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Wide heart monitor use tied to missed alarms

Matthew Cavanaugh for The Boston Globe

Laurie Bouffard, a cardiac monitor technician, kept an eye on a bank of monitors at Baystate Medical Center in Springfield.

It used to be that only the most fragile patients were wired to a cardiac monitor. Now, some hospitals are building “war rooms’’ with row upon row of screens to track patients’ heart rate and rhythm. Others, such as Tufts Medical Center in Boston, have installed monitors at every bedside.

The burgeoning use of heart monitors allows hospitals to care for sicker patients on regular floors - typically without hiring as many nurses as they do in intensive care units - and to admit patients faster, easing emergency room congestion. Many physicians routinely put patients on the monitors, knowing they can save lives by catching life-threatening abnormalities. And since monitoring is noninvasive, it seems harmless.

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But an expanding group of researchers, many of them nurses, are questioning the proliferation of monitoring, saying it is a prime cause of the dangerous problem of alarm fatigue. The more patients there are on monitors, they say, the more the machines’ warning alarms blare, leading nurses to become desensitized to the beeps and tune them out. This phenomenon has been linked to dozens of patient deaths nationwide, according to an analysis published this year by the Globe.

Seventeen hospitals worldwide participating in a $3.9 million-study funded by the National Institutes of Health have found widespread over-monitoring of patients. The researchers found that 26 percent of patients who were being monitored for abnormal heart rhythms at these hospitals did not meet the criteria for being monitored.

They identified 783 patients who were not at increased risk for an irregular heart rhythm and did not need to be monitored for arrhythmia based on widely-accepted guidelines from the American Heart Association, but 85 percent of them were monitored anyway, according to results published in the Journal of Electrocardiology last year.

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A smaller study, led by UMass Memorial Medical Center and not yet published, found even higher levels of excessive monitoring at four hospitals.

“A lot of people who are on monitors are on them for very justifiable reasons,’’ said Marjorie Funk, a professor at the Yale University School of Nursing who is leading the international study, which includes Yale-New Haven Hospital, Baystate Medical Center in Springfield, and two Maine hospitals. But, she said, caregivers too often use monitors “as a kind of babysitter.’’

‘I have heard physicians say, “I want so-and-so on a monitor because I want people to pay attention to him.’’ That’s not a good use of a monitor.’

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“I have heard physicians say, ‘I want so-and-so on a monitor because I want people to pay attention to him.’ That’s not a good use of a monitor. Because more monitoring means more alarms and more alarms means more false alarms.’’

The majority of monitor alarms - nearly 80 percent in a recent California study - are triggered not by life-threatening heart problems but by unimportant changes triggered by nothing more than a patient coughing or sitting up in bed.

The Yale researchers also found that many patients are kept on monitors too long.

Dr. David Bates, chief quality officer at Brigham and Women’s Hospital in Boston, said he “hardly ever sees anyone turn off a monitor and they should.’’

And he said the problem will worsen as hospitals rapidly add monitors, in part to avoid medical errors - such as missing a patient’s heart problem - that can now bring financial penalties from insurers.

Jeanine May, a Yale nurse who visited the hospitals in the study, said many of the units, most dedicated for heart patients, had policies that all patients must be monitored for arrhythmia and heart rate, regardless of their symptoms and diagnoses, “probably because it’s far easier than evaluating each patient.’’

Researchers found that by not evaluating each patient, there is a danger of patients not being monitored for more complicated but rarer problems such as ischemia, or reduced blood flow to the heart. Just 35 percent of 339 patients who should have been monitored for ischemia had their monitors set to detect that particular problem.

Caregivers generally believe “there’s no downside’’ to monitoring, May said. And some believe “better safe than sorry,’’ when failing to monitor that one patient who has a fatal heart attack could lead to a malpractice lawsuit.

May said she would sit in units and hear “alarm after alarm and alarm. It’s constant and by the end of the day it’s white noise.’’

At half of the hospitals in the study, nurses are completing an online education course on appropriate monitoring and, starting in February, May will measure whether there has been improvement, compared with hospitals that did not provide the instruction. Still, while nurses usually program the monitors, doctors order monitoring in the first place, and few hospitals are educating them.

Companies that make heart monitors have seen their revenue climb, even as they plan to extend the technology into homes.

Philips and General Electric, two of the largest heart monitor makers, would not comment about their sales. But analysts who follow the industry said monitoring on general hospital floors has climbed 8 percent to 10 percent annually over the past decade, mostly for wireless cardiac monitors.

The companies are pushing hard to extend monitoring further into all areas of hospitals and even for patients who are discharged home.

“Philips and GE have decided that the 40 percent of patients in hospitals who are not being monitored should be,’’ said John Collins, director of engineering and compliance at the American Society for Healthcare Engineering, which is part of the American Hospital Association.

How many more alarms will blare - or who will answer them - is unclear, he said.

Still, some monitor industry executives believe adding monitors is best for patients.

Jim Welch, vice president of clinical engineering and patient safety at Sotera Wireless, a San Diego company that makes monitoring technology, said it makes sense to monitor all hospital patients, because it is impossible to predict which patients will deteriorate.

He said companies such as Sotera are developing technology that more accurately measures a patient’s decline than heart monitoring alone - and therefore will produce fewer false alarms.

At Tufts, Terry Hudson-Jinks, vice president of patient care services, said installing monitors next to all adult and pediatric beds has allowed the hospital to relieve bottlenecks by finding beds faster for patients coming from the emergency room and intensive care units and being transferred from other hospitals.

Doctors and nurses, she said, “are able to make thoughtful decisions’’ about removing patients from monitors “because they are not worried about whether they will be able to get it back’’ if the patient needs it again.

Funk, of Yale, said stepping back from technology “is very controversial,’’ and she believes nurses will be bombarded with the ever louder clamor of more alarms, given the forces pushing for more monitoring.

Baystate is trying to combat the problem in its new $296-million wing, scheduled to open in March, by redesigning units so nurses work near their patients, rather than at a central station, and therefore would not be as distracted by alarms for patients who are not their own - although all nurses still will be notified of the most serious warnings.

The hospital also has adopted “purposeful monitoring,’’ meaning a careful evaluation of each patient.

“This is more time consuming at first,’’ said Virginia Staubach, assistant director of cardiac, critical care and pulmonary services, “but it will make the day easier, better, and safer for patients in the long run.’’

Liz Kowalczyk can be reached at kowalczyk@globe.com.
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