2nd Potential Alarm Fatigue Death in 4 Years in Boston Area Hospitals

‘Alarm fatigue’ a factor in 2d death

by Liz Kowalczyk

The second patient death in four years involving “alarm fatigue’’ at UMass Memorial Medical Center has pushed the hospital to intensify efforts to prevent nurses from tuning out monitor warning alarms.

Nurses exposed to a cacophony of beeps may no longer hear them or begin to ignore them, and that’s what appears to have happened in the latest case: A 60-year-old man died in an intensive care unit after alarms signaling a fast heart rate and potential breathing problems went unanswered for nearly an hour, according to state investigators who reviewed records at the hospital.

The death occurred in August 2010 but was not reported to the state Department of Public Health until this spring. The state cited various violations by the hospital, including not responding to alarms “in a timely manner.’’

The fatality was remarkably similar to another at the Worcester teaching hospital four years ago, when nurses didn’t hear or ignored alarms indicating that the battery on an elderly woman’s monitor needed to be replaced. After the battery failed, 77-year-old Madeline Warner suffered cardiac arrest and the alarm didn’t sound.

Warner’s death in 2007 led the hospital to adopt aggressive measures to improve nurses’ responses and tackle alarm fatigue, which can occur when nurses hear alarms – many of them false – all day long. But the new death shows the problem continues, as it does at hospitals nationwide. It has led to at least 200 patient deaths since 2005 and likely hundreds more, according to a Globe investigation published earlier this year.

“I don’t think any hospital has fully solved this problem,’’ said Maria Cvach, an assistant director of nursing at Johns Hopkins Hospital in Baltimore and a specialists on alarm fatigue. At Hopkins, which is known for its intense focus on reducing false alarms and alarm fatigue, Cvach said she still sees nurses “not hearing or not answering alarms’’ because “they go off all the time.’’

Executives at UMass Memorial declined to comment about the latest death. The Globe obtained the Department of Public Health report on the case through a freedom of information request. The document does not say who disclosed the death to the state or provide a reason for the reporting delay, but the Globe’s stories on alarm fatigue, which included an account of Warner’s death, appeared several weeks before the health department was called.

The state inspectors’ report, which omits the patient’s name and other identifying details, indicates that the patient also was the apparent victim of a medication error. It does not make clear the extent to which that error or alarm fatigue contributed to the patient’s death.

The patient had been cutting down a tree and was struck in the head with a large branch in July 2010, breaking bones in his face and causing bleeding in his brain. After surgery at UMass Memorial, the patient was often restless and agitated. He kept removing a monitor that measured whether his blood had enough oxygen, triggering an alarm to sound much of one day – which could have been a factor in desensitizing nurses.

Read the entire article at Boston.com

Sick Buildings Bounce Back with Molecular Superhero

Long after the flood waters have receded, buildings may be left unlivable. Even minor flooding or unrecognized water pooling can invite a growing hazard – mold.

For some people, certain varieties of mold can be dangerous and even deadly. Mold toxins can suppress the immune system. According to the Extention website, “Mycotoxins are chemicals produced by fungi (molds) under certain conditions.” The Health Guide states that “the type of matter on which the mold is on, the level of humidity and pH all work together to produce mycotoxins. Exposure to these mycotoxins is what can bring humans to conditions that can be deadly.”

It does not take long for the spores to find an inconspicuous haven in a structure. Occupants may experience vague symptoms and the building may be deemed as having Sick Building Syndrome (SBS) if the cause is not known. According to the CDC, biological contaminants are one of four major areas of concern when dealing with SBS. Mold can gain a foothold in hard to see or seldom visited areas such as ceiling tiles or air ducts.

Once established, the spores will hide out, waiting for the next opportunity to flourish. Homeowners may feel they have cleaned up sufficiently, even dutifully hiring contractors to rip out and replace affected sections of their homes. Assuming that simply drying wet building surfaces or areas is sufficient to avoid mold problems is a hazardous mistake. According to the article “Don’t Make These Top Ten Toxic Black Mold Mistakes” by lindyphil, “…if toxic mold spores and mold colony growths run out of moisture, they do not die. Instead, mold becomes dormant, patiently waiting for high humidity or a future water leak to resume mold growth.”

There is an alternative to abandoning your mold infested property or living with a dormant dangerous monster. For those who fear debilitating allergic reactions to the dreadful black mold and its many cousins, the solution is a molecular superhero.

The Center for Indoor Research states “that chlorine dioxide gas can be effective to a degree as a fumigant for the inactivation of certain fungal colonies…” Chlorine dioxide fumigation took center stage during the Anthrax scare in October of 2001. The potentially affected buildings were successfully fumigated with a technique patented by Sabre Technical Services and utilized by it’s subsidiary, Bio-One. According to Realty Times, “Although the jury is still out on the health effects of household mold, the same chlorine-gas fumigation process that Bio-One uses on anthrax and other bio-hazards appears to work well on mold.”

In a report by the Center for Indoor Air Research, Department of Microbiology and Immunology, Health Sciences Center of Texas Tech University, the fungi Stachybotrys chartarum, Chaetomium globosum, Penicillium chrysogenum, and Cladosporium cladosporioides were all pitted against chlorine dioxide gas. “C. globosum colonies were inactivated an average of 89%. More than 99% of ascospores of C. globosum were nonculturable.” All others were completely inactivated. According to an EPA Guidance Manual, “Alternative Disinfectants and Oxidants”, chlorine dioxide is “a strong oxidant and disinfectant. Its disinfection mechanisms are not well understood, but appear to vary by type of microorganism.”

In small scale applications of non-porous surfaces, simply applying liquid chlorine dioxide with a spray bottle or dampened cloth is an effective use of this non-toxic fungicide.

Chlorine dioxide has long been implemented in hospital settings and food and other industries as a sanitizing agent and for water purification. Chlorine dioxide is becoming popular as a dietary supplement often called Miracle Mineral Supplement, coined by the gold assayer turned researcher, Jim Humble. The quality of life has been raised for those suffering from debilitating illnesses such as Malaria and AIDS, thanks to the diligent efforts of those that believe in the power and importance of chlorine dioxide.

Chlorine dioxide is a selective killer inside the body. Because of the manner in which it inactivates or destoys disease causing fungus, bacteria and virus, friendly flora native to the human body are not directly affected. Although high concentrations of chlorine dioxide will irritate skin and give off explosive gas, it breaks down into harmless components over a short period of time, though not briefly enough to not dispatch pathogens. This allows it to be used in buildings, in water and directly on food and in and of itself not have to be removed, such as already existent mycotoxins from mold.

This simple molecule is relatively cheap and efficient and non-toxic in lower concentrations, as well as having a wide spectrum of applications. When used properly it can save property, resources, and improve the quality of life. Although it is gaining popularity among the general public, applications for pioneers are still being taken. Clinical and laboratory research is still sorely needed. The truth about this simple and effective molecular superhero needs advocates willing to spread accurate and complete information.