Transcript TOP 10 MOST FREQUENTLY SCORED STANDARDS

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
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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
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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 Alert
Recommendations
① Leaders ensure there is a process for safe
alarm management and response in highrisk 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 Alert
Recommendations
③ Establish guidelines for alarm settings. Define
when alarms are not clinically necessary
④ Establish guidelines for tailoring alarm
settings and limits for individual patients
(who can modify and when)
⑤ Implement routine inspections and
maintenance of alarm-equipped devices.
⑥ Staff training on above
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Sentinel Event Alert
Recommendations
⑦ Adhere to manufacturer instruction for
use, eg: replace single use leads, replace
batteries
⑧ Assess acoustics of alarm sounds
⑨ Set as a leadership priority
⑩ Establish a team to address
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New NPSG on Alarm Safety
NPSG.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
2014
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Many Variables
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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 illdefined
• 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
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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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