Why can’t the ICU be more like a cockpit?

In the world of patient safety, we’re constantly reinforcing the importance of teamwork and communication, both among clinicians and with patients. That’s because we know that patient harm so often occurs when vital information about a patient’s care is omitted, miscommunicated or ignored.

Yet for all we do to improve how humans work together, clinicians compete against an environment in which there is very little teamwork or communication among the technologies that they need to care for patients. And there’s little that clinicians or hospitals alone can do about it.

Take, for example, the plethora of alarms from cardiac monitors and other devices that compete for clinicians’ attention. Vendors act as if we are in an alarm race, with each making their devices’ beeps more annoying but no clear prioritizing of the most important alarms. A study on one 15-bed Hopkins Hospital unit a few years ago found that a critical alarm sounded every 92 seconds. As a result, nurses waste their precious time chasing an ever-growing number of false alarms—or becoming desensitized to false alarms and ignoring them. Across the country, this has had tragic consequences, as patients have died while their alarms went unheeded. (Read a 2011 Boston Globe series about this issue.)

In most other high-risk industries, such as aviation and nuclear power, technologies are integrated. They talk to each other, and they automatically adjust based on feedback. Indeed, because of systems integration, pilots fly a small amount of a flight, and even in some treacherous situations, they hand over the reins to the autopilot. Although Southwest Airlines or the U.S. Air Force can buy a working plane, you cannot buy a working hospital or ICU. You must put it together yourself.

There are many other examples of how health care is grossly under-engineered. Consider these:

• The main therapy to reduce mortality in patients with acute lung injury is to program the breathing machine to deliver “small breaths” and low pressure. However, patients receive that treatment only about 20 percent of the time. The electronic health record does not “tell” the breathing machine that you have acute lung injury or alert doctors to provide this potentially life-saving therapy.
• A primary intervention to reduce mortality in patients with sepsis is to give the right antibiotics fast, generally within an hour of when sepsis begins. Because sepsis is diagnosed with several tests taken at different times rather than a single test, the diagnosis is often delayed by many hours. The diagnosis could be automated—and the need for antibiotics displayed—if the monitors and electronic health record communicated with one another.
• To prevent pneumonia in patients on ventilators, one of the main interventions is to elevate the head of the bed to 30 degrees or more. Yet we often measure the angle by looking at it and guess wrong more often than we guess right. There is typically not a highly visual display of the angle, let alone remote monitoring of it.

Health care organizations are making major investments in electronic health records (EHR) in the belief that it will solve their problems. But today’s EHRs have crude decision support, rudimentary analytics and, most concerning, limited examples of sharing data with other technologies such as monitors, infusion pumps, and ventilators.

No one group has the ability to fix this. What we need is an unprecedented level of teamwork and communication among the industry, clinicians, researchers and other groups to make the many devices and information technologies work together.

We’ve taken what we hope will be the first step toward realizing that vision. On Feb. 2 in Baltimore, the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality hosted a conference attended by several select companies, a foundation, and researchers from across Johns Hopkins University, including the Applied Physics Laboratory, who believed that we are stronger together than alone and that we can make ICU care safer.

Attendees included representatives from systems integrators (Lockheed Martin) as well as manufacturers of noninvasive monitoring technologies (Masimo Corporation), devices (CareFusion), pharmaceuticals (Sanofi-Aventis), space and furniture solutions (Nurture by Steelcase), and innovative infection control products (Cantel Medical). The Gordon and Betty Moore Foundation participated as well. Design firm IDEO facilitated the event.

The idea was risky. Before the conference, I wasn’t sure that the different groups would want to work together. But in the end, the day was magical.

We agreed to cooperate, to be interdependent rather than independent, to be cooperative rather than competitive. The company leaders were genuinely moved and passionate about improving patient safety, quality and value. They recognized the importance of integrating technologies and sharing data. They know they could solve this problem right now if we commit to it. We identified several projects in which we might start collaborating right away, and we hope to select projects and move forward with them.

The sharing and integration of technologies should be the norm rather than the exception. In the future, we should not contract with vendors of EHR or other technologies if they do not agree to integrate their systems. All of these companies have improving patient outcomes and safety in their mission statements, yet they cannot live it if they work in silos.

Our meeting was energizing. We have seen the future. It is not solely in electronic health records. It is in linking EHR with all of our monitors, infusion pumps, beds, and other technologies. It is about engaging patients and their families as active members of the care team. It is to have a system that continuously learns and improves. This is what personalized medicine is all about. It is ensuring that the care we give you takes into account your specific values, genes, medical history and risks. We can do this right now if we agree to work together. We have the technology. The question is, Do we have the will?