Volume 11
Issue 5
March 4, 2016
PRESBYbulletin Penn Presbyterian Medical Center
Tackling Alarm Fatigue Alarm fatigue occurs when care providers become desensitized to the sound and may fail to respond when the alarm finally portends a true, clinically significant event. Alarm fatigue is a well-documented problem in critical care. In fact, The Joint Commission’s sentinel event database includes reports of 98 alarm-related events between January 2009 and June 2012. Of the 98 reported events, 80 resulted in death. Now, a team at Penn Presbyterian is tackling the issue by rolling out an initiative aimed at decreasing nuisance alarms at PPMC. Last month, Patricia O’Brien, MSN, RN, CRNP, Maria Carpenter, MSN, RN, AG-CNS-BC, CCRN, and Laura Solano, MSN, RN, CCNS, PCCN, CCRN-K, hosted a grand rounds presentation and discussion focused on clinical alarm management and reducing unnecessary alarms. Unlike clinically relevant alarms, where a diagnostic or therapeutic decision is required to resolve a problem, nuisance alarms indicate that a parameter has been violated, but does not require clinical intervention. “In assessing our alarm management, we analyzed cardiac monitor data in three PPMC units in August 2014 and found that an alarm sounded in the MICU once every 1.2 minutes, in the former CCU once every .69 minutes, and on the former 4-East unit once every 1.8 minutes,” said O’Brien, a nurse unit based educator in the MICU. Solano, a clinical nurse specialist, noted that nationally, nurses spend roughly 16 to 35 percent of their time responding to alarms. “Alarms are meant to redirect our attention from something less important, to something more important. And yet, up to 80 percent of clinical alarms are not actionable.” Nurses distracted by these ongoing noises are at risk of losing concentration and experiencing other stress related symptoms, and can fall behind in their work if they err on the side of caution and check every alarm immediately. And, as Carpenter pointed out, the harm of non-clinical alarms stretches beyond the patient’s health and safety. False alarms, she said, affect the trust that patients and their families place in a care team. “Imagine sitting in your relative or friend’s room, and alarms keep sounding but are going unanswered. Unless you work in a clinical space, you’d probably think your friend or family (continued on back)
RELIGIOUS HOLIDAYS IN MARCH Several holidays in the Hindu, Christian and Jewish traditions occur in March. These events can add deep meaning to patients and families being affected by illness and can become great sources for hope and solace amid health crises. However, they can also cause patients to feel “far from home” as hospitalization may disrupt their normal celebration. For most Christians in the West, following the Gregorian liturgical calendar, Sunday, March 20 (Palm Sunday) marks the beginning of Holy Week, which ends with Easter on Sunday, March 27. Also this month, Hindus will celebrate Maha Shivaratri on Monday, March 7, and Holi on Wednesday, March 23. The Jewish celebration of Purim begins at sundown on Wednesday, March 23rd, and continues through day of Thursday, March 24th.
Tackling Alarm Fatigue (continued from front)
member was being ignored, and potentially put in danger,” said Carpenter, a clinical nurse specialist for 3-south. “Patients and their families want to know that we are focused on what is important and relevant to their care and recovery, and we know from feedback we’ve received in surveys that it doesn’t instill confidence to be told that an alarm doesn’t mean anything. It simply leaves the patients and their loved ones confused and feeling like we don’t care.” Recognizing that alarm management is a necessary part of clinical care, guides have been developed to help clinicians assess the risks associated with alarms. And, as part of the project currently underway at PPMC, data is being gathered so that recommendations may be provided to each unit to guide them in further optimizing their monitor default settings for their patient population. “Alarm Management Strategies must be carefully thought out, tested, and continuously evaluated to assure achieving the right balance of patient safety and quality of care with the reduction/elimination of alarm fatigue,” said Solano. “With an eye toward improving patient care by reducing alarm fatigue, we’re currently reviewing contributions from all RN’s and RCP’s on clinical alarm management, and encourage staff to seek out nuisance alarms in their areas and work together to find solutions.”
Last Chance to Purchase Tickets for the PPMC 15th Annual Gala!
penn presbyterian medical center board of trustees, administration & faculty invite you to the 15th annual gala March 18, 2016 6pm - 9pm
food, music, silent auction & high spirits
BUILD A NEW YOU IN THE NEW YEAR! Last November, the Healthy Rewards Wellfocused program rolled out Build A NEW You, a campaign to help build awareness of your current health status and help you take steps to improve or maintain your good health. Throughout November and December, the focus was on emotional health and well-being. There were new challenges in the Healthy Rewards site focusing on sleep, setting your schedule, and other things to reduce stress. There were also Stress Management techniques lunch n’ learns offered onsite at nine locations across the Health System. Since we began the new year, new programs and initiatives have been announced focusing on knowing your numbers, physical health, and good nutrition. Make sure you know your numbers and health risks by completing the online well-being assessment in the Healthy Rewards site and by receiving an onsite biometric screening (when they are offered) or regularly checking in with your doctor. You’ll learn about your BMI, cholesterol, blood pressure and glucose levels. You’ll also earn 500 Healthy Rewards points when you complete the well-being assessment and get your annual biometric screening! If you visit your doctor during the year, don’t forget to take the Health Provider Screening with you and fax it in after you receive your results. You can download it from the Know Your Number Challenge under “My Plan” when you log onto the Healthy Rewards web site. Be on the lookout for more onsite activities to participate in to help you earn some extra healthy reward points.
$150 per Ticket | Complimentary Valet Parking Provided
Proceeds benefit Penn Heart and Vascular at PPMC Business Casual | RSVP by March 11, 2016 Visit PennMedicine.org/WorldsFair Questions? Contact Sally Barsh at 610.715.9508 or PPMC.Benefit@uphs.upenn.edu Contact Us: Katie Delach | katie.delach@uphs.upenn.edu | http://news.pennmedicine.org/inside/presbybulletin/