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The whir of the ventilators.
The web of wires and tubes that wind across the walls.
The flashing of lights and the constant buzzing and beeping of monitors by the patient’s bedside.
These sights and sounds are standard in any hospital Intensive Care Unit (ICU). Every mechanism is essential to monitoring a critically ill patient’s vital signs and can mean the difference between life and death for the patient.
This scenario may sound intimidating, even distracting. Now imagine you are a nurse in an ICU surrounded by dozens of critically ill patients at all hours of the day and night, responsible for these devices and the patients’ well-being.
Although hospital technologies are designed to improve patient safety, they can create new hazards if not carefully implemented and managed.
The U.S. Joint Commission on Patient Safety reported that between January 2009 and June 2012, nearly 100 documented hospital device alarm-related hazards occurred in hospital ICUs and telemetry units across the country. Of those, 80 resulted in a patient’s death. The remaining caused a patient permanent loss of function and unanticipated additional needed care.
Unfortunately, perils like these transpire every day in hospitals nationwide and are a result of system and staff failures to respond in a timely and appropriate manner to alarm signals.
The Commission found that in these cases the major contributing factors were: absent or inadequate alarm systems, improper alarm settings, alarm signals not audible in all areas, or alarm signals
turned off. In 2013, the Commission made addressing and improving clinical alarm system safety a national goal.
Tackling an alarming trend
One researcher in the School of Nursing at The University of Texas Health Science Center at San Antonio is on a mission to improve safety outcomes for patients in the ICU through her study “Usability Testing of ICU Cardiac Monitors: Guiding Quality Initiatives on Improving Clinical Alarm Systems Safety.”
Azizeh Sowan, Ph.D., RN, assistant professor in the Department of Health Restoration and Care Systems Management, is leading this unique study that analyzes both the alarm system technology and staff performance involved in safely and effectively caring for critically ill patients in the hospital.
“Hospital staff has the ultimate responsibility of ensuring patients are safe throughout their hospital stay,” Dr. Sowan said. “Nurses in particular must be alert, experienced with protocols and tailored care plans for every patient, and up-to-date with hospital equipment at all times.”
With technology advancing at such a high rate, Dr. Sowan said hospital devices are becoming more sophisticated and complex in design and function.
“Every day in a single hospital, hundreds of alarms are triggered by patients’ bedside monitors that are programmed to sense when patients are in distress. Those can translate into several thousand alarms sounding during a single shift depending on the unit,” Dr. Sowan said. “Nurses are the primary responders to these monitors and the patients’ needs,” she said.
Not all of the alarms require immediate intervention, however. The U.S. Joint Commission on Patient Safety estimated that between 85 percent and 99 percent of alarm signals do not require clinical intervention, such as when alarm parameters are set too rigidly causing alarms to sound precipitously and often; default settings are not adjusted for the individual patient; electrocardiography (ECG) electrodes have dried out; or sensors are not placed correctly on a patient’s body.
“Oftentimes, health care workers become desensitized or immune to the multiple alarms sounding and can become overwhelmed by information. This phenomenon is called ‘alarm fatigue,’” Dr. Sowan said. “In some cases, health care workers respond by simply turning an alarm volume down, turning it off, or adjusting the alarm settings outside the limits that are safe and appropriate for the patient—all of which can have serious or fatal consequences,” she said. Some common patient injuries or deaths the Commission traced back to alarms included those caused by falls, delays in treatment, improper ventilator settings and medication errors.
Partnering to protect patients
Funded by a grant from the UT Health Science Center’s Nursing Advisory Council in 2015, Dr. Sowan reached out to School of Nursing alumnus Charles Reed, Ph.D., RN, CNRN, to partner with her in assembling a team at University Hospital, the UT Health Science Center’s teaching hospital.
Dr. Reed earned his B.S.N. in 1996, his M.S.N. in 2006 and his Ph.D. in 2014 all from the School of Nursing and now serves as executive director of the Center for Nursing Excellence at University Hospital.
With University Hospital in close proximity to the university and with Dr. Reed at the helm of the hospital’s patient care program, Dr. Sowan said “we had the trifecta of resources—leadership, facilities and equipment, and availability of participants”—for their study.
Dr. Reed added, “The collaboration between the School of Nursing faculty and University Hospital is first rate. It creates a pipeline for innovation and provides an excellent training ground for students who rotate through the program.” Dr. Reed said more than 100 UT Health Science Center nursing students rotate through University Hospital each year to train and shadow their nurses.
Drs. Sowan and Reed assembled a team to conduct the study in University Hospital’s cardiac/transplant ICU.
“National research tells us that triggered alarm rates are the highest in ICUs across the nation and that cardiac monitors are associated with the highest number of alarms and patient deaths,” Dr. Sowan said.
Nurse team leaders Ileana Fonseca, M.S.N., RN, and Ana Vera, M.S.N., RN, collaborated with Albert Tarriela, RN, CCRN, to advance the studies. All work at University Hospital.
Fonseca and Vera collected data from a survey of 30 ICU nurses at University Hospital, observed and monitored how the nurses used and interacted with the monitors, and performed usability tests of the monitors.
Fonseca, who earned her M.S.N. in 2013 from the School of Nursing, said the study is uncovering a surplus of valuable information.
“What we’re finding is that although all monitors are basically built and operate in a similar way, nurses navigate them in different ways,” Fonseca said. “The newer models, like the ones University Hospital uses, are highly complicated,” she said. “With the responsibility of caring for multiple critically ill patients, nurses need proper training and troubleshooting skills and practice on this technology.”
Dr. Sowan said the study is one-of-a-kind because it builds on two previous alarm fatigue studies embarked on in 2013.
Albert Tarriela, RN, CCRN, who was among the 2013 study leaders, delved deeper into the details of the technology by working with a representative of the company that manufactures the monitors and a University Hospital biomedical engineer. They were able to retrieve and analyze data from the devices that shed light on how the devices work, how they are programmed, how the various settings operate and how nurses navigate them.
“This previous knowledge coupled with the results from our current nurse surveys is allowing us to devise a training plan for nurses so they can learn how to adjust the parameters of the monitors to function safely and appropriately for each individual patient in their care,” Dr. Sowan said. “One size does not fit all. Customizing care in all aspects and comprehensive training for all nurses are crucial to patient safety.”
As a result of Dr. Sowan’s research, Dr. Reed and his nursing team have achieved a 25 percent reduction of the total number of false alarms triggered in the cardiac/transplant ICU at University Hospital. Training and simulation sessions are being developed that will guide nurses in all hospital units and floors to efficiently and effectively program and operate monitors to prevent errors.
“It’s an exciting time to be a nurse with these new advancements in professional training,” said Ileana Fonseca, M.S.N., RN. “It also makes me proud to be a part of this important research that is coming from my alma mater—our very own School of Nursing. Ultimately, it’s going to improve the work environment for nurses nationwide and most importantly, create a safer environment for our patients.”
Azizeh Sowan, Ph.D., RN
Dr. Azizeh Sowan’s successful track record in creating evidence-based practice resources for nurses and her expertise in informatics has given her team a leading edge in research. Prior to joining the UT Health Science Center faculty, Dr. Sowan was a nurse researcher in her home country of Jordan where she created an interactive evidencebased practice course that was placed online for health care professionals in 15 Jordanian hospitals. The course served as a resource to help clinicians learn how to find answers to research questions involving patient care. The success of the project earned Dr. Sowan the “Best Nursing Project in the Arab World Award” from the League of Arab States just three years ago.
“I’ve always had an interest in mathematics, physics and incorporating logic and statistics into nursing research,” she said.
For more information about Dr. Sowan, visit UTHSCSA.edu/stories and search for Dr. Azizeh Sowan.
Charles Reed, Ph.D., RN, CNRN
Mentoring nurses and nursing students is something Dr. Charles Reed enjoys most about his career. That’s because he remembers being mentored by nurses he admired, including his own mother, Suellen Reed, Ph.D., RN, who was among the School of Nursing’s first cohort of faculty members when the school opened in 1969. She served as an associate dean and retired in 2000.
“When I was a kid, my mom would sometimes take me with her to the office in the School of Nursing,” Dr. Reed said. “I felt really comfortable there because it was an environment where learning and caring about people were encouraged. I wanted to be a part of that when I grew up.” Today, Dr. Reed is fulfilling his dream. Armed with three degrees in nursing from the UT Health Science
Center, Dr. Reed leads in multiple roles: as executive director of the Center for Nursing Excellence at University Hospital, as a nationally published researcher, and as a mentor to hundreds of nursing students who rotate through University Hospital as part of their curriculum.
“It is a privilege to be where I am today,” he said. “I have the School of Nursing, my mom and my mentors to thank for putting me on this remarkable path.”