NR 361 Discussion Distractors in our Environments 

NR 361 Discussion Distractors in our Environments 

NR 361 Discussion Distractors in our Environments 

As a nurse, you have many responsibilities. Nurses are multitaskers they monitor the patients, medications, equipment, and much more while documenting everything that has been done.   “Most technologies are designed by people unfamiliar with nurses’ workflow, and they fail to appreciate the multitude of other devices the nurse is simultaneously managing” (Ruppel & Funk, 2018). Therefore, due to these designers not understanding what a nurse’s role is the technology that we use does not always fit well with the nursing roles. Multitasking is overwhelming and nursing is a hard job in general adding the two can cause errors. Bed alarms are designed to alarm when the patient is moving off the bed. The alarm can also go off when the patient makes certain movements not just moving off the bed.  For example, a nurse working a unit with several patients. One of the patients has a bed alarm and tends to make it go off on purpose multiples times. When the nurse arrives, the patient asks her about her day but does not need assistance. At the end of the night the nurse is busy when that patients bed alarm goes off, but the nurse ignores it because of what she experienced all day. “This alarm fatigue is compounded by the number of potential false alarms during a nurses’ work shift” (Hebda, Hunter, & Czar, 2019). The patient had called the nurse to ask for assistance to the bathroom. When the nurse did not respond the patient went alone and fell on the way and broke his leg. This is an ethical because there was a poor patient outcome due to unknown distraction and continuous false alarms. One of the nursing ethical guiding principles is “nonmaleficence: the obligation for doing no intentional harm” (Hebda, Hunter, & Czar, 2019).  The nurse did not do intentional harm but cause harm due to the intentional disregard of the bed alarm.

“Alarms are by intent interruptive. Interruptions are typically considered to have a negative effect on patient safety. However, interruptions have been associated with an increased risk of errors” (Ruppel & Funk, 2018). The evidence shows that alarms are used to help patients, but they are a risk for negative patient safety. There is still need for research on how to join the two worlds where they can work together. One way is the lessen the nurses workload so that she does not feel overwhelmed to the point where they ignore their patients.

References

Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.

Ruppel, H., & Funk, M. (2018). Nurse–Technology Interactions and Patient Safety. Critical Care Nursing Clinics of North America, 30(2), 203-213. doi:10.1016/j.cnc.2018.02.003

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Thank you for sharing your perspective on the difficulties nurses face with the distraction of false alarms when added to their busy schedule. You mentioned multitasking; nurses frequently cannot avoid multitasking on really busy shifts but there is a growing body of literature that identifies multitasking as less productive than we conventionally think. A time and motion study by Yen, Kelley, Lopetegui, Rosado, Migliore, Chipps, & Buck (2017) showed a concern that such multitasking, promoted by current media/cultural norms, can actually interfere with the amount and quality of time spent with patients.

  • Interestingly, a study of college students by Lepp, Barkley, Karpinski,  & Singh (2019) found that multitasking can produce negative consequences for learning, particularly in an online environment.

Kind regards,

Professor PJ

References:

Lepp, A., Barkley, J. E., Karpinski, A. C., & Singh, S. (2019). College students’ multitasking behavior in online versus face-to-face courses. SAGE Open, 9, 1-9. doi:10.1177/2158244018824505  Yen, P. Y., Kelley, M., Lopetegui, M., Rosado, A. L., Migliore, E. M., Chipps, E. M., & Buck, J. (2017). Understanding and visualizing multitasking and task switching activities: A time motion study to capture nursing workflow.   (Links to an external site.)Links to an external site.American Medical Informatics Association  (Links to an external site.)Links to an external site.Annual Symposium Proceedings, AMIA Symposium, 2016, 1264-1273 (Links to an external site.)Links to an external site.

NR 361 Discussion Distractors in our Environments 
NR 361 Discussion Distractors in our Environments 

Nursing workflow is unique and it is very important that we have an input on any design that will impact our job’s workflow. A basic example we experienced at my hospital is when one of our telemetry units was remodeled and the nurses were not asked for any input. The flow of the nurse’s station was so dysfunctional, it was set up like a classroom. The computers were set up in rows so close together that it made it virtually impossible to respond quickly to alarms or any urgent situation for that matter. We had to practically climb over one another. This added to a decrease in response time to alarms which was an increase for patient risk of injury. It was a costly mistake and the unit was redesigned. Now the trend is to consult the individual unit to better understand the needs of the particular specialty in regards to its workflow. Luckily there was a lot of nursing input considered when my facility chose to go with a new operating system. We chose Epic.

   Bed alarm fatigue is also an issue at my workplace. One thing that helps, aside from making sure staff is deactivating the alarm prior to getting patients up, is the alarm sensitivity buttons. Our bed alarm sensitivity can be adjusted based on weight or increased risk. I can appreciate your suggestion of a decreased ratio however, I don’t believe I will experience that anytime soon.

When I imagine a hospital, I picture bright white lights in the halls and patient rooms, the smell of Clorox wipes or germicidal wipes, and then the sound of never-ending beeping alarms. Even my patients have complained about the sound IV pumps make when alarming about downstream or upstream occlusions, or when an infusion is complete. I do believe alarms are useful in preventing harm to patients. In my time as a nurse, I have noticed many situations in which alarm fatigue or lack of alarms has caused poor outcomes for patients. One example that comes to mind, is when a patient who appeared to be medically stable, suffered an Anterior ST segment elevation myocardial infarction. The patient’s telemetry monitor did not alarm to the change in heart rhythm. The patient used the call light to ask for help because he became symptomatic of the MI he was experiencing. Upon review of the telemetry strips, the patient’s ST segment had changed for 12 minutes before the patient called for help. The patient did unfortunately pass away, but there were no legal repercussions since the patient’s death was not due to negligence. Had the telemetry monitor alarmed, and been silenced by a medical professional, then that would be considered negligence. This death took a toll on all of the healthcare team members including the physicians, nurses, CNAs, and telemetry technicians involved. At our hospital, the telemetry monitors have the same constant alarm sound for VTACH as for when the patient’s oxygen saturation decreases. The same rhythmic alarm sounds when a lead has been removed as when the monitor detects a PVC. Our textbook mentions how a nurse may experience alarm fatigue during their shift because of the high number of potential false alarms they hear (Hebda, Hunter, & Czar, 2019, p.12). I believe the solution to alarm fatigue is to change the sounds made by these alarms for different kinds of alerts. A deadly cardiac rhythm such as VTACH or severe bradycardia should have distinctly different alarm sound than the alert for an oxygen saturation of 88%, especially if the patient has COPD or another disease that may cause the patient to have consistently low oxygen saturations. According to the article, Alarm fatigue a top patient safety hazard, “85%-90% of alerts are false or nuisance alarms, indicating conditions that don’t require clinical interventions” (Jones, 2014, p. 178). In my opinion, 1 single PVC should not warrant a sound alarm, but it should show a visual alarm. Changing alarm sounds and tones may also be useful, such as verbal commands or different sounds for critical alerts vs routine alerts.

References

Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.

Jones K. (2014). Alarm fatigue a top patient safety hazard. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 186(3), 178. https://doi.org/10.1503/cmaj.109-4696

Give an example of an ethical or legal issue that may arise if a patient has a poor outcome or sentinel event because of a distraction such as alarm fatigue. What does evidence reveal about alarm fatigue and distractions in healthcare when it comes to patient safety?

Alarm fatigue is a prevalent issue in nursing. I have floated to the telemetry unit at my hospital and witnessed it first-hand, and even the nurses I was working with that day acknowledged that it’s hard for them to run to every alarm when often times it’s nothing. But it’s not always nothing.

In March of 2012 in Willow Grove, Pennsylvania, alarm fatigue caused the death of a young patient. ME was 17 years old, she was getting her tonsils removed in same day surgery center. She received the medication fentanyl after surgery and the staff failed to notice her change in respiratory status. Unfortunately, when they did notice, it was too late to save her. Due to her lack of oxygen, she suffered severe brain damage and she died 15 days later. The lawsuit states that the alarms were muted, therefor not properly alerting the nurses of her change in condition (Teen’s death, $6million settlement put the spotlight on alarm fatigue, 2013). There were important changes made after this event, but a patient was harmed by a known problem that wasn’t addressed.

There also should be a discussion about the number of alarms that sound every day. We don’t get alarm fatigue because they are few and far between, alarm fatigue happens when the alarms are constantly going off. In a dissertation by Colleen Lindell, she found that hospitals with fewer alarms per day had much quicker response times and fewer reports of alarm-related patient events (2018). An alarm-reduction policy was implemented in this hospital and it was shown to reduce fatigue, increase response time, and reduce patient harm (Lindell, 2018).

How can it be improved? Implementing an alarm reduction policy seems to be a good place to start. Educating nurses on how to use technology properly as an assessment tool rather than a substitution can also improve patient outcomes. The percent of alarms that are actually “real” actionable alarms ranged from 36% to less than 1% (Hebda, Hunter, Czar, 2019). Not even half of the alarms are ones that need addressed on a good day. Unnecessary alarms ultimately cause what they’re intended to prevent.

Lindell, C. (2018). Medical Device Alarm Systems: A Multi-Hospital Stufy of Alarm-Related Events, Caregiver Alarm Response, and Their Contributing Factors. The Univeristy if Wisconsin- Milwaukee, ProQuest Dissertations Publishing, 181.

Hebda, T., Hunter, K. & Czar, P. (2019). Handbook of Informatics for Nurses & Healthcare Professionals 6th edition. Pearson. New York, NY.

Teen’s death, $6million settlement put the spotlight on alarm fatigue. (2013). Same-Day Surgery, 37(6).

Thanks for sharing the care experience of your mother during her hospitalization. I had a similar experience to yours. My mother had a fever and UTI in the SNF and transferred to the hospital. Her blood pressure dropped and unresponsive. The critical care physician team rounded when I was at my mother’s bedside, and they recommended me to put her No Code that she may not survive another day. I refused that. When they found that I am a registered nurse, they didn’t disturb my emotion. The third day, my mother was in the critical care unit,  she developed stage 3 pressure injury on the sacrum and gangrene on the toes due to the tightness of SCD. My mother woke up the next day after the intubation and support of a mechanical ventilator.  She remembered what happened and listened to everything. A nurse working within the complex healthcare environment must provide quality, safety, and efficient care. 

It was an interesting of time-motion study to understand nursing workflow, specifically multitasking and task switching activities using TimeCaT, a comprehensive electronic time capture tool, to visualize the workflow. In summary, nurses often multitask and task switch in their critical thinking, which is not observable. Nurses may juggle the various needs of patients, families, and co-workers. This study should include the perceived workload at the end of observation to strengthen study findings in the future. Thanks for the reference to the time-motion study to capture the nursing workflow.

I think anytime we hear the story of a death related to preventable circumstances it makes us reflect on the care we provide.  There are constantly new ideas, devices, and innovations to help make our jobs more efficient, effective, and increase patient success.  One current focus in healthcare is the redesigning workflow processes for improved efficiencies (Hebda et al., 2019) This process can enhance healthcare quality and safety and improve care coordination ( What is workflow redesign? Why is it important?, 2019).  Although patient safety and aiding nursing is being considered when developing new devices, redundant noises do become exhausting.  Creating ways to beat this problem is an interesting topic, as we all have opinions from personal experience.  I myself wonder if a difference would be seen by critical alarms sounding only at the nurse’s station.  This would reduce the nurse looking for lights and hearing beeping from every room.  Typically, someone is at the nurse’s station, if an alarm sounded for true emergent things, this would also reduce the time it takes for someone to attend to the alarm.  

I worked in an acuity hospital and there we had a “nurse on a stick.”   The device read all vital signs at the increments set by the nurse and if there was an abnormal reading, it would alarm a monitor at the nurses’ station, where the unit manager monitored at all times.  

Reference: 

Hebda, T., Hunter, K. & Czar, P. (2019). Handbook of Informatics for Nurses & Healthcare Professionals 6th edition. Pearson. New York, NY.

What is workflow redesign? Why is it important? (2019, April 29). Retrieved August 13, 2020, from https://www.healthit.gov/faq/what-workflow-redesign-why-it-important

“Preventing harm to patients while providing their care continues to be a complex and costly understating for any hospital or healthcare system.” (Kai & Lipschultz. 2015). We as nurses are constantly trying to maintain the best care and sometimes under very stressful situations. We may be assisting a patient to the bathroom while another patient’s bedside alarm is going off. This is not always the case, but it happens frequently. At times nurses do not feel that the alarms mean anything and will ignore them for a period of time assuming that it is a patient asking for a glass of water or wanting to ask a question. This is not an excuse to condone the reaction, but an observation of being a nurse for many years. Some departments that have alarms and they all sound similar. The IV alarm, feeding pumps, bed alarms and call lights all can have similar sounds in some areas of the hospital, and this can create confusion as to the importance of the alarm. Alarm fatigue can be caused by the amount of alarms in the care setting. “This alarm fatigue is compounded by the number of potential false alarms during a nurses’ work shift.” (Hebda, Hunter & Czar. 2019). When alarms go unanswered then serious consequences could happen for the patient, nurse and facility. A patient may fall and be injured from ignoring a bed alarm. Another patient’s cardiac alarm may have went off 4 or 5 times and the nurse sees that the patient is fine and decides that it must be malfunctioning and decides to ignore the next alarm and the patient could be in cardiac arrest. Many issues arise from too many or false alarms.

Improvement could be to reduce the number of alarms within the care setting. I have a big thing about call lights sounding. I would like to see the implementation of an intercom system from a patient’s room to the desk. This way there is not another sound going off in the hallways and the patient just speaks their needs right to the desk and then they can immediately triage the need. If a patient needs assistance to the restroom we know that takes precedence over someone needing a cup of coffee. Patients that need assistance to the restroom need attention first before they attempt on their own. IV’s need monitored through a different system so we can see if the alarm is due to air in the line or if it is because the medication is done infusing. Bed alarms should have a very specific alarm so that we know a patient may have fallen is attempting to get out of bed on their own and they are a fall risk.

Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses and healthcare professionals (6th ed.). Pearson.

Kai, S., & Lipschultz, A. (2015). Patient safety and healthcare technology management. Biomedical Instrumentation & Technology, 49 (1), 60-65. Retrieved from: https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=25621652&site=eds-live&scope=siteLinks to an external site.