Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias

BMJ Quality and Safety

Volumn 22, Issue 1, 2013, Pages 72-83

  Kobayashi, Leo ^a   Parchuri, Ramakrishna ^b   Gardiner, Fenwick G ^b   Paolucci, Gino A ^b   Tomaselli, Nicole M ^b   Al Rasheed, Rakan S ^b,c   Bertsch, Karina S ^b   Devine, Jeffrey ^b   Boss, Robert M ^b   Gibbs, Frantz J ^a   Goldlust, Eric ^a   Monti, James E ^a   O'Hearn, Brian ^b   Portelli, David C ^a   Siegel, Nathan A ^a   Hemendinger, David ^d   Jay, Gregory D ^a,b,e  

^a BROWN UNIVERSITY   (United States)

^b RHODE ISLAND HOSPITAL   (United States)

^c KING SAUD BIN ABDULAZIZ UNIVERSITY FOR HEALTH SCIENCES   (Saudi Arabia)

^d Information Services   (United States)

^e Brown University   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BIOENGINEERING; EMERGENCY WARD; HEART ARRHYTHMIA; HEART VENTRICLE TACHYCARDIA; HOSPITAL BED; HUMAN; OUTCOME VARIABLE; PROSPECTIVE STUDY; SIMULATION; SINUS BRADYCARDIA; TELEMETRY;

ARRHYTHMIAS, CARDIAC; EMERGENCY SERVICE, HOSPITAL; HOSPITAL DESIGN AND CONSTRUCTION; HOSPITAL INFORMATION SYSTEMS; HUMAN ENGINEERING; HUMANS; PATIENT SIMULATION; QUALITY IMPROVEMENT; TELEMETRY;

EID: 84872178074     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2012-001134     Document Type: Article

References (73)

1. Hollander JE, Sites FD, Pollack CV, et al. Lack of utility of telemetry monitoring for identification of cardiac death and life-threatening ventricular dysrhythmias in low-risk patients with chest pain. Ann Emerg Med 2004;43:71-6.
2. Atzema C, Schull MJ, Borgundvaag B, et al. ALARMED: adverse events in low-risk patients with chest pain receiving continuous electrocardiographic monitoring in the emergency department. A pilot study. Am J Emerg Med 2006;24:62-7.
3. Grossman SA, Shapiro NI, Mottley JL, et al. Is telemetry useful in evaluating chest pain patients in an observation unit. Intern Emerg Med 2011;6:543-6.
4. Holly J, Hamilton D, Bledsoe J, et al. Prospective evaluation of the treatment of intermediate-risk chest pain patients in an emergency department observation unit. Crit Pathw Cardiol 2012;11:10-13.
5. Pines JM, Rich VL, Schwartz AR, et al. Lack of utility of telemetry monitoring during transport to inpatient beds for identification of dysrhythmias for emergency department patients with potential and known acute coronary syndromes. Crit Pathw Cardiol 2005;4:117-20.
6. Singer AJ, Visram F, Shembekar A, et al. Telemetry monitoring during transport of low-risk chest pain patients from the emergency department: is it necessary? Acad Emerg Med 2005;12:965-9.
7. Caglar S, Leffler S. Prevalence of life-threatening arrhythmias in ED patients transported to the radiology suite while monitored by telemetry. Am J Emerg Med 2006;24:655-7.
8. Kowalczyk L. For nurses, it' s a constant dash to respond to alarms. Boston Globe. (2011, February 13) www.boston.com/news/local/massachusetts/ articles/2011/02/13/for-nurses-its-a-constant-dash-to-respond-to-alarms/ (accessed 18 Jul 2012)
9. Kowalczyk L. No easy solutions for alarm fatigue. Boston Globe. (2011, February 14). www.boston.com/lifestyle/health/articles/2011/02/14/no-easy- solutions-for-alarm-fatigue/ (accessed 18 Jul 2012)
10. Kowalczyk L. State reports 11 patient deaths linked to alarm fatigue inMassachusetts. Boston Globe. (2011, December 29). www.bostonglobe.com/metro/ 2011/12/29/state-reports-detail-patient-deaths-linked-alarm-fatigue- massachusetts/C8y3itRvd4WiGnR40sVHxN/story.html (accessed 18 Jul 2012)
11. Kowalczyk L. Groups target alarm fatigue at hospitals. Boston.com. (2011, April 18). www.boston.com/lifestyle/health/articles/2011/04/18/groups-target- alarm-fatigue-at-hospitals/ (accessed 18 Jul 2012)
12. Kowalczyk L. FDA working to trim hospital 'alarm fatigue'. Boston.com.articles.boston.com/2012-03-24/health-wellness/31237407-1-alarms- medical-devices-maisel (accessed 18 Jul 2012)
13. Alarm Safety Resource site. Emergency Care Research Institute (ECRI). 2012. https://www.ecri.org/Forms/Pages/Alarm-Safety-Resource.aspx (accessed 18 Jul 2012)
14. Norman DA. The design of everyday things. New York, NY: Currency/Doubleday, 1988.
15. Carayon P. Human factors and ergonomics in health care and patient safety. In: Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ: Lawrence Erlbaum, 2007:3-20.
16. Wilson JR. A framework and a context for ergonomics methodology. In: Wilson JR, Corlett EN, eds. Evaluation of human work-a practical ergonomics methodology. 2nd edn. London: Taylor and Francis, 1995:1071-96.
17. EDC. Design for patient safety: a scoping study to identify how the effective use of design could help to reduce medical accidents. Cambridge: Engineering Design Centre, University of Cambridge, UK, 2004.
18. Drews FA, Westenskow DR. Human-computer interaction in health care. In: Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ: Lawrence Erlbaum, 2007:423-37.
19. Israelski EW, Muto WH. Human factors risk management in medical products. In: Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ: Lawrence Erlbaum, 2007:615-47.
20. Ward J, Clarkson J. Human factors engineering and the design of medical devices. In: Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ: Lawrence Erlbaum, 2007:367-82.
21. Kerr JH. Warning devices. Br J Anaesth 1985;57:696-708.
22. Fenn J. When to leap on the hype cycle. Gartner Group, 1995.
23. Kayser RG, Ornato JP, Peberdy MA. American Heart Association National Registry of Cardiopulmonary Resuscitation. Cardiac arrest in the emergency department: a report from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2008;78:151-60.
24. Tsien CL, Fackler JC. Poor prognosis for existing monitors in the intensive care unit. Crit Care Med 1997;25:614-19.
25. Chambrin MC, Ravaux P, Calvelo-Aros D, et al. Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive Care Medicine 1999;25:1360-6.
26. Buß B, Friesdorf W. Ergonomics; noise and alarms in healthcare- an ergonomic dilemma. In: Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ: Lawrence Erlbaum, 2007:347-63.
27. Seagull FJ, Xiao Y, Mackenzie CF, et al. Auditory alarms: from alerting to informing. Proc IEA 2000/HFES 2000 Congress 2000:1223-6.
28. Woods DD, Falk SA. Noise stimuli in the acute care area. Nurs Res 1974;23:144-50.
29. Hilton BA. Noise in acute patient care areas. Res Nurs Health 1985;8:283-91.
30. Kahn DM, Cook TE, Carlisle CC, et al. Identification and modification of environmental noise in an ICU setting. Chest 1998;114:535-40.
31. Balogh D, Kittinger E, Benzer A, et al. Noise in the ICU. Intensive Care Medicine 1993;19:343-6.
32. Breznitz S. Cry-wolf: the psychology of false alarms. Hillsdale: Lawrence Erlbaum, 1983:1-100.
33. Xiao Y, Mackenzie CF, Jaberi M, et al. Alarms: silenced, ignored, and missed. Anaesthesiology 1990;73:995-1021.
34. Lawless ST. Crying wolf: false alarms in a pediatric intensive care unit. Crit Care Med 1994;22:981-5.
35. Woods DD. The alarm problem and directed attention in dynamic fault management. Ergonomics 1995;38:2371-93.
36. Bell L. Monitor alarm fatigue. Am J Crit Care 2010;19:38.
37. Bell L. Alarm fatigue linked to patient's death. Interview by Laura Wallis. Am J Nurs 2010;110:16.
38. Kowalczyk L.'Alarm fatigue' linked to patient's death. Boston Globe. (2010, April 3). www.boston.com/news/local/massachusetts/articles/2010/04/03/ alarm-fatigue-linked-to-heart-patients-death-at-mass-general/ (accessed 18 Jul 2012)
39. Lipskis DJ, Dannehl KN, Silverman ME. Value of radiotelemetry in a community hospital. Am J Cardiol 1984;53:1284-7.
40. Estrada CA, Prasad NK, Rosman HS, et al. Outcomes of patients hospitalized to a telemetry unit. Am J Cardiol 1994;74:357-62.
41. Estrada CA, Rosman HS, Prasad NK, et al. Role of telemetry monitoring in the nonintensive care unit. Am J Cardiol 1995;76:960-5.
42. Schull MJ, Redelmeier DA. Continuous electrocardiographic monitoring and cardiac arrest outcomes in 8,932 telemetry ward patients. Acad Emerg Med 2000;7:647-52.
43. Hollander JE, Valentine SM, McCuskey C, et al. Are monitored telemetry beds necessary for patients with nontraumatic chest pain and normal or nonspecific electrocardiograms? Am J Cardio. 1997;79:1110-11.
44. Durairaj L, Reilly B, Das K, et al. Emergency department admissions to inpatient cardiac telemetry beds: a prospective cohort study of risk stratification and outcomes. Am J Med 2001;110:7-11.
45. Kelly AM, Kerr D. It is safe to manage selected patients with acute coronary syndromes in unmonitored beds. J Emerg Med 2001;21:227-33.
46. Snider A, Papaleo M, Beldner S, et al. Is telemetry monitoring necessary in low-risk suspected acute chest pain syndrome. Chest 2002;122:517-23.
47. Benezet-Mazuecos J, Ibanez B, Rubio JM, et al. Utility of in-hospital cardiac remote telemetry in patients with unexplained syncope. Europace 2007;9:1196-201.
48. Larson TS, Brady WJ. Electrocardiographic monitoring in the hospitalized patient: a diagnostic intervention of uncertain clinical impact. Am J Emerg Med 2008;26:1047-55.
49. Siebig S, Kuhls S, Imhoff M, et al. Intensive care unit alarms- how many do we need? Crit Care Med 2010;38:451-6.
50. Siebig S, Kuhls S, Imhoff M, et al. Collection of annotated data in a clinical validation study for alarm algorithms in intensive care- a methodologic framework. J Crit Care 2010;25:128-35.
51. Tompkins C, Orwat J. A randomized trial of telemonitoring heart failure patients. J Healthc Manag 2010;55:312-22.
52. Graham KC, Cvach M. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care 2010;19:28-34.
53. CvachM, DangD, Foster J, et al. Clinical alarms and the impact on patient safety. Initiatives in Safe Patient Care 2. Burlington, VT: Saxe Healthcare Communications, 2011.
54. Kobayashi L, Shapiro MJ, Sucov A, et al. Portable advanced medical simulation for new Emergency Department testing and orientation. Acad Emerg Med 2006;13:691-5.
55. Kobayashi L, Lindquist D, Jenouri I, et al. Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation. Resuscitation 2010;81:463-71.
56. Funk M, Parkosewich JA, Johnson CR, et al. Effect of dedicated monitor watchers on patients' outcomes. Am J Crit Care 1997;6:318-23.
57. Stukshis I, Funk M, Johnson CR, et al. Accuracy of detection of clinically important dysrhythmias with and without a dedicated monitor watcher. Am J Crit Care 1997;6:312-17.
58. Chen EH, Hollander JE. When do patients need admission to a telemetry bed? J Emerg Med 2007;33:53-60.
59. Dhillon SK, Rachko M, Hanon S, et al. Telemetry monitoring guidelines for efficient and safe delivery of cardiac rhythm monitoring to noncritical hospital inpatients. Crit Pathw Cardiol 2009;8:125-6.
60. Moldenhauer K, Sabel A, Chu ES, et al. Clinical triggers: an alternative to a rapid response team. Jt Comm J Qual Patient Saf 2009;35:164-74.
61. McGillicuddy DC, O'Connell FJ, Shapiro NI, et al. Emergency department abnormal vital sign "triggers" program improves time to therapy. Acad Emerg Med 2011;18:483-7.
62. Kyoso M, Uchiyama A. ECG data reduction method for medical telemetry systems. Front Med Biol Eng 2001;11:131-52.
63. Curtis DW, Pino EJ, Bailey JM, et al. SMART-an integrated wireless system for monitoring unattended patients. J Am Med Inform Assoc 2008;15:44-53.
64. Pollack CV.Wireless cardiac event alert monitoring is feasible and effective in the emergency department and adjacent waiting areas. Crit Pathw Cardiol 2009;8:7-11.
65. Ko J, Gao T, Rothman R, et al. Wireless sensing systems in clinical environments: improving the efficiency of the patient monitoring process. IEEE Eng Med Biol Mag 2010;29:103-9.
66. Steimann F, Adlassnig KP. Clinical monitoring with fuzzy automata. Fuzzy Sets Systems 1994;61:37-42.
67. Becker K, Thull B, Kasmacher-Leidinger H, et al. Design and validation of an intelligent patient monitoring and alarm system based on fuzzy logic process model. Artif Intell Med 1997;11:33-5.
68. Ireland RH, James HV, Howes M, et al. Design of a summary screen for an ICU patient data management system. Med Biol Eng Comput 1997;35:397-403.
69. Leite CR, Sizilio GR, Neto AD, et al. A fuzzy model for processing and monitoring vital signs in ICU patients. Biomed Eng Online 2011;10:68.
70. Borowski M, Siebig S, Wrede C, et al. Reducing false alarms of intensive care online-monitoring systems: an evaluation of two signal extraction algorithms. Comput Math Methods Med 2011;2011:143480. Published Online First: 27 February 2011.
71. Hu X, Sapo M, Nenov V, et al. Predictive combinations of monitor alarms preceding inhospital code blue events. J Biomed Inform 2012;45:913-21.
72. Blum JM, Tremper KK. Alarms in the intensive care unit: too much of a good thing is dangerous: is it time to add some intelligence to alarms? Crit Care Med 2010;38:702-3.
73. Saeed M, Villarroel M, Reisner AT, et al. Multiparameter intelligent monitoring in intensive care II: a public-access intensive care unit database. Crit Care Med 2011;39:952-60.