Transcript TOP 10 MOST FREQUENTLY SCORED STANDARDS

Alarm Fatigue and other EC/LS Hot
Spots for Clinical Managers
October 2011
Jennifer Cowel, RN MHSA
Speaker
Jennifer Cowel, RN MHSA
TJC Experience: Former TJC Hospital
Surveyor and former Director of Service
Operations in Accreditation in Central Office
 Accreditation and regulatory compliance
consultant
Vice President and Principal Patton
Healthcare Consulting
630-664-8401
[email protected]
Alarm Fatigue & Top Scored
What, Me Worry?
• Alarm Fatigue – JC Online Aug 2011
• Issue highlighted at TJC Executive Briefings
• 4 of the top 5 scored standards were in EC or
LS
• In 2011 - LSC days increased
• Surveyor Focus on industry trends
• Alarms have led to Immediate Threat
2012 Decision Categories
•
PDA
Ex: Immed Threat to Life or
falsification or fail to clear RFIs
after two tries when in CONT
Contingent
Accreditation
Ex: Failed AFS after 2 tries, or No
License, etc
Accreditation with Follow-upEx: Too many RFI’s
CoPs non compliant.
Survey (AFS)
Accredited
Ex: Compliant or
cleared all RFIs w/
ESC
Perspectives 11/2010
Alarm Fatigue
A Growing Problem
• FDA article reports 566 patient deaths
between 2005 – 2008, related to alarms
• The numbers are self reported and are likely
to be higher
• Twenty-five years ago, few, if any alarms on
equipment
• Today – increasing equipment and increase in
type & # of alarms
Alarm Fatigue
A high-profile Problem
• A patient on cardiac monitor died after V-Fib,
dysrhythmia processing turned off
• Perinatal monitor did not audibly alarm fetal
distress, only visual, went unnoticed
• A patient stopped breathing but staff just
didn’t hear the monitor
10 Years of TJC Focus
• Sentinel event alert in 2002 focus on clinical
ventilator alarms
• Introduced NSPG
• Moved clinical alarms to standards ‘05
• Participating in fall summit by AAMI, ACCE,
ECRI
• Problem continues to grow
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.
Taking a Good Thing Too Far
• Go beyond the visual/audible alarm, to cell
phone, pager alerts, dashboards, nurse call
systems
• Beyond the basics – bed alarms, chair alarms,
IV, call button, hand sanitizer.
• Study of alarms in critical care units
– 900 to 1300 alarms per day, per unit.
• Alarms every 66 seconds
Understanding the Issues
• FDA published results of 216 manufacturer
reports on monitor related deaths
• TJC analyzed sentinel events for monitor
related causes
Common Causes
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Staff are overwhelmed by the # of alarms
Staff don’t respond or hear alarms
Staff turn-off or turn down alarms
Alarm settings not returned to original setting
after a patient move
• Alarm not properly relayed to wireless or
paging system
Common Causes
• Nuisance Alarms reduce sensitivity
– As many as 99% of ICU alarms are false, or noncritical alarms
– No routine replacement of batteries, leads to
excessive “low battery” alarms
– Put a “ring” on it - The solution to many problems
or RCAs is to add an alarm on it to prevent
recurrence.
– Alarms just become back ground noise
Causes – Cont.
• The Sound of the Alarm
– 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.
– Sounds are difficult to learn, differentiate which
alarm
– Difficulty learning > 6 alarm signals
Causes – Cont.
• Alarm noise contributes to sound level in unit,
disrupts sleep and environment of healing
• Users can turn alarms off, change parameters,
reduce volume.
• Alarms are not tailored to the individual
patient
• Nurses block out noise to focus on task
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
Reducing False Positives
• A Johns Hopkins Study: lower SpO2 alarm
from 90& to 88% reduced alarms by more
than 50%
• Place delays on alarms, delay alarm by 15
seconds. Journal of Emergency Medicine
(JEM) study. Reduced false positives by 80%
• Get to only the alarms staff care about
Improving Safety of Alarms
Cont.
• 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
Improving Safety of Alarms
Cont.
• Alarm Notification Alternatives
– Consider central surveillance room with monitor
watchers than notify care givers
– Consider alarm integration systems that directs
alarms to devices worn by staff
Improving Safety of Alarms
Cont.
• 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
Improving Safety of Alarms
Cont.
• 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
Top Scored EC & LS Standards
• Surveyors see these everywhere, low hanging fruit
• These are seen by both the LSC surveyor and the
clinical surveyors
• Prevent them from seeing these at your organization
and create an impression on day 1
Exits and Cluttered Corridors
(LS.02.01.20 -57%)
Hospital maintains means of egress
• Easy to find issues, educate on:
– Blocked or locked egress doors
– Corridor clutter, storage in hallways
• Linen carts and latex carts will be scored
– Exit signs – burned out, enough, proper location,
– “No Exit” signs posted
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Fire Protection Features
(LS.02.01.10 - 57%)
Building & fire protection features minimize the
effects of fire, smoke and heat.
– Fire and smoke doors labeled, correct type, close,
label visible, under cut, door gaps, adhesive tape
over latch
– Penetrations are sealed with correct material – IT
cables biggest offender. Consider a work permit
and inspection
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Fire Doors, cont
• Inspect and maintain fire doors
– Appropriate fire rating on doors
and frame
– Door positively latches
– Door had a closure
– No gaps > 1/8 inch, or
undercut
>3/4 inch
– Resulted in ITL if multiple problems
Fire Protection Equipment
(EC.02.03.05 – 42%)
Hospital inspects, tests & maintains
fire safety equipment.
 Includes testing of: fire alarms boxes, smoke
detectors, sprinklers, portable extinguishers,
magnetic release devices, tamper switches
& water flow devices.
 If outsourced to a vendor keep the report, read the
report and act on problems!
 Make sure reports are tied to an inventory of devices
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Fire Extinguisher Dating
(EC.02.03.05 cont.)
 Month, day, year and initials of inspector
required per NFPA 10-1998
 They will review the tag
 If bar coded, they will review documentation
 Required monthly
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Fire Protection Equipment
(EC.02.03.05 – 42%)
Hospital inspects, tests & maintains
fire safety equipment.
 Includes testing of: fire alarms boxes, smoke
detectors, sprinklers, portable extinguishers,
magnetic release devices, tamper switches
& water flow devices.
 If outsourced to a vendor keep the report, read the
report and act on problems!
 Make sure reports are tied to an inventory of devices
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Medical Gas
(EC.02.05.09 – 20%)
• Hospital inspects, tests & maintains medical
gas and vacuum systems.
• Get vendor reports, fix problems noted
• Gas shut off valves must be labeled with
rooms they shut off. Staff must know who can
shut these off and when.
• Alarms must be working. Has led to ITL
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Provide/Maintain Fire Systems and Equip
(LS.02.01.35 33%)
Sprinklers
• 18 inch rule
• Sprinkler pipes can not support other items
like cables or wires
• Sprinkler head clean and free of obstruction,
collar flush
Medical Gas
(EC.02.05.09 – 20%)
• No parking zone!
• Get vendor reports, fix problems
• Gas shut off valves must be labeled
with rooms they shut off.
• Staff know who can shut these off
• Alarms must be working. Led to ITL
• Test & inspect & maintain medical gas
and vacuum per policy
Safe, Functional Environment
(EC.02.06.01 – 20%)
• Areas scored here: furnishing and equipment are in good
repair, the environment meets needs of patient.
• Ripped mattresses, cracked ceiling tile, mold, broken
wheel chair
• In behavioral health units do environmental risk
assessment for suicide risks. Either fix or implement
other safety interventions such as increase monitoring.
Document and keep your risk assessment. ( or scored at
EC.01.01.01)
Safety and Security
(EC.02.01.01 – 15%)
Hospital manages safety and security risks
• Complete risk assessments on areas of potential risk
• Scored in sensitive areas such as Labor and Delivery,
Pediatrics
• Trace your own policies, do staff stop you or surveyor
when they enter area?
• See unsecured O2 scored here JKC
Strategies for Success
Preparing Clinical Areas
• Rollout the Clinical Area Checklists
– Email them out, assign, implement, collect them
back, analyze compliance
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Involve/educate clinical & frontline staff
Everyone knows who to call to get fixed
Identify areas to improve, fix it, then reassess
Make LS an every day expectation!
Strategies for Success
Do Mock Surveys
• Conduct mock tracers in clinical areas
• Do EOC System Tracer during your Mock
survey
– Use the documentation checklist
– “show me where this is documented”
– Look for missing dates, think medication
refrigerators when doing this!
Strategies for Success
• Review your eSOC quarterly for updates,
completion of projects
• Validate that ILSM evaluations exist on paper
for each PFI on the eSOC
• Work with facilities staff and learn the
language
Strategies for Success
• Make use of the PPR to document compliance
– Record the name and location of each report that
documents compliance
– Helps during on-site survey!
• When in doubt, get clarity from SIG
Survey Process Preparation
• Before your next survey prepare for and/or
practice the following:
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Day one documents – surveyor planning session
Environment of Care system tracer
Document Review session *
Emergency Management system tracer
LSC building tour *
Now That You Know…
fix it
• Options for managing self identified deficiencies in LS.02.xx.xx
– LS.04.xx.xx
– Correct it immediately
– Fix in 45 days in corrective maintenance – document it.
– If it takes >45 days, create a Plan for Improvement (PFI) in
your e-SOC
– Consider equivalency request to TJC
Managing the Onsite Survey …
GOOD MORNING, WE ARE HERE FROM THE JOINT COMMISSION
• Validate ID on the extranet
• Institute your calling tree
• Everyone or their back up initiates the preplanned action.
• Rooms are freed up,
• Documents are rolled in, opening conference
starts. Optional information shows great
things only
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Institute the Action Plan
Everyone in Position
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QUESTIONS?
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