Popular Mills Session Shines Spotlight on Alarm Management
It was standing-room only for The Joint Commission (TJC) update from George Mills—a popular session that always attracts healthcare technology management professionals at the AAMI Annual Conference & Expo.
A pressing area of concern for many in attendance was clinical alarms, particularly ahead of TJC's 2014 National Patient Safety Goal (NPSG) on alarm management. If approved, the NPSG would require healthcare facilities to make alarm management a top priority. Mills spent a lot of time discussing alarms and the NPSG as hospitals try and eliminate alarm fatigue.
Currently, ignoring patient alarms has become “normalized deviance.” He cited one instance in which a third-shift nurse turned off patient alarms in the evening so patients could sleep. She would turn them back on before she left, but she had to leave early one morning and forgot. As a result, a patient died.
“Normalized deviance, is it a good thing?” he asked rhetorically. “Absolutely not,” he answered.
Although the NPSG touches on many important aspects of clinical alarms management, Mills said he thinks it is missing something by not addressing human factors, as some healthcare providers and nurses might not know what specific alarm signals mean, thus leading to confusion and potentially putting patients at risk.
Mills also took a moment to point out that TJC rarely cites other agencies. However, he noted that the NPSG refers readers to the AAMI and ECRI Institute's websites for additional information, and added that he thought it was wonderful that TJC was looking to the experts for guidance.
The AAMI Foundation’s Healthcare Technology Safety Institute (HTSI) has looked into numerous issues that could compromise patient safety, with alarm fatigue being a top priority. Earlier this year the institute submitted comments to TJC on the proposed NPSG, providing some of its ideas for improving alarm system management.
Two other topics Mills was keen on addressing were patient lifts and fixed seating for patients in halls. The former topic was of special importance to Mills, whose son was in the hospital following an accident last year. Hospital staff attempted to put his son in a wheelchair using a piece of plywood, despite there being a lift 75 feet down the hallway. Mills tried to convince them to walk down and bring it to the room, but they refused. They almost dropped his son, making Mills wonder just how many patients will be dropped because no lift is available. He urged hospitals to have lifts outside patient rooms—something TJC allows as long as there is a means of egress with a five-foot wide clear corridor.
Mills also pushed for the fixed seating, as it would give stroke victims a chance to walk around and do physical therapy. There are not enough staff to follow patients through the hall with wheelchairs. This situation forces some patients to stay in bed and gain weight, as they don't get the exercise they need.
Following the first 90-minute session, Mills held a Q&A with audience members. One interesting topic Karen Waninger, clinical engineering director at Community Health Network in Indianapolis, IN, brought up was disaster preparedness—does a hospital have the inventory available for back up in case of a natural disaster—and whether TJC was making that a bigger priority.
Mills replied that disaster preparedness is something TJC is looking at more fully. He cited St. John's Regional Medical Center in Joplin, MO, as an example. The facility sustained major damage in the devastating tornado that pounded the town, but the Clinical Engineering Department had a list of what devices it needed and rescued them immediately. “In my mind, that really crystallized preparedness,” Mills said.
Posted: 06.02.13