[LorenPechtel]

And how about the fact that there are simply too many of them!

I was once in the recovery room with my wife. For some reason the sensor was having a very hard time reading her pulse. The normal bips would frequently fail. Too many failures in a row and the alarm would start it's EEEEEE scream we've all seen from Hollywood. It would shut up as soon as it managed to pick up a beat.

Hers was definitely not the only one in the room occasionally screaming. The nurses were completely ignoring it. Quite understandably so as it was obviously doing false alarms. But in a flood of false alarms like that are the real ones going to be noticed??

[takinola]

I used to work as a field engineer on oilfields and rigs. We had panels of equipment, each with their own alarms and beeps. Once the rig manager (the client) remarked that we were ignoring the alarms, snidely insinuating that we should pay more attention given the possibility of things going wrong.

The reality was we knew what was going on just by listening to the alarms. I could predict which alarm was going to go off before it did and so I could safely (appear to) ignore them. I would only panic if an unexpected alarm went off (or happened in an unexpected sequence). It is possible the same situation was going on in the hospital.

[KennyBlanken]

Nope. Alarm fatigue is a well documented problem in the medical field.

Like residents who are getting a few hours of sleep over days worth of high-stress / high-stakes work, poor hand-washing between patients, and not clearly printing one's handwriting on prescription forms - all things that kill patients - doctors and hospital administrators just don't care enough.

For a profession that is supposedly so pure morality-wise - do no harm, patient privacy, etc - doctors are remarkably careless.

[hiAndrewQuinn]

"They just didn't care enough" is an argument which can explain everything about how 1 person operates, half of a 10 person group, and roughly 0% of an entire profession. It's a question of the economic incentives at play far more than doctors universally deciding not to give a shit.

The economic recommendation is to deregulate the medical personnel industry and allow supply to increase. A great many smart and good people would love to become doctors but aren't in love with 5 years of residency and taking a quarter million dollars in debt to make less than their dropout cousin does at Netflix.

[nabusman]

Pure deregulation can lead to a bit of anarchy, but a more measured approach that ensures that the regulation doesn't act as a way to decrease supply and increase profits for the industry would make sense. Probably something for Lina Khan to look into.

[nradov]

The easiest way to increase the supply of physicians would be to increase Medicare funding for residency programs. We already have a surplus of smart and good people who would love to become doctors. Every year some of them graduate from medical school with an MD/DO degree but are unable to practice medicine because they don't get matched to a residency slot (some of them do get matched the following year).

https://savegme.org/

There has already been deregulation to an extent. The scope of practice for lower licenses such as Nurse Practitioners and Physician Assistants has been increased in many states such that they are now allowed to perform most primary care services. This is a great option for other smart and good people who don't want to spend 3 - 7+ years in residency and take on enormous student loans.

[matheusmoreira]

> deregulate the medical personnel industry and allow supply to increase

And salaries to plummet.

Who's gonna be the first to volunteer to spend about 14 hours of their day in some shithole hospital nearly every day sacrificing their own health and sanity for the sake of others, all while making a fraction of what people here make? Deny people their prosperity and suddenly going to medical school turns into a stupid and irrational decision and something only rich people will put up with for the status.

[hiAndrewQuinn]

Plummeting salaries for doctors means better average healthcare at all price points for the rest of us.

Plus, play the tape forward. You're working 14 hour days and your pay has been halved in the last 5 years. What can you negotiate on? More pay probably isn't an option. How about working only 12 hour days for 6/7s the (already reduced) pay? That might be doable. In a decade, you might even be working a normal 9 to 5 again. The horror!

[matheusmoreira]

Negotiate? Just quit. At some point you're better off doing literally anything else with your limited time on this earth. Way too much time and effort for too little reward. Who's looking forward to doing a decade of hard training only to end up with some 9-5 job and salary? That's just absolute nonsense.

Becoming a doctor is quite simply a stupid decision if you're not gonna get rich off it. You're replying to a citizen of a country which implemented your idea and then some. Believe it when I say the "get into medical school and you're set for life" meme has worn off.

You haven't seen the damage that stupid indebted underpaid doctors are capable of causing. I'm actually afraid of getting sick. Killing patients? I've seen worse.

[LorenPechtel]

Alarm fatigue is very real. And the lack of sleep is very real.

Where you go off the rails is with saying "don't care enough". This is a market problem, not a problem with individuals. "We don't overwork our people" isn't a selling point with insurance. The budget is pretty much fixed, a company that doesn't overwork their people ends up in the red.

[jandrese]

False positives are definitely a problem. When you read industrial accident reports one extremely common theme is some sensor that was notifying the controller of the problem, but that sensor had a history of false positives so it was disregarded. Companies that don't take false positives seriously are inherently dangerous.

[krisoft]

> When you read industrial accident reports one extremely common theme is some sensor that was notifying the controller of the problem, but …

I remember an accident report. It was about a container ship which had a bad flooding incident in their engineering spaces. One thing the report pointed out that the engineers had ways to fight the flooding, but they were not doing them because they were playing whack-a-mole with all the alarms caused by the flood. If i recall correctly the engineers kept ignoring the waist deep and rising water and prioritised silencing the alarms. (And not because they were stupid, but just because the many independent blaring alarms task-saturated them.)

[Johnny555]

they were playing whack-a-mole with all the alarms caused by the flood

That's common in computer monitoring systems, at my last job when we had a serious outage, we'd get dozens of pager alerts, it was hard to figure out the root cause because so many alerts fired that were caused by the root cause. I.e. like if the root cause was a root volume was out of disk space, the "unable to log in" alert was superfluous and not helpful. Eventually we moved to a better system that had a betrer sense of hierarchy for alerts as well as a way to easily silence them.

[teeray]

Many of those companies fall into the trap of “well, we’d rather a noisy alarm that catches the problem than a silent one that doesn’t.” Both are problems. The former just makes management feel like a problem would be caught be the on-call.

[throwaway173738]

The ventilator company I worked for tried very hard to avoid false positives because we were very concerned about alarm fatigue. We also tried to ride the line on false negatives. It’s really hard.

Sometimes the alarm limits are set incorrectly by the RT or aren’t forgiving enough to allow some motion. When you see an entire ward of nurses totally ignoring alarms it’s a management failure. Either there aren’t enough nurses available to manage the issue or there aren’t enough technicians to properly configure the equipment for each patient. If someone dies because of that then it’s ultimately the hospital’s fault.

[LorenPechtel]

The day I encountered it I have no idea of what sensitivity controls might have existed but the problem was unquestionably the system failing to recognize that what had just transpired was a beat. The trace on the screen looked like a beat to me, but not always to it.

I will not say it was a management failure because I don't know if management could have done anything about it. Given the total indifference of the nurses I strongly suspect they couldn't do anything.

[makeitdouble]

Management could be the most relevant part. A silent alarm is management's fault, a wrongly ignored noisy alarm can be pushed as staff's fault.

[heavenlyblue]

Pretty certain management have 0 control over which alarms can be disabled on the equipment. And I would bet that the equipment from other brands have the same issue.

[kmoser]

It's hard to solve the problem of false positives when the decision to sound an alarm is reliant on a single sensor that may start to become detached (e.g. glue/tape failure). If you think the solution is multiple sensors, well, what happens when one sensor indicates an alarm condition and the other doesn't? Now you have another potential false positive. Not to mention it's untenable to connect twice as many leads to a patient.

[bee_rider]

If they’d use three sensors, they could vote. If one sensor often votes differently from the other two, it could be marked as defective and replaced or re-seated.

Three times as many leads would be pretty annoying, though.

[lostlogin]

You’ve hit the nail on the head. It’s often tedious getting one to work.

[LorenPechtel]

That could partially be addressed by making the sensor include the concept of not working. Run a small electric current across the sensor, if that current fails the sensor knows that it's not monitoring and can report it as a loose sensor rather than as a failure of whatever it's supposed to be sensing.

[kelnos]

> Companies that don't take false positives seriously are inherently dangerous.

Alarms with incessant false positives are inherently dangerous. Sure, there's some threshold of false positives, under which we should still expect people to investigate all alarms. But above that threshold, how can we continue to blame the people involved? The hardware is at fault.

[nradov]

Please propose a design for better hardware then. You'll make a fortune and do a lot of good in the process.

Seriously, what would motivate you to make a comment like that? Do you think medical device engineers and clinicians are unaware of the false alarm issue and haven't already tried a variety of improvements? There is an inherent trade-off between false alarms and missing a real problem. And devices need to be not only accurate but also affordable, durable, and cost effective. It's not easy to get this right.

[pjerem]

I think GP was talking about the people who don’t try to reduce false positives (by actively searching for solutions to reduce them), not the ones ignoring them because they are used to.

[Buttons840]

There will always be false positives and false negatives, they have to be balanced.

If the cost of a actual negative is 100 and the cost of an actual positive is 1. You'd expect there to be approximately 100 times more false negatives, because we want to be 100 times more sensitive to the costly negative condition.

I'm this sense, the alarms in hospitals make sense. Actual negative are very costly.

But this is a cold mathematical analysis that doesn't consider alarm fatigue and the cost of people learning to ignore the alarm. I wonder how to best model human nature in this calculation?

An optimal solution would require considering all alarms, and modeling the fact that every alarm given is another alarm ignored (assuming the hospital is operating at capacity, if it's below capacity the solution is easy, just manually check all alarms). This system might realize that the 4th "no pulse" alarm of the night for Alice would detract from the 1st "no pulse" alarm for Bob, and that Bob's is more likely to need attention. I'd be terrified to program such a system though, and from what I've seen in corporate programming environments, I'm not confident any company could get this right.

[LorenPechtel]

You have it backwards.

They really do not want false negatives because that gets them sued. Thus the system will be set up to err on the side of false positives--the current liability climate does not blame them for alarm fatigue.

Consider a local case (although it's possible it was overturned on appeal): Yes, the doctor was unquestionably playing loose with standard safety precautions. His behavior transmitted blood-borne infections. He died in prison which was well deserved.

However, the lawyers went hunting for some deep pockets. The manufacturer of the drug involved in the cross contamination. They made various size vials, including some that were bigger than would be used on one patient. This permitted the doctor to contaminate between patients and got them hit with a $250M verdict. (Never mind that had they truly only used clean needles with them like they should have there never would have been an issue. They used a new needle but the old syringe.)

That's the sort of insane legal pressure driving the garbage.

[btach]

Anecdote: At an ED I used to work at, our cardiac monitors got "upgraded" to another manufacturer. Silencing false alarms was a black hole of a game of whack-a-mole. You could never silence them all, another would just pop up to spite you. Anyway, one night, it was continuing to alarm and being ignored (with a glance occasionally to make sure). Except somebody was in v-tach and the person who noticed was a medic bringing a patient in. Thank goodness they noticed amid the noise! (We had as good of outcome as could be expected with that patient, and they went to the cath lab and lived).

[dmurray]

What would have happened if the medic didn't notice and the patient died? Would you have got the blame for ignoring it, or management for creating a situation where you had no choice but to ignore some alarms because of false positives, or the manufacturer, or would it have been swept under the rug as "the patient was having heart failure and unfortunately even our state-of-the-art medical care couldn't save him"?

All of those sound superficially plausible to me, although I have my ideas on which are more likely... Would you even do an, um, incident post mortem for something like that or would it just be a statistic?

[btach]

There would definitely be an investigation, as all sentinel events are investigated. Management would do their RCA and I'm sure the issue with alarm fatigue would be ignored or underplayed (Something bad happen? make sure an alarm sounded. If staff ignored it, it must be the fault of the staff). I doubt any one person would be in trouble as it was a collective/systemic failure, but I don't know exactly what would have come of it. Likely a policy change or daily reminders for the next few weeks about not ignoring the monitors even if it has been going off nonstop for hours. Maybe extra charting or peer audits. It's a lot less expensive and effort to put pressure on staff than it is to change technology (even if it is as little as setting different, more sane, defaults). Depending on what was recorded from the monitor to the chart, if it looked like there wasn't a delay in resuscitation/cardioversion (like if the lethal rhythm wasn't recorded initially), it may have been just put down as clinical course for the patient, like you suggested. My perspective of that place is a bit jaded (and therefore biased), that place was a toxic burn-out factory. BTW, "post mortem"? Thanks, the morbid humor made me laugh!

[LorenPechtel]

They will try as hard as they can to pin system failures on the unfortunate person who was in charge of the system.

Or, a local case, the nurses were complaining about shoddy supplies. Eventually the holes in the swiss cheese lined up and a baby died. The hospital tried to treat it as a murder by the nurse. (Claiming the line was cut, rather than it broke.)

[_yb2s]

Hospitals have a sort of manic "New York Stock Exchange" energy and environment to them... The entire environment of a modern hospital seems brutally incompatible with the type of peaceful relaxing environment you'd want to reduce stress and improve patient outcomes. Bright lights, constant noise, loud electronics, preventing patients from sleeping based on whatever schedule is convenient to medical staff, etc.

I think they could substantially improve patient outcomes by taking some tips from the best modern birthing centers, and make a quiet, relaxing, dimly lit, and peaceful environment at hospitals. I'd also say add some plants, natural (wood) surfaces and natural light, but realize that might make it hard to keep things sterile and private. It would make sense to create a rough schedule for each patient also with a consistent "left alone unless there is an emergency" time for sleep, etc.

I would imagine a calm and quiet physical environment would also reduce stress, fatigue, and improve performance of the medical staff themselves.

[nradov]

You're not wrong. ICU delirium is a serious problem.

https://www.statnews.com/2016/10/14/icu-delirium-hospitals/

But it's tough to make improvements. Regular hospital design is (roughly) optimized for staff productivity. They need to be able to treat and monitor many patients simultaneously which requires clear sight lines, good lighting, and a high level of automation. A more humane hospital design would also require more staff at a time when we already have a severe shortage. Where would the funding come from?

[Aeolun]

Don’t think it’s so unrealistic to make a sterile green environment with fake plants. Fairly certain it doesn’t matter too much.

[gravescale]

I honestly believe that a pair or noise cancelling headphones and an eye mask would have statistically noticable effects on outcomes. The bright, noisy environment of a hospital makes good, natural sleep basically impossible and that is brutal on even healthy people.

My ward even managed to have the (networked digitally controlled, and do presumably very expensive) lighting set up so the night lighting was inside the curtains and shining directly into the bed spaces, and the main ward lights would come up if you touched the wrong thing (even the nurses weren't quite sure exactly what the proximal causes of lighting changes was). With the pumps alarming the whole time (about once per night, per patient, up to 20 minutes until resolution each time) plus all the other regular medical checks preventing any extended quiet time, it was absolutely exhausting at a very deep level.

[matheusmoreira]

Hospitals are not "peaceful relaxing environments". They are large scale industrial operations designed to process as many people as possible. There simply aren't enough resources to afford every single person a "relaxing environment". You do the best you can for as many as you can. All this "relaxation" stuff will quickly be converted into spare capacity the second large numbers of severely wounded people start showing up at the emergency room.

If you're a multibillionaire then obviously you can just hire and equip your own private medical team that will focus 100% of their attention and care exclusively on you and your needs. The vast majority of the humans will never have that luxury. Normal people enter the system and are processed like everyone else.

[LorenPechtel]

I suspect the patients would fare better if active noise cancelling headphones were issued to every patient.

[matheusmoreira]

I've yet to see a study that shows noise cancelling headphones reduce patient mortality in any way whatsoever. Until there is such a study, money is better spent on things that are actually known to reduce mortality. Such as drugs.

[ler_]

Knowing how to trend the patient's health is probably more useful than relying on all the alarms. People hardly deteriorate from one second to the next if you know what to expect from their baseline. At least that's what I did when working as a nurse. However, I never worked in some place like the ICU, so the approach might be different in that case.

[deanresin]

My Mom recently had brain surgery and was recovering. Her machine would go off all the time and it took forever for a nurse to come buy and fiddle with it. I would joke to my Mom that it probably meant she was dying. Those beeps were so annoying. If anything, they should be beeping in the nurse's control area. It seems ridiculous it has to beep loud enough for a nurse down the hallway to hear it when it never seemed to be anything urgent or dangerous. Certainly, no one came running.