Suffering from ‘alarm fatigue,’ LVH-Pocono staff ignored alerts. A patient died four days later, state report says

An inspection by the Pennsylvania Department of Health found that Lehigh Valley Hospital-Pocono’s emergency department was chronically understaffed leading to situations that were unsafe for patients who received inadequate care in many instances.

In late November, staff in Lehigh Valley Hospital-Pocono’s cardiovascular telemetry unit took 14 minutes to respond to an alarm that sounded because one patient’s blood oxygen level fell to a critically low level, an inspection by the Pennsylvania Department of Health found.

By the time hospital staff finally responded, the patient had passed out and fallen onto the floor. Staff were able to stabilize and revive the patient, but not before the patient suffered brain damage. The patient died four days later.

An inspector with the Department of Health found at the time that the incident occurred false alarms in the cardiovascular telemetry unit were common and many staff suffered from “alarm fatigue.”

The state report, which covers an inspection from Dec. 19 to Dec. 28, found the facility “failed to ensure staff continually observed telemetry monitors,” “failed to respond to critical telemetry alarms” and “failed to administer life-saving measures in a timely manner.”

The hospital was not issued any fines and didn’t face any other penalties as a result of the report, Mark O’Neill, spokesperson for the Pennsylvania Department of Health, said.

Jamie Stover, a spokesperson for LVHN, said the hospital takes matters like this seriously.

“The safety, health and wellness of our patients is always a priority,” Stover said. “LVH-Pocono immediately self-reported the incident to the Pennsylvania Department of Health and continues working with the Department of Health on opportunities for improvement, which have already been made.”

The Department of Health report states that the deficiencies noted in December are a repeat of ones that were documented in a July 2019 inspection, where an inspector observed numerous occasions where there were no hospital staff watching telemetry monitors.

LVH-Pocono has been found in noncompliance with many Pennsylvania and even federal regulations between that 2019 incident and this recent one. During 2020 and 2021, the state published numerous reports about ongoing issues at the hospital, particularly in its emergency department. The ongoing noncompliance with regulations lead to LVH-Pocono being placed on a provisional license in March 2021.

The hospital had its full state license restored in March 2022.

What the state report says

A telemetry monitor is a portable device that monitors a patient’s heart rhythm, respiratory rate and oxygen saturation. It automatically transmits this information to a central monitor.

At the time, the patient’s oxygen saturation was 92%. The blood oxygen saturation level for a typical healthy person is 95% to 100%, though people with certain breathing conditions may have consistent levels as low as 90%.

If the patient’s oxygen saturation level fell to dangerously low levels or some other issue arose, the telemetry monitor’s alarm would go off.

The hospital’s policy requires that medical and surgical telemetry units begin monitoring patients when they arrive, and for monitoring to continue unless a doctor orders it to stop. To help accomplish this, hospital staff working in telemetry units carry phones on them that signal whenever an alarm goes off for a patient; according to the hospital’s policy, telemetry pagers or phones “must be set on an audible tone.”

The inspector stated that patient alarm rhythms are visible from the telemetry system’s nurse phones.

If a red alarm isn’t addressed within two minutes, all other phones or pagers in the unit will receive a notification. All red alarms require a registered nurse to determine whether the alarm is a true emergency.

At 7:49 a.m., the patient’s oxygen saturation level fell to 77%, a dangerously low level, and a red alarm went off. But it wasn’t until 8:03 p.m. — 14 minutes later — that a nursing assistant walked into the room and found the patient passed out on the floor.

CPR was immediately initiated and the patient received two rounds of epinephrine, which revived them. The patient was transferred to the intensive care unit at 8:30 a.m. But it was too late — the patient had experienced an anoxic brain injury, or brain damage caused by lack of oxygen.

After conversation with the patient’s family, MR1 was placed on comfort measures. The patient died the afternoon of Dec. 3.

Medical records referenced in the report showed that prior to MR1’s death,the patient was also experiencing low levels of oxygen and increased levels of carbon dioxide in the blood as well as respiratory failure from influenza A.

A travel nurse contracted by the hospital who was interviewed during the inspection said false telemetry monitor alarms were a frequent occurrence at the hospital, “which caused significant alarm fatigue among staff.”

During the investigation, the state inspector also observed that staff had the ability to control the volume of the alarms on their phones. The investigator reported that one hospital employee had set the volume so low that “a patient alarm was not audible with the background noise of the unit.”

In another interview, an employee said there was no staff member assigned to observe the telemetry monitors on Nov. 29, and telemetry monitor staff were removed from the monitors in June as a result of the upgraded telemetry monitoring system.

This employee told the inspector the new telemetry monitoring system did not require staff to sit at the monitors and observe them.

Yet the travel nurse said they “had traveled to many hospitals throughout the country and had never seen a telemetry monitored unit without a telemetry tech or staff member observing the cardiac monitors continuously.”

An individual referred to in the report as OTH1 said their expectation for physician-ordered continuous telemetry monitoring “was a staff member observing the telemetry monitors 24 hours a day, 7 days a week.”

What changes were made at LVH-Pocono

As a result of the inspection, the hospital issued a plan of correction and took multiple steps to address the conditions highlighted in the state report, particularly alarm management and alarm fatigue.

The hospital placed an observer in the cardiovascular telemetry unit to provide constant watch of the telemetry monitor. A representative from the company that sold the hospital its telemetry monitoring system also conducted an onsite inspection to ensure equipment was working correctly.

The hospital also created a mandatory, two-part educational program for cardiovascular telemetry nurses that included face-to-face and online education. The education included expectations and guidance for:

• Signing into devices and assigning patients
• Ensuring alarm volume on mobile devices are audible
• Troubleshooting alarms
• Verifying alarms at shift change
• Documentation in the medical record
• Use of the telemetry monitoring system

The hospital reported that in an effort to enforce this education, it increased huddles in the cardiovascular telemetry unit to twice daily through the end of December.

The hospital also began auditing medical records of cardiovascular telemetry patients to determine if the attending nurse was signed into and carrying their mobile device, that mobile devices were set to an audible tone, that alarms were set per hospital policy and to verify whether a physician or other care provider was notified after red alarms.

And the hospital pledged to take other steps to improve alarm management and decrease alarm fatigue such as providing ongoing reinforcement to cardiovascular telemetry nurses based on a review of audit findings. Hospital leadership also said it would continue to review policies and procedures of best practices to decrease unnecessary alarms and alarm fatigue.

Morning Call reporter Leif Greiss can be reached at 610-679-4028 or [email protected].

©2023 The Morning Call. Visit mcall.com. Distributed by Tribune Content Agency, LLC.