Missed Alarms: What Can Hospitals Learn from SCM Best Practices?

At the end of December, the Boston Globe published an article titled, “Wide heart monitor use tied to missed alarms.” I had a strong feeling I had read that article before, and then I realized I was having a déjà vu moment — ARC had published a strategy report in 2004 focused on alarm management strategies for manufacturing plants.

Here are the opening paragraphs from the Boston Globe article:

It used to be that only the most fragile patients were wired to a cardiac monitor. Now, some hospitals are building “war rooms’’ with row upon row of screens to track patients’ heart rate and rhythm. Others, such as Tufts Medical Center in Boston, have installed monitors at every bedside.

 

The burgeoning use of heart monitors allows hospitals to care for sicker patients on regular floors – typically without hiring as many nurses as they do in intensive care units – and to admit patients faster, easing emergency room congestion. Many physicians routinely put patients on the monitors, knowing they can save lives by catching life-threatening abnormalities. And since monitoring is noninvasive, it seems harmless.

 

But an expanding group of researchers, many of them nurses, are questioning the proliferation of monitoring, saying it is a prime cause of the dangerous problem of alarm fatigue. The more patients there are on monitors, they say, the more the machines’ warning alarms blare, leading nurses to become desensitized to the beeps and tune them out. This phenomenon has been linked to dozens of patient deaths nationwide, according to an analysis published this year by the Globe.

Similarly, process manufacturing facilities, such as chemical plants, refineries, and power generation plants, also use alarms widely. These alarms measure things like the flow rate of liquids, liquid levels, pressure, temperature, whether equipment is functioning properly, and environmental emissions. There are set thresholds and when readings go outside the acceptable limits, an alarm occurs.

The Boston Globe article did not say how many alarms can go off in a day at a hospital, but at a large refinery it can average over 14,000 per day. I’m sure hospitals are not close to that scale.

Process plant alarming also has a degree of complexity not associated with an individual patient. According to the ARC Strategy report:

Many of the alarms in existence today are often related only to the process variable they are connected to, they are not aware of other alarms. This can result in a phenomenon called alarm showers or cascading alarms. These occur when one failure causes many process variables to trip their preset alarms. The result can be catastrophic when the quantity of alarms masks the real source of the problem and causes delays in operator corrective actions.

The solution to alarm fatigue can be similar in both hospitals and process plants. The Boston Globe article pointed out that many patients don’t really need to be on a heart monitor because their condition is not serious enough to warrant it. And even patients that do warrant alarms are often kept on them too long.

Similarly, “alarm rationalization” is part of the solution in manufacturing plants. As the ARC report highlights, “[A] systematic process…results in a reduction of the number of alarms, alarm prioritization, validation of alarm parameters, evaluation of alarm organization, and the number of alarms assigned to an operator, and finally alarm presentation.” This process of systematic alarm rationalization in factories is frequently based on continuous improvement methodologies such as Six Sigma.

I have written before about how hospitals could improve by using supply chain best practices (see “The Logistics of Flowing Patients” and “The Ottawa Hospital’s Supply Chain Transformation”). I remain convinced that health care could be improved if hospitals looked at some of the best practices that exist in manufacturing and the supply chain.