Managing Alarm Fatigue Teaching Presentation
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Transcript Managing Alarm Fatigue Teaching Presentation
Presentation Title
Sub Information
Strategies
for
Managing
Alarm
Fatigue
Presentation Title
An Evidence-Based Approach for Understanding and Managing Alarm Fatigue
Sub Information
in the Acute and Critical Care Environment
May 2013
Copyright © 2013 American Association of Critical-Care Nurses
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Learning Outcomes
Describe the causes and impact of alarm fatigue.
Outline the causes of nuisance and false-positive alarms.
Explain the impact of alarm fatigue on patient safety.
Summarize the impact of false-positive and nuisance alarms on
patient safety.
Examine the evidence-based implementation strategies for
improving
patient safety.
Sub
Information
List nurse-led strategies for individualizing patients’ alarm
parameters.
Presentation Title
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The Extent of the Problem
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Unintended Consequences—Patient Death
Since 2005, more than 216 patient deaths have been directly
attributed to alarm fatigue.
2007
77-year old was admitted to a telemetry unit.
Alarms for “low battery” went unanswered.
Patient had cardiac arrest and died.
January 2010
89-year-old patient was in the ICU.
Bedside alarm was turned off.
Alarmed sounded at the central nurses’ station.
Nurses on duty said they did not hear the alarm or see the digital
display.
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Unintended Consequences—Patient
Death (cont’d)
August 2010
60-year-old man was admitted to the ICU after a tree fell on him,
resulting in facial trauma and head injury.
He was agitated and received lorazepam 5 mg IV push. The order
was for “small doses up to 5 mg.”
An hour later, tachycardia and low oxygen saturation (SpO2) alarms
went unanswered for an hour.
Respiratory arrest was called. Patient was resuscitated and placed
on a ventilator.
CT scan showed an anoxic injury of the brain.
Family withdrew the patient from life support after several days.
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Defining the Problem
Alarm Fatigue
Occurs when staff members are exposed to an excessive
number of alarms.
Staff become desensitized to alarms.
Results in sensory overload:
— Staff frustration
— Delayed alarm response
— Missed alarms
— Patient safety events
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Contributing Factors
Nuisance Alarms
May interfere with patient care.
Are perceived as annoying.
Are not the result of adverse patient conditions.
Distract from other tasks or focus.
False Alarms
Are detected by a medical device.
Indicate the need for a response.
Are triggered without a true patient event.
Are usually the result of:
http://en.ecgpedia.org/wiki/Main_Page
— Parameters not set to actionable levels
— Too tight thresholds
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The Reality
Technology
Natural part of the environment
Physiologic monitoring
Standards of care and practice
Devices
Only as reliable as the clinicians who use them
Alarms
Inherent in the clinical environment
Intended to alert clinicians to deviations from a predetermined
“normal” status
Compromise patient safety if ignored
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Staff Perceptions
Alarms are a necessary evil.
May not view alarm fatigue as a problem or real threat to
patient safety.
Alarms may be used as a stop-gap measure for a lack of
monitoring.
Use of alarms is a possible means to eliminate and/or replace
staff or clinicians with technology.
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Rethinking What We Do
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Rethinking What We Do
Alarm fatigue is a complex issue:
Unique set of circumstances and vulnerabilities
— Hospital and organizational culture
— Nuisances specific to patient unit
Many variations of common problems
— Apathy for “leads off” and “low battery” alarms
— Communication breakdowns
— Competing priorities
Alarm data are difficult to obtain
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Rethinking What We Do (cont’d)
2011 ECRI Institute Report
Staff overloaded with alarms will
improperly modify alarm setting.
Alarm settings should be modified
only after careful consideration of
each patient’s condition.
https://www.ecri.org/Documents/Alarm-Management-Safety-Review.pdf
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Proactive Response
The best way to prevent alarm fatigue is through proactive alarm
management.
Inquire whether you have the ability and authority to adjust
alarms of physiologic monitoring systems
Tailor alarm parameters to the:
— Individual patient
— Specific patient population
Evaluate whether the:
— Alarms are audible and visually displayed.
— Critical alarm sound is distinguishable over unit noises and other
alarms.
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Proactive Response (cont’d)
Decrease false-positive alarms.
Degrade the clinician’s ability to decipher priority alarms.
Ensure proper skin preparation technique before placing ECG
electrodes.
Troubleshoot false alarms when they occur.
— Avoid ignoring them.
— Avoid alarm work-arounds.
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Proactive Response (cont’d)
Do not overuse physiologic monitoring.
— Avoid keeping the patient on telemetry monitoring longer than
necessary.
— Consider the American Heart Association and American College of
Cardiology’s evidence-based Practice Standards for
Electrocardiographic Monitoring in Hospital Settings.
Never turn off an alarm.
— Consider silencing while you troubleshoot.
— Assess the reason for the alarm.
— Intervene as appropriate.
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Managing Environmental
Alarms
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Laser Sharp Focus
Alarm Management
Orchestration
— Culture
— Staff responsibilities
— Technology
— Policies and procedures
— Processes
Must support:
— Prompt and efficacious alarm verification
— Notification
— Response
— Documentation
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Alarm Management Models
Alarm Prioritization
Visual and audible distinctions of alarms are provided.
Indicates the level of urgency of the response.
Alarm Escalation Plan
Designates the caregiver to receive initial alarm notification.
Identifies an additional caregiver as a backup in case no
response to the alarm occurs.
Time intervals for escalation are
defined.
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Alarm Management Models (cont’d)
Decentralized Alarm Coverage Model
Direct alarm notification
— From central station
— From remote displays
— From devices themselves
Unit-based monitor watchers
— Continuous watch central station displays
— Notification directly to a patient’s nurse
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Alarm Management Models (cont’d)
Remote Centralized Monitoring Surveillance Model
Room is separated from the care area.
Dedicated monitor watchers are provided.
Alarm notification is provided to the nurse via telephone or pager.
Reduces patient and caregiver exposure to the noise and demand of
nuisance alarms.
Alarm Integration Model
Clinical device alarms are transmitted to a central system.
System communicates with caregiver via devices such as a pager or
telephone.
System has potential to:
— Relay alarms only
— Attempt to filter out nuisance alarms
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Alarm Management Strategies
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Alarm Management Strategies
Must involve multidisciplinary team:
Chief Nursing Officer
Director of Quality
Key Medical Staff
Clinical Engineering
Nurse Managers
Clinical Nurse Specialists and Educators
Frontline Nurses
Information Technology Staff
Analyze:
Adverse events
Near misses
Did alarms contribute to the patient event?
Observe alarm coverage.
Survey staff regarding alarm concerns.
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Alarm Management Strategies (cont’d)
In collaboration with frontline staff, develop policies that will:
Define specific alarm levels.
Describe the expected response to each level.
Identify the back-up plan, should the responsible person be unable to
respond.
— Expectations and accountability must be aligned with the principles of
a blameless culture.
— Reporting of issues is encouraged and transparent.
Develop reports that will:
Provide a benchmark.
Provide ongoing data about predefined quality parameters.
Measure the progress.
Identify areas of focus and work to attain high levels of staff compliance.
Clinicians must immediately address alarms:
Alarms should never be turned off.
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Alarm Management Strategies (cont’d)
Organizations should communicate to patients and visitors that prompt
responses to alarms are a top priority in keeping patients safe.
Make all alarms actionable:
Clinicians only alerted to clinically significant alarms that require
response
Addressed by analyzing default alarm parameters and ensuring
parameters are appropriate for the individual patient
On-going education and validation of staff competency on
customizing alarm parameters
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Alarm Management Strategies (cont’d)
Consider a brief delay in alarm notification (5 to 10 seconds).
Avoids alarm notification for a problem that quickly resolves.
Important: Incorporated delay must not jeopardize quick access to
emergent care.
Implement preventive maintenance.
Prepare the skin before applying ECG electrodes.
Routinely replace ECG electrodes every 24 hours to prevent them
from drying out.
Consider setting a 5- to 15-second delay for SpO2 alarms.
Individualize SpO2 alarm threshold to the patient’s condition.
Consider upgrading to the next-generation pulse oximetry.
Use disposable, adhesive pulse oximetry sensors, and replace them
when no longer properly adhering to the patient’s skin.
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Alarm Management Strategies—
Ventilator Alarms
Collaborate with Respiratory Care Practitioners.
No standard default alarm settings exist for ventilators.
The American Association of Respiratory Care Practitioners
published a consensus statement regarding alarms:
— Level 1: Events that are immediately threatening if left unattended for
short periods (e.g., power failure, apnea)
— Level 2: Events that are potentially life threatening if left unattended for
longer periods (e.g., circuit leak, positive-end expiratory pressure [PEEP] alarms)
— Level 3: Nonventilator events that are not likely to be life threatening but
a possible source of patient harm if not addressed.
Consider using a 360-degree visual display screen on all high-priority
ventilator alarms. High-priority alarms are displayed in red;
medium-priority alarms are displayed in yellow.
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Core Alarm Management Strategies—
Infusion Pumps
IV Infusion Pumps
No replacement for nursing assessment
Proactively identify any problems that might interfere with the
prescribed infusion rate
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Core Alarm Management Strategies—
Bed Alarms
Bed-Exit Alarms
Widely used as a fall prevention strategy
Used only in these clinical scenarios:
— Patients with delirium and cognitive impairment
— Patients who are unable to walk without support or who
have an unsafe gait
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Return on Investment
Organizational focus likely to yield positive improvements in:
• Patient satisfaction
• Clinical outcomes
• Clinical documentation relevance
• Staff morale
• Effectiveness of the care team
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Real World Success Stories:
Examples of Successful
Alarm Management
and Patient Safety Efforts
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Johns Hopkins Hospital Experience
Demonstrated that the number of nonactionable alarms can be
reduced:
— Thereby decreasing caregivers’ alarm burden without
compromising patient safety by making modest default parameter
changes;
— Standardizing care policies and equipment; and
— Providing reliable secondary alarm notification.
The organization invested the time to understand the problem.
— Studied and tested various solutions
— Shared knowledge among various staff and departments
The project was a collaborative effort, involving contributions
from nurses, physicians, clinical engineers, and IT personnel, as
well as the cooperation of the hospital’s monitor vendor.
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Massachusetts General Hospital
Experience
The hospital approached the incident in a transparent manner and
conducted a thorough system review that led to improvements in care
delivery including:
— Holding monthly drills in the ICUs, and timing how long it takes
members of the health care team to respond to alarms
— Arranging seminars and webinars on reducing false alarms, as well as
identifying proactive ways to safeguard against alarm fatigue
— Disabling the “off” switches on 1,100 cardiac monitors
— Installing more speakers to ensure alarms are clearly heard
— Sending low-battery warnings, as well as alarms for many potential lifethreatening changes in a patient’s condition, directly to nurses’ cell
phones and pagers
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NorthShore University Health System
Experience
Four-hospital system reviewed the status of clinical alarms on medicalsurgical telemetry units.
Multidisciplinary team consisted of staff nurses, clinical nurse
managers, clinical coordinators, physicians, risk management, nurse
educators, and biomedical engineering.
Two different monitoring companies were in the system; one unit
from each monitoring company was chosen for pilot testing.
— First pilot unit was a 24-bed progressive care unit. After intervention,
alarms dropped from 27,000 per month to less than 12,000 (56%
reduction).
— Second pilot unit was a 40-bed unit with alarms exceeding 114,332 per
month. After intervention, alarms dropped to approximately 15,000
(87% reduction).
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Christiana Health System Experience
Developed system-wide alarm policy and protocols:
Defined its alarm management strategy for alarmed medical
equipment, including remote continuous ECG monitors, standard
cardiac monitors, pulse oximeters, and infusion pumps
Resulted in:
Improved patient safety and environment of care
Shared sense of responsibility and additional support for nurses
Improved patient throughput
Key learnings:
An organizational approach to alarm standardization is important:
— Clinical staff work on multiple units and of various shifts
— Clinical staff must know what to expect from an alarm system
— Prevention of over-monitoring on one unit versus under-monitoring on
another
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Toolbox of Alarm Management Resources
AACN Practice Alert (http://www.aacn.org/practicealerts)
The Joint Commission proposal: 2014 National Patient Safety Goal on
Alarm Management
ECRI Institute (http://www.ecri.org)
Healthcare Technology Foundation (http://thehtf.org)
U.S. Food and Drug Administration Medical Devices
(http://www.fda.gov/default.htm)
Advancing Safety in Medical Technology Healthcare Technology Safety
Institute (http://www.aami.org/htsi/)
Industry partners
—
—
—
—
—
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Physiologic monitoring system manufacturers
Ventilator manufacturers
Infusion pump manufacturers
Pulse oximetry device manufacturers
Bed manufacturers
Wired and wireless communication systems manufacturers
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Bibliography
ECRI Institute. Top 10 health technology hazards for 2013. Health Devices. 2012;
41(11):1-23. Available at: https://www.ecri.org/FormsPages/ECRI-Institute-2013Top-10-Hazards.aspx. Accessed December 2, 2012.
Association for the Advancement of Medical Instrumentation Foundation/Healthcare
Technology Safety Institute (AAMI Foundation/HTSI). Safety innovations: using data
to drive alarm improvement efforts. The Johns Hopkins Hospital experience.
Available at: http://www.aami.org/htsi/SI_Series/Johns_Hopkins_White_Paper.pdf.
Accessed January 9, 2013.
AAMI Foundation/HTSI). Safety innovations: recommendations for alarm signal
standardization and more innovation. The Christiana Care Health System experience.
Available at: http://www.aami.org/htsi/si_series/christiana_care_alarm_signal.pdf.
Accessed March 7, 2013.
American Association for Respiratory Care (AARC). Consensus statement on the
essentials of mechanical ventilators—1992. Respir Care 1992; 37(9):1000-1008.
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Presentation Title
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