Lean-out the Noise

Not always the best idea…

In lean practices visual management is a central idea. Broadly, the term encompasses the philosophy and tools associated with establishing a real-time grasp of the status of a process by seeing the nature and level of demand, bottlenecks in the flow, defects and other aspects of situational awareness. Yet as important as seeing the process is, sounds can also serve as important elements of process awareness. But it is hard to see the signal from the noise in visual management if a process and work area is cluttered hence the emphasis on establishing and maintaining order through methods such as 5S. Similarly, one can consider the noise level of a work area a key determination in whether or not sound helps process stakeholders to better establish and maintain good flow. Literally, if there is too much noise one cannot hear the important signal.

An example of this phenomena is described in a U.S. study that looked at noise levels in healthcare processes. The Boston Globe reported:

The national organization that accredits hospitals is proposing a new patient safety goal: hospitals must urgently tackle the failure of medical staff to respond to patient alarms, a common phenomenon known as alarm fatigue.

The Joint Commission previously, in 2004, made improving alarm safety part of its national patient safety goals, which signaled it was a top priority. However, the agency soon dropped the goal, thinking that hospitals had solved the problem. But a Boston Globe investigation in 2011 revealed that the problem was continuing.

The Globe identified at least 216 deaths nationwide between January 2005 and June 2010 linked to the dozens of alarms on patient monitors, which track heart function, breathing, and other vital signs.

In many cases, medical personnel didn’t react with urgency or didn’t notice an alarm, a type of desensitization that occurs from hearing alarms — many of them false — all day long.

In one case, at UMass Memorial Medical Center in Worcester, nurses failed to respond to an alarm that sounded for about 75 minutes, signaling that a patient’s heart monitor battery needed to be replaced. The battery died, so when the patient’s heart then failed, no crisis alarm sounded. In another instance at Massachusetts General Hospital, an elderly man suffered a fatal heart attack while the crisis alarm on his cardiac monitor was turned off and staff did not respond to numerous lower-level alarms warning of a low heart rate.

Under the Joint Commission’s proposal, hospital leaders must make alarm safety a priority, conduct an inventory of alarms and decide which ones are unnecessary, and educate staff about the hospital’s alarm policies, as a condition of accreditation.

The Journal of the American Medical Association reported in March 2013:

Electronic health records may be putting doctors into information overload. When the government offered to reward doctors and hospitals for adopting electronic records the goal was to improve efficiency and patient safety. An unexpected consequence, however, is the large number of electronic alerts that many primary care providers receive every day.

In a survey of more than 2,500 doctors, physicians reported receiving 63 alerts per day on average. About 70 percent said this is more than they can manage. The consequences of alert fatigue include abnormal test results being overlooked. Almost one-third of the physicians in the survey admitted they had missed lab reports that ought to have triggered more prompt patient follow-up and treatment.

Scrapping electronic health records is not the answer. Lab results are too often missed in paper-based systems as well. The authors suggest that doctors should learn how to use filtering systems to better highlight important alerts. They should also set up a system to ensure follow-up on every patient test. And patients should not assume that no news is good news. Instead, if they do not get a report about lab results in a timely fashion they should ask for their test results and an explanation of the findings.

Andre Picard in the Globe and Mail writes:

Anyone who has been a patient or a visitor to a hospital knows they are noisy places. But rarely do we acknowledge that the cacophony, in addition to being a source of irritation, can be downright dangerous. The Economic Cycle Research Institute publishes an annual list of the top-10 technology-related safety hazards and, year-after-year, “alarm hazard” comes out on top.

The problem is not that alarms – which are used on all manner of medical equipment such as infusion pumps, feeding devices, ventilators and heart monitors – don’t work well. On the contrary, they work all too well. Or, more precisely, all too often.

There are a number of potential problems with alarms: The signal is not successfully communicated to staff; the alarm does not provide caregivers with enough information; or the caregiver does not know how to respond.

But there is one problem that overwhelms all the others: the frequency of alarms. This results in alarm fatigue – the term given to the common practice of health professionals turning off alarms because they are deemed to be annoying or irrelevant.

Consider that a single patient in a critical-care unit, hooked up to a panoply of machines, can trigger up to 700 alarms a day, according to one study. And research has shown, time and time again, that about 90 per cent of alarms are false alarms. Is it any wonder that nurses and physicians – and often patients themselves – become inured to the noise?

Fire alarms work because they are a rarity – a clear signal of potential danger. When everything from electrodes falling off someone’s chest to a heart stopping sets off the same alarm bells, then nothing is an emergency.

When alarms are distracting or ignored, bad things can happen: Medication errors are made because health workers can’t concentrate; patients get up for help and fall; people suffer brain damage and death because their supply of oxygen is cut off, and so on.

So the starting point has to be using alarms appropriately. Right now, they tend to be overused because equipment manufacturers and health workers want to cover their butts and avoid lawsuits by monitoring everyone. One study found that one in four patients getting cardiac monitoring actually needed it.

Manufacturers and hospitals also have a tendency of using standard end-points that trigger alarms. But patients have widely varying health status, so the alarm settings have to be personalized. This, in turn, requires training. But too little is invested in training, especially of the nurses who bear the brunt.

In the cockpit of a plane, there are numerous alarms, but the warning systems differentiate between true emergencies and issues that can wait. Alarms in hospital rooms need the same standards.

For that to happen, alarm fatigue has to become a priority – on the ward, in hospital administration and among accreditation bodies and regulators. In the U.S., the Joint Commission, a group that accredits hospitals, has made reducing alarm hazards a priority, and it is bearing fruit. Canada is way behind. There are few data collected on the extent of the problem – aside from anecdotes – and hence little incentive to correct it.