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Enhanced Notification of Critical Ventilator Events

Affiliations of the authors: Department of Medical Informatics, LDS Hospital, Intermountain Health Care (RSE, KVJ, TK, WLH); Department of Medical Informatics, University of Utah School of Medicine (RSE, DKV); Departments of Respiratory Care (VBF), Information Services (CRL), Pulmonary and Intensive Medicine (GET), Intermountain Health Care, Salt Lake City, UT.

Correspondence and reprints: R. Scott Evans, MS, PhD, Department of Medical Informatics, LDS Hospital, 8th Avenue and C Street, Salt Lake City, UT 84143-0001; e-mail: <ldevans{at}ihc.com>.

Received for publication: 04/30/05; accepted for publication: 07/12/05.

Mechanical ventilators are designed to generate alarms when patients become disconnected or experience other critical ventilator events. However, these alarms can blend in with other accustomed 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 system to monitor critical ventilator events through our existing hospital network. Whenever an event is identified, the new system takes control of every computer in the patient's intensive care unit and generates an enhanced audio and visual alert indicating that there is a critical ventilator event and identifies the room number. Once the alert is acknowledged or the event is corrected, all the computers are restored back to the pre-alert status and/or application. This paper describes the development and implementation of this system and reports the initial results, user acceptance, and the increase in valuable information and patient safety.

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