What clinicians can learn from commercial aviation

by Mary Jahrsdoerfer, Ph.D., R.N.

Between 2006 and 2016, the Health Technology Foundation (HTF), a non-profit organization that advocates for the development of safe and effective health IT, conducted a series of surveys designed to capture the impact of device alarms on clinical workflow and hospital practices.

The latest survey, in 2016, found “few improvements in perceptions of clinical alarm safety and management occurred in the past 10 years, and several positive trends noted between the 2006 and 2011 surveys were reversed in the 2016 survey. Most concerning was the near doubling of respondents indicating that their institutions had experienced an adverse patient event related to clinical alarms.”¹

In fact, in all areas measured, including alarm frequency, patient care disruption and trust in alarms, perceptions on the efficacy of alarm management declined since the inaugural survey. (See figure below)

It’s clear that despite an aggressive mandate from the Joint Commission and a near-consensus from patient-facing clinicians regarding the dangers of alarm fatigue, excessive, mostly spurious, alarms continue to proliferate in many health systems.

Even stringent alarm management efforts—whether accomplished with hospital protocols or technology—fall short because the reduction in overall alarm volume is insufficient and patient safety remains a reactive process, only kicking into gear when an adverse event is imminent.

Why Patient Safety is Elusive

More than 250,000 patients die every year in American hospitals—the nation’s third leading cause of death. By contrast, the number of fatalities on large commercial U.S. airlines between 2009 and 2018 was zero. To put that in context, there are an average of 87,000 flights in the U.S. every day, which means that over that time span, 286 million domestic flights occurred without a single fatality.

How was the aviation industry able to achieve such an incredible safety record, while the healthcare industry struggles even modestly reduce an unacceptable number of preventable patient injuries and deaths?

Regulations and standards certainly played a critical role, but a core reason air travel is so safe is the industry’s proactive approach to risk mitigation. Through the acquisition, analysis and sharing of aviation safety data, industry professionals identify and prevent emerging threats, then continuously monitor and refine the effectiveness of a preventative measure.

Patient safety in healthcare largely relies on monitoring practices that are reactive and retrospective. Data used to better grasp a patient’s physiology over time is often taken from the historical record in the electronic health record and pieced together episodically from narrow parameters on individual devices.

Continuous surveillance, in contrast, is represents significant shift toward prospective anticipation and clinical collaboration—and aligns more closely to the protocols of the aviation industry.

A Peek Around the Corner

Continuous surveillance’s superiority over traditional monitoring lies in its clinical attributes: Attention, Timeliness, Recognition, Intuition, Analysis, Action and Collaboration. As I noted in a recent paper defining the differences between the two terms, monitoring may possess one or more of these attributes, but clinical surveillance requires all seven.

A patient who succumbs to an undetected adverse event can be compared to a plane crash. Aviation accidents are usually the result of a combination of separate events that cascade into a larger and more significant problem. Similarly, in hospitals, a single alarm from a device that measures, say, heart rate, may not be indicative of a threat. However, heart rate combined with other measurements, such as oxygen saturation, respiratory rate and end-tidal carbon dioxide may point to an imminent problem.

By capturing real-time, continuous data flow from multiple sources that can be filtered and intelligently analyzed for clear and significant trends, continuous surveillance facilitates timely interventions long before a life-threatening event occurs. An objective of predictive analytics is to uncover relationships among seemingly unrelated measurements, then validating or correcting those assumptions.

Continuous surveillance enhances clinical encounters, allowing nurses, respiratory therapists and other patient-facing staff to focus on the individual, rather than the device (and its alarms), recognize physiological patterns deleterious to a positive health outcome, and act on that holistic, real-time information in collaboration with the rest of the clinical team.

Clinical surveillance is team-based, allowing multiple caregivers to assess a holistic portraits of multiple patients from a centralized location or via mobile alarm notifications.

Proactive Patient Safety

Health systems face big challenges in balancing alarm management and patient safety. Escalation of care is costly in terms of resource utilization, morbidity and mortality. Interventions that precede crisis events will better reduce the strain on the patients and clinical staff.

Progressing to continuous clinical surveillance throughout the hospital requires a careful investment of time and money in addition to workflow considerations to ensure the highest level of patient safety. While most hospitals have the infrastructure in place to build a comprehensive clinical surveillance program, scaling this capability across the enterprise will require a real-time, connected healthcare platform that combines comprehensive and vendor-neutral medical device integration with powerful middleware, advanced alarm management, advanced analytics and robust distribution capabilities

Hospitals that empower their clinicians to make more intelligently informed decisions utilizing the data that are already available will be in the best position to ensure the long-term safety of the patients they care for.

REFERENCE

1. Ruppel H, Funk M, Clark JT, Gieras I, David Y, Bauld TJ, Coss P, Holland ML. AJCC attitudes and practices related to clinical alarms: a follow up survey. Am J Crit Care. March 2018; 27(2).