un­in­ten­tion­ally miss­ing one, Kline said.

De­spite re­ceiv­ing more at­ten­tion in the past few months, alarm fa­tigue was on the Joint Com­mis­sion’s radar in 2003 when it named it as one if its Na­tional Pa­tient Safety Goals, said Paul Schyve, the or­ga­ni­za­tion’s se­nior vice pres­i­dent. It was deleted in 2005 be­cause re­ports had im­proved sig­nif­i­cantly, he said, but that trend has changed and the num­bers are creep­ing back up once again. A con­stant stream of alarms can eas­ily lead to fa­tigue, Schyve said, draw­ing an anal­ogy to the fre­quent alerts of­ten present in com­put­er­ized physi­cian or­der-en­try sys­tems.

There were two parts to the ini­tial 2003 pa­tient-safety goal re­gard­ing alarm fa­tigue: reg­u­lar main­te­nance and en­sur­ing alarm vol­umes were set high enough. In 2004, there were nine re­ports of non­com­pli­ance from sur­vey­ors; that num­ber has since climbed to more than 30.

At Mas­sachusetts Gen­eral, trans­parency and quick action has helped make the best out of a very un­for­tu­nate sit­u­a­tion, Erick­son said.

“We know this is a na­tional is­sue and some­thing that hap­pens at other hos­pi­tals,” Meyer said. “It has gal­va­nized us to look at our cul­ture, make im­prove­ments in our pro­cesses, and do the right thing for our pa­tients.”

Alarm fa­tigue can oc­cur when nurses work in ex­ces­sively noisy en­vi­ron­ments or face high num­bers of low-pri­or­ity alerts.

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