Reminders -- in the form of checklists -- have been on a roll lately. They can be the answer to how to guide an airplane through takeoff, whether your child is ready for kindergarten, patient safety in the UK, and surgery in the US. Checklists are mostly voluntary. Professionals want to improve, so they use a checklist as a reminder tool and are then less likely to forget steps.
But what happens when the person in question doesn’t want to be reminded?
A recent CMS report blames reminder overload on a patient death that occurred at Mass General. According to Modern Healthcare, the patient was one of 31 on a surgical floor staffed by 10 nurses. During a 20 minute period, the patient’s heart rate slowed and then stopped. Nurses did not hear the repeated warnings because the volume on the bedside crisis alarm monitoring the patient's arrhythmia was set to “off.”
Mass General, the article said, has responded:
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 shift-to-shift handoff conversations.”
The article goes on to describe a similar problem at Johns Hopkins Hospital. The findings of that study, published early this year in the American Journal of Critical Care, state that one unit had 500 alarms per patient per day, and most were low-priority and required no clinical action. By thinking about the specific patient population served, and prioritizing alarms from there, the hospital was able to reduce the alarm figure to 200. They also use backup systems including pager and cell phone alerts.
“Alarm fatigue,” as the headline writers describe the issue, is also a major worry about electronic medical records. A key purported advantage of electronic records and computerized physician/provider order entry (CPOE) is their decision support feature. Despite the promise of improved outcomes and reduced costs, some studies have shown that alarm fatigue stifles the potential of this innovation (see here and here).
To make matters worse, this is occurring against a backdrop of unrealized quality potential. According to AHRQ’s National Healthcare Quality Report for 2009 (via Modern Healthcare), postoperative sepsis jumped eight percent in a year and postoperative catheter-associated urinary tract infections increased 3.6 percent. Overall quality improved 2.3 percent, and as AHRQ Director Dr. Carolyn Clancy wisely stated, this is “unacceptably slow.”
The solution to these problems? Why, iPads, of course. I am only half-jesting. The device or something much like it may be exactly what health care needs to truly “go electronic.” One CIO seems to agree. If clinicians can get excited about (and engaged with) their reminder technology, health might come ever closer to the checklist/reminder balance.