Sounds and silence

NPR on nursing innovations

Alarm fatigueSeptember 25, 2014 — In recent months, reports on National Public Radio’s Morning Edition have highlighted the important roles that nurses can play in improving hospital care through new clinical initiatives. On January 27, 2014, the radio network aired Richard Knox’s piece on the efforts of Boston Medical Center to combat “alarm fatigue.” That is the well-documented threat to patient safety that occurs when hospital staff confronted with a cacophony of health monitoring alarms have trouble distinguishing those that matter most. The report mainly quoted nurses, including a nurse manager, as well as highlighting the fact that the hospital’s successful effort to address the problem had been detailed in the Journal of Cardiovascular Nursing. And today, NPR aired a piece by Sarah McCammon about the recent efforts of nurse “care coordinators” at the Savannah, Georgia health system Memorial Health to reduce costly hospital re-admissions by working closely with patients–talking to them–to manage chronic conditions like diabetes and heart disease. This report relied mainly on quotes from one of the care coordinators, who described his work in helping patients make lifestyle changes and navigate the health care system in some detail. The piece also included success stories. It did seem to reflect some surprise that these nurses were not providing fairly routine bedside care. And it quoted the health system CEO on the program’s goals. So some might assume that the nurses’ care was being directed by others, when it is actually well within nurses’ own holistic practice model. Still, both pieces offer portraits of skilled nurses improving hospital care, and we thank those responsible.

Alarms in my dreams

“Talk to patients”

Alarms in my dreams

The report on alarm fatigue is headlined “Silencing Many Hospital Alarms Leads To Better Health Care.” It describes the “constant stream of beeps and boops” that “doctors and nurses” recognize as signaling important health messages. Boston Medical Center systems engineer James Piepenbrink explains that three tones signal a crisis, two a warning. The piece notes that “an analysis” found that the hospital’s cardiac care unit was having an average of 12,000 alarms per day. The report quotes Deborah Whalen, a clinical nurse manager at the hospital:

Alarm fatigue is when there are so many noises on the unit that it actually desensitizes the staff. If you have multiple, multiple alarms going off with varying frequencies, you just don’t hear them.

And that can be deadly, the piece explains, quoting Whalen as saying that the hospital has been “lucky” not to have recorded any deaths from alarm failure. A 2011 Boston Globe investigation found more than 200 deaths nationwide related to the problem, and the Joint Commission warned of almost 100 instances of harm related to the problem in 2013, including 80 deaths. The piece quotes “Dr. Ana McKee,” the Commission’s chief medical officer, as saying that is just the tip of the iceberg because of underreporting.

Alarm fatigueMcKee also says this technology threat is at the top of the Commission’s list of issues for hospitals to address. But Boston Medical Center seems to have done so, eliminating audible signals for the vast majority of its alarms, such as for low heart rate; raising others to a higher “crisis” level, such as for a pause in heart rhythm; and giving nurses “authority to change alarm settings to account for patients’ differences.” Whalen says that

many, many, many alarms disappeared. And instead of 90,000 alarms a week [in the cardiac unit], we dropped to 10,000 alarms a week. … I think less is better. If you have more and more data, more and more alarms, more and more technology — [it’s] bad data in, bad decisions made.

The piece notes the hospital’s “success in reducing alarm fatigue is detailed in the Journal of Cardiovascular Nursing.” Now, “when a ‘crisis’ alarm sounds, the staff can easily hear and respond.” Staff nurse Amanda Gerety says that it’s more manageable and pleasant, plus “I don’t hear alarms in my dreams anymore.” A photo in the online story shows Gerety manipulating a seemingly complex set of monitors displaying vital signs, with an indirect quote from her saying that crisis warnings are now easier to hear. The piece concludes that patients like it better as well, because nurses are more likely to hear the “nurse-call button.”

This report has many good elements. It quotes two nurses, including a nurse manager who speaks with authority about alarm fatigue and the hospital’s solution. And the photo of Gerety shows her working with monitors that should strike most readers as requiring fairly advanced health skills. The report also states that the hospital’s efforts to address alarm fatigue were described in the impressive-sounding Journal of Cardiovascular Nursing, although it would have been even better had the piece said who wrote the study. Co-authors seem to have included Whalen, three other nurses, a physician, and Piepenbrink. The story says patients like the change because nurses can now hear the call button, but it might also have noted that nursing research has shown quieter units can improve outcomes by allowing patients to rest. And the report might have noted the likely benefits to nurses. Unnecessary alarms can exacerbate understaffing and burnout by adding to nurses’ stress levels and wasting their time, which in turn endangers patients. But on the whole, the piece commendably relies mainly on nurses in discussing a key health issue in which nurses probably are most expert–not something we can take for granted.

“Talk to patients”

Today’s piece is “To Prevent Repeat Hospitalizations, Talk To Patients,” and its personal focus is on Savannah nurse Kevin Wiehrs. Right off the bat, the reporter finds it notable that “instead of giving patients shots or taking blood pressure readings, [this nurse’s] job is mostly talking with patients like Susan Johnson.” The online piece includes a photo of Wiehrs doing just that, dressed in a white coat and evidently taking notes. He is reportedly following up after diabetes patient Johnson’s meeting with her physician, “talking through her medication, exercise and diet.”

“So it sounds like you cut back on your sweets, things that have a lot of sugars in them. What about vegetables, your portions of food?” Wiehrs asks Johnson. “Have you made any changes with that?”

Johnson says she has, a little bit. The report says Wiehrs was a hospice nurse for 15 years and before that a social worker. Now he is one of five new “care coordinators” at Memorial Health who focus on “patients with poorly controlled chronic conditions like diabetes and heart disease.”

“Some of these patients have fought with their diabetes for many years and get very complacent with the whole situation and feel that, ‘No matter what I do, it’s not going to make a difference,'” he says. “But it does.” It’s hard to persuade people to change, Wiehrs says. … He says they often approach him and say, “I’ve been coming to this office before; I’ve seen these physicians. And now you’re somebody new. What are you doing, and why do you want to talk to me?”

The report says Memorial Health is spending $500,000 per year on care coordination “in the belief that the program will save money in the long run and improve the quality of care.” CEO Maggie Gill, who evidently has an MBA, “wants Wiehrs to teach patients to care for themselves” and hopes that managing conditions this way will avert health crises. She explains that her health system provides about $30 million in free care each year and will need to keep doing that, since Georgia is one of the states that have chosen not to expand Medicaid under the Affordable Care Act. At the same time, Medicare has lowered reimbursements for certain patient re-admissions, and Gill hopes to prevent those. She cites one care coordinator who managed to teach a difficult diabetic patient’s wife to monitor and deliver insulin, evidently preventing two or more emergency department visits.

Wrapping up with more on Wiehrs, the piece notes that he says patients do end up trusting him. He follows up on their general health, medication, and appointments, and when necessary he contacts drug companies or does online research to help them get drug discounts. He notes that he may have to “get creative” and spend extra time, but because of his experience he knows how to navigate the health care system. And he describes a patient who “practically bounded into his office recently, breathing easier thanks to new asthma inhalers.” The piece says the hope is that “little improvements like that will add up to big savings to the health system — and will improve the health of patients.”

This is another report that does a good job highlighting a promising care initiative in which nurses play the key role. Wiehrs gets multiple quotes. And the piece makes clear that the care coordinators are improving patient outcomes and helping to contain health costs, especially with the anecdotes about the asthma and diabetes patients. The photo of Wiehrs in his white coat presents him as a serious health professional. Unfortunately, the piece does not make clear that what Wiehrs does fits squarely within nurses’ traditional scope of practice and that all nurses are trained as patient educators and supposed to be educating every one of their patients. So there is a risk that readers will think this is just some new invention of business managers like Gill, who have to instruct nurses on the benefits of a holistic approach.

The report also seems to reflect surprise that Wiehrs is not doing fairly straightforward physical tasks at the bedside, as if that is all nursing is–a vision of the profession that has been reinforced by Hollywood and other popular media for decades. But many if not most nurses would be doing the kinds of things Wiehrs does for patients if they had time.

Still, the piece does show to some extent what skilled nurses do to improve patient outcomes, and we thank NPR for that.

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