Clinical Alarm Management by Tuality P.I.N. The Professional Interdisciplinary Newsletter

Tuality HealthCare Clinical Alarm Management Joint Commission National Patient Safety Goal Tuality HealthCare Hillsboro, Oregon Clinical Alarm Safety Committee 10/2015 ÂŠ 2015 Tuality HealthCare All rights reserved

Plan: Reduce Alarm Fatigue and Improve Patient Safety Clinical Alarm Management & Alarm Fatigue

Act:

Key Performance Improvement Initiative

1. Create a Clinical Alarm Policy 2. Standardize Alarm Defaults 3. Initiate Alarm Interventions 4. Improve Alarm Documentation

Problem: Increase of Clinical Alarms & Alarm Fatigue

Study: Perform a Clinical Alarms Audit at Tuality HealthCare * PDSA: Rapid quality improvement cycle (Plan Do Study Act) ÂŠ 2015 Tuality HealthCare

Do: Identify and manage high frequency false alarms and alarm nuisance

Alarm Fatigue Incidence  566 incidents of patient harm due to alarm fatigue (FDA 2011)  80 alarm related sentinel events that resulted in patient death (Joint Commission 2013)  80-90% of all alarms are false, these statistics are probably under-reported (AHA 2014)

Over the last 30 years, Clinical alarms have increased significantly! In 1983 there were 6 alarms in an ICU. In 2011 there were >40 alarms in an ICU. Studies found that humans can differentiate among an average of 6 different alarm sounds. Alarm fatigue has been identified as a phenomenon where staff are frustrated with, immune to or tune out alarms due to becoming numb to the increased number of alarms in the health place, which could lead to unsafe responses that could be fatal to patients. (AACN 2013) ÂŠ 2015 Tuality HealthCare

Why reducing alarm fatigue is important in today’s workplace  As of July 1, 2014, leaders have established “Alarm System Safety” as a critical access hospital priority.  Hospitals have been tasked to identify alarm signals and determine how alarms are managed in the workplace to reduce alarm fatigue for it’s workforce and increase patient safety.  Standardization contributes to safe alarm system management. © 2015 Tuality HealthCare

Tuality identified the top 3 nuisance alarms that were of highest frequency with no clinical indication

• SpO2 <89% & lost signal

• Heart Rate >120 bpm & lead off

• Non-Critical Arrhythmias

#1 False Alarm

#2 False Alarm

#3 False Alarm

PCU 814 alarms/12 hour shift 53 alarms per patient (avg. census 15)

80 alarms per patient (avg. census 7)

Tuality developed a new Clinical Alarm Policy C-30G to address the following issues and concerns: 1. Determines the clinically appropriate settings for alarm signal defaults 2. When alarm signals can be disabled 3. When alarm parameters can be changed 4. Who in the organization has the authority to set/change alarm parameters 5. Who in the organization has the authority to set alarm parameters to â&#x20AC;&#x153;OFFâ&#x20AC;? 6. Responsibilities for monitoring, documenting and responding to alarm signals 7. Checking individual alarm signals for accurate settings, proper operation, and detectability

Clinical Alarm Policy C-30G Policy Objectives:  Defines 3 types of Patient Alarms: 1. Physiological Patient Alarms 2. Patient Care Alarms 3. Patient Assistive Alarms  Describes Staff Procedures & Responsibilities  Provides the Standardized Alarm Default Settings & Parameters © 2015 Tuality HealthCare

Physiological Patient Alarm Definition 1. Physiological Patient Alarms Alerting systems incorporated into medical instrumentation used for signaling staff or personnel that a baseline evaluation of patients vitals or condition has reached a critical threshold value or has fallen outside of Hospital standardized default settings. Some Physiological Patient Alarms Examples: • • • •

Cardiac Monitors Alarms Fetal Heart Tone Alarms Apnea Alarms Ventilator Alarms

Patient Care Alarm Definition 2. Patient Care Alarms Alert systems incorporated into medical instrumentation used for signaling staff or personnel that the patient’s treatment or intervention has been interrupted, has ceased or completed, requires continuation of programming or involves medical attention to evaluate and troubleshoot the patient care intervention. Some Patient Care Alarm Examples: • • • •

IV Pump Alarm PCA Pump Alarm Epidural Pump Alarm Feed Tube Pump Alarm

Patient Assistive Alarm Definition 3. Patient Assistive Alarms Non-physiological alert systems incorporated into patient assistive equipment used for signaling staff or personnel to respond to patient safety or mechanical issues, not related to a patients vitals or condition or interventional treatments. Note: Non-physiologicial alarms may be silenced, reset or reapplied by a competent certified direct patient care clinician Patient Assistive Alarms Examples: ● ● ● ●

Physiological Patient Alarms & Patient Care Alarms MAY ONLY BE ALTERED OR TEMPORARILY SILENCED by a Physician, Nurse or Respiratory Therapist This task may be delegated to a competent certified direct patient care clinician, if the task is within their scope of practice in the State of Oregon.

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g n i P g n i P

Personnel & Staff Alarm Responsibilities  Registered Nurses: Based on clinical assessments, nurses must ensure that all alarms are set to activate at the appropriate setting for each patient and are sufficiently audible with respect to distances and competing noise within the unit.  Respiratory Therapy: Set up and monitor settings for ventilatory equipment, including alarm limits, function and audibility.  Biomedical Engineering: performs regular preventative maintenance on all patient care equipment which includes performance and alarms testing.  All Other Personnel: Alert the appropriate clinician of clinical alarms. © 2015 Tuality HealthCare

Alarm Default Settings and Parameters  Nursing should be aware that Physician orders are not required to change default parameters, however documentation in the EMR of alterations and changes to alarms are required.  Standardized default settings are pre-programmed by Tuality BioMed for all “physiological patient alarm” monitoring systems.  Clinical alarm values will revert back to default settings when systems are reset for a new patient or turned off.  Nursing may determine individualized alarm settings for each patient based on the patients clinical status and baseline.

Tuality New Standardized Alarm Default Settings Physiological Parameter Heart Rate/High Heart Rate/Low Respiratory Rate/High Respiratory Rate/Low Sp02/Low Systolic Blood Pressure/High Systolic Blood Pressure/Low Diastolic Blood Pressure/High Diastolic Blood Pressure/Low Mean Arterial Pressure/High Mean Arterial Pressure/Low Apnea (Respiratory Pause) Fetal Heart Tones/High Fetal Heart Tones/Low

Standardized Adult Settings 130 bpm 50 bpm 30 breaths/min 10 breaths/min 89% 200 mmHg 90 mmHg 120 mmHg 40 mmHg 120 mmHg 50 mmHg 20 secs ÂŠ 2015 Tuality HealthCare

Family Birth Unit Neonate Settings 160 bpm 110 bpm 60 breaths/min 30 breaths/min

60 mmHg 30 mmHg

160 bpm 110 bpm

Required Alarm Documentation in the Electronic Medical Records for changes and alterations to settings

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New EMR Documentation Shift Report SBAR Format for Alarms

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At no time shall any clinician, including physicians, shut off or adjust medical equipment alarm volumes to an

Alarm Volume Guidelines & Exceptions

INAUDIABLE LEVEL!

 Non-nursing staff may not independently silence , turn off or alter Physiological Alarms or Patient Care Alarm settings or audibility levels.

Buzzz

OFF

 Monitor Telemetry Techs & CNA’s are responsible to immediately respond to all alarms by assessing the patient and/or following the chain of command notification process when alarms occur.  Alarm changes may be delegated to a competent certified direct patient care clinician.

Alarm Nuisance Interventions Intervention: Prep skin for ECG electrodes by: 1. Washing area with soap and water 2. Wiping with a rough washcloth or gauze 3. Removing excessive hair 4. Roughen skin with electrode sandpaper

Rationale: One stroke of an abrasive surface can reduce artifacts caused by the electrode-skin interface. Proper skin preparation before ECG electrodes are placed decreases skin impedance and signal noise, thereby enhancing conductivity. False signals are recorded when there is poor electrode contact.

Sandpaper Backing

(AACN Practice Alert 2013)

R U B ÂŠ 2015 Tuality HealthCare

Alarm Nuisance Interventions Intervention:

Changing electrodes daily can decreases lead failure by 46% Rationale:

Changing ECG electrodes daily can decrease the number of false alarms due to the electrode gel drying out or electrodes peeling off due to sweat and increased mobility or patient movement.

(AACN Practice Alert 2013)

ÂŠ 2015 Tuality HealthCare

Alarm Nuisance Interventions Intervention: Customize (increase) delay time settings and (decrease) threshold percent settings on SpO2 monitors to meet the patients baseline status Rationale:  The combination of both customized alarm delay and threshold settings optimizes the SpO2 monitor to its highest potential. Delaying a setting on the SpO2 alarm to 15 seconds or 19 seconds can reduce the frequency of alarms by 50% and 70%, respectively.  When the SpO2 alarm threshold was reduced from 90% to 88%, the number of alarms decreased by 45%.  When both a 15-second delay and an alarm threshold of 88% were applied, a “six-fold reduction” was demonstrated in the number of SpO2 alarms.

Alarm Nuisance Interventions Intervention:

Monitor only those patients with clinical indications for monitoring Rationale:

 An example of a false alarm is the alarming of “irregular rhythm” on the cardiac monitor for a patient who has chronic atrial fibrillation. Because the patient’s baseline rhythm is irregular, this alarm has no clinical relevance.  The American Heart Association developed guidelines for ECG monitoring in hospitalized patients, specifying who should be monitored and for how long.  85% of patients with no indication for monitoring had cardiac monitoring in place. (AHA standards 2011)

(AACN Practice Alert 2013)

Ta k e Ac t ion Now - Avoid Ala r m F a t igu e La t e r

ÂŠ 2015 Tuality HealthCare

Case Scenarios #1 A nurse is caring for a patient with chronic obstructive pulmonary disease whose resting SpO2 is 89-90% on 2L oxygen. The patient desaturates to 86% while ambulating, talking or eating but recovers within 20 seconds to 89% at rest. It would be appropriate for the nurse to make which of the following alterations to the patientâ&#x20AC;&#x2122;s SpO2 alarm? A. Turn off the SpO2 alarm when the patient ambulates, talks or eats B. Call the MD for orders to change the SpO2 settings C. Decrease the low threshold to 86% and increase the delay to 20 seconds ÂŠ 2015 Tuality HealthCare D. Continue the current default setting at 89%

Case Scenarios #2 A Clinical Nursing Assistant 2 immediately responds to a patients room after being alerted to multiple sounding alarms. The Clinical Nursing Assistance hears 2 alarms ringing. The patient is climbing out of bed causing it to activate the rapid call light alarm and the IV pump is chirping and flashing. Which of the following patient alarm/s may the Clinical Nursing Assistant 2 silence, reset or reapply? A. Bed Alarm B. IV Pump C. Bed Alarm and IV Pump D. None of the above ÂŠ 2015 Tuality HealthCare

Case Scenarios #3 A Physical Therapist enters a patient room to provide routine rehabilitation and ambulatory therapy services. The patient is connected to IV fluids, SCDâ&#x20AC;&#x2122;s and a CPM (Continuous Passive Movement) machine to the left leg. It would be appropriate for the Physical Therapist to perform which of the following? A. Remove the SCDs and only treat the right leg in bed B. Disconnect the CPM, SCDs and ambulate the patient with IV fluid running C. Ask the nurse to disconnect all treatments and lines for rehabilitation D. Disconnect the CPM, SCDs and silence the IV pump alarm while ambulating ÂŠ 2015 Tuality HealthCare

Case Scenarios #4 A nurse has determine that it is necessary to make a change to the patientâ&#x20AC;&#x2122;s physiological alarm settings based on the patientâ&#x20AC;&#x2122;s conditional baseline to remove nuisance alarms and decrease alarm fatigue. The correct procedures and responsibilities for this nurse include which of the following? A. Chart alarm changes in the EMR including new value and reason for change B. Report the alarm changes at shift report using SBAR summary page C. Reset the alarm setting back to the original defaults at the end of their shift D. A & B Only

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Case Scenarios #5 A nurse in the recovery room is providing continuous visual monitoring at the bedside post operatively and has turned off all the physiological alarms. This is a clear violation of the New Clinical Alarm Policy? A. True B. False

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Case Scenarios #6 Which of the following interventions can clinicians implement to reduce alarm fatigue? A. Proper skin prep before applying electrodes & changing electrodes daily B. Monitor only those patients who have clinical indication for monitoring C. Customize alarm parameters and delay settings based on patients baselines D. All of the above

ÂŠ 2015 Tuality HealthCare

References:  Sendelbach, Sue RN, PhD, CCNS, FAHA; Jepsen, Stacy MSN, APRN, ACNS-BC, CCRN. 2013. Alarm Management American Association of Critical Care Nurses: Approved by the AACN EvidenceBased Practice Resources Work Group, April 2013 Website Retrieved 9/2015: http://

www.aacn.org/wd/practice/content/practicealerts/alarm-management-practice-alert.pcms?menu=practice

 Joint Commission Warns of Alarm Fatigue Multitude of Alarms From Monitoring Devices Problematic Mike Mitka, MSJ JAMA. 2013;309(22):2315-2316. doi:10.1001/jama.2013.6032. http ://jama.jamanetwork.com/article.aspx?articleid=1696094

 Sue Sendelbach, RN, PhD, CCNS, FAHA Stacy Jepsen, MSN, APRN, ACNS-BC, CCRN Approved by the AACN Evidence-Based Practice Resources Work Group, April 2013. http:// www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf  http://www.aacn.org/wd/practice/content/practicealerts/alarm-management-practice-alert.pcms? menu=practice