First, Do No Harm: How Intelligent Communication Technology and Alarm Management Can Improve Patient Safety

Benjamin Kanter, MD, FCCP & CMIO, Vocera Communications, Inc.
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Benjamin Kanter, MD, FCCP & CMIO, Vocera Communications, Inc.

Hospitals have a long history of being a testbed for innovative communication technologies. Whether it was for the adoption of the first modern paging system in the 1950s or the more recent adoption of hands-free badge communicators and secure texting via smartphones. Being able to connect the right people with the right information in a timely fashion is critical to achieving high-quality healthcare delivery.  

Communication in hospitals is largely event driven: An event has taken place, and it’s critical that a confirmed transmission of that event is made to a member or members of the care team. Hospitals are a very complex environment, and many messages between care team members have time constraints.  The longer it takes to deliver a message, the greater the delay in response—and treatment delays often result in adverse outcomes, both clinical and financial. CIOs attempting to improve hospital communications (person-to-person and machine-to-person) must solve complex problems brought about by two recent technological developments: The “internet of (hospital) things” (IOhT) and smartphones.  

In a relatively short period of time, the hospital communication environment has become exceedingly cluttered and often fatiguing, with multiple systems now communicating directly with hospital staff.  Physiological monitors, beds, scheduling systems, IV pumps, ventilators, and many other systems frequently sound alarms or send messages that may or may not be actionable. Healthcare authors have defined clinical decision support (CDS) as a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare.  Alarm signals originating from biomedical devices are one subtype of CDS messaging.

 Reducing opportunities for communication delays or breakdowns is a notable and laudable achievement 

Now that hospitals are beginning to provide smartphones for their clinical staff, the IOhT enables alarm signals to bypass a unit clerk and to be sent directly to a patient’s primary caregiver. This process enables best practice CDS messaging: Getting the right information (alarm annunciation) to the right person(s) in the right intervention format through the right channel at the right point in the workflow. From a technical standpoint, two other factors come into play: Using the right technology and having the right security.  

Reducing opportunities for communication delays or breakdowns is a notable and laudable achievement. However,  the rapid development and implementation of medical-grade handheld smart devices has the potential to disrupt nursing operations. Their use creates entirely new communication pathways and nursing workflows. While new technologies have the capacity to provide patient and care team benefits, if the transition to the new workflows is not managed with the proper governance, it can potentially lead to chaos and patient harm. As with the introduction of any new clinical tool, ‘Primum Non Nocere’ rules the day: First, do no harm.

Nursing workflow has been characterized as non-linear, interruption driven, unpredictable, and with frequent task switching. Electronic health records (EHRs) encourage a task-driven workflow, further complicating a nurse’s ability to perform critical thinking skills, potentially leading to delays in patient care. Now add to that new personal communication devices, and there becomes an obligation to ensure that those devices do not, instead become personal interruption devices– impeding rather than enhancing care delivery. Is there a “best” approach?

Evaluating the Capability Maturity Model as a Framework for Alarm Management

Alarm fatigue has been repeatedly recognized as one of the major technological safety hazards in the hospital environment. Alarm signals compete with all other message sources for a clinician’s attention, and with each alarm notification there is inevitably distraction. Since each clinician has a limited attention bandwidth, messages (whether text or voice) must be considered in aggregate: alarms with ad hoc messages, text messages with voice communications, and so on.  

This approach takes careful planning. A recent journal article suggested that using a generalization of the Capability Maturity Model (CMM) may be an appropriate framework to aid an organization’s ability to manage alarms. Published in the May/June 2016 edition of Biomedical Instrumentation & Technology [Welch, Rayo, Kanter et al], the authors generalize the CMM and apply it to alarm management. Originally developed by the Software Engineering Institute at Carnegie Mellon University to improve software development, the model consists of five stages, each building on those that precede it.  

Stage one

Stage one reflects an organization that has a predominately ad hoc approach to alarm management issues. Stage one organizations are unlikely to have formed an alarm management committee and have not developed robust polices to guide alarm settings or subsequent responses. Data to objectively guide alarm management are not present.

Stage two

Stage two organizations have developed the infrastructure to tackle alarm management issues at an institutional level. These organizations have acknowledged that improving alarm management is an important initiative, and have established an executive champion and an alarm management committee. The committee should be multi-disciplinary and empowered to tackle policies and procedures. The committee must also perform an environment of care assessment of alarm sources, settings and responses, and be prepared to organize a pilot project to reduce alarm related issues.

Stage three

Level three organizations have completed the pilot project and can show an improvement in alarm management control using objective data. The organization has begun to move from an ad hoc approach to combat alarm problems to one that is more proactive. Once the organization can demonstrate measurable improvements and an ability to collect and analyze performance metrics at a local/pilot level, the organization is set to move on to stage four, improving performance throughout the institution.

Stage four

Capitalizing on the success and learnings of stage three, stage four organizations demonstrate an ability to manage alarms at an institutional level. Stage four organizations can demonstrate consistent objective metrics indicating lasting improvements in alarm performance.  

Stage five

As pointed out in the Welch article, stage five is largely aspirational. The ultimate goal: That no patient should be harmed as the result of inappropriate alarm management is being achieved, and the entire organization is proactively engaged in managing alarm system vulnerabilities, while continuously looking ahead to improve methodologies and technologies.

Information technology service management (ITSM) philosophically emphasizes the importance of using standardized best-practice processes to insure the successful management of IT operations. The Joint Commission (TJC), a not-for-profit hospital accreditation and certification organization, has established a National Patient Safety Goal (06.01.01) focused on improving alarm management. Although TJC is now using this as part of their accreditation review, they do not specify the processes by which hospitals should improve alarm management.  

Though the CMM does not embrace the totality of IT services, it does provide a best-practice approach to standardize the development, implementation and adoption of alarm management practices. CIOs modernizing hospital communications must take into account the unusually fragmented nature of nursing workflow, and allow for careful oversight and governance to ensure care delivery goals are met.

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