Controlling Care Unit Chaos - Overcoming Alert Fatigue in the Clinical Environment

On February 2^nd, I was blessed once again as my wife gave birth to the newest member of our family.  After a complication-free delivery and smooth discharge, I was left with two very memorable experiences.  First, I got to witness the miracle of life begin.  There is no more powerful moment than to see a person appear into the world.  Truly breathtaking.  Secondly, albeit a very distant second – I watched the technology and enhanced workflows I evangelize with our clients come together in a truly elegant way.  Nurse call systems and Electronic Health Record Systems integrating with WLAN phones, RFID tags standing guard to ensure infant and parent safety, wireless infusion pumps communicating with the inpatient pharmacy,  and fetal monitors offering status to clinicians of the pending miracle.  Bits and bytes, ones and zeroes, floating invisibly through the air to alert caregivers of critical events.  To the untrained eye and ear, it may not have even been noticeable – but to me, it was tremendously encouraging. 

We have come a very long way.  In the not-so-distant past, the most alerting a clinician would have had to deal with may have been two phones ringing simultaneously.  Now, there are desk phones, smart phones, nurse call systems, overhead pagers, alphanumeric pagers, PCs, RFID tags, telemetry alerts, digital signage, etc. all vying for the attention of a single clinician.  With so many events to keep tabs on, it’s no surprise to hear that an average shift in a hospital requires a nurse to walk four and a half miles (Mobile Health Alliance).  Of course, it also begs the question – have we over-adopted?  With so many beeps and pings to tend to, won’t the clinician just become desensitized or overwhelmed by it all?  After all, the Joint Commission has documented just how significant a breakdown in communication can be.  With 62% of accidental deaths and 80% of serious medical errors being attributed to communication failure, how can so many alerts possibly be good for patient outcomes?  Well, my recent experience demonstrates just how to achieve the proper balance between too few and too many of them.  Not once did a nurse or physician demonstrate signs of what is known as alert fatigue.  Rather, technology seemed to empower them to be more responsive and more attentive.  Something as ubiquitous in today’s world as a smart phone became a powerful clinical instrument.

So, how DOES a hospital achieve this balance?  To start, they must dive deep into three categories:

• Alert Management – Consider priorities, delivery assurance, clarity, and saturation points of the alerts
• Capacity Management – Determine how tight parameters are set, what staff is available to address the alerts, and the logistics involved to respond
• Policy Management – Audit assignment logistics, escalation procedures, time-to-respond intervals, and disablement requirements

With an understanding of how a care unit consumes alerts, hospitals can deliver the right data, to the right person, on the right device, at the right time, with the right context.  In order to do this, it is important to let the message drive the medium.  A clinical emergency needs to be prioritized over a simple food request, and a weather alert needs to be delivered in a matter different from, say, a patient’s discharge notice.  Additionally, regulatory issues come into play:

• HIPAA – Is Protected Health Information (PHI) secure to ensure compliance?
• HCAHPS – Is the alert management program recognizing the importance of noise reduction, responsiveness, safety and overall patient satisfaction?
• Joint Commission – Is the organization poised to address the 2014 safety goal set forth?

Needless to say, this is no easy undertaking – but with links to patient safety and cases of mortality, it is absolutely critical.  In fact, the ECRI Institute has placed “Alarm Hazards” at the top of the list of technology hazards for consecutive years.  These alerting technologies available in today’s care unit are not going away, so organizations need to understand how to use them effectively.  Care units should continually assess their environment, provide gap analysis to an ideal alert management program, and embrace efficient technologies to aggregate data, enhance workflow, improve outcomes, and increase patient satisfaction. 

Popping the Cap - Blurring the lines between patient convenience and improved outcomes

As movement toward an Electronic Health Record (EHR) continues to proliferate, enhancements of this increasingly all-encompassing technology are now beginning to pop up.  While it’s often touted (and hotly-debated) that the presence of EHR will improve patient outcomes, the concept of extracting clinical data from one source (the EHR) in order to improve workflow or add convenience is finally making an impact.  I make a habit of discussing with my clients how powerful and convenient it can be for physicians when clinical applications and unified communications systems are tightly integrated - but how about patients?  How can the same core fundamentals be used to drive patient engagement?  If we consider how and when a patient actually comes into contact with his or her patient data without a clinician serving as intermediary, the scope narrows quickly.  The most common instance is medication and prescription management.  It is quite amazing that many physicians still scribble a prescription onto a small pad, which the patient then couriers to the pharmacy for fulfillment.  Thankfully, however, a Meaningful Use requirement of the use of e-prescription has curtailed this behavior to a point where most pharmacies offer an electronic methodology of receiving and filling prescriptions.  But what happens once the medication runs out, and a refill is needed - or worse (and as common) never gets filled to begin with?  The patient is now in charge of the health process.  This presents both a challenge and opportunity for care providers.  More and more organizations are leveraging this nexus of patient, provider, and medicine to improve outcomes through technology.  By integrating on-line or call center applications with the EHR, strategies can be developed to drive medication adherence and offer counsel on drug efficacy and reactions.  

With the advent of the Accountable Care Organization (ACO), and in turn a renewed focus on outcome over encounter, providers are looking hard at the impact the pharmacy has on health.  In fact, with one third of US hospitals now managing their own in-house pharmacies, ACO team members can ensure that patients being discharged leave with their meds, and can check on adherence via data analytics platforms that interface with the EHR’s pharmacy application and call center reports.  By categorizing high-risk patients, follow-up calls utilizing the same can be performed to consult adherence, side effects, and overall efficacy.  
A recent success story of this comes from Hennepin County Medical Center helped cut admissions by 42 percent, ED visits by 37% and saved an average of $2,500 through such a program such a program.

      
      Looking toward the future, it is easy to see that something as simple as refilling a prescription over the phone can easily turn into something far greater.  Imagine what can happen next.  Perhaps it’s an ad hoc video consult between the care team pharmacist and a patient experiencing a minor side effect with their medication.  Or maybe it’s pulling up a recent prescription from an on-the-move ambulance while consulting with a Neurologist and potential stroke victim.  Regardless of the use case, the more we integrate, the more significant the impact technology can have before, during or after the point of care.  Remember, Accountable Care is about enhancing the provider/caregiver experience to improve population health.  What better way is there than to take inherently disparate interactions of a clinician interacting with a data system, and a patient interacting with a data system, and have them all integrate, nay collaborate, together?