patient care

As an allied health professional, I know that communication is an important tool. You need to communicate well with other disciplinary teams to deliver a holistic care for the patient. You also need to communicate well with your patient to understand their concerns. During my student days, however, I always received feedback from my clinical supervisors that I was too quiet and I needed to speak up more. In an environment that requires teamwork, I was finding it difficult to settle myself into the team fast enough to feel comfortable.

That changed when I had the opportunity to visit an overseas hospital in the United Kingdom for a month for clinical placement. One day, a patient I was caring for during that period brought her grandchildren along with her. She saw me and motioned for me to come over. It was her last day of treatment. She held my hands and said, “Girls, this is Atiqah. She’s the girl I was telling you about who is from Singapore. She’s been with me from the start till the end. And I am so thankful for that.”

I was and am still a very reserved person. Having a patient acknowledge my individual presence when I’m part of a team was encouraging. I’d never felt noticed in that way. Though we didn’t talk much, she said I listened to her very well, despite being a part of a team.

It was then when I realized I don’t need to talk as much as extroverts do to be good at my job. As an introvert, I listen well. This is my strength. And this is how I will contribute as a team member and as a healthcare professional for my patients. Sometimes, people forget that communication also involves listening. In today’s busy and extroverted world, I vow to be that listening ear for my patients.

Quiet Revolutionary - Atiqah Samsuri

This is probably my favorite story from www.quietrev.com

2

Hi there! I’m finally feeling well enough to write another post, after I’ve been fiddling with some of my anti-stress-balls. Also, my girlfriend and I went to a LUSH shop earlier and I got some lovely bath bombs! But now, this is what’s been going on lately:

1. The date for my appointment concerning my DBT in-patient treatment changed and is now only two and a half weeks away. I’m pretty sure that I won’t show up at all, because I’m still unable to talk, and there is nothing to talk about, and I’m just a shit, really. Also, I have no idea what to expect from this appointment.

2. I’ve cried in front of my girlfriend. Twice. Out of the blue, I couldn’t even tell her what was wrong. I imagine it triggered me that her in-patient stay organization seems to go smoother than mine. But really, there wasn’t a reason for me to cry like a baby two days in a row. I felt like the most manipulative bitch ever when she held me and told me she loves me.

3. I’m struggling with managing basic daily tasks still, but on top of that, I’m supposed to plan my trip to Amsterdam, which is just one week away, and I really don’t feel able to. (So any suggestions on what I could do in Amsterdam are welcome.) Also, my girlfriend will leave the bookshop where we’re both working, and everyone depends on me for a nice goodbye present and it makes me wanna cry because I’m terrible at organizing anything.

So in conclusion, everything stresses me, I’m eating way too much because of that, and my hair started falling out again and I’ve even had a tinitus for two days because of all that stress even though I literally do not have anything to stress that much about AAAAAAAARGH. Thank God for those bath bombs.

A doctor discovers an important question patients should be asked

This patient isn’t usually mine, but today I’m covering for my partner in our family-practice office, so he has been slipped into my schedule.

Reading his chart, I have an ominous feeling that this visit won’t be simple.

A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.

He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.

Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him.

Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.

With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum.

A cardiologist and a nephrologist haven’t been able to help him, I reflect,so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle… .

Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try.

Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”

I pause, then look this frail, dignified man in the eye.

“What are your goals for your care?” I ask. “How can I help you?”

The patient’s desire

My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.

He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”

His daughter, looking tense, also faces her father and waits.

“I would like to be able to walk without falling,” he says. “Falling is horrible.”

This catches me off guard.

That’s all?

But it makes perfect sense. With challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked.

A wonderful geriatric nurse practitioner’s words come to mind: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.”

Suddenly I feel that I may be able to help, after all.

“We can order physical therapy — and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.

He smiles. His daughter sighs with relief.

“He really wants to stay at home,” she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.

“I know that you’ve decided against dialysis, and I can understand your decision,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”

He nods.

“We have services designed to help keep you comfortable for whatever time you have left,” I venture. “And you could stay at home.”

Again, his daughter looks relieved. And he seems … well … surprisingly fine with the plan.

I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable — at home.

Back home

Although I never see him again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on his wife to have him die at home, she says, but he’s adamant that he wants to stay there.

A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on him.

The nurse confirms that he is near death.

I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?

Two days later, and two months after we first met, I fill out his death certificate.

Looking back, I reflect: He didn’t go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.

Several months later, a new name appears on my patient schedule: It’s his wife.

“My family all thought I should see you,” she explains.

She, too, is in her late 80s and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she’s lost some weight. No, she isn’t depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.

“He liked you,” she says.

She’s suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, she stopped going for medical care.

I ask why.

“They were just doing more and more tests,” she says. “And I wasn’t getting any better.”

Now I know what to do. I look her in the eye and ask:

“What are your goals for your care, and how can I help you?”

-Mitch Kaminski

Source

Not a checklist

Psych has been a pretty sobering rotation. It’s easy to get worn out by the stories of childhood abuse, substance dependence, poverty, poor coping skills, and maladaptive behaviors. It’s easy to get frustrated with patients who look away when you come in the room, who give monosyllabic answers, who won’t help you help them, who actively fight all your efforts. Telling yourself over and over ‘they are sick, they are sick, they are sick’ only goes so far if you’re honest with yourself.

On inpatient consult service, I was sent to see A, a quadrapalegic, Hep C+, HIV+, stage 3 kidney failure patient who was just discharged last week and returned to us with a fever and 20 bed sores, one of which was very advanced. When I went to do the new patient workup, they wouldn’t look at me, barely answered my questions. It was a frustrating interview, like most consult interviews seem to be. On rounds we diagnosed them as depressed (can you blame them though?) and prescribed an SSRI. All in all my interactions with them were less than 10 minutes total. 

The next day when I went to see them our conversation was better. They were awake, spoke loud enough for me to hear, and actually answered my questions. Then they asked if I knew someone. It took me a few minutes to figure out who they were talking about, but it turns out A was referring to one of the students who was on consult before me- Sir Orthopod. Conventiently, this student was rotating on the inpatient psych floor in the same facility. I asked A if they would like me to see if Sir Orthopod can come visit today, A said they would very much like that and actually smiled. 

I immediately texted Sir Orthopod the patient’s room number, asked him to go see the patient. Sir Orthopod remembered them, and said he’d visit as soon as he could. I went on to see my next patient, write my notes, get done as soon as possible so I could eat and relax for a little bit.

A few hours later as I was eating my lunch in the doctor’s lounge, mindlessly scrolling on Facebook, when Sir Orthopod came and sat next to me. I asked, “How is A doing? I can’t get anything out of them, but they seem to really like you.“ 

He replied, "Yeah, when we had them I had a hard time getting them to talk to me too. One day I had an extra hour so I went up there and just talked to them about stuff. They’re really lonely, and nobody spends very much time with them.”

That hit me. I definitely could have spent more time with A. I mean, they are quadrapalegic and has a huge host of chronic medical conditions and very painful bed sores. They never have visitors. They lie alone in a dark ICU room, punctuated by this or that doctor or nurse or coming in for a minute, and watch TV all day- they can’t even change the channel or volume if they want. Were I in their shoes, I’d be desperate for human interaction too. Most gut wrenching of all, I had done the thing I swore up and down I’d never do: treat patients like items on a checklist, to be taken care of as quickly as possible. 

As medical students we have the immense luck of having no real responsibilites. Sure, we see patients and write notes, but our responsibilities are very superficial in reality. The residents and attendings are the ones who are so overloaded with responsibilites that they can’t spend more then 10-20 minutes with a patient in a day. But medical students? We have all the time in the world. Today, after I finish my notes and do a set of practice questions, I’m going to see if A would like some company.

Advice to Med Students: How To Impress a Resident/Attending (The Patient Care Episode)

Since a lot of you are about to start the clinical part of your training, and I’m about to get med students for the first time, I figured I’d put together a little how-to (in 3 episodes) with the help of my fellow residents.

  • Take initiative with your patients. Know all their info: what meds they’re on, their labs, their histories, etc.
  • Check back on your patients in the afternoon. Follow their labs or tests done during the day and think about what needs to be done about them. Otherwise you’ll find that a ton of stuff has happened the next day and you’ll be out of the loop. 
  • Have your notes written before the resident rounds so they can read them and hopefully give you feedback on them.
  • Always attempt to write an assessment and plan on your notes, no matter how simple it is. “Continue current management” is usually not an acceptable plan. What needs to be done before this patient can go home? 
  • In surgery, always ask permission (preferably from the attending) to scrub in. I do this still as a resident. If they say yes, get your gloves and gown for the scrub tech because they’re probably not prepared for you. 
  • Ask to do procedures, but don’t expect to get them. The residents are always first in line. If it’s a procedure they’re confident doing and they have time to teach you, they’ll probably let you do it. 
  • If we ask if you want to do a procedure, always say yes. Even if you don’t want to. 
  • In the outpatient setting, always offer to help write the note. Rarely will a resident turn you down, and you will really help them out. They will still review and change it, but it will definitely help.
  • Be available. You don’t have to be a shadow, but don’t expect your resident to call you for admissions/procedures/check out, because she will forget. If you haven’t heard from the resident in a while, check back in with them. She may have forgotten you were around and might send you home early!
3

best of trash-pals

A Patient-Centered Hospital - Part I

I have often wondered, while wandering the desolate halls of the hospital, “why do we round at 6 am?”  Frankly, no one has given me a good answer.  The common reply is a frightening response: “that’s how it has always been done.”  Where else in modern society do we allow such tradition to trump innovation, or  convenience?  Everywhere you look there are companies that become widely successful based on innovations that increase customer satisfaction.  The business world has even created a whole concept on this idea, termed disruptive innovation.  A disruptive innovation is an innovation that completely upends the industry it is introduced in.  Notable examples include digital books, tablet computers, and media streaming services. For some reason this mentality does not always translate to the patient care environment.

I would propose to you that the last place healing people should be is a hospital.  Little rest can occur in the alarm-ridden, ceaseless activity of most medical floors.  To satisfy the early morning rounding of the medical team, phlebotomists come in at all hours of the night ensuring labs are updated.  To meet quality measures, nurses walk in and out of patient rooms to record vitals at regular intervals.  And through all of this, various medical professionals call on patients based on their own schedule – medicine and surgery often very early in the morning, radiologists as imaging facilities allow, and subspecialists later in the day after clinic.  To sum this up, patients are brought to rest in a strange environment, with bizarre noises, and a multitude of healthcare workers flitting in and out of there room, all the while in a very uncomfortable bed.  Is it any wonder most people report being exhausted by the time they leave the hospital (Ubel, 2013)?  

The current hospital model also lends itself to the overuse of healthcare resources in the form of daily labs, readily available consultations, and unnecessarily aggressive treatments.  Perhaps worst of all, we corral sick people together, allowing for mass exposure to pathogens and creating a breeding ground for super infections like C-diff and MRSA.  Depending on the statistics you look at, hospitals could actually be classified as a leading cause of death in the U.S. (James, 2013).

So why do we use them? Because “that’s how it has always been done.”  This isn’t entirely true, but has been for the past 100 years or so.  It is astounding that after the enormous sums of money invested in making hospitals safe, quality-oriented, and patient-centered, the U.S. healthcare system is left with the same decades old complaints.  Hospitals are noisy, impersonal, error prone, and full of terrifying complications. Most service industries would not survive with such inattention to the complaints of consumers.  However, hospitals are unique in that they provide goods that individuals literally cannot live without.  More importantly, healthcare is a market in which there is little free choice – patients go where their insurance directs them and get the services that insurance will cover with no transparency about the prices and success rates of what they are purchasing.  

The careful reader will note I have highlighted many complex and theoretically unsolvable problems. But that is not how a disruptive innovator thinks, particularly one as disagreeable as I.  Over the coming weeks I hope to further tease out some of these problems and offer my potential solutions.  

Just maybe all of these words will convince you that, with some disagreeableness and disruption, we could do things better.  

Citations/Further Reading

James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-8. DOI: 10.1097/PTS.0b013e3182948a69

Ubel, P. (2013, June 19). Sleep Deprivation in Hospitals Is a Real Problem. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2013/06/sleep-deprivation-in-hospitals-is-a-real-problem/276960/

Heme/Onc Wards: Mama Bear MD-A

I hope that EKG technician is proud of herself, making a man with metastatic cancer cry by insulting him for not understanding her instructions. 

HE’S BLIND, YOU WORTHLESS WASTE OF OXYGEN. THERE ARE SIGNS PLASTERED ALL OVER THE ROOM THAT SAY SO TO MAKE SURE ALL THE STAFF KNOW THAT HE’S BLIND.

There is a special place in hell for people like this. 

I contacted her supervisor immediately and am currently writing a formal complaint. With dates and times and specifics and names of witnesses.

Don’t fuck with my patients. 

Don’t FUCK with cancer patients. 

Don’t FUCK with people with disabilities. 

Don’t FUCK with people who are sick, in the hospital, dying. 

What the FUCK is wrong with some people??

Why are you doing this? Think about it.

[This post is inspired by the events of last night.]

I am a volunteer for the local women’s shelter (aka- the Center). Two nights a week, from 6pm-6am, I am on-call to be a hospital advocate for victims of assault. Usually on Sunday and Tuesday nights.

Last night, which was a Monday night, I get a call at 3am from the Center. I wasn’t supposed to be on-call, but they told me nobody else was scheduled. In cases like this a staff person, who works 8-5 at the Center, is supposed to go in and take care of things. I told them that if nobody could come to call me back.

I hung up and lay there, in my warm bed in the darkness, thinking about what I had heard about this client. Something truly traumatic and tragic happened to her. And I didn’t have anything tomorrow until 3pm. I knew that it was now impossible for me to do nothing; so I got up, called the Center back, and said, “I’ll do it.” And went in and did what I could for her for several hours in the middle of the night.

Why? Because I knew that I was absolutely capable of helping this woman, a victim of brutal sexual assault, who was currently alone in a busy ER. For me, being able to help someone in need and not helping is the one of the cruelest things I could do. It's tantamount to a slap in the face, as far as I’m concerned. I was compelled by something inside me to go in, even though I technically didn’t have to. 

This event solidified my drive to become a physician; when push came to shove, when action was called for, my personal calling to help those in need won over selfish desires. I’m in this for the right reasons, because I can’t stand idle when I know there is suffering and I can do something about it. 

Think of it this way: it’s one thing to say you want to help people, what really matters is what you do in the event someone genuinely needs help when it is inconvenient for you. Listen: words mean nothing. Are you willing to give up personal time for others? Are you really willing to sacrifice that much of your time and energy? If you aren’t, then I would recommend pursuing a different career. 

And it’s ok if to realize you aren’t cut out for such a commitment. No shame, no judgement. It is better to decide now rather than later when you are in over your head and discover you give no shits about these sick people. The life of a doctor isn’t for everyone.

So that’s my advice. Really look deep into yourself, into the ugly parts, and try to discern if you have what it takes. If not, that’s ok. Get the fuck out while you still can. If you don’t, you are doing a tremendous disservice not only to yourself but to also every unfortunate patient to fall into your care. They don’t deserve that.

If you think the details are not important, then leave the profession now. Our job is saving lives, a most ancient and honorable profession. If we have a bad day, someone will pay for our mistakes with suffering or even death. Since the early beginnings of EMS, patients and even rescuers have lost their lives because attention was not paid to the details. Many of us can recall patients that we might have saved if we had been a little smarter, a little faster, or a little better organized. Make no mistake, there is no “high” like saving a life, but we carry the scars of our failures all our lives.

Your mind-set and attitude are very important. You must be concerned but not emotional, alert but not excited, quick but not hasty. Above all, you must continuously strive for what is best for your patient. When your training has not prepared you for a situation, always fall back on the question: “What is best for my patient?”

When you no longer care, burnout has set in, and your effectiveness is severely limited. When this happens, seek help. (Yes, all of us need help when the stress overcomes us.) or seek an alternative profession.

—  John E. Campbell, MD, FACEP
How do you handle unreasonable patients?

I want to be a doctor, but I’m scared I won’t be able to handle unreasonable patients. I’m really a shy person that has trouble speaking up about certain things. I feel like I would keep saying sorry if a patient got mad at me. My doctor however is the opposite of me. She would always yell at me when I did something wrong (like forget to take my meds) I cried one time after getting off the phone with her cus she yelled at me so bad one time. -nerdxalert

Before I get to your question, let me say that your doctor is a jerkface. As doctors it is not our job to act like parents and scold our patients like children when they don’t do what we want. There is never any cause to yell at a patient. Never. 

That being said, there will be patients who will make you want to yell. And cuss. And throw things. And you can do all of those things in the comfort of your own home. Or your blog ;).

In the beginning of your medical training you will be afraid to ask a patient even the most innocent questions about their lives. You will worry constantly about what your attendings, residents, and patients think of you. But as you progress you will develop a boldness in your demeanor and a tough skin that repels foolishness from patients. 

There are a lot of reasons that a patient may seem unreasonable, and the way you will handle them will depend on the situation. Some patients will have some misunderstanding about their care, in which case you can try to correct the misunderstanding or at least apologize for it. Other patients have personality disorders and no amount of reason from you is going to change them. The way they are responding to you is part of who they are. Those you just have to let roll off your back.

Then there are times when patients (or more often, their family members) are going through very emotional events which makes it very difficult for them to see reason. For those you have to show compassion and empathy.

And of course there’s always the possibility that the patient is not the unreasonable one–maybe you are the unreasonable one. Or at least they see it that way. That’s when it’s time for you to humble yourself and apologize for whatever wrong (or perceived wrong) you’ve committed against them and figure out a way to make the situation better. 

You also have to realize that a patient’s emotional response does not necessarily mean they are angry at you. They may be angry at the system, angry at an injustice done to them, frustrated with their own situations, experiencing physical or emotional pain, or a whole host of other emotions.

So when dealing with unreasonable patients, check your own emotions first. Then rely on your training, your tact, compassion, and clinical judgement to get you through.

Readers who are in patient care: how do YOU deal with unreasonable patients?

There’s a certain joy that caring for others brings to your life. For a few brief moments in time you’re able to forget about external difficulties, hospital politics, unit backbiting tendencies, and other assorted daily administrative challenges designed to test your patience. It’s those moments when it’s just you, and your patient, that you are reminded of why you wanted to be a nurse, even in the midst of a disastrous day
—  Nurse X
A Patient-Centered Hospital - Part II: Bells are Ringing

As I sat typing my note, I heard an alarm go off.  I glanced around, looking for its source.  It was an IV machine, somewhere in a patient room, announcing to all that could hear that it had finished its infusion.  There was no nurse in sight.  We are discouraged from turning off the IVs without their permission, so the alarm continued, and continued, and continued.  Shortly thereafter an ECG alarm went off, signaling an abnormal rhythm. I glanced in the room and saw a respiratory therapist had been adjusting the patient’s electrical leads.  Behind me, somewhere down the hall, a third alarm went off signaling God knows what. 

If you are not used to being in the hospital, it can be a noisy place.  Alarms ring out in the halls.  Carts are wheeled around to bring food, supplies, and often life-sustaining medication.  The chatting between coworkers ensures that at all hours there is a constant din. And this, of all places, is where we send people to rest.  Hospitals are not designed with the patient in mind.  But they could be.

Let’s reimagine some of the above scenarios in a patient centered manner.  First, there must be a decision about what requires an alarm.  The term alarm fatigue, which has recently gained popularity in describing this conundrum, describes situations in which the ubiquity of alarms detracts from their usefulness.  Anyone who grew up with small siblings understands you can eventually grow accustomed to the most annoying of noises.  Indeed, patient deaths have been ascribed to healthcare works ignoring alarms (Kowalczyk, 2011).

Second, there needs to be a discussion about how alarms (or alerts) should be delivered.  For example, does an alarm need to signify the completion of an infusion?  What if a text page went to a nurse’s mobile device (many hospitals now use nursing communication systems that can send and receive text pages and calls)?  The alert could then be placed in the queue from which it can only be removed by addressing it manually at the actual infusion pump.  This allows non-emergent alarms to cease being alarms.  By making them less invasive alerts, actual audible alarms become more meaningful.  

At the other end of this spectrum, are there alarms that should be set off without need for human intervention?  Typically, a hospital staff member has to send out certain codes, which increases the amount of time to dispatch the appropriate response.  Some responses are delayed dramatically by the above mentioned alarm fatigue.  What if an alert about falling oxygen saturations combined with heart and respiratory rate changes automatically signaled a code blue across the hospital’s PA system?  This takes out the guesswork and increases the sensitivity of the code system.  It would likely create more false positives, however I find that more comforting than false negatives from ignored alarms.  

These ideas are not the resolution; they are an attempt at a conversation.  I am astounded that solutions to these well-documented problems have not permeated the healthcare field.  The cessation of needless noises in the hospitals – the beeps and boops of non-urgent alarms – would go a long way in making it a more peaceful place where patients can get rest, which can improve healing (Gumustekin, Seven, Karabulut, et al., 2004).  Wasn’t that the whole point of a hospital to begin with, a place of rest and healing? Hold that thought – somewhere I hear an alarm going off, and I intend to stop it.    

Citations/Further Reading

Chopra V, Mcmahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. JAMA. 2014;311(12):1199-200.

Cvach M. Monitor alarm fatigue: an integrative review. Biomed Instrum Technol. 2012;46(4):268-77.

Gumustekin K, Seven B, Karabulut N, et al.  Effects of Sleep Deprivation, Nicotine, and Selenium on Wound Healing in Rats. International Journal of Neuroscience.  2004, Vol. 114, No. 11 , Pages 1433-1442 (doi:10.1080/00207450490509168)

Kowalczyk, L. (2011, September 21). ‘Alarm fatigue’ a factor in 2nd death. The Boston Globe. Retrieved from http://www.boston.com/lifestyle/health/articles/2011/09/21/umass_hospital_has_second_death_involving_alarm_fatigue/

Krachman SL, Criner JG, D’Alonzo GE. Sleep in the Intensive Care Unit. Chest. 1995;107(6):1713-1720. doi:10.1378/chest.107.6.1713

Varpio L, Kuziemsky C, Macdonald C, King WJ. The helpful or hindering effects of in-hospital patient monitor alarms on nurses: a qualitative analysis. Comput Inform Nurs. 2012;30(4):210-7.