Barbara Drew, R.N., Ph.D., FAAN
Distinguished Professor, University of California, San Francisco,
School of Nursing
Imagine
this...
Imagine
this...
Smarter Hospitals - Safer Patients –MITRE Office, Baltimore , April 2, 2015
Battling Alarm
Fatigue
Alarmed &
Potentially
Dangerous
ECG Monitoring Research Lab, UCSF School of Nursing
A True Story…
 In 2010, a male patient recovering from heart surgery
(Mass General Hospital, Boston); monitored with an
EKG device while waiting for surgery to implant a
pacemaker for an intermittent slow heart rate problem
 Patient ate breakfast, visited with family, walked
around the unit, took a bath
 9:53 am: low HR alarms sounded repeatedly; 10 RNs
working on the unit that morning did not recall
hearing those alarms
 10:00 am: HR dropped below 40 but crisis level
arrhythmia alarm did not sound because alarm had
been changed to a non-audible text message alarm by
someone on the night shift
 10:16 am: Patient found dead
Aftermath…
 Investigators for the Centers for Medicare &
Medicaid Services:
“Changing audible arrhythmia alarms to
inaudible & nurses not recalling hearing low HR
alarms are indicative of alarm fatigue which
contributed to the patient’s death.”
 Front page of the Boston Globe newspaper;
multiple press stories on radio/TV
 Hospital settled lawsuit before it went to trial for
$850,000
Could this happen at UCSF ?
Monitor
device
sound
speakers
turned to
the wall
Tina Mammone & Barbara Drew
!
Monitor alarm
silence button
high-lighted at
the central
nurses’
station
Contact your Biomedical Dept. immediately; external (alarm) speaker is unplugged
UCSF Alarm Study
October, 2012 - October, 2014
Study Units:
Five adult ICUs
Total, 77 beds
All physiologic waveforms, measurements,
alarm settings, &
alarms for all patients
(waiver of consent)
Funded by GE Healthcare
Drew, et al. (2014) Insights into the Problem of Alarm Fatigue… PLOS ONE 9(10): e110274.
UCSF Alarm Study
77 Physiologic Monitors (GE Solar 8000i ) in 5 adult ICUs
CARESCAPE MC Network
Special research
version GE
CARESCAPE
Gateway
Central
Station
CARESCAPE IX Network
IX Router &
Firewall
HOSPITAL
ENTERPRISE NETWORK
Hospital enterprise
network
BedMasterEx
Client for
viewing
within UCSF
BedMasterEx Software
(Excel Medical Electronics)
VPN
BedMasterEx
link for
viewing
outside UCSF
UCSF Alarm Study
How many alarms occurred in
the 31 days of March, 2013 in
our 5 adult ICUs (77 beds)?
Total Alarms
(audible & inaudible)
2,558,760
Arrhythmia
1,154,201
Parameter
612,927
Technical
(too hi; too low)
(signal problem)
Audible Alarms
791,632
381,560
Audible Alarm Burden, 187 alarms/bed/day
UCSF Alarm Study
How accurate were the arrhythmia alarms?
Alarm Type
% False
# Alarms
# False
1. ASYSTOLE
792
531
67%
2. VFIB/VTACH
158
51
32%
3. VTACH
3861
3352
87%
4. ACC VENT
4361
4135
95%
5. PAUSE
2239
1963
88%
6. VBRADY
1260
1219
97%
12671
11251
89%
TOTAL
Drew, et al. (2014) Insights into the Problem of Alarm Fatigue… PLOS ONE 9(10): e110274.
Display Lead
Display Lead
Importance of
infrastructure to review
all 7 available leads !
Same False Alarm…
Non-artifact Lead
Importance of infrastructure to
create smarter alarms that fuse
EKG with pressures, SpO2, etc.
What do hospitals need to battle
alarm fatigue & keep patients safe?
IT Infrastructure
1. Analyze sentinel events
2. Test alarm fatigue solutions
3. Create large multi-hospital databases open to scientists
• Develop smarter alarms
• Develop individual patient profiles
to detect deterioration (The Precision
Medicine Initiative: Data-Driven Treatments)
We made the front page!
ECG Monitoring Research Lab, UCSF School of Nursing
Smarter Hospitals - Safer Patients –MITRE Office, Baltimore , April 2, 2015
Thank You
[email protected]