Alarm Fatigue Revisited

Here is a little throw back from one of our most popular posts! I know it can be searched but thought you all might enjoy seeing something from 2010....

 

Wednesday, September 15, 2010

Alarm Fatigue

I was cooking a BIG meal – one with several burners going, the oven on, and even the microwave.  It was one of those “Martha Stewart has nothing on me moments.” (Ok, I was really more like a I'm a tall version of Rachel Ray) There were 4 boys running in and out asking questions and trying to “help” - other kitchen noises like the garbage disposal, can opener, food processor plus of course the TV was on in the other room. It was loud - like the Chiefs Stadium when we beat the Chargers on Monday night – LOUD! The point is I had a lot going on and neglected to set the egg timer for one of my pans and ignored the beeping on the oven……all of this to say we ended up eating at Culvers that night.

My kitchen scenario is much LESS intense than a nursing floor. No one was critically ill, there were no emotionally distraught family members, there was no Code Blue – it was a kitchen. (Well, the food was critically ill by the end of it – I digress) The point is think about your most intense - loud - busy moments and then think of how much more intense - loud - and busy the nurse is and you will begin to understand  “Alarm Fatigue”.

On a floor with 30 patients with IV pumps, nurse call, telemetry, other physiological alarms, etc there is bound to be some noise. The current methodology of listening for an alarm can really hinder productivity – but leave productivity out of it – it is a major safety concern.

Let’s take an easy one - Do you know the most common way we document a response to an IV pump alarm? The patient has pressed their call button and the nurse is notified that the IV Pump was dinging in their room. Think about how scary that is for a patient and their family – who has no idea what the dining means. Do you know the most inexpensive way to fix that problem? Automate an IV pump alarm to the caregivers wireless and explain to the patient and their family what will happen if the alarm goes off. (BTW – repeat that information every time you enter the room for rounding.)

Here’s a freebie - Depending on your nurse call system there is generally a quarter inch jack that can take a contact closure alarm – old school – this is the way my Dad did it when he sold nurse call in the early 1980’s. Order the cord you can use it tomorrow in your hospital. IF you have a question (hospital) – call or email me I will walk you through it. There are much more expensive ways to automate these as well.

The challenge is at some point in alarm automation and “management” you simply begin to displace the problem. If a clinical alarm device is trigger happy then your wireless device will be as well. Too many alarms is still TOO MANY ALARMS – just because it’s quieter on the unit does not mean its better. At some point it’s time to really review the technology that is making the alarm happen, AND review the process of who is getting what alarm when and why. The event in Boston was not due to the alarm noise, really it wasn’t even due to accountability because no one “heard” the alarm. The Critical alarm was turned off and the Warning alarms were ignored. Some automation would’ve helped the issue but it may not have solved.

Patient safety officials across the country have said the heart patient’s death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.  ()http://www.boston.com/news/local/massachusetts/articles/2010/04/03/alarm_fatigue_linked_to_heart_patients_death_at_mass_general/?page=1

It’s tragic that a death occurred due to an alarm issue, and no family should have to go through that.  That death should be a rally point for all of us in the device industry.  

Define the Strike Zone

As a working mom with 4 boys juggling soccer practices, games, school events, and career can be really a challenge….but it’s what I signed up for when I took on this CEO role.  A few months ago, I was fortunate enough to get done early with a meeting in and grab a flight home to make it too Tucker’s baseball game.  I was glad I made it, because there was a great learning moment…..

Tucker (aka #2) stepped up on the mound and took his first warm up pitch….zip! It flew right over the catchers head and smashed into the fence causing the parents to jump.  He shook his head….frustrated….and quickly he took his next pitch…..ZIP! This time harder.   Still over the catchers head.  A mother behind me exclaimed “Someone needs to tell that boy not to throw so hard or he might injure someone.”  I bit my tongue, my response would have been “Lady wrap your kid in bubble wrap and let’s play ball.”  Instead I stood up and walked over to the fence saying “bring it down Tuck” and the mom whispered her remaining comments to her friend. 

If the other team didn’t have such an affinity to swing at high outside balls, then it would’ve been a looong inning.  The umpire held true to the strike zone so every batter went to a full count.  Fortunately, the young batters just liked to swing the bat so the inning ended quickly.  He headed to the dug out – head hung low – and sat down. 

I walked over to check on him “Hey Wild Thing are you ok?” (He didn’t understand the movie reference, but it made me smile)

“My pitches were high.”
“It happens…. sometimes we make mistakes – just bring your pitches down.  He was calling a generous strike zone -”
“But mom, it’s not my fault!” Tucker interrupted me “I didn’t expect to pitch tonight, my Dad wasn’t here to warm me up, and the coach made me clean up someone else’s mess.” 
My eye brows raised….for those of you that don’t speak Kourtney my eyebrows are my “tell” (I will never be able to play poker)… “Excuse me – whose hand did the ball leave? Who threw the pitches?”
 “Me….but”
“Tucker, you threw the pitches – you are responsible for the result.  It’s not enough just to get it over the plate – it has to be in the strike zone.  Now quit complaining and get ready for the next inning.”

Every Pitcher knows that his goal is to throw the ball over the plate in a way that the batter will swing at it (and hopefully not make contact).   It’s a universal understanding for baseball.  The umpire provides the detail on what and where he should focus – the umpire sets the actual strike zone. 

In the same way, every hospital knows that their strategic goal is to have satisfied patients, satisfied employees, and provide quality service….this has been the edict for years.  (Those goals should be the same for every business)  HCAHPS are not a new or revolutionary understanding of providing care that satisfies the needs of the patients.  HCAHPS simply defines the strike zone.  Instead of the general idea of throwing the ball over the plate – we must have “satisfied” customers – HCAHPS provides categories and expectations.  (We can all debate the validity of using “always” but that’s a blog for another time.)

Additionally, HCAHPS defines personal responsibility for our employees and a structure to hold them accountable for those actions.   Tucker threw his pitches high and outside – he was responsible for the every pitch he threw – good or bad.  He had the best intentions to throw a strike, but when the pitch left his hand….it was off the mark.  As his quasi coach that night, I was able to observe be outside the interaction from outside the field.  When he got to the dugout, I provided instruction based on his actions….in essence at the “point of care” I was able to instruct him on his next action.  In the weeks that followed, he pitched to me in the front yard and I could coach him based on his need.  (Did I mention I was a catcher for 10+years…poor kid)

As leaders in our organization it is important to engage during the work day – providing insight into how our team can improve what they are doing based on our outside perspective.   It’s critical that we create coaching moments outside of the heat of battle based on the information collected….Tucker throws a lot of high pitches.  I observed his grip, release, and stance during the game and was able to coach him in the front yard towards a better pitch.  You as leaders need information about how your employees serve your clients - defining not only what your expectation is but what your clients expectation is to find ways to continuously improve.   

 

Are you coaching your team to a better result? 

Do you have the information to be able to do so? 

Do you know what your patients except and are you meeting those expectations? 

Are you depending on post discharge data where the patients view of care has "settled" from the actual experience?

Are you comparing their feedback with the actual to define benchmarks? or do you set arbitrary benchmarks based on your gut feel?

How are you daily engaging at the point of care - gathering data, providing information, and creating coaching moments?