Sound the Alarm!

Strategies for Alarm

Management in the

Rush NICU

Steven B Powell MD

John E Overby BSN

Connie L Weissman MS

Carol A Squires BS

Jean M Silvestri MD

October 21st, 2015

Disclosures/Conflicts

©2007 RUSH University Medical Center

• No Disclosures

Background

• The Joint Commission has issued National Patient Safety Goal on Alarm Management

• Over-exposure to multiple alarms can result in alarm fatigue

• Devices at bedside have grown significantly

• Safe alarm management is a challenge for NICUs transitioning from open bay to single family room (SFR) environments

The Joint Commission NPSG 2015

• Identify the most important alarm signals to manage based on the following:• Input from the medical staff and clinical

departments

• Risk to patients if the alarm signal is not attended to or if it malfunctions

• Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue

• Potential for patient harm based on internal incident history

• Published best practices and guidelines

©2007 RUSH University Medical Center

The Joint Commission NPSG 2016

• Establish policies and procedures for managing the previously identified alarms and address the following:• Clinically appropriate settings for alarm signals

• When alarm signals can be disabled

• When alarm parameters can be changed

• Who in the organization has the authority to set alarm parameters

• Who in the organization has the authority to change alarm parameters

• Who in the organization has the authority to set alarm parameters to “off”

• Monitoring and responding to alarm signals

• Checking individual alarm signals for accurate settings, proper operation, and detectability

©2007 RUSH University Medical Center

Open Bay

Single-Family Rooms

Pod A(18 beds opening)

Pod B(18 beds opening)

Pod C(19 beds opening)

NICU – 8 Tower

Workflows

• For existing workflows to work, nurses must

be able to receive alerts from both the

patients’ systems and from other staff

• Alerts must have assigned priority to

differentiate important alerts from less

important to avoid alarm fatigue

• Escalation required if busy or no response

Alarm Fatigue

• Over-exposure to alarms can result in alarm fatigue– Ignoring critically important alarms

• Devices at bedside have grown significantly– Vital sign monitors, ventilators, infusion pumps, pulse

oximeters, capnographs, feeding pumps

• Can generate hundreds of alarms per patient per day, overloading staff

• Risk recently rated first in patient safety threats by ECRI Institute

• Joint Commission has issued National Patient Safety Goal on Alarm Management and Sentinel Event on Medical Device Alarm Safety

Hospital Leadership

“Default alarms are

my safety net against

Sentinel events.”

“When in doubt –

turn on the default

setting.”

Bedside Nurse

“Responding to alarms is

just one task on a huge

and growing list.”

“All these alarms don’t

help keep patients safe.”

“Alarm management

is a technology problem

to be fixed.”

Alarm

Fatigue

Objective

• Integration of physiologic monitors,

ventilators, and nurse-call to wireless

phones to create virtual “line of sight” to

patients after transitioning from open-

bay to SFR environments

• To mitigate alarm fatigue by adjusting

parameters of alarm management and

notification platform

The process

• Create a team – multidisciplinary

– Hospital Leadership

– Physicians

– Nurses and Nursing Administration

– Respiratory Care

– Biomed/Clinical Engineering

– Information Technology

– Risk/Legal

June 2014 RUSH Team of the Quarter

Steven Powell NICU Attending-Team Leader

Jean M. Silvestri Director of the NICU

David Vines Chair/Program Director Respiratory Care Program

Keith Roberts Director, Respiratory Therapy

Sara Murphy Respiratory Therapy

John E. Overby NICU RN

Melinda D. Noonan Project Sponsor- AVP Children’s Hospital

Natasa Djukic Project Coordinator, Women’s and Children’s Services

Patty Nedved AVP, Prof. Nursing Practice

Debbie Gist Unit Director, NICU

Jody Selenica AUD, NICU

Elizabeth Myers Risk Management

Karen M. Silvestri Risk Management

Bonnie Macius Risk Management

Amanda McGee Risk Management

Susan O’Leary Risk Management

Lisa Swiontek AVP, Clinical Information Systems

Scott Finkle IS Director, Systems Development & Integration

Christopher J. Kaspar IS Director, Systems Integration

Carol Squires IS Project Leader

Robert Elder IS Director, Capital Projects

Susan Kovach IS PM, Nurse-call

Scott Simon IS PM, Draeger

Connie L. Weissman IS Senior Analyst

Cheryl M. Liggett IS Project Leader

Randy Johnson Clinical Engineering for NICU

Jonathon Arrington Clinical Engineering

Gene Ward Clinical Engineering

Mike Lamont VP, Capital Projects

Tito Luna IT Telecomm

Alden Brugada IT Telecomm

Interfaces

• Inputs

– Nurse-call – Rauland Responder 5

– Draeger Infinity Acute Care System

– Ventilators – Puritan Bennett 840

– EPIC ADT data

– Cisco call manager

• Outputs

– Cisco VOIP phones

– SQL reporting server

Design

• NICU– Draeger – 13 Monitor alarms

– Covidien – 48 Ventilator alarms

– Rauland – 41 Nurse-call alerts

• Labor & Delivery– Rauland – 19 Nurse-call alerts

• Mother Baby Unit– Rauland – 2 Nurse-call alerts

• System Alerts– Heartbeat function added to all servers

– 29 system monitoring alerts

Physiologic Monitors Ventilators Nurse Call

Alarm Management and

Notification Platform

Simulation-based Training

• Procedural skills

• Clinical decision-making

• Teamwork

• Communication

• Inter-professional team training

• Testing new facilities

TESTPILOT

• Rhode Island Hospital adult emergency

department 2005

• Rhode Island Women and Infant’s

Hospital NICU 2009

• Rush NICU 2014

Transport Enhanced Simulation Technologies for

Pre-Implementation Limited Operations Testing

Goals of TESTPILOT

• Evaluate integration of new and existing

systems and workflows

• Identify latent safety threats

TESTPILOT

• Multidisciplinary team

– Headed by Dr Beverley Robin

• Eight clinical scenarios

• 10 NICU patient rooms equipped

• In situ simulations, varying levels of

fidelity

• 30 minute simulations, 60 minute

debriefing

• Videotaping

TESTPILOT Participants

• Nurses (12)

• Neonatologists (2)

• Nurse practitioners (2)

• Residents (4)

• Respiratory Therapists (4)

• Patient Nursing Assistants (2)

• Clerks (2)

• Lactation consultant (1)

• Pharmacist (1)

• X-ray technician (1)

• Confederates (parents, L&D and transport nurses)

Threats to Patient Safety

Identified by TESTPILOT

31%

16%13%

14%

11%

6%9%

Communication

Equipment

Ergonomics

Systems/Workflow

Facilities

Family-centered care

Environmental Safety

Methods - Design

• Critical Alarms

(Apnea/Asystole/Brady/Desat) go

directly to phones with no delay

• Non-Critical and Advisory Alarms have

delays before forwarding to phones to

allow recovery of patient

• If no response, escalation to “buddy”

and then to pod leader

Draeger Patient Monitor Alarms

Methods - Modifications

• Ongoing evaluation and review of

alarm transmission

• After 3 months review, changes made

including blocking transmission of most

non-critical alarms to phones

• After 8 months, additional safety

measures implemented, including Split

Screen and No Pass Zone policy was

implemented.

Physiologic Monitor Alarms March-May 2015

Alarm Class Alarm Type Total Alarms Alarms %

Critical Apnea 11,779 3.1%

Critical Asystole 1,828 0.5%

Critical Bradycardia (<60) 6,151 1.6%

Critical Desaturation (<78) 59,230 15.8%

Non-Critical High HR (>200) 35,871 9.6%

Non-Critical HR Low (<100) 4,503 1.2%

Non-Critical Sat High (>95) 22,445 6.0%

Non-Critical Sat Low (<88) 189,808 50.8%

Non-Critical Art BP Low 192 0.1%

Non-Critical NIBP Low 199 0.1%

Advisory Sat Ld off 32,158 8.6%

Advisory ECG Ld off 9,767 2.6%

Advisory Art Ld off 13 0.0%

All Total 373,944 100.0%

Monitor Alarms at Bedside

Alarm Fatigue

• Staff quickly complained of alarm

overload

• Committee formed to evaluate alarm

fatigue

• Staff surveys and online meetings

• List of main concerns created

• Team tasked with resolving issues

Alarm Modifications – 3 months

• Decrease the volume of Draeger Central Station– Decibel meter to measure volume at central and decrease

sound

• Remove the Draeger yellow alarms for HI and LO Sat– Yellow alarms of High and Low Saturation and High HR

blocked to phone

• Right button should allow for both 'escalate' and 'acknowledge'– Soft keys recustomized to allow easier use

• Can we allow '2' as a volume option?– Phone volume limits lowered from 3 to 2 out of 7

• Is it possible to allow users to select vibrate mode?– Vibration decreased for all except 2 Life Threatening alarms

Alarm Modifications – 3 months

• The Nurse-call sign in process takes a long time– Re-education sessions for assignment sign-in

• Reduce the Nurse-call alerts coming into the duty station in the break room. – All but codes and deliveries removed from other areas

• Versus: Lingering lights and no lights failures continue to be an annoyance on NICU and L&D– Recalibrated Versus sensors, development for integration to

Connexall

• Can alert auto-escalate if user is on the phone?– Cisco phones can't autoescalate when in use

• Oncoming personnel should be able to take outgoing personnel off duty as part of report process– Working with Rauland for improvement in user interface

Additional Safety Measures – 8 months

• Split screen

• No pass zone for red alarms

• Large central monitor screens

• Vigilant staffing patterns: overall 1:2 staffing

• Proximity of room assignments

• Partial door opening to view alarms

• Buddy escalation of alarms

• Safety huddle- at report

• Safety huddle in the pod identifying concerning patients

©2007 RUSH University Medical Center

Heat Map

Physiologic Monitor Alarms Per Patient Per Day Transmitted

to Phones by Period and Total Alarms 2014-2015

Alarm Type Mar-May June-Oct Nov-Mar TotalApnea 3 3 3 46,080Asystole 1 0 1 8,260Bradycardia (<60) 2 3 2 39,060Desaturation (<78) 17 37 27 451,278High HR (>200) 10 0 0 0

HR Low (<100) 1 1 1 18,779Sat High (>95) 6 0 0 0Sat Low (<88) 53 0 0 0Art BP Low 0 0 0 1,520NIBP Low 0 0 0 498Sat Ld off 9 11 10 159,595ECG Ld off 3 3 4 54,263Art Ld off 0 0 0 116Total 105 59 49 1,027,573

Conclusions

• Use of a Alarm Management and

Notification Platform created a virtual “line

of sight” from providers to the patient in an

SFR environment

• Review and modification of alarm

algorithms reduced non-critical alarm

burden

• Successful implementation requires a

multidisciplinary team approach

Limitations

• Alarm Fatigue not easily quantifiable

• Changes to algorithms of alarm

transmission was based on clinical

judgement

• Further studies are needed to assess

safety impact of alarm strategies

Ongoing Alarm Activities

• Alarm Management Committee

• Ongoing meetings to review alarm fatigue

• Process for Developing Policies

• Comprehensive Alarm Management Policy

• Compliance with 2016 TJC NPSG

The Future

• Comprehensive Data aggregation

– Allows direct population of Epic data from

Draeger/other devices

– Many drivers for various devices

• Smart pump alarms

• Anesthesia carts

• Capnographs