Whats that noise? Bedside monitoring in the Emergency Department

ObjectiveTo determine the frequency, duration and type of audible monitor alarms in an ED, utilising the standard manufacturer’s classification.MethodsThe audible monitor alarms and the timing of any intervention related to the patient monitoring was observed and recorded.Results110 Patients admitted to the Majors area or Resuscitation Room were observed for a total of 93 hours. One monitor was observed at a time. Alarm noise was generated 29% of the observation time. Overall, 429 alarms lasting 21 hours 27 minutes were judged to be positive and 143 alarms lasting 5 hours 47 minutes, negative. 74% of Resuscitation Room and 47% of Majors alarms were silenced or paused. Alarm limit parameters were only adjusted after 5% of alarms in Resuscitation Room and 6% of alarms in Majors.ConclusionsWhilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. We have demonstrated that there is a high probability of near-continuous alarm noise from patient monitoring in a 10-bedded Majors area. We make suggestions for methods of noise reduction and intend to implement some of these within our own ED.     

Customizing Physiologic Alarms in the Emergency Department: A Regression Discontinuity,Quality Improvement Study

IntroductionClinical alarms promote patient safety by alerting clinicians when there is an indication or change in a condition requiring a response. An excessive volume of alarm fires, however, contributes to sensory overload and desensitization, referred to as alarm fatigue, which has significant implications when alarms are missed. This evidence-based, practice project aimed to implement and evaluate a program that reduces the number of clinically nonactionable, physiologic alarms in an emergency department. Although alarm fatigue is an important negative consequence, the focus of this project is not on alarm fatigue but on measures to reduce the volume of clinically nonactionable alarms that lead to alarm fatigue. The Iowa Model was used as a conceptual framework.MethodsThis project involved adjusting default alarm settings and implementing an education plan on the safe use of alarms. The sample population included all patients on physiologic monitors at an emergency department. Retrospective data were collected, and regression discontinuity design was applied to compare the rate of alarm fires triggered by the physiologic monitor between pre- and postimplementation of an alarm protocol.ResultsA significant change in the rate of alarm fires occurred with an estimated reduction of 14.96 (P = 0.003). There were no reports of adverse outcomes such as a delay in responding to a change in patient condition or delay leading to cardiopulmonary arrest.DiscussionA reduction in nonactionable, physiologic alarms was attained after implementing multimodal strategies inclusive of adjusting default settings, staff education on managing alarms, and emphasis on staff accountability.     

Collection of annotated data in a clinical validation study for alarm algorithms in intensive care—a methodologic framework

Introduction

Monitoring of physiologic parameters in critically ill patients is currently performed by threshold alarm systems with high sensitivity but low specificity. As a consequence, a multitude of alarms are generated, leading to an impaired clinical value of these alarms due to reduced alertness of the intensive care unit (ICU) staff. To evaluate a new alarm procedure, we currently generate a database of physiologic data and clinical alarm annotations.

Methods

Data collection is taking place at a 12-bed medical ICU. Patients with monitoring of at least heart rate, invasive arterial blood pressure, and oxygen saturation are included in the study. Numerical physiologic data at 1-second intervals, monitor alarms, and alarm settings are extracted from the surveillance network. Bedside video recordings are performed with network surveillance cameras.

Results

Based on the extracted data and the video recordings, alarms are clinically annotated by an experienced physician. The alarms are categorized according to their technical validity and clinical relevance by a taxonomy system that can be broadly applicable. Preliminary results showed that only 17% of the alarms were classified as relevant, and 44% were technically false.

Discussion

The presented system for collecting real-time bedside monitoring data in conjunction with video-assisted annotations of clinically relevant events is the first allowing the assessment of 24-hour periods and reduces the bias usually created by bedside observers in comparable studies. It constitutes the basis for the development and evaluation of “smart” alarm algorithms, which may help to reduce the number of alarms at the ICU, thereby improving patient safety.     

Effect of bundle set interventions on physiologic alarms and alarm fatigue in an intensive care unit: A quality improvement project

ObjectiveTo determine if the implementation of an evidence-based bundle designed to reduce the number of physiologic monitor alarms reduces alarm fatigue in intensive care nurses.DesignThis quality improvement project retrospectively reviewed alarm data rates, types, and frequency to identify the top three problematic physiologic alarms in an intensive care unit. An alarm management bundle was implemented to reduce the number of alarms. The Nurses’ Alarm Fatigue Questionnaire was used to measure nurses’ alarms fatigue pre- and post-implementation of the bundle.SettingA combined medical surgical intensive care unit at an accredited hospital in the United States.ResultsThe top three problematic alarms identified during the pre-implementation phase were arrhythmia, invasive blood pressure, and respiration alarms. All three identified problematic physiologic alarms had a reduction in frequency with arrhythmia alarms demonstrating the largest decrease in frequency (46.82%). When measuring alarm fatigue, the overall total scores increased from pre- (M = 30.59, SD = 5.56) to post-implementation (M = 32.60, SD = 4.84) indicating no significant difference between the two periods.ConclusionAfter implementing an alarm management bundle, all three identified problematic physiologic alarms decreased in frequency. Despite the reduction in these alarms, there was not a reduction in nurses’ alarm fatigue.     

Evaluation of the cardiorespiratory monitor SpiroGuard C for infants. Improved registration of respiratory events by new sensors and intelligent alarm management system

OBJECTIVES: The SpiroGuard C is a commercially available cardiorespiratory monitor working with field plethysmography, wireless signal transmission and a novel alarm management system. In order to determine the recognition rates for central, mixed and obstructive apneas, a prospective clinical trial was performed comparing frequency and kind of signals from the monitor with those simultaneously registered by polysomnographic studies. DESIGN: Normal respiratory and alarm signals of the monitor under investigation were integrated into a polysomnographic setting. All central, mixed and obstructive apneas lasting more than 10 seconds as well as all alarms obtained from the monitor were evaluated. RESULTS: 47 series of monitor recordings could be evaluated in parallel to polysomnographic studies: the detection rate for central apneas was 298/328 (90.85%), for mixed apneas 9/41 (21.95%) and for obstructive apneas 0/36 (0%). Out of the total of 708 registered alarms 359 (50.71%) were false alarms, 307 (43.36%) were apnea-related and 42/708 (5.93%) were alarms due to technical problems. 177 of the 359 false alarms (49.30%) occurred during apneas that were shorter than 10 seconds, 119 (33.15%) were related to bad signal quality, and 55 (15.32%) were caused by movement artifacts. CONCLUSION: The recognition rate for central apneas was high (> 90%), while sensitivity for mixed and obstructive apneas was not satisfactory. Approximately half of the alarms were false alarms. These could be reduced by setting the apnea detection time to > 15 seconds, by tighter fastening of the respiration belt (improving the signal transmission), and by turning off the instrument when the child is awake and physically active. The wireless system renders the SpiroGuard C an attractive alternative for home monitoring.     

How Emergency Physicians Approach Refusal of Observation after Naloxone Resuscitation

BackgroundPatients who are resuscitated with naloxone frequently refuse a period of observation, even though they may be suffering from a variety of medical and psychiatric comorbidities. Emergency physicians (EPs) are then confronted with the challenge of how best to serve patients’ interests while respecting autonomy.ObjectivesWe sought to characterize how EPs think about this kind of dilemma and the strategies they use to resolve them.MethodsWe conducted qualitative semi-structured interviews with a convenience sample of 59 emergency physicians attending the American College of Emergency Physicians’ Scientific Assembly in October 2018. Three case vignettes highlighting different clinical and ethical features served as prompts. Interviews were analyzed using a constant comparative method to identify patterns of responses and derive key themes.ResultsAcross the vignettes, EPs demonstrated diverse approaches to observation, assessing decision-making capacity and encouraging compliance. Some EPs refused to comply with a patient's wishes even when they had determined a patient demonstrated capacity. Conversely, a few EPs were willing to allow patients to leave the emergency department (ED) without assessing capacity, or despite determining that the patient lacked capacity. Common reasons for complying with patients' demands were concerns about the patients' rights and concerns about the safety of staff. Most physicians interviewed reported no institutional guidelines or education on the topic, and many physicians expressed an interest in providing medication for addiction treatment in the ED.ConclusionsEPs approach this clinical and ethical dilemma in widely divergent ways. Consensus about strategies for navigating patients’ wishes relative to clinical concerns are needed to help EPs manage these challenging cases.     

Staff Duress Alarms for Workplace Violence in the Emergency Department: A Mixed-Methods Evaluation

IntroductionComplex personal duress alarms may be implemented as part of a multicomponent approach to preventing and mitigating workplace violence in emergency departments. Evaluation of duress alarms after implementation has been identified as a gap in the literature. The purpose of this quality improvement project was to examine the impact of a duress alarm system on workplace violence and user experience in an urban emergency department.MethodsA comprehensive system evaluation was performed using a mixed-methods approach, which included retrospective data review, key informant interviews, observations, and a survey. Forty clinical staff at an emergency department in North Carolina were interviewed and provided feedback on the duress system.ResultsFindings indicated that the duress system was not associated with a decrease in workplace violence, and that the majority of clinical staff did not even wear the duress alarm. Staff indicated that the primary barriers to use of the alarm were the bulky design of the alarm badge, inadequate education about the alarm device and process, and the lack of a reliable and timely response from security.DiscussionOngoing engagement of clinical staff is critical to the success of health care technology implementations. Staff feedback, periodic re-education, and recurring process evaluations are vital to ensuring the continued relevance of systems, especially when staff safety is the intended purpose.     

Causes of constraints to patient flow in emergency departments: A comparison between staff perceptions and findings from the Patient Flow Study

Objectives: The objectives of the study were: (i) to survey staff perceptions of causes of delay in patients' journeys through the ED; (ii) to identify and analyse key constraints to patient flow using real‐time diagnostic/decision support software (Patient Flow Study); and (iii) to assess the correlation between staff perceptions and data from the Patient Flow Study. Methods: ED and non‐ED staff were surveyed prior to the Patient Flow Study. The survey involved ranking the likely reasons for delay at three set points after triage (160, 320 and 480 min). Real‐time data on delay in patients' journeys through the ED were collected over a period of 5 weeks. The correlation between staff perceptions and study data at the three time points was calculated using Spearman's rank correlation coefficient. Subgroup analysis was performed on the basis of staff position, years of experience at St George and whether they had previously attended training on constraints to flow. Results: A total of 68 staff responded to the questionnaire (response rate 42%). During the study period, 4555 ED attendances (97% of all presentations) were analysed for causes of constraint. Strong correlation between staff perceptions and real‐time data was only found among some subgroups at the point 160 min from triage. Conclusions: Overall, staff perceptions regarding causes of constraint to patient flow do not correlate well with data obtained from real‐time analysis.     

Crossing the handover chasm: Clinicians' perceptions of barriers to the early detection and timely management of severe sepsis and septic shock

PurposeThe purpose was to identify barriers to the early detection and timely management of severe sepsis throughout the emergency department (ED), general ward (GW), intermediate care unit (IMC), and the intensive care unit (ICU).Materials and methodsFive multicenter focus group discussions with 29 clinicians were conducted. Discussions were based on a moderation guide were recorded and transcribed. Qualitative analysis was performed according to the principles of the concept mapping method and the framework approach.ResultsThe major causes of the delayed detection and treatment could be summarized in a framework of communication errors and handover difficulties throughout patients' course of treatment, which can be divided into 5 core areas: inadequate histories before hospital admission; poorly coordinated handovers between the ambulance service and the ED; delayed patient transfer between the ED and the GW as well as delays in patient transfers between the GW and the ICU by, for example, a lack of bed capacity and a shortage of staff. Generally, participants from all wards mentioned that the urgency with which septic patients needed to be treated was not communicated.ConclusionsOur study shows the need to improve intra- and interunit handover processes in hospital care, which would ensure a holistic treatment concept, thereby improving patient care.     

A breathing circuit alarm system based on neural networks

Objective. The objectives of our study were (1) to implement intelligent respiratory alarms with a neural network; and (2) to increase alarm specificity and decrease false-alarm rates compared with current alarms.Methods. We trained a neural network to recognize 13 faults in an anesthesia breathing circuit. The system extracted 30 breath-to-breath features from the airway CO₂, flow, and pressure signals. We created training data for the network by introducing 13 faults repeatedly in 5 dogs (616 total faults). We used the data to train the neural network using the backward error propagation algorithm.Results. In animals, the trained network reported the alarms correctly for 95.0% of the faults when tested during controlled ventilation, and for 86.9% of the faults during spontaneous breathing. When tested in the operating room, the system found and correctly reported 54 of 57 faults that occurred during 43.6 hr of use. The alarm system produced a total of 74 false alarms during 43.6 hr of monitoring.Conclusion. Neural networks may be useful in creating intelligent anesthesia alarm systems. The authors wish to thank Lue-Ellen Merchant for her assistance in the preparation of this article.     

Attitudes and beliefs of emergency department staff regarding alcohol-related presentations

ObjectiveThis study examined emergency department (ED) staff attitudes and beliefs about alcohol-related ED presentations in order to recommend improved detection and brief intervention strategies.MethodsThe survey was conducted at two inner-Sydney hospital EDs in 2006 to explore ED clinical staff’s attitudes, current practice and barriers for managing alcohol-related ED presentations. The sample included N = 78 ED staff (54% nurses, 46% doctors), representing a 30% response rate.ResultsManagement of alcohol-related problems was not routine among ED staff, with only 5% usually formally screening for alcohol problems, only 16% usually conducting brief interventions, and only 27% usually providing a referral to specialist treatment services. Over 85% of ED staff indicated that lack of patient motivation made providing alcohol interventions very difficult. Significant predictors of good self-reported practice among ED staff for patients with alcohol problems included: being a doctor, being confident and having a sense of responsibility towards managing patients with alcohol-related problems.ConclusionsThis study reported that many staff lack the confidence or sense of clinical responsibility to fully and appropriately manage ED patients with alcohol-related problems. ED staff appear to require additional training, resources and support to enhance their management of patients with alcohol-related problems.     

The helpful or hindering effects of in-hospital patient monitor alarms on nurses: a qualitative analysis

Patient monitors generate alarms to signal changes in vital signs. Some research suggests these alarms can improve patient safety. Other reports caution that these systems generate false alarms and create nursing workflow interruptions. These findings require contextualization by qualitatively investigating the lived experiences of nurses working with these monitors. Research into the dynamics involved in nursing responses to alarms can provide insights for monitor development and implementation. This study's purposes were (1) to describe the frequency of alarms generated by patient monitors and nursing responses and (2) to report nurses' explanations of the impact of alarms on workflow and strategies for responding to alarms. Forty-nine hours of observations and 14 interviews were conducted at a Canadian medical center. Four hundred forty-six monitor alarms (1 every 6.59 minutes) were observed. Of these, 70% had no immediate response from nurses. Furthermore, 34 red alarms (potential life-threatening) were observed, with 41% having no immediate response. Nurses reported feeling overloaded by alarm frequency. They described learning to interpret alarm data and developing workaround strategies (eg, ignoring alarms). Paradoxically, alarms prompted nurses to regularly consider and interpret patient information. We suggest the interpretive work associated with workarounds may hold benefits mitigating the potential harms of ignoring alarms.     

What is the effect of reporting all emergency department radiographs?

Objectives: To evaluate the effect of formal radiological reporting of all emergency department (ED) radiographs on clinical practice and patient outcome, and to consider whether a selective reporting policy might prove safe and effective.

Methods: All radiographs taken in a single ED over a six month period were prospectively studied simultaneously in both the emergency and radiology departments to detect cases where a radiograph that was considered normal by ED staff was then reported as abnormal by the reporting radiologist. Whenever such a discrepancy occurred the patient's records were scrutinised to ascertain the source of the discrepancy, with a gold standard interpretation derived from senior clinical review and additional investigations where indicated. The clinical impact of the radiologist's formal report was then assessed. Accuracy of interpretation was considered in relation to the grade of ED staff and the radiographic examination obtained.

Results: During the study period, 19 468 new patient attendances to the ED generated 11 749 radiographic examinations. Discrepancies were detected in 175 patients (1.5% of all radiographic examinations). Of these, 136 (1.2%) were subsequently shown to have been incorrectly interpreted in the ED (ED false negatives), with 40 patients (0.3%) undergoing a change in management as a result. In the remaining 39 the ED interpretation was judged to be correct (radiology false positives), with 16 patients undergoing further investigations or visits to the ED to confirm this.

Conclusions: The formal reporting of ED radiographs by the radiology department detects a number of clinically important abnormalities that have been overlooked. However, this formal reporting also generates a number of incorrect interpretations that may lead to further unnecessary investigations. Some groups of ED radiographs (such as those interpreted by an ED consultant and films of the fingers and toes) may not require formal radiological reporting. The adoption of a selective reporting policy may reduce the reporting workload of the radiology department without compromising patient care.

     

Repeated use of the emergency department: qualitative study of the patient's perspective

Objective—To explore what lies behind repeated emergency department (ED) use, from the patients'' own perspectives. Methods—Qualitative study based on in depth interviews with frequent users of the ED at the Huddinge University Hospital, Sweden. Ten adult patients having visited the ED 6–17 times in the previous 12 months were interviewed. The personal meaning they attached to the symptoms and their encounters at the ED were inductively analysed, thereby relating patient behaviour to life conditions. Results—The frequent ED visitors perceive pain or other symptoms as a threat to life or to personal autonomy. Irrespective of whether or not the patients relate their health problems to a traumatic event, overwhelming anxiety compels them to seek urgent help. Clear cut diagnoses are seldom mentioned. Although none of the patients is homeless or totally lacking in means, the narratives reveal struggles with adverse life circumstances and medical, psychological and/or social problems, including alcohol or other substance misuse. Occasional referrals from the ED to a psychiatrist seem not to lead to any continuous treatment or to a change in the patients'' health seeking behaviour. Satisfaction with care becomes adversely affected when the patients perceive that the ED staff classifies their use of the ED as inappropriate or when their symptoms are belittled. Conclusions—From their own perspectives, frequent ED visitors are in need of urgent care. It is particularly important to these patients that the personal meaning they attach to their symptoms is attended to and respected by the ED staff.     

Development of an Alarm Sound Database and Simulator

Objectives. The purpose of this study was to develop an interactive software package of alarm sounds to present, recognize and share problems about alarm sounds among medical staff and medical manufactures. Methods. The alarm sounds were recorded in variable alarm conditions in a WAV file. The alarm conditions were arbitrarily induced by modifying attachments of various medical devices. The software package that integrated an alarm sound database and simulator was used to assess the ability to identify the monitor that sounded the alarm for the medical staff. Results. Eighty alarm sound files (40MB in total) were recorded from 41 medical devices made by 28 companies. There were three pairs of similar alarm sounds that could not easily be distinguished, two alarm sounds which had a different priority, either low or high. The alarm sound database was created in an Excel file (ASDB.xls 170 kB, 40 MB with photos), and included a list of file names that were hyperlinked to alarm sound files. An alarm sound simulator (AlmSS) was constructed with two modules for simultaneously playing alarm sound files and for designing new alarm sounds. The AlmSS was used in the assessing procedure to determine whether 19 clinical engineers could identify 13 alarm sounds only by their distinctive sounds. They were asked to choose from a list of devices and to rate the priority of each alarm. The overall correct identification rate of the alarm sounds was 48%, and six characteristic alarm sounds were correctly recognized by beetween 63% to 100% of the subjects. The overall recognition rate of the alarm sound priority was only 27%. Conclusions. We have developed an interactive software package of alarm sounds by integrating the database and the alarm sound simulator (URL: ). The AlmSS was useful for replaying multiple alarm sounds simultaneously and designing new alarm sounds interactively.     

Hospital variation in risk-standardized hospital admission rates from US EDs among adults

Background

Variation in hospital admission rates of patients presenting to the emergency department (ED) may represent an opportunity to improve practice. We seek to describe national variation in hospital admission rates from the ED and to determine the degree to which variation is not explained by patient characteristics or hospital factors.

Methods

We conducted a cross-sectional analysis of a nationally representative sample of ED visits among adults within the 2010 National Hospital Ambulatory Care Survey ED data of hospitals with admission rates from the ED between 5% and 50%. We calculated risk-standardized hospital admission rates (RSARs) from the ED using contemporary hospital profiling methodology, accounting for patients' sociodemographic and clinical characteristics.

Results

Among 19 831 adult ED visits in 252 hospitals, there were 4148 hospital admissions from the ED. After accounting for patients' sociodemographic and clinical factors, the median RSAR from the ED was 16.9% (interquartile range, 15.0%-20.4%), and 8.1% of the variation in RSARs was attributable to an institution-specific effect. Even after accounting for hospital teaching status, ownership, urban/rural location, and geographical location, 7.0% of the variation in RSARs from the ED was still attributable to an institution-specific effect.

Conclusions and relevance

There was variation in hospital admission rates from the ED in the United States, even after adjusting for patients' sociodemographic and clinical characteristics and accounting for hospital factors. Our findings suggest that suggesting that the likelihood of being admitted from the ED is not only dependent on clinical factors but also at which hospital the patient seeks care.