Michael F. Rayo

Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response

Although there are powerful incentives for creating alarm management programmes to reduce ‘alarm fatigue’, they do not provide guidance on how to reduce the likelihood that clinicians will disregard critical alarms. The literature cites numerous phenomena that contribute to alarm fatigue, although many of these, including total rate of alarms, are not supported in the literature as factors that directly impact alarm response. The contributor that is most frequently associated with alarm response is informativeness, which is defined as the proportion of total alarms that successfully conveys a specific event, and the extent to which it is a hazard. Informativeness is low across all healthcare applications, consistently ranging from 1% to 20%. Because of its likelihood and strong evidential support, informativeness should be evaluated before other contributors are considered. Methods for measuring informativeness and alarm response are discussed. Design directions for potential interventions, as well as design alternatives to traditional alarms, are also discussed. With the increased attention and investment in alarm system management that alarm interventions are currently receiving, initiatives that focus on informativeness and the other evidence-based measures identified will allow us to more effectively, efficiently and reliably redirect clinician attention, ultimately improving alarm response.

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners

Objective Although there is a growing recognition of the importance of active communication behaviours from the incoming clinician receiving a patient handover, there are currently no agreed-upon measures to objectively describe those behaviours. This study sought to identify differences in incoming clinician communication behaviours across levels of clinical training for physicians and nurses. Methods Handover observations were conducted during shift changes for attending physicians, resident physicians, registered nurses and nurse practitioners in three medical intensive care units from July 2011 to August 2012. Measures were the number of interjections from the incoming clinician and the communication mode of those interjections. Each collaborative cross-check, a specific type of interactive question, was subsequently classified by level of assertiveness. Results 133 patient handovers were analysed. Statistical differences were found in both measures. Higher levels of training were associated with fewer interjections, and a higher proportion of interactive questioning to detect erroneous assessments and actions by the incoming provider. All groups were observed to use the least assertive level of a collaborative cross-check, which contributed to misunderstandings. Nurses used less assertive collaborative cross-checks than physicians. Conclusions Differences across clinician type and levels of clinical training were found in both measures during patient handovers. The findings suggest that training could enable physicians and nurses to learn communication competencies during patient handovers which were used more frequently by more experienced practitioners, including interjecting less frequently and using interactive questioning strategies to clarify understanding, and assertively question the appropriateness of diagnoses, treatment plans and prognoses. Accompanying cultural change initiatives might be required to routinely employ these strategies in the clinical setting, particularly for nursing personnel.

Barriers and facilitators to adoption of soft copy interpretation from the user perspective: Lessons learned from filmless radiology for slideless pathology.

Background: Adoption of digital images for pathological specimens has been slower than adoption of digital images in radiology, despite a number of anticipated advantages for digital images in pathology. In this paper, we explore the factors that might explain this slower rate of adoption. Materials and Method: Semi-structured interviews on barriers and facilitators to the adoption of digital images were conducted with two radiologists, three pathologists, and one pathologist′s assistant. Results: Barriers and facilitators to adoption of digital images were reported in the areas of performance, workflow-efficiency, infrastructure, integration with other software, and exposure to digital images. The primary difference between the settings was that performance with the use of digital images as compared to the traditional method was perceived to be higher in radiology and lower in pathology. Additionally, exposure to digital images was higher in radiology than pathology, with some radiologists exclusively having been trained and/or practicing with digital images. The integration of digital images both improved and reduced efficiency in routine and non-routine workflow patterns in both settings, and was variable across the different organizations. A comparison of these findings with prior research on adoption of other health information technologies suggests that the barriers to adoption of digital images in pathology are relatively tractable. Conclusions: Improving performance using digital images in pathology would likely accelerate adoption of innovative technologies that are facilitated by the use of digital images, such as electronic imaging databases, electronic health records, double reading for challenging cases, and computer-aided diagnostic systems.

Determining the Rate of Change in Exposure to Ionizing Radiation From CT Scans: A Database Analysis From One Hospital

PURPOSE Cancer risks associated with radiation from CT procedures have recently received increased attention. An important question is whether the combined impact of CT volume and dose reduction strategies has reduced radiation exposure to adult patients undergoing CT examinations. The aim of this study was to determine differences in radiation exposure from 2008 to 2012 to patients receiving CT scans of the abdomen, head, sinus, and lumbar spine at a midwestern academic medical center that implemented dose reduction strategies. METHODS Data were collected from two internal data sets from 2008 to 2012 for general medicine and intensive care unit patients. These data were used to calculate annual CT volume, rate, average effective dose, radiation exposure, and estimated cancer risk. RESULTS A 37% reduction in abdominal CT volume was found from 2008 to 2012. However, no volume reductions were found for CT examinations of the head or lumbar spine, and the decrease in sinus imaging was minimal. Dose reduction strategies resulted in 30% to 52% decreases in radiation exposure for the targeted body areas. The combined reduction in volume and dose per procedure reduced estimated induced cancers by 63%. CONCLUSIONS Exposure to ionizing radiation from these examinations was reduced at one institution because of reduced volumes of procedures and the reduction of each procedures effective dose through new protocols and technologies. Although both the volume reduction and dose reduction strategies contributed to the reduced exposure, it seems that investments in implementing the protocols and new technology had the greatest effect on future cancer risk.

Implementing an institution-wide quality improvement policy to ensure appropriate use of continuous cardiac monitoring: a mixed-methods retrospective data analysis and direct observation study

Background Hospitals have been slow to adopt guidelines from the American Heart Association (AHA) limiting the use of continuous cardiac monitoring for fear of missing important patient cardiac events. A new continuous cardiac monitoring policy was implemented at a tertiary-care hospital seeking to monitor only those patients who were clinically indicated and decrease the number of false alarms in order to improve overall alarm response. Methods Leadership support was secured, a cross-functional alarm management task force was created, and a system-wide policy was developed based on current AHA guidelines. Process measures, including cardiac monitoring rate, monitored transport rate, emergency department (ED) boarding rate and the percentage of false, unnecessary and true alarms, were measured to determine the policys impact on patient care. Outcome measures, including length of stay and mortality rate, were measured to determine the impact on patient outcomes. Results Cardiac monitoring rate decreased 53.2% (0.535 to 0.251 per patient day, p<0.001), monitored transport rate decreased 15.5% (0.216 to 0.182 per patient day, p<0.001), ED patient boarding rate decreased 36.6% (5.5% to 3.5% of ED patients, p<0.001) and the percentage of false alarms decreased (18.8% to 9.6%, p<0.001). Neither the length of stay nor mortality changed significantly after the policy was implemented. Conclusions The observed improvements in process measures coupled with no adverse effects to patient outcomes suggest that the overall system became more resilient to current and emerging demands. This study indicates that when collaboration across a diverse team is coupled with strong leadership support, policies and procedures such as this one can improve clinical practice and patient care.

Comparing the Effectiveness of Alerts and Dynamically Annotated Visualizations (DAVs) in Improving Clinical Decision Making

Objective: The aim of this study was to compare the effectiveness of two types of real-time decision support, an interrupting pop-up alert and a noninterrupting dynamically annotated visualization (DAV), in reducing clinically inappropriate diagnostic imaging orders. Background: Alerts in electronic health record software are frequently disregarded due to high false-alarm rates, interruptions, and uncertainty about what triggered the alert. In other settings, providing visualizations and improving understandability of the guidance has been shown to improve overall decision making. Method: Using a between-subject design, we examined the effect of two forms of decision support, alerts and DAVs, on reducing the proportion of inappropriate diagnostic imaging orders for 11 patients in a simulated environment. Nine attending and 11 resident physicians with experience using an electronic health record were randomly assigned to the form of decision support. Secondary measures were self-reported understandability, algorithm transparency, and clinical relevance. Results: Fewer inappropriate diagnostic imaging tests were ordered with DAVs than with alerts (18% vs. 34%, p < .001). The DAV was rated higher for all three secondary measures (p < .001) for all participants. Conclusion: DAVs were more effective than alerts in reducing inappropriate imaging orders and were preferred for all patient scenarios, especially scenarios where guidance was ambiguous or based on inaccurate information. Application: Creating visualizations that are permanently displayed and vary in the strength of their guidance can mitigate the risk of system performance degradation due to incomplete or incorrect data. This interaction paradigm may be applicable for other settings with high false-alarm rates or where there is a need to reduce interruptions during decision making.

Framework for Alarm Management Process Maturity

Tandi Bagian, MSE, is program analysis officer in the National Center For Patient Safety of the Department of Veterans Affairs in Ann Arbor, MI. Email: tandi.bagian@va.gov Editor’s note: The AAMI Foundation’s National Coalition for Alarm Management Safety developed this framework for medical device alarm management. This article is intended to guide stakeholders in developing sustainable solutions and to serve as a foundation for discussions with hospital executives, healthcare technology managers, patient safety officers, and risk managers. The framework is not intended to be prescriptive but rather a guide for continuous improvement efforts to reduce nonactionable alarms of all types originating from medical devices.

Handoff Communication: Implications For Design

Handoff communication is one of the most typical clinical communication mechanisms in a healthcare setting to transfer information and responsibilities of the care provider. Handoff communication is varied across settings, provider type, and even within a clinical unit. Information technology has the capability to support handoff communication, with better understanding of handoff communication needs and variations. This panel examines (1) how handoff communication happens in the healthcare setting through mini-cases (2) insights on information technology design for handoff communication.

Patient-Centered Handovers: Ethnographic Observations of Attending and Resident Physicians

Handover communication improvement initiatives typically employ a “one size fits all” approach. A human factors perspective has the potential to guide how to tailor interventions to roles, levels of experience, settings, and types of patients. We conducted ethnographic observations of sign-outs by attending and resident physicians in 2 medical intensive care units at one institution. Digitally audiotaped data were manually analyzed for content using codes and time spent using box plots for emergent categories. A total of 34 attending and 58 resident physician handovers were observed. Resident physicians spent more time for “soon to be discharged” and “higher concern” patients than attending physicians. Resident physicians spent less time discussing patients which they had provided care for within the last 3 days (“handbacks”). The study suggested differences for how handovers were conducted for attending and resident physicians for 3 categories of patients; handovers differ on the basis of role or level of expertise, patient type, and amount of prior knowledge of the patient. The findings have implications for new directions for subsequent research and for how to tailor quality improvement interventions based upon the role, level of experience, level of prior knowledge, and patient categories.

Designing for collaborative autonomy: updating user-centered design heuristics and evaluation methods

As we design automated and autonomous products that make increasingly sophisticated inferences and stronger interjections in a wider range of settings, it is increasingly critical to conceptualize these products as cognitive agents, and not simply as passive tools. Our repertoire of heuristics and techniques must expand to explicitly support not only a person’s ability to take actions, but also to make sense of the world, determine the applicability of current and future plans, and select appropriate actions among many alternatives. These machine agents will also be expected to perform some or all of these functions themselves. Collectively, these attributes can be thought of as facilitating collaborative autonomy, in which all agents in the system can express initiative and cede authority based on their understanding of the world. However, product design is not the first discipline to face these problems or design these types of solutions. Cognitive Systems Engineering has been integrating and adding to the knowledge base in these areas for over 30 years. With some effort in translating their findings to our projects, we will be able to accelerate innovation and avoid the pitfalls and unintended consequences of previous attempts at increasing inference and interjection.