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Wake up! This is alarming! ALARM FATIGUE Kara Polichetti 1 © ECRI Institute 2011 What is Alarm Fatigue? Alarm fatigue occurs when clinical personnel fail to respond appropriately to alarms due to excessive or inability to understand the priority or critical nature of alarms. As a result, clinical personnel will be desensitized to alarms, and will ignore them and even turning them off. 2 http://www.youtube.com/watch?v=9rdcso5cpN8 © ECRI Institute 2011 3 An Alarming Challenge More and more devices with alarms More and more patients are connected to one – or many alarm-based devices 150-400 alarms per patient per day can be typical in a critical care unit Alarm-based devices are not standardized in many institutions Flexible alarm setting features allow for inconsistent use of alarms 4 Alarm Management is Complex 5 Culture Conundrum It’s not my job! We don’t have any problems. We’ve never had an alarm event. No foundation for improvement 6 It’s the vendor’s fault! ALARM FATIGUE Why is it important? The Food and Drug Administration (FDA) received 566 reports of patient deaths related to alarms on monitoring devices from 2005 through 2008 The ECRI Institute has identified alarm hazards as their number 1 top hazard for 2012 JCAHO recognized Alarm Fatigue as critical and integrated this into their accreditation standards 7 The Consequences are Alarming And Still in the News “Alarm Fatigue” a Concern for New Haven Hospitals. New Haven Register, June 11, 2011 8 A Typical Event “Patient admitted with chest pain and shortness of breath---Was on a monitored unit. At 3:25 am, patient’s nurse noticed the leads were off and on checking on the patient found him in the bathroom unresponsive. Resuscitation efforts were unsuccessful. Monitor showed the leads had come off at 2:32 am …” Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis, A Pennsylvania Patient Safety Advisory Supplemental Review, March 2008 9 Example of Alarm Fatigue Ventilator-dependent patient – frequent coughing Coughing triggers high-pressure alarm Frequent response to alarm by nurse with no real problem Pressure alarm limit increased to minimize the number of false-positive alarms An accident waiting to happen Patient movement crimps breathing circuit Secretions clog the endotracheal tube Inadequate ventilation (inhalation or expiration) 10 Some Questions to Ask Does the nurse understand the purpose of the high-pressure alarm? Was the nurse’s competence in ventilator use validated? Does the hospital have a policy for who can and cannot set ventilator alarms? Is there a policy on how ventilator alarms should be set? If so, is it generic or does it consider specific circumstances? Does the hospital have ventilator responsive-valve features, which can reduce nuisance high-pressure alarms? 11 Causes Studies have shown as many as 99% of ICU alarms are false or non-critical alarms. These are called nuisance alarms and are the leading contributor to alarm fatigue Alarms fail to function as expected It is difficult to distinguish which machine's alarm is going off Nurses may block out noise in order to concentrate on current task. 12 NURSES PROBLEMS? Nurses have an overabundance of notifying devices (nurse calls, pagers, phones, overhead pagers, and monitor alarms) Lower patient to nurse ratios increase the number of relevant alarms per nurse Monitors with undirected alarms alert all nurses instead of specific nurses 13 Problem Reporting Data Underreporting Some estimates suggest that the actual number of alarm-related deaths is ten-fold higher or more than what problem data shows Ability to do analytics on data is very limited I literally had to read every report (around 20) in a recent problem reporting analysis Actual reports often don’t have much information Typical language (paraphrased) - During use of device alarm did not sound and patient died 14 15 16 How can we improve? 16 Assess if sufficiently staffed with enough nurses How many nuisance/false-positive alarms are there in the unit per day Tiered response system would allow for quicker response time and delegation Set individual parameters Actionable/tailored alarms would create less nuisance alarms The combination of all alerts to one device, "Smart alarms" to monitor multiple device in relation to each other Centralized monitoring with allocated staff member to alarm personnel Pop up screens EDUCATION & TRAINING!!! References Borowski, M., Gorges, M. & Fried, R. (2011). Medical device alarms: biomed tech. 56(2): 73-83 ECRI Institute. Alarm related terms. Paper presented at the advancing safety in medical science clinical alarms 2011 summit. Herndon, October 4-5, 2011. FDA: US Food and Drug Administration. (2011). FDA patient safety news: alarm monitoring problems. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript-rss.cfm?show=106. Accessed July 10, 1012. Graham K., & Cvach, M. (2010). Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. American journal of critical care. 19(1): 28-34 Korniewicz, D & Kenney, B. (2012). Precenting ventilator alarm fatigue: before you silence that next nuisance alarm, be sure to read this article. Advance for nurses. 5(1): 15-18. Lynn L. & Curry, J. (2011). Patterns of unexpected in-hospital deaths: a root cause analysis. Patient safety in surgery. 5(1):3 Taenzer A., Pyke J. & McGrath, S. (2011). A review of current and emerging approaches to address failure-to-rescue. Anesthesiology 115:421–31 17 THANK YOU!!! 18