Maximizing Clinical Alarm Safety: Sharing Our Story Objectives Call

5/1/2015
Objectives
• State the purpose of NPSG 06.01.01.
• Define alarm fatigue.
• Identify two strategies to reduce alarm
fatigue in clinical areas.
Maximizing Clinical Alarm
Safety: Sharing Our Story
OAHQ Conference, May 2015
Laura Pease, MSN, RN, Director of Quality
Laurie Joyce, BSN, RN, Senior Quality
Improvement Nurse
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Call to Action
• Multidisciplinary Alarms Committee
established in May 2013.
• Responding to proposed NPSG 6.
• Alarm fatigue focus at the 2013 NTI (AACN
National Teaching Institute).
• Response to incident in which cardiac monitor
alarm was turned off.
• Initial focus determined to be reduction of
nuisance alarms related to cardiac telemetry
monitoring.
Call to Action
The beginning of our story.
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The Joint Commission Sentinel Events Alert
issued April 8, 2013
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2014 NPSG 06.01.01
• Alarm-equipped devices are essential to
providing safe care to patients
• However, devices present a multitude of
challenges and opportunities:
• “Improve the Safety of Clinical Alarm
Systems.”
• Joint Commission approved in June
2013.
• Four elements of performance.
• Implementation to occur in two phases.
o When their alarms create similar sounds.
o When default settings are not changed.
o When there is a failure to respond to their alarm signals.
• From January 2009 to June 2012 there were
98 alarm related events reported and 80
resulted in death.
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5/1/2015
Phase One
Phase Two
• Begins January 1, 2014.
• Hospitals required to:
• Begins January 1, 2016
• Hospitals will be expected to:
• Establish alarm safety as an organizational
priority.
• Identify the most important alarms to
manage based on internal situation.
• Establish policies and procedures for
managing the alarms identified in EP2.
• Educate staff and LIPs about the purpose
and proper operation of alarm systems for
which they are responsible.
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Multidisciplinary Committee
• Established multidisciplinary committee
late 2013.
• Included nurses, physicians, risk
management, clinical engineering.
• System committee later established.
• Overall education of members.
Getting Started
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NPSG: Alarms Gap Analysis
Gap Analysis
Category of Alarm
• Created an inventory of all equipment
with alarms in clinical areas.
• Audibility Study.
• Assessed risk for each type of
equipment:
• Severity Rating
• Probability
• Identified cardiac/telemetry alarms as
top priority.
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Equipment
1. Cardiac/Physiologic Alarms (2014)
Hard-wired, telemetry
2. Respiratory Alarms (2015)
Ventilators, Pulse Ox., CPAP/BI-PAP
3. Prevention of Falls (2015)
Bed, chair and commode alarms
4. Pumps
Infusion pumps
Feeding pumps
PCA’s
Blood warmers
5. Communication
Patient call system
Code Blue
Panic buttons
Vocera
6. Treatments
Sequential compression devices
Wound Vac
Blanket warmer
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2
5/1/2015
System Alarm Committee
Risk Analysis
Equipment
Can
Severity rating
alarm
Able to
Location of
(SR) likely result
volume
be
Can
Amount if the alarm is not
discern
alarm in
Is alarm
alarm be adjusted proximity to
of alarm attended to by
the
audible? alarm? silenced or reset? nurse's station errors? staff in a timely
? Y/N
Y/N
Y/N
(feet)
basis
Y/N
Y/N
Probability (P)
an inappropriate
staff response
after the alarm Assessment
has activated
Score (AS)
Chair Occupancy Alarm
Y
Y
NA
Y
varies to 150 ft
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3
9
Hill Rom Bed Alarm
Y
Y
NA
N
varies to 150 ft
3
3
9
Posey Bed Alarm
Y
Y
NA
Y
varies to 150 ft
3
3
9
Dynamap
Y
Y
NA
N
varies to 150 ft
1
1
Alaris Pump
Y
Y
Y
Y
varies to 150 ft
2
4
8
SCD Pump
Y
Y
N
N
varies to 150 ft
2
5
10
Kangaroo Pump
Y
Y
Y
N
varies to 150 ft
1
4
4
Nurse Call Bell
Y
Y
N
N
varies to 150 ft
3
3
9
Bathroom Call
Y
Y
N
N
varies to 150 ft
3
3
Code Blue Call
Y
Y
N
N
varies to 150 ft
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1
5
TeleMon
Y
Y
N
N
varies to 50 ft
4
3
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Central Station Tele Monitor
Y
Y
Y
N
varies to 150 ft
5
4
20
CADD pump
Y
Y
N
N
varies to 50 ft
5
2
10
PCEA
Y
Y
Y
N
varies to 150 ft
2
4
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2014: System Committee Established
• Overall education of members.
• Revised system-wide policy: Clinical Alarms
• Tracking Tool:
• Inventory list/Clinical Engineering involvement.
• Rank order by risk (risk assessment tool).
• Competencies developed and completed for
cardiac monitoring/ staff education.
• Gap assessment.
• Assessed capital equipment needs.
• Monitoring (continued).
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Goals
• To develop and implement an individualized
clinical alarm management program based on
evidence-based practice.
• To establish consistency in practice in all
telemetry areas and all intensive care units.
• To increase nursing awareness of clinical
alarm management.
• To reduce nuisance alarms by 20%.
Goals
What are we trying to accomplish?
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Alarm Fatigue
• Alarm fatigue occurs when clinicians become
desensitized to the constant noise of alarms or
overwhelmed by the sounds and turn alarms
down or off.
• Many patient care areas have numerous
alarm signals and the resulting noise tends to
desensitize staff and cause them to miss or
ignore alarm signals.
• Nineteen out of 20 hospitals surveyed rank
alarm fatigue as a top patient safety concern.
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Decreasing Alarm Fatigue:
Reducing Nuisance Alarms
• Goal: To reduce the number of non-actionable
alarms.
• Data collection and analysis.
• Review of default settings.
• Partner with physician groups for approval.
• Initiate parameter changes.
• Re-collect the data.
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5/1/2015
ACTION PLAN: Nursing Practice
• Assessment of nursing knowledge and current
practice - Utilized Survey Monkey.
Action Plan: Reduction of
Cardiac Nuisance Alarms
1. Which cardiac/tele monitor task were you educated on?
2. Do you know the alarm default settings for your unit?
3. How many times do you silence the tele alarms during your
shift?
4. During a shift, how many times do you respond to lifethreatening alarms?
5. Have you adjusted alarm setting on the tele/bedside
monitors?
6. Which alarms have you adjusted the settings for? (HR, BP,
SpO2, PVC,RR, Arrhythmia, other)
7. Reasons for adjusting the alarm settings.
8. Did you need to obtain an MD/LIP order to adjust the alarm
settings?
9. Do you communicate alarm settings to the next RN during
hand-off?
10. How are alarm settings communicated to the next RN?
11. How often do you change electrodes?
Step-by-Step
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ACTION PLAN: Alarm Parameters
ACTION PLAN: Nursing Practice
• Development of audit tool.
• Completion of initial 5 day alarm audit on each
division.
• Review of current default settings and preintervention data.
• Implementation of changes low risk alarm
parameters:
• Literature review.
• Review and approval by appropriate
medical teams.
• Completion of post-intervention 5 day alarm
audit and compilation and sharing of results.
• Results confirmed suspected inconsistencies
in practice and knowledge.
• Development of Nurse Practice Guideline for
cardiac monitoring:
• G-853.
• Includes daily electrode changes.
• Development and implementation of telemetry
competencies:
• All telemetry and ICU nurses.
• Care of the telemetry patient.
• Individualization of parameters.
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Action Plan
Action Plan: Daily Audit Tool
YELLOW
Paired PVC’s
Multi-form PVC’s
High # PVC’s
Non-sustained VT
Pacer no capt.
Pacer not pacing
Pause
HR > 120
HR < 50
Irregular HR
Missed beat
TOTALS:
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5/1/2015
Action Plan
Results
How did we do?
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Results: Example Alarm Reduction
in the SICU
Results
% Decrease in Nuisance Alarms Per Patient
• Pre-Intervention DATA:
Grand Total of Alarms = 3702 for 5 days
Number of alarms per day = 740
Average Bed Census – 16
Number of alarms per day per patient = 46
• Post-Intervention DATA:
Grand total of Alarms = 2703 for 5 days
Number of alarms per day = 540
Average Bed Census = 17
Number of alarms per day per patient = 32
80%
70%
Percentage
60%
50%
Average Decrease = 44%
40%
30%
20%
10%
0%
L50
LT3
LT5
LT7
SCC 3
SCC 5
SICU
MICU
CICU
NSU
Division
Percentage Decrease
Percentage decrease = 38%
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Results: Repeat Nursing Survey
• Lower percentage of times they silence an
alarm during a shift.
• Higher percentage of times they respond to a
life-threatening alarm.
• Higher percentage have adjusted alarm setting
on the bedside/tele monitors.
• Less adjustments made to the PVC and
arrhythmia alarms after the default settings
were changed.
• Doubled the percentage of nurses knowing to
change the electrodes every 24 hours.
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Lessons Learned
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5/1/2015
Lessons Learned
• Get your team together and review the
resources available on-line.
• Get started and outline action plan.
• Engage your leaders and develop champions.
Next Steps
Continuing our Story
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Next Steps
Alarm Response Audit
Goals 2015
• Next focus – Respiratory alarms and
prevention of falls.
• Facilitate partnerships to champion the
remaining alarm categories:
• Pumps
• Treatment
• Communication
• Staff education.
• Monitoring – CLIPSS tracer.
• Sustainability – Ongoing auditing of responses
to alarms.
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Date & Time of Test:
Department or Unit:
Room:
Type of Alarm
Time of Alarm to Initial Response by Staff (mins)
Remote Monitoring in Place (eg, Central Station)?
Alarm was clearly audible to staff?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
If no, why not?
(Barrer, Vol decreased, high ambient noise
level, alarm off, similar alarm, other)
Did Staff respond promoptly?
Cause of alarm was clearly identified by staff
Risk Assessment Score
Scoring for Risk Assessment:
Proximity of Alarm
to Staff:
1. < 5
FT
2. 5-20 FT
3. >20 FT and high
ambient noise level
4. Barrier exists
between alarm and
caregiver
Frequency of Alarm:
1. alarm activates 1-7 x's
per week
2. alarm activates < 1 x per
week, more than 1 x per
month
3. alarm activates <1x per
month
4. false alarms are frequent
and cause staff not to
respond
Staff Preparedness:
**Add all
1. alarm is routine and all
circled items
staff are knowledgeable
2. alarm is occassional but to score risk
is part of annual
assessment
competency program
and place on
3. alarm is rare and few
line above
staff are knowledgeable
4. staff did not respond
promptly and appropriately
Low Risk Score: < 6: No action required. Continue scheduled alarm systems tests
Med. Risk Score: 6-8: No action required. Continue schedule alarm systems tests and consider ways to reduce the risk level
High Risk Score: >8: Submit action plan for reducing risk level score with this form.
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Questions?
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