Brian McAlpine, Extension Healthcare
With alarm management top of mind thanks to the Joint Commission’s 2014 National Patient Safety Goal, hospitals continue to look for ways to limit alarm fatigue. According to Brian McAlpine, vice president of product management and marketing for Extension Healthcare, his company advocates a broader view. Its platform, Extension Engage, involves partnering with hospitals to suppress nonactionable alarms so caregivers only receive urgent notifications. But the platform also gives nurses the tools to conduct secure messaging, set message priority, and communicate their own availability, reducing internal interruptions for improved patient safety.
McAlpine has a long history of working with medical device connectivity and integration, including stints at Siemens, Dräger, and Capsule. “It’s just something I’m passionate about,” he says. We recently spoke with McAlpine about the system’s features, what’s new in the recently released fifth edition, and how nurses are responding to the technology.
24×7: What problems are your products trying to solve?
McAlpine: At a basic level, we provide an alarm management platform that will allow hospitals to have the data in order to understand what’s going on in their environment—and then use that data to effectively reduce noise and clinical interruptions in the environment and create better, more responsive workflows to critical alarms and events.
24×7: What do you mean by clinical interruptions?
McAlpine: Our scope is not just alarms; it’s anything that causes an interruption in the clinical environment. Clinical interruptions are any distraction, whether it be noise from the environment, interruptions from other coworkers, or equipment that interrupts a nurse’s train of thought or workflow. We take a broader look at the problem than just alarm fatigue, although that is a core focus of our company. Our projects start by working with hospitals to identify all the sources of their noise and interruption—and of course medical devices like patient monitors and ventilators are a significant contributor. But our premise is that as a hospital, you could solve the alarm fatigue problem and still be left with significant clinical interruptions that are causing safety issues.
24×7: How does Extension’s platform work?
McAlpine: We focus on collecting baseline data and look at the incidence of interruptions. If you don’t have any data, then how do you know that you’re improving anything? We do a sampling across the different care environments to show hospitals what their environment looks like. Hospitals often have as many as 300 to 600 alarms per patient, per day. Then we work with them to implement our platform, which includes the ability to collect alarm data and contextual information about the environment as well. We collect, filter, and apply advanced rules to the alarm data, and then provide notifications for only the most critical, actionable alarms. We’ll log and store the nonactionable alarms, because it’s still valuable to know all those potential interruptions occurred.
We don’t specifically silence the alarms. We work with hospitals to give them the tools so that they can decide which alarms need to get suppressed or silenced on the medical devices. We can work with hospitals to suppress the alarms in various ways. For example, certain nonactionable alarms can be turned off. Then we apply an advanced rule that says if the same alarm keeps occurring over a 5-minute period, then, and only then, should a caregiver get notified. The other technique that can be implemented is the delaying of alarms for 10 or 15 seconds before notifying a clinician. If a patient rolls over in bed, that may trigger a few alarms. But if the patient calms down, the situation levels off, and the alarms go away on their own. Studies have shown that delays introduced through the use of middleware have significantly reduced the occurrence of alarm fatigue.
24×7: Can hospitals customize your system’s algorithm to set their own notification thresholds?
McAlpine: All of our rules are completely customizable, and every hospital applies those rules a little bit differently. One of the advanced things our system can do is look at data from multiple sources, and trigger rules based on different conditions. We can look at alarms from a patient monitor and lab results from the lab system. A premature ventricular contraction (PVC) event with a cardiac patient normally triggers nonactionable alarms. But if PVC alarms are going off, and the blood test shows that the patient’s potassium level has spiked above a certain number, then those PVC alarms are actually considered clinically significant. Under those specific conditions, a nurse would want to be notified immediately. That’s an example of taking an advanced rule and combining data from multiple sources to more intelligently notify a clinician.
24×7: Once the platform is in place, how does staff receive the alerts?
McAlpine: In the early days, it was through one-way and two-way pagers. That migrated into voice over IP (VoIP) phones, including Vocera badges. All are capable of receiving alarm messages, and in some cases additional alarm information. Now the market is rapidly shifting to smartphones because of the rich user interface and partly because of the ability to integrate with secure messaging. It also can be less interruptive.
Most hospitals use shared devices owned by the hospitals and assigned to the nurses when they start their shift. The nurses will pick up their device and log in, and that will tell us they’re available to receive alarms. When the middleware receives the alarm, we’ll look up who is assigned to receive that alarm through the staff assignment function. If a nurse is responsible for four patients and alarms go off for those patients, they’ll receive those notifications. In some cases if they can’t respond, the system will escalate those alarms or events to their backup or another available caregiver. It’s guaranteed message delivery.
24×7: Are nurses constantly updating their status so the system knows their availability in case an alert comes through?
McAlpine: With the legacy devices, it was much harder. With smartphones, it’s much easier to touch a button to update your status to say “with a patient.” We’ve built functions into our software to allow a nurse who is administering medication to set an automatic 5 or 10-minute timer for an unavailable period. In a busy environment, it’s very cumbersome for nurses to remember that they put themselves on “unavailable” half an hour ago. Our system will automatically make them available at the end of 5 or 10 minutes.
Based on the location of a nurse, we can also automatically make them unavailable. For example, if they’re in an isolation unit with a patient, there is no way they’re going to come out to respond to another patient alarm or event. We can automatically bypass those nurses and find another available caregiver. Managing availability, presence, and location are three very critical functions. That contextual information is used to help supplement the information in our system to determine who, how, and when to notify of an alarm or an event.
24×7: How do you manage clinical interruptions unrelated to alarms?
McAlpine: One of the ways to reduce interruptions from one nurse needing assistance from another is to use smart messaging. Let’s say a nurse needs assistance. In the past, they would use their phone to call another nurse—which always causes an immediate interruption. With secure messaging, on the other hand, I can ask you a question, and you can reply now, 10 seconds later, a minute later, or 5 minutes later. If I put a priority on the message and you’re in the middle of administering medication, you could wait until that process is done. You can configure different ring tones and vibrations—for example, if the phone vibrates twice fast, the message is not very critical, but if it vibrates three times fast, that’s a critical message. Now you’re receiving messages, but you’re not necessarily getting interrupted. And if I need to interrupt you for something very, very critical, I can still do that.
24×7: What sort of reduction are you seeing in total alarm volume?
McAlpine: It’s fairly significant. We have the VA Gainsville hospital that reduced their incidence of alarms by over 80%, and another hospital that reduced their telemetry alarms by over 70%. It really is dependent on the type of care unit. In critical care units where there are lots of alarms going off, that represents a bigger opportunity for reduction.
24×7: How have nurses responded to the use of smartphones with your platform?
McAlpine: If you had asked me that question 2 or 3 years ago, I would have said that some nurses are a little afraid of the technology. But more and more, because of what’s going on in people’s personal lives with smartphone devices, it’s becoming just accepted. We have nurses complaining that they can’t do half the things on their device at work that they can do on their smartphone at home. Most of them adapt pretty quickly.
24×7: What are the key changes in the fifth generation of your platform?
McAlpine: A lot of them are related to the scalability and supportability of our product. As we’ve expanded our company and our platform, we recognize that hospitals are adopting the technology across the entire hospital. Five or 7 years ago, the market was really about smaller deployments and solving problems within a couple care units in the hospital. Now, most hospitals are looking at the technology and realizing that the problem with alarm fatigue and interruption really spans the entire hospital. They’re looking to deploy it across the whole enterprise, across all their hospitals.
