title: Unit-wide notification of ventilator disconnections.
abstract: The alarms generated by mechanical ventilators when patients become disconnected can blend in with other typical sounds of the intensive care unit. Ventilator alarms that go unnoticed for extended periods of time often result in permanent patient harm or death. We developed a unit-wide system to monitor ventilator disconnection alarms. When a disconnection is identified, the system takes control of every computer in the patient's intensive care unit and generates an enhanced audio and visual alert. This system was tested in four ICUs at LDS Hospital. Acceptance by medical personnel was very high and patient safety was improved through early intervention that avoided prolonged hypoxia. In addition, the system facilitated root cause analyses and new safety strategies.
authors.affiliation: Medical Informatics/Information Systems, LDS Hospital, Intermountain Health Care, Salt Lake City, Utah, USA.
authors.forename: R Scott
authors.initials: RS
authors.lastname: Evans
authors.forename: Kyle V
authors.initials: KV
authors.lastname: Johnson
authors.forename: Vrena B
authors.initials: VB
authors.lastname: Flint
authors.forename: A Tupper
authors.initials: AT
authors.lastname: Kinder
authors.forename: William L
authors.initials: WL
authors.lastname: Hawley
authors.forename: Charles R
authors.initials: CR
authors.lastname: Lyon
authors.forename: David K
authors.initials: DK
authors.lastname: Vawdrey
authors.forename: George E
authors.initials: GE
authors.lastname: Thomsen
mesh_terms: D004868:Equipment Failure; D006801:Humans; D007362:Intensive Care Units; D008838:Microcomputers; D012122:Ventilators, Mechanical