Hüske Kraus, Dirk - Alarmierende Alarme Präsentation 2016
Transcription
Hüske Kraus, Dirk - Alarmierende Alarme Präsentation 2016
Alarmierende Alarme: „Alarm fatigue“ auf der Intensivstation Ursachen, Auswirkungen und Gegenmaßnahmen Dr. Dirk Hüske-Kraus – Clinical Director M2O Services – Philips Medizinsysteme Böblingen Eine nichtmedizinische Einführung… “A similar accident took place on 5 October 1999 at Ladbroke Grove. […] It was again caused by a driver passing a signal at danger[…] As a result 31 people died […] and a further 227 passengers were taken to hospital. […] It was found that the driver of the local train had cancelled the AWS alarms at the single yellow and double yellow aspect signals preceding the red signal SN109...”1 “The authors concluded that his action of depressing the acknowledge button had become a conditioned response, a phenomenon that was not uncommon amongst conductors.”2 There was another Brady alarm (38 < 40) which sounded at 2:12:39 which was superseded by an Asystole alarm some thirty seconds later which was silenced by the user five seconds later. The Brady alarm limit was changed from 40 to 38 but the patient’s ECG had dropped to 17 where a Brady alarm sounded at 02:13:56 (***BRADY 17 <38) and was silenced some 5 seconds later by the users. From 2:14:03 to 02:44:00 there were 11 Asystole alarms silenced by the users. Per the alarm logs the device appears to be performing normally and the alarms annunciating appropriately. It does not appear that the device caused or contributed to the patient event.3 1 20.4.2016 Dr. Dirk Hüske-Kraus Beispiele Federal investigators concluded that “alarm fatigue’’ experienced by nurses working among constantly beeping monitors contributed to the death of a heart patient at Massachusetts General Hospital in January. In a report released yesterday, the investigators said 10 nurses on duty that morning could not recall hearing the beeps at the central nurses’ station or seeing scrolling tickertape messages on three hallway signs that would have warned them as the patient’s heart rate fell and finally stopped over a 20-minute span. Additionally, federal investigators said the volume for a separate audible crisis alarm on the patient’s bedside monitor was turned off the night before by an unknown person. Mass. General executives had previously told the Globe that this crisis alarm had been inadvertently turned off. But investigators for the Centers for Medicare & Medicaid Services said that desensitization to alarms that actually sounded also was a factor in the patient’s death. […] link 2 20.4.2016 Dr. Dirk Hüske-Kraus Beispiel aus GB An elderly hospital patient suffered severe brain damage and died after staff turned down the volume on an alarm system monitoring his heart. David Bough, a 65-year-old driving instructor, was in hospital waiting to have a defibrillator device fitted to his heart when it stopped beating. But because staff at the University Hospital of North Staffordshire cardiology unit could not hear the alarm, it was 15 minutes before they realised Mr Bough was in grave danger. They were alerted by his daughter, Marie McHugh, who was unable to get a response from him when she came to visit and noticed a warning light flashing on the equipment. Doctors were able to restart Mr Bough’s heart, but his brain had been starved of oxygen and he died six days later. An investigation found the volume of the heart-monitor alarm had been turned down to 40 per cent of its maximum on November 21, 2008. The speakers had also been turned the wrong way and covered in paperwork.[…] link 3 20.4.2016 Dr. Dirk Hüske-Kraus Noch ein Beispiel (D – OP) Der Anwalt erhob schwere Vorwürfe gegen die Medizinerin und warf ihr eine "glatte Lüge" bei der Aufklärung der Todesumstände vor. "Das Schockierende für mich ist, dass die Horrorzustände in der Klinik kein Einzelfall waren. […]Es lag keine Verkettung unglücklicher Umstände vor, sondern eine Kumulation von Sorgfaltspflichtverletzungen." Sie sitzt zusammengefallen da während der Aussage des Gutachters, die Züge angespannt, eine gezeichnete Frau. Nach Carolin Wosnitzas Tod ist sie schwer depressiv geworden, wurde mit Alkohol am Steuer erwischt, musste ins Gefängnis. Sie ist hochverschuldet, hat ihren Beruf aufgegeben. 4 20.4.2016 Aber es ist zum Beispiel kaum zu verstehen, dass keinem Arzt oder Pfleger im OP auffiel, dass das akustische Signal nicht funktionierte, das während der Operation mit jedem Herzschlag einen Ton abgibt. Ist kein Herzschlag mehr da, kommt ein Warnton. Müsste ein Warnton kommen. In der Alsterklinik blieben die Apparate stumm. Marion F. bemerkte den Herzstillstand erst, als die "stark gebräunte Patientin auffällig blass" wurde. Der Richter versucht, das nachzuvollziehen: "Das kennt man doch auch aus dem Fernsehen: Das fällt doch auf, wenn der Ton ausfällt", sagt er. "Na ja, das ist so ein Dauerton", antwortet die Angeklagte. Den höre sie schon seit 20 Jahren, er sei ihr "nicht mehr bewusst". Dr. Dirk Hüske-Kraus Alarm fatigue Definition Alarm fatigue (Alarmmüdigkeit) ist eine “Desensibilisierung” klinischen Personals durch zu viele irrelevante Alarme medizinischer Geräte. 5 20.4.2016 Dr. Dirk Hüske-Kraus Noch mehr Beispiele (OP und Aufwachraum) One such dentist recognized an alarm as a sudden decrease in the pulse oximeter reading. He replaced the oximeter probe on several different fingers and then on several fingers of the opposite hand in an attempt to get a normal reading, but the readings were all still abnormal. He then requested a pulse oximeter from another operatory and that also appeared to be faulty until the patient eventually suffered a hypoxia-induced cardiac arrest.1 The parents of Mariah Edwards won a $6 million malpractice settlement after their 17-year-old daughter died last year following a tonsillectomy at a Pennsylvania surgery center. After the surgery, the high school junior was given a potent painkiller that slowed her breathing. By the time nurses checked on her 25 minutes later, she had suffered profound and irreversible brain injury. She died 15 days later. […] A nurse said in her deposition that the alarm on the respiratory monitor was muted, said Joel Feller, an attorney for the family. After Edwards’ death, the center announced several changes, including that alarms would no longer be muted. 6 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue: Die Fakten • Zwischen 150 und 350 Alarme pro Patient und Tag überfluten ITS-Mitarbeiter1-3. Oft konkurrieren verschiedene Geräte nahezu ununterscheidbar um Aufmerksamkeit4-7. • Lebensbedrohliche Situationen können durch Fehlalarme überdeckt werden, Alarmmüdigkeit kann zu Todesfällen führen8-9 • Zu viele Alarme unterbrechen pflegerische Tätigkeiten, desensibilisieren das Personal und erhöhen den Streß für Patienten10 7 20.4.2016 Dr. Dirk Hüske-Kraus 150 ‐ 350 Alarme pro Patient und Tag Alarm fatigue: Auswirkungen Häufige, irrelevante Alarme Stress, kognitive Belastung Unnötige Arbeitslast Häufige Unterbrechungen v. Pflegetätigkeiten Fehler und Auslassungen Mitarbeiter‐ zufriedenheit MA‐Gesundheit MA‐Bindung 8 Effizienz 20.4.2016 Desensibilisierung und Überlastung Unangemessene Reaktionen a. Alarme Schlafphasen circadianer Rhythmus gestört UE & Komplikationen Dr. Dirk Hüske-Kraus “Noise pollution” & “Hyperaktivität im Patientenzimmer” Patienten‐ zufriedenheit Reputation Alarm fatigue: Ursachen Anpassung von Alarmgrenzen auf Patient & klinische Situation Disziplin: Hautvorbereitung, Maßnahmen am Patienten, Pat. aus Bett Insuffiziente Sensoren: Qualität, Lebensdauer Verwendung alarmreduzierender Funktionen proaktives“ Monitoring Schwellwertlogik oft inadäquat „Overmonitoring“ Alarm „broadcasting“ Häufige, irrelevante Alarme 9 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue: Handlungsoptionen 43% Alarmreduktion1, wenn Mitarbeiter die Alarmgrenzen an den Patienten(-status) anpassen 47% Reduktion der Alarmfrequenz2,3 durch Verzögerungsintervalle bei potentiell selbstkorrigierenden Ereignissen, z.B. leichte, transiente SpO2-Entsättigung Alarmreduktion2,4,5 durch Vermeidung von Alarmen bei Maßnahmen am Patienten 45% Reduktion3 der SpO2 Alarme durch Schwellwertsenkung 90% -> 88% Alarmreduktion6 durch täglichen Elektrodenwechsel 10 20-44% 70% 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue: Handlungsoptionen Anpassung der Grenzen an Situation/Status Disziplin: • Hautvorbereitung • Maßnahmen am Patienten „Alarm policy“ Verbrauchsmaterialien & Sensoren Training/Schulung Alarmverteilung Monitoring: • Proaktiv • Multiparameter • Alarmreduzierende Funktionen 11 Monitoring nach Indikation – Overmonitoring Konfiguration • Brauchbare Grenzwerte • Profile passend zum Patienten (-status) 20.4.2016 Dr. Dirk Hüske-Kraus Regelmäßiger Elektrodenwechsel Alarm fatigue auf der ITS: Caveat 12 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue: Handlungsoptionen In God we trust. Anybody else bring data! Kreiskrankenhaus, NL 26.1 rote Alarme pro Tag und Bett (gesamt 264) Kreiskrankenhaus, F 92.2 rote Alarme pro Tag und Bett (gesamt 268) Universitätsklinik, F 5.6 rote Alarme pro Tag und Bett (gesamt 93) 13 20.4.2016 Dr. Dirk Hüske-Kraus Städtisches Krankenhaus, D 7.6 rote Alarme pro Tag und Bett (gesamt 382) Ergebnisse Projekt in Nieuwegein, NL • 40% nachhaltige Reduktion vermeidbarer Alarme • In Kooperation mit den klinischen Mitarbeitern • Mitarbeiterzufriedenheit • Patientenzufriedenheit Für „Kostenrechner“ 14 Alarm 40% Betten Auslastung 12 90% 145 Alarme pro d und Patient 3950 Patiententage p.a. Alarm absolut 574.000 p.a. MA‐Bindung / Alarm 5s 800 MA‐Stunden p.a. , 0,5 FTE 20.4.2016 Dr. Dirk Hüske-Kraus Projektüberblick Beteiligte Status & Empfehlungen Umsetzung (opt.) Nachkontrolle 15 Arbeitspakete Zeit Ergebnisse Kunde Pflege: 3 Tg Ärzte: 2 Tg Med. Tech. 0,5 Tg Philips Consultants Data analyst Application Sp. Interviews, shadowing Quick‐wins identifizieren & umsetzen Datenanalyse Empfehlungen 3‐6 Wochen “Baseline Assessment”‐Bericht • Detailanalyse • “Quick win”‐Ergebnisse • Empfehlungen • Benchmark Pflege: 5 Tg Ärzte: 2 Tg Med. Tech 1 Tg Consultants Data analyst Application Sp. Umsetzung der Empfehlungen Training Konfiguration Datenerhebung & ‐analyse Übergabe 3‐6 Wochen Abschluss‐Bericht • Übersicht über alle Aktivitäten • Vorher‐Nachher‐Vergleich • Weitere Empfehlungen • Benchmark Pflege: 1Tg Ärzte: 0,5Tg Consultant Data analyst Datenanalyse Empfehlungen 20.4.2016 Dr. Dirk Hüske-Kraus 2‐4 Tage Bericht • Entwicklung • Empfehlungen Beispiele (präinterventionell) 16 20.4.2016 Dr. Dirk Hüske-Kraus Beispiele (während Intervention) 17 20.4.2016 Dr. Dirk Hüske-Kraus Was lehrt uns das? Das Problem „Alarm fatigue“ 18 Das Vorgehen 20.4.2016 Das Ergebnis Dr. Dirk Hüske-Kraus Vielen Dank für Ihre Aufmerksamkeit Dr. Dirk Hüske-Kraus – [email protected] ! 19 20.4.2016 Dr. Dirk Hüske-Kraus Backup slides 20 20.4.2016 Dr. Dirk Hüske-Kraus Noch ein nichtmedizinisches Beispiel… “A cascading series of events caused the computer to notice SEVEN HUNDRED things wrong in the first few minutes of the accident. The ONE audible alarm started ringing and stayed ringing continuously until someone turned it off as useless. The ONE visual alarm was activated and blinked for days, indicating nothing useful at all. The line printer queue quickly contained 700 error reports followed by several thousand error report updates and corrections. The printer queue was almost instantly hours behind, so the operators knew they had a problem (700 problems actually, though they couldn’t know that) but had no idea what the problem was.”1 Akute Überlastung Three Mile Island, 28.3.1979, 4 a.m. 21 20.4.2016 Dr. Dirk Hüske-Kraus Mehr Beispiele… The second patient death in four years involving “alarm fatigue’’ at UMass Memorial Medical Center has pushed the hospital to intensify efforts to prevent nurses from tuning out monitor warning alarms. Nurses exposed to a cacophony of beeps may no longer hear them or begin to ignore them, and that’s what appears to have happened in the latest case: A 60-year-old man died in an intensive care unit after alarms signaling a fast heart rate and potential breathing problems went unanswered for nearly an hour, according to state investigators who reviewed records at the hospital. The death occurred in August 2010 but was not reported to the state Department of Public Health until this spring. The state cited various violations by the hospital, including not responding to alarms “in a timely manner.’’[…] [A previous patient’s] death in 2007 led the hospital to adopt aggressive measures to improve nurses’ responses and tackle alarm fatigue, which can occur when nurses hear alarms - many of them false - all day long. But the new death shows the problem continues, as it does at hospitals nationwide. It has led to at least 200 patient deaths since 2005 and likely hundreds more, according to a Globe investigation published earlier this year. link 22 20.4.2016 Dr. Dirk Hüske-Kraus Noch mehr… DES MOINES, Iowa -- An Iowa man died at a Des Moines hospital in March after a nurse deliberately shut off the alarms used to monitor patients' conditions, newly disclosed state records show. Michael Deal, a 65-year-old Army veteran from Spirit Lake, died March 29 at the VA Central Iowa Healthcare System hospital. Bernard Nesbit, a registered nurse in the hospital's telemetry unit where patients are kept for continuous monitoring, was subsequently fired for having turned off an array of alarms that were hooked up to all of the patients in that unit. […] "We found the patient unresponsive, ashen, pale, cyanotic and unresponsive. … Daryle check(ed) for a pulse as we began calling out to the RNs, requesting a Code Blue be called. … He said that he later checked the patient monitors and it appeared that all of the alarms in the unit had been shut off for roughly three hours. During that time, Deal's blood-oxygen level dropped "slowly" from a normal level in the 90s to the 30s — a dangerously low level — for 45 minutes before he and Jager realized what had happened. link 23 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue auf der ITS Epidemiologie: US-endemisch? D F 2008 US 2007 Artikel zu “Alarm fatigue” UK 300 200 100 2014 2013 2012 2011 2010 2009 2006 2005 2004 2003 2002 2001 2000 0 FDA erweitert Review medizinischer Geräte wg. 'alarm fatigue‘, erwähnt 566 “alarm‐ related patient deaths” Joint Commission: Nationales Patientensicherheitsziel “Clinical Alarm Safety” ECRI: “Alarm Hazards” Nr. 1 der “Health Technology Hazards 2015” (‘14, ‘13, ‘12…) 24 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue Definition ECRI Wikipedia Alarm fatigue occurs when one is exposed to a large volume of alarms and as a result, becomes desensitized to the firing alarms. Desensitization can lead to longer response times or failure to acknowledge important alarms. Alarm fatigue is sensory overload in clinicians who are exposed to an excessive number of alarms, which can result in desensitization to alarms and unacknowledged alarms. Patient deaths have been attributed to alarm fatigue. “Alarm fatigue” (Alarmmüdigkeit) ist eine Desensibilisierung klinischen Personals durch zu viele irrelevante Alarme medizinischer Geräte “Bei der Alarmmüdigkeit (“alarm fatigue”) handelt es sich genau genommen nicht um eine Störung der Aufmerksamkeit, sondern um einen motivational bedingten Schutz der Aufmerksamkeit: was beständig zu Unrecht die eigene Aufmerksamkeit in Anspruch nimmt, verliert an Wertigkeit”1 25 20.4.2016 Dr. Dirk Hüske-Kraus Handlungsoptionen? 1. Breite Übereinstimmung, dass Alarmmüdigkeit ein signifikantes Problem der Patientensicherheit ist. 2. Die wenigsten Teilnehmer sagen, dass ihre Einrichtung konkrete Maßnahmen ergriffen hat oder plant Quelle: STA survey 2014 3. Die Studie legt eine große Unsicherheit nahe, wie dem Problem zu begegnen ist. Quelle: Junicon web survey 2012, n=56 26 20.4.2016 Dr. Dirk Hüske-Kraus Therapeutische Optionen Fachgesellschaften/Verbände in D? EU? 27 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue im OP: Die Fakten • Ähnlich hohe Alarmfreguenzen: 1/0,33min ‐ 1/4,5 min1,2,3 (weniger Daten verfügbar1 ), ähnlich hohe Raten irrelevanter Alarme: 64%‐77%1,3 • Niedrige Unterscheidbarkeit der Alarme hinsichtlich Wertigkeit und Herkunft4,5,6,7, hohes Maß an Ablenkung8 und Stress9 • Alarme werden oft stumm geschaltet10,11 oder ignoriert mit dem Risiko der verzögerten Reaktion auf kritische Ereignisse3,10 28 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue auf der ITS Detail: „Overmonitoring“ Overmonitoring: “Monitoring for conditions without clinical indication or undue continuation of monitoring/telemetry” Studien1,2 zeigen, dass in einer Vielzahl von Fällen inadäquates Monitoring (overmonitoring, undermonitoring) zu finden ist. Beispiel: Almost all (99%) patients with an indication for arrhythmia monitoring were being monitored, but 85% of patients with no indication were monitored. Of patients with an indication for ischemia monitoring, 35% were being monitored, but 26% with no indication were being monitored for ST-segment changes. Only 21% of patients with an indication for QT interval monitoring had a QTc documented, but 18% of patients with no indication had a QTc documented.1 29 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue auf der ITS Detail: Intervalllogik Patient safety (deteriorations detected & cared for adequately) HR alarms continuous: „meaningless“ – deteriorations not detected („combined sensitivity“↓) 10 30 Almost no HR alarms (sensitivity↓) Highest sensitivity and specificity: HR alarmes „meaningful“ 50 70 90 110 130 150 1/m 30 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue auf der ITS Detail: Alarmreduzierende Funktionen (A): With a desaturation to 86% with a duration of 20 seconds, the audible alarm becomes active only after the alarm condition has persisted for 15 seconds. (B): With a desaturation to 84% with a duration of 5 seconds, no audio alarm occurs. Adapted from http://www.masimo.com/pdf/whitepaper/LAB6138B.pdf 31 20.4.2016 Dr. Dirk Hüske-Kraus (C): With a sudden desaturation to 80%, the audible alarm activates immediately Alarm fatigue auf der ITS Detail: „Proaktives Monitoring“ Horizon display has been set up to meet SIRS criteria. Also, etCO2 and SpO2 were added to adress the patient’s diagnosis of pneumonia and poor respiratory condition. Here, the baseline was set to represent target values. The deviation bars clearly show that the patient’s current values are significantly deviated from where we would like them to be. The trend indicator also confirms that the patients condition in the preceding ten minutes is worsening. The only stable measurement is the temperature, but this is also not within our desired range. 32 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue auf der ITS Detail: „Proaktives Monitoring“ 33 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue auf der ITS Detail: Grenzen der Schwellwertlogik Lynn 2011: Patterns of unexpected in-hospital deaths: a root cause analysis 34 20.4.2016 Dr. Dirk Hüske-Kraus Alarm fatigue auf der ITS Therapeutische Optionen: Multiparameter-Alarme Scenario Detect what SVT + BP: Supraventricular Tachycardia and Blood Pressure –indicate high heart onset of paroxysmal atrial rate with low blood pressure, as frequently occurs in patients with Atrial fibrillation fibrillation and a rapid ventricular rate. Tachycardia associated with hypertension, as commonly occurs with light sedation, would not trigger this alarm VTACH + BP: Indicate ventricular tachycardia with low blood pressure. This Vtach with low blood pressure definition would be much less likely to be triggered by motion artifact than the EKG alarm is. LV shock: Detect Left ventricular failure (cardiogenic shock). TPX & TPND: Detect either tamponade or tension pneumothorax Hypovl: Indicate low blood pressure from hypovolemia 35 Parameters Limits/Trigger Time HR (Pulse) ART sys Pulse (HR) HR (Pulse) PVC ARTsys Pulse (HR) left ventricular shock ARTsys CVPmean PAPdia Perf tamponade (obstructive shock) ARTsys CVPmean Perf PAPdia hypovolemia ARTmean CVP Perf NIBPm 20.4.2016 Dr. Dirk Hüske-Kraus +40% within 59 sec ‐15% within 59 sec >110 bpm for 20 sec +30 bpm within 20 sec ***Vtach ‐30% within 20 sec >110 bpm for 10 sec <78 mmHg for 300 sec <16 mmHg for 300 sec >16 mmHg for 300 sec <1.2 for 300 sec <78 mmHg for 180 sec >16 mmHg for 180 sec ‐20% within 3 min >16 mmHg for 180 sec <50 mmHg for 300 sec <5 mmHg for 300 sec ‐20% within 120 sec/10 min <55 mmHg for 300 sec “Correlation of information across alarms can suppress artifact, increase the positive predictive value of alarms, and can employ more sophisticated definitions of alarm events than present single‐sensor based systems.”1 Ursachen… metrology man milieu Stressors Redundancy Habits Noise Algorithms Over-monitoring Attitude Infrastructure Qualification Architecture Resilience Configuration Fault Sensors, electr. Acuity Adv. features Homogeneity Distribution Compliance Usability Activity ““material”” 36 machine 20.4.2016 Sensor application Procedures on pat. Profile selection Threshold tailoring method Dr. Dirk Hüske-Kraus Monitore sind nicht die einzigen Ursachen Source: ECRI Alarm Safety Handbook 37 20.4.2016 Dr. Dirk Hüske-Kraus ..und die Folgen Patientensicherheit Patientenwohlbefinden Neurologische Komplikationen Störungen VWD↑ Ängstlichkeit Inadeaquate Reaktion auf Ereignisse Schlafqualitat Irrelevante Alarme Personalbindung u. -gewinnung Kognitiver Stress Arbeitslast Prozesseffizienz Desensibilisierung Durchsatz/Umsatz Reputation KH-Performance Mitarbeiter 38 20.4.2016 Dr. Dirk Hüske-Kraus Therapeutische Optionen AAMI “10 Ideas for safe alarm management”1 • Issuing a call to action, championed by executive leadership, which recognizes the challenges, risks, and opportunities of alarm management, and committing to solving them. • Bringing together a multidisciplinary team to spearhead action and build consensus. • Gathering data and intelligence to identify challenges and opportunities. • Prioritizing the patient safety vulnerabilities and risks to target with alarm management improvements. • Setting and sharing goals, objectives, and activities to address these vulnerabilities and risks. • Developing and piloting potential solutions. • Evaluating the effectiveness of improvements and making adjustments as needed. • Developing policies and procedures. • Educating staff to build and maintain competencies. • Scaling up and sustaining by creating ownership at the unit level and with continuous improvement. 39 20.4.2016 Dr. Dirk Hüske-Kraus Therapeutische Optionen? AACN “Alarm Management Performance Improvement Plan”1 40 Assemble an interdisciplinary Alarm Management Team Collaborate with Clinical (Biomedical) Engineering to collect alarm data Define and categorize alarm types. Determine the clinical significance associated with alarms Conduct a thorough analysis of all data collected to understand the scope of the alarm problem, focusing on trends Conduct nonpunitive evaluations/observations of how alarms are managed on a particular patient care unit and shift Identify the goal or outcome measures that will guide change and improvement efforts Implement targeted alarm management strategies or interventions incrementally Monitor progress and sustain improvements Develop patient care unit policies and protocols Provide ongoing staff education and support. Engage managers in coaching staff members regarding alarm management performance expectations. Remain abreast of changing technology. 20.4.2016 Dr. Dirk Hüske-Kraus Therapeutische Optionen? AACN “Practice Alert”1 Provide proper skin preparation for ECG electrodes Wash the isolated electrode area with soap and water, wipe the electrode area with a rough washcloth or gauze, and/or use the sandpaper on the electrode to roughen a small area of the skin. Do not use alcohol for skin preparation; it can dry out the skin. Change ECG electrodes daily Change daily or more often if needed. Customize alarm parameters and levels on ECG monitors Customize the alarms to meet the needs of individual patients. Set customized alarms within 1 hour of assuming care of a patient and as the patient’s condition changes Customize delay and threshold settings on oxygen saturation via pulse oximetry (SpO2) monitors Collaborate with an interprofessional team, including biomedical engineering, to determine the best delay and threshold settings. Use disposable, adhesive pulse oximetry sensors, and replace the sensors when they no longer adhere properly to the patient’s skin. 41 20.4.2016 Dr. Dirk Hüske-Kraus Therapeutische Optionen AACN “Practice Alert” (cont’d) Provide initial and ongoing education about devices with alarms. Provide education on monitoring systems and alarms, as well as operational effectiveness, to new nurses and all other health care staff on a periodic basis. Budget for ongoing education when purchasing monitoring systems. Establish interprofessional teams to address issues related to alarms, such as the development of policies and procedures Determine the default alarms for the equipment being used. Evaluate the need to upgrade to next-generation pulse oximetry. Consider developing a culture of suspending alarms when nurses perform patient care that may produce false alarms. Standardize monitoring practices across clinical environments. Monitor only those patients with clinical indications for monitoring 42 Collaborate with an interprofessional team to determine those patients in a population or care unit who should be monitored and what parameters to use. Use the American Heart Association’s Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation 20.4.2016 Dr. Dirk Hüske-Kraus Therapeutische Optionen? AAMI “Die fünf größten Wissenslücken im Alarm Management”1 1. Mangel an Dokumentation und Daten, um unerwünschte Ereignisse analysieren und Ursachen verstehen zu können. 2. Fehlen von evidenzbasierten Richtlinien für die Konfiguration von Alarmeinstellungen 3. Mangelhaftes Verständnis, welche Typen von Alarmsignalen geeignet sind, die richtige Reaktion zu bewirken 4. Zu wenig Wissen, welche Patienten für wie lange gemonitored werden sollten 5. Zu wenig Verständnis über die beste Art von “sekundärer Alarmierung” 43 20.4.2016 Dr. Dirk Hüske-Kraus