alarm fatigue: improve alarm management & patient safety in 2014 patton healthcare consulting 1
TRANSCRIPT
Alarm Fatigue: Improve Alarm Management & Patient Safety in 2014
Patton Healthcare Consulting
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Alarm Fatigue Focus Issue
• A sentinel event alert was released in April ’13• Focus of a new National Patient Safety Goal
for 2014• Alarms have led to Immediate Threat– Alarm being shut off or silenced– Not resetting alarm after silenced– Not trained on all equipment– Result in patient death
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What is Alarm Fatigue?Or Crying Wolf
• Alarm fatigue occurs when clinical personnel fail to respond appropriately to alarms due to inability to understand the critical nature or priority of the alarm. Staff become desensitized after experiencing and handling so many. Alarms are ignored or turned off.
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Taking a Good Thing Too Far
• Study of alarms in critical care units – Hundreds of alarms per patient per day – thousands of alarms per unit per day.
• Beyond the basics – bed alarms, chair alarms, IV, call button, hand sanitizer.
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Understanding the Issues
• Between 85% and 99% of ICU alarms are false, or non-critical alarms, don’t need response
• FDA published results of 216 manufacturer reports on monitor related deaths
• TJC analyzed sentinel events for monitor related causes
• 98 events reported, 80 deaths, 13 permanent loss of function, 5 added LOS
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Common Causes• Staff are overwhelmed by the # of alarms• Staff turn-off or turn down alarms• Alarm settings not set appropriately• Alarm default not reset after a patient move• Alarm malfunctions such as not properly
relayed to wireless or paging system or battery• Nurses block out noise to focus on task
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Causes – Cont.
– Inadequate staff training and sounds are difficult to learn, differentiate which alarm
– Put a “ring” on it - The “too-easy” solution to many problems
– Med Equipment companies create their alarm to fetch attention, the beeping is intended to irritate
– Sounds of alarms do not differentiate a ‘notification’ from a critical event.
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2013 TJC Sentinel Event Alert
• Combined set of recommendations from TJC, the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute.
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Sentinel Event AlertRecommendations
①Leaders ensure there is a process for safe alarm management and response in high- risk areas.
② Prepare an inventory of alarm-equipped medical devices and identify the default alarm settings and appropriate alarm limits.
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Sentinel Event AlertRecommendations
③Establish guidelines for alarm settings. Define when alarms are not clinically necessary
④Establish guidelines for tailoring alarm settings and limits for individual patients (who can modify and when)
⑤Implement routine inspections and maintenance of alarm-equipped devices.
⑥Staff training on above
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Sentinel Event AlertRecommendations
⑦Adhere to manufacturer instruction for use, eg: replace single use leads, replace batteries
⑧Assess acoustics of alarm sounds⑨Set as a leadership priority⑩Establish a team to address
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New NPSG on Alarm SafetyNPSG.06.01.01
1 Establish alarm safety as a priority (7/2014)2 Identify the most important alarm signals to
manage (throughout 2014)3 Establish policies and procedures for
managing clinical alarms. (1/2016)4 Educate staff and LIP’s about the purpose
and proper operation of alarm systems (1/2016)
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NPSG.06.01.01 EP 3• Policy and Procedure should address:– Clinically appropriate settings for alarm signals– When alarm signals can be disabled– When alarm parameters can be changed – Who has the authority to set alarm parameters – Who can change alarm parameters – Who can turn alarm “off” – Monitoring and responding to alarm signals– Checking individual alarm signals
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What to do Now• Assign the task to quality committee or safety
committee• Review alarm literature and your own data• Decide which alarms are most important to
manage – ICU, telemetry, ED, OR and PACU alarms likely to be high priority
• Seek leadership approval for priorities/plan• Document your efforts and decisions early
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Many Variables
• Patient Population• Unit layout• Staffing - numbers and mix• Care model• Delineation of responsibility• Culture• Technological capabilities and configuration
Gather Data and Input
• Look at actual events and near misses• Determine underlying root causes• Conduct routine rounding aimed at alarms– Listen to staff concerns; what worries them?– Flow chart the processes for alarm notification
and response– Look for obvious issues • Pagers not worn, delayed responses, poor audibility
Potential Root Causes
• Responsibility for alarm response is ill-defined
• Competing priorities (e.g., patient satisfaction tied to a low-noise level on unit)
• Assumption that someone else will respond• Lack of escalation plan with responsibilities
and time intervals defined
Concrete Steps to Improving Safety/Effectiveness of Alarms
• How many alarms are tolerable to staff to avoid fatigue? Anesthesiology Today study suggests 2 – 4 per patient/day
• Reduce Thresholds for alarms, use evidence based approach.– Define when a clinician needs to go to bed side
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Reducing False Positives
• A Johns Hopkins Study: lower SpO2 alarm from 90% to 88% reduced alarms by more than 50%
• Low heart rate 60 to 50 = 88% reduction• High heart rate 120 to 150 = 85% reduction• Place delays on alarms, delay alarm by 15
seconds. Journal of Emergency Medicine (JEM) study. Reduced false positives by 80%
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Improving Safety of Alarms
• Equipment maintenance – Reduce low battery alerts by replacement– Deactivate or limit overrides– Routine testing of alarms
• Selection of equipment – Vendors with meaningful alarm sounds – Implement intelligent escalation of alerts– Involve staff in equipment selection
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Improving Safety of Alarms
• Staff Training– Train staff on meaning of all alarm sounds– Train staff to check patient before silencing
any alarm– Train staff on new equipment – Train staff on proper alarm placement, skin
preparation, ensure competence
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Improving Safety of Alarms
• Develop and implement policies• Who can change alarm settings• Who needs to be monitored• What are default settings• Who is responsible for performing clinical alarm
monitoring rounds• Develop audit tool to measure compliance with
established policies• Develop and complete check list at shift change
for patient alarm settings
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Questions???• Kurt Patton– [email protected]
• Jennifer Cowel– [email protected]
• John Rosing– [email protected]
• Mary Cesare Murphy– [email protected]
Please visit and bookmark www.pattonhc.com
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