Jeanette Ives Erickson, RN, is chief nurse and senior vice president for
patient care at Massachusetts General Hospital in Boston and a doctoral student at
the
MGH Institute for Health Professions. She is also a member of the US
Health &
Human Services National Advisory Council on Nurse Education and Practice.
Q. Three years ago I had a knee replacement surgery
at Brigham & Woman's Hospital. The first night of my surgery, I was hooked
up to a monitor that would beep if I stopped breathing -- I would wake to
the sound of the loud beeping -- When no one came to shut off the alarm, I
would ring the nurse's bell. No one still came into the room. I rang the
bell several times and finally a nurse called over the speaker for me to
stop ringing the bell as she could hear the alarm. Finally when someone
did come into the room and shut it off, I asked if they would show me how
to shut off the alarm.They said no they could not do that. Well this
went on all night until an aid came on duty.
Fortunately, I would wake up with the alarm and could breath just fine,
however it was a very difficult night without hardly any sleep. I think
the aides showed more caring than some of the nurses. I was thrilled to
see a column on "€œPatient alarms often unheard, unheeded." After reading
the story, I realized this issue is common and a problem that needs to be
solved. No one should have to die because of a battery dying or unheeded
attention to the alarms that are meant to save lives.
What is being done about this issue in the hospitals?
A. First, let me say that I’m sorry you had such an upsetting experience, and I hope you are now doing well after your knee replacement surgery. As you read in the recent Globe series, the issue of clinical monitoring is a complex and multi-faceted one. Please be assured that hospitals are constantly working to improve their systems and take appropriate measures to see that patients are well cared for and safe. The short answer to your question about what is being done to address the challenges with monitors is that hospitals are taking a multi-pronged approach to the issue – and indeed, we are making significant progress. We’re cultivating a culture of alarm sensitivity, ensuring that all alarms are responded to, raising awareness and educating staff. Across the country there are many efforts under way to work with industry to design monitors that are highly sensitive to relevant changes in the patient's health status with greater accuracy. We’re also looking at how the specific alerts are delivered to caregivers – whether at the patient's bedside, hardwired to a central monitoring area, sent via a wireless signal or displayed on an electronic signs notifying the entire care team. We’re re-examining clinical criteria for monitor use, with an eye toward reducing the unnecessary use of alarms. And we’re tailoring alarm settings for the individual patient. The ultimate and universal goal is to use this important technology in a way that best supports clinical care and patient safety.
Q.
How many patients is a nurse responsible for on a
typical shift? What is the optimal patient/nurse ratio? At what level
does the ratio become dangerous for patients and/or nurses?
A. Nurse staffing is intricate and nuanced, and requires very careful attention to details that most people are not aware. My personal value system is that the staff nurses who are with the patient in the moment know best about that patient’s need for nursing care. While there are certainly prescriptive formulas for determining how many nurses are needed to take care of a specific number of patients, these formulas are often too rigid. Determining the ideal staffing level is part art and part science. Staffing can vary from patient to patient and from unit to unit, and can change over time throughout any health care institution. The goal with staffing is to have the right nurse with the right skill for the right patient at the right time. The local team on a unit is in the best position to determine the ideal staffing. Formulas can be helpful guideposts, but making the right staffing decision requires keen awareness, critical thinking and perspective. The factors that must be considered when making decisions are the acuity of the patient, the experience of the nurse, systems that support nursing practice and the geographical design of the unit. And Nursing cannot do this alone. We are fortunate to work with nursing assistants, therapists, physicians, secretaries, chaplains, interpreters, social workers, technicians and many others in the care of our patients. What is important to consider here is the nurse’s professional responsibility for clinical assessment, expert judgment and creative planning to ensure the best nursing assignments and staffing levels. The bottom line is that the patients’ needs must determine the staffing level at any given moment.
Q. How important is technology aimed at reducing
clinically insignificant (nuisance) alarms?
A. You raise an important question. High-level clinical monitoring involves designing a highly reliable system that takes into consideration several working parts: the human factor (staff and patients), the environment of care, and the technology. What you’ve read in the Globe about the current state of clinical alarms is that there is too much overall “noise” in the system. Alarms go off with great frequency, and the vast majority of these alerts are “false alarms.” Any technological advance that can help separate the noise from the useful information would be invaluable. By reducing the number of false alarms, we enable the monitors to do what we need them to do: alert clinicians to relevant clinical changes in the patient at the earliest possible moment.
