Vigilance in the Face of Fatigue

The probe into ventilator deaths undertaken by The Boston Globe points to "alarm fatigue" as a key reason for failure of these systems. However, as the stories from the Detroit Free Press about patient safety concerns at nursing homes point out, there are numerous other "fatigue" issues involved with failure of ventilators and other clinical processes, including overwhelmed staff, under-competent staff, under-armed regulators, and an industry under financial strain.

Vigilance is often the byword we use in steeling ourselves to be watchful for patient safety, however, how do you ensure adequacy of vigilance in the face of fatigue - when the demand for it requires intensity, concentration, time, competence - all of which are at a premium even at the best of times. This is a complex problem which will not go away with exposes, fines, shame, root cause analyses, and disciplining of staff. Its a symptom of a system gone considerably awry, and a distressing illustration of the harm that can occur at the "sharp end".

Overwhelming as the task may seem, the solution will entail a careful redesign of care systems such that staff who care for patients on ventilators have the knowledge, training, experience, time, and support to ensure that they can deliver the care required. Relegating this to another case of "alarm fatigue" may be tempting, but it risks the thinking that we could solve it if only we had better alarms or more attentive staff. Staff will only be able combat the collective fatigue if they are placed into roles that they can manage, and provided with adequacy of workload such that patient care does not suffer.

Despite the mostly impressive drive over the recent decade to improve healthcare quality, we have largely failed to highlight and support adequacy of workload as a foundation of patient safety. All frontline nurses and doctors can readily point out that patient safety starts with a manageable workload. However, these repetitive patient safety failures demonstrate that we keep placing staff in "unsafe" working conditions and somehow expecting good outcomes. The accountability belongs to the leadership not to the staff. This complex problem cannot be addressed by the clinicians on the front lines; rather, it should be a call to leaders to design clinical systems more effectively and to put their staff in situations in which they can succeed.

The Regulator's Dilemma: Censure or Close a Nursing Home

This article points out a difficult dilemma, if you close a facility because its not performing well what do you do for patient access? Healthcare is a difficult business, with some barriers to entry, as well as limited supply of particular resources (including physicians, nurses, hospital beds, and/or nursing facilities). If you shut any of these resources down, you do so with the realization that this is not an entirely "renewable" resource, and also with the realization that the free market may not spring forth to supply an alternative - particularly for the poor, elderly, vulnerable members of society.

The article is part of the "Trust and Neglect" series by the Detroit Free Press which attempts to shed light on the challenges of the nursing home industry in Michigan. The first article in the series talks about the extent of the problem and adds names and stories to make the numbers real.



Many of the cases should disturb all of us:

• Staff tied a residents hands hands together with a garbage bag
• Respiratory therapist forgot to connect a patient to a ventilator; and also forgot to check his vitals
• Nurse fell asleep on the job allowing a patient to wander out of the facility

The reasons behind these mistakes are theoretically remediable:

• Nursing homes try to cover up errors
• Staff are overwhelmed
• Homes don't follow their own procedures
• Staff are not competent for the roles they are assigned 

Some healthcare systems related issues that appear to be contributing:

• Bureaucratic rules that burden homes and their staff with too much paperwork
• Differences among inspectors about interpretation and application of rules
• Regulatory systems dependence on "fines, surveys, and lists" to censure chronically underperforming homes 

The common thread here appears to be lack of staffing, which results from low operating margins, which are only going to come under increasing pressure as the industry has recently gone through an 11% cut in reimbursement. Where will the solution to protect patient safety come from when the staff are already overwhelmed and the industry is going to face increased financial pressures?

We need more aggressive redesign of care processes, simplification of protocols, reduction of bureaucracy and paperwork. Perhaps this can lower costs of operations, and increase the amount of time that staff can spend on patient care. 

Different business models have to emerge that are able to provide adequate, safe, quality care. Perhaps the "accountable care organization" model now being promulgated for Medicare patients - which rewards practitioners and facilities for reducing cost and improving quality - can provide a new financial model for facilities to improve their care processes.

A new regulatory framework also has to emerge to solve the "dilemma" posed by this report. In addition to fines, inspections, surveys, and lists, more aggressive action should be taken to ensure that staffing is appropriate to provide adequacy of care; or perhaps repeat offenders should be "mandated" to implement a structured, supervised "performance improvement system".