Understanding the "alarm problem" associated with continuous physiologic monitoring of general care patients.

Study Aim: The aim of this study is to investigate the impact of alarm configuration tactics in general care settings. Methods: Retrospective analysis of over 150,000 hours of medical/surgical unit continuous SpO2 and pulse rate data were used to estimate alarm rates and impact on individual nurses. Results: Application of an SpO2 threshold of 80% vs 88% produced an 88% reduction in alarms. Addition of a 15 second annunciation delay reduced alarms by an additional 71% with an SpO2 threshold of 80%. Pulse rate alarms were reduced by 93% moving from a pulse rate high threshold of 120-140 bpm, and 95% by lowering the pulse rate low threshold from 60 to 50 bpm. A 15 second annunciation delay at thresholds of 140 bpm and 50 bpm resulted in additional reductions of 80% and 81%, respectively. Combined alarm frequency across all parameters for every 24 hours of actual monitored time yielded a rate of 4.2 alarms for the surveillance configuration, 83.0 alarms for critical care monitoring, and 320.6 alarms for condition monitoring. Total exposure time for an individual nurse during a single shift ranged from 3.6 min with surveillance monitoring, to 1.2 hours for critical care monitoring, and 5.3 hours for condition monitoring. Conclusions: Continuous monitoring can eliminate unwitnessed/unmonitored arrests associated with significant increased mortality in the general care setting. The "alarm problem" associated with these systems is manageable using alarm settings that signify severely abnormal physiology to alert responsible clinicians of urgent situations.

A Pragmatic Method for Measuring Inpatient Complications and Complication-Specific Mortality.

OBJECTIVES: The primary objective of this study was to develop hospital-level metrics of major complications associated with mortality that allows for the identification of opportunities for improvement. The secondary objective is to improve upon current metrics for failure to rescue (i.e., death from serious but treatable complications.). METHODS: Agency for Healthcare Research and Quality metrics served as the basis for identifying specific complications related to major organ system morbidity associated with death. Complication-specific occurrence rates, observed mortality, and risk-adjusted mortality indices were calculated for the study institution and 182 peer organizations using component International Classification of Disease, Tenth Revision codes. Data were included for adults over a 4-year period, with exclusion of hospice patients and complications present on admission. Temporal visualizations of each metric were used to compare past and recent performance at the study hospital and in comparison to peers. RESULTS: The complication-specific method showed statistically significant differences in the study hospital occurrence rates and associated mortality rates compared with peer institutions. The monthly control-chart presentation of these metrics provides assessment of hospital-level interventions to prevent complications and/or reduce failure to rescue deaths. CONCLUSIONS: The method described supplements existing metrics of serious complications that occur during the course of acute hospitalization allowing for enhanced visualization of opportunities to improve care delivery systems. This method leverages existing measure components to minimize reporting burden. Monthly time-series data allow interventions to prevent and/or rescue patients to be rapidly assessed for impact.

Inpatient Respiratory Arrest Associated With Sedative and Analgesic Medications: Impact of Continuous Monitoring on Patient Mortality and Severe Morbidity.

OBJECTIVES: The primary study objective was to investigate the impact of surveillance monitoring (i.e., continuous monitoring optimized for deterioration detection) on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A second objective was consideration of the results in the context of previous investigations to establish practice recommendations for this approach to patient safety. METHODS: Retrospective review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was performed for a 10-year period. Systematic analysis of all adult general care inpatient data followed by chart review for individual patients was used to identify patient death or permanent harm (i.e., ventilator dependency, hypoxic encephalopathy) related to administration of sedative/analgesics. RESULTS: Of 111,488 patients in units with surveillance monitoring available, none died or were harmed by opioid-induced respiratory depression when surveillance monitoring was in use. One patient died from opioid-induced respiratory depression in a unit where surveillance monitoring was available; however, the patient was not monitored at the time of the adverse event. In unmonitored units (15,209 patients during 29 months of incremental implementation), three patients died from opioid overdose (19.73 deaths per 100,000 at risk patients). The reduced death rate when surveillance monitoring was available (0.0009%) versus not available (0.02%) was significant (P = 0.03). CONCLUSIONS: For a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on death from sedative/analgesic administration in the general care setting. This approach to patient safety can help address the risk of sedative/analgesic-related respiratory arrests in hospitals.

Understanding Interpersonal and Organizational Dynamics Among Providers Responding to Crisis.

Patient rescue occurs in phases: recognizing the problem, communicating the concern, and treating the complication. To help improve rescue, we sought to understand facilitators and barriers to managing postoperative complications. We used a criterion-based sample from a large academic medical center. Semistructured interviews (n = 57) were conducted, which were audio-recorded and transcribed verbatim. Thematic analysis and consensus coding was performed using NVivo 11. We used a framework matrix approach to synthesize our coding and identify themes that facilitate or impede rescue. Clinicians identified root causes for delays in care, such as recognizing patient deterioration, knowing whom to contact and when, and reaching the correct decision-making provider. This study identified significant variation in communication processes across providers caring for surgical patients. Targeted interventions aimed at improving and standardizing these aspects of communication may significantly influence the ability to effectively identify and escalate care for postoperative complications.

Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

A Systems Approach to Design and Implementation of Patient Assessment Tools in the Inpatient Setting.

Failure to rescue events, or events involving preventable deaths from complications, are a significant contributor to inpatient mortality. While many interventions have been designed and implemented over several decades, this patient safety issue remains at the forefront of concern for most hospitals. In the first part of this study, the development and implementation of one type of highly studied and widely adopted rescue intervention, algorithm-based patient assessment tools, is examined. The analysis summarizes how a lack of systems-oriented approaches in the design and implementation of these tools has resulted in suboptimal understanding of patient risk of mortality and complications and the early recognition of patient deterioration. The gaps identified impact several critical aspects of excellent patient care, including information-sharing across care settings, support for the development of shared mental models within care teams, and access to timely and accurate patient information. This chapter describes the use of several system-oriented design and implementation activities to establish design objectives, model clinical processes and workflows, and create an extensible information system model to maximize the benefits of patient state and risk assessment tools in the inpatient setting. A prototype based on the product of the design activities is discussed along with system-level considerations for implementation. This study also demonstrates the effectiveness and impact of applying systems design principles and practices to real-world clinical applications.