Clinical decision support in the fight against alarm fatigue By Nancy Zimmerman Healthcare facilities have become centers of sensory overload, with systems issuing far too many unnecessary alarms. How out of control is it? Studies estimate that 72 percent to 99.4 percent of all clinical alarms have no clinical relevance. 1 This overload causes “alarm fatigue,” with desensitized clinicians ignoring alarms that really do present critical information. The impact on patient safety is significant: according to the Joint Commission, there were 138 deaths reported from 2010 to June 2015 because of missed or bypassed alarms.2 One way provider organizations are combating alarm fatigue is by leveraging advanced clinical decision support (CDS) tools that more accurately issue alarms only when immediate clinical attention is required. These CDS platforms run on top of EMR systems and analyze clinician EMR entries, including details recorded in free-text notes. The system compares those entries to evidence-based best practices, and to patient information stored in the systems of labs, radiology and other data points outside the EMR, to assist clinicians in arriving at accurate diagnoses – and to alert clinicians to issues that cannot be easily observed. The more precise its analysis and clinical understanding, the better the CDS system can both inform care and avoid contributing to alarm fatigue. Prompting only for actions not yet taken The system’s ability to interpret clinical information entered in free-text EMR notes is essential to avoiding alerts suggesting that clinicians do something they’ve already addressed. For example, most CDS systems are programmed to assist with pain management, which is typically documented in EMR menu selections. In non-typical pain management, such as OB pain control after an epidural, clinicians may need to record assessments in free-text notes. If the CDS system can’t read and interpret those notes, any alarm it issues relative to pain management will likely be an annoyance. But, if the system can read and interpret those notes accurately, it can avoid issuing irrelevant alarms – and issue accurate alarms when encountering a verified deviation from best practices in OB pain management. Circumventing the cries of “wolf” Routine false alarms based on incomplete information can condition clinicians to also ignore truly urgent alarms. EMRs commonly issue sepsis alerts for all patients based on systemic inflammatory response syndrome (SIRS) criteria. Continuing with the OB example, women in labor don’t fit the typical profile, and their normal hard breathing, with elevated respiratory and heart rates, can set off a hard-stop sepsis alarm. Clinicians learn to quickly take steps to eliminate such alarms so they can continue their regular workflow. In that rare case when the OB patient actually is at risk of septic shock, clinicians may mistakenly assume that it’s just one more false alarm, unwittingly putting the patient at tremendous risk. Advanced CDS systems can correct this situation by more accurately identifying potential progression toward septic shock based on a complete understanding of the patient’s condition over time. Rather than relying solely on standard SIRS criteria, a CDS system monitoring a patient’s recent clinical history can detect trends such as a slow rise in white 1 2
American Association of Critical-Care Nurses Advanced Critical Care Volume 24 , Number 4, 2013 The Journal of Advanced Practice Nursing, Jan. 15, 2016
blood cells in successive lab tests, or detect that while vital signs remain relatively constant within the normal range, the patient is slowly becoming hypotensive or developing a slightly elevating fever. In this way, a CDS system can avoid false sepsis alarms for OB patients, and more accurately detect risk of septic shock among all patients. Synchronizing alarms with workflows Many alarms are based on specific diagnoses. This can especially contribute to alarm fatigue in emergency department (ED) settings, where clinicians typically base their work on initial assessment and chief complaint, and document diagnoses at or near the time of ED discharge. If the system is programmed to issue alerts according to standard procedural checklists, such as for all patients with a fever, clinicians will know from direct observation and physical exam that many or most of the alerts will be irrelevant. If, however, the CDS system takes into account which screens the clinicians are working in, it can issue more fully informed alerts at the correct point of clinical decision-making – rather than prematurely issuing an alert for something the clinicians are actually working toward. It can also more accurately prompt near the end of a care process for a needed action that really was overlooked. Alarm fatigue is avoidable, and advanced systems are eliminating it As with many advancing categories of healthcare IT, CDS systems have been steadily improving in their ability to deliver highly meaningful clinical value. For CDS systems, that ultimately means that every alert should be for an actual clinical mistake about to happen, rather than a mistake on the part of the CDS system itself. When advanced CDS systems get it right, clinicians receive so few alerts that they sometimes forget the system is there, which is the exact opposite of alarm fatigue – and when they do receive an alert, they are grateful for the meaningful assistance. About the author: Nancy Zimmerman is Chief Nursing Officer for medCPU