Sound the Alarm! Strategies for Alarm Management in the Rush NICU. October 21 st, 2015

Transcription

1 Sound the Alarm! Strategies for Alarm Management in the Rush NICU Steven B Powell MD John E Overby BSN Connie L Weissman MS Carol A Squires BS Jean M Silvestri MD October 21 st, 2015

2 Disclosures/Conflicts No Disclosures 2007 RUSH University Medical Center

3 Background The Joint Commission has issued National Patient Safety Goal on Alarm Management Over-exposure to multiple alarms can result in alarm fatigue Devices at bedside have grown significantly Safe alarm management is a challenge for NICUs transitioning from open bay to single family room (SFR) environments

4 The Joint Commission NPSG 2015 Identify the most important alarm signals to manage based on the following: Input from the medical staff and clinical departments Risk to patients if the alarm signal is not attended to or if it malfunctions Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue Potential for patient harm based on internal incident history Published best practices and guidelines 2007 RUSH University Medical Center

5 The Joint Commission NPSG 2016 Establish policies and procedures for managing the previously identified alarms and address the following: Clinically appropriate settings for alarm signals When alarm signals can be disabled When alarm parameters can be changed Who in the organization has the authority to set alarm parameters Who in the organization has the authority to change alarm parameters Who in the organization has the authority to set alarm parameters to off Monitoring and responding to alarm signals Checking individual alarm signals for accurate settings, proper operation, and detectability 2007 RUSH University Medical Center

6 Open Bay

7 Single-Family Rooms

8 Pod A (18 beds opening) NICU 8 Tower Pod B (18 beds opening) Pod C (19 beds opening)

9 Workflows For existing workflows to work, nurses must be able to receive alerts from both the patients systems and from other staff Alerts must have assigned priority to differentiate important alerts from less important to avoid alarm fatigue Escalation required if busy or no response

10 Alarm Fatigue Over-exposure to alarms can result in alarm fatigue Ignoring critically important alarms Devices at bedside have grown significantly Vital sign monitors, ventilators, infusion pumps, pulse oximeters, capnographs, feeding pumps Can generate hundreds of alarms per patient per day, overloading staff Risk recently rated first in patient safety threats by ECRI Institute Joint Commission has issued National Patient Safety Goal on Alarm Management and Sentinel Event on Medical Device Alarm Safety

11 Hospital Leadership Default alarms are my safety net against Sentinel events. When in doubt turn on the default setting. Alarm Fatigue Bedside Nurse Responding to alarms is just one task on a huge and growing list. All these alarms don t help keep patients safe. Alarm management is a technology problem to be fixed.

12 Objective Integration of physiologic monitors, ventilators, and nurse-call to wireless phones to create virtual line of sight to patients after transitioning from openbay to SFR environments To mitigate alarm fatigue by adjusting parameters of alarm management and notification platform

13 The process Create a team multidisciplinary Hospital Leadership Physicians Nurses and Nursing Administration Respiratory Care Biomed/Clinical Engineering Information Technology Risk/Legal

14 June 2014 RUSH Team of the Quarter Steven Powell Jean M. Silvestri David Vines Keith Roberts Sara Murphy John E. Overby Melinda D. Noonan Natasa Djukic Patty Nedved Debbie Gist Jody Selenica Elizabeth Myers Karen M. Silvestri Bonnie Macius Amanda McGee Susan O Leary Lisa Swiontek Scott Finkle Christopher J. Kaspar Carol Squires Robert Elder Susan Kovach Scott Simon Connie L. Weissman Cheryl M. Liggett Randy Johnson Jonathon Arrington Gene Ward Mike Lamont Tito Luna Alden Brugada NICU Attending-Team Leader Director of the NICU Chair/Program Director Respiratory Care Program Director, Respiratory Therapy Respiratory Therapy NICU RN Project Sponsor- AVP Children s Hospital Project Coordinator, Women s and Children s Services AVP, Prof. Nursing Practice Unit Director, NICU AUD, NICU Risk Management Risk Management Risk Management Risk Management Risk Management AVP, Clinical Information Systems IS Director, Systems Development & Integration IS Director, Systems Integration IS Project Leader IS Director, Capital Projects IS PM, Nurse-call IS PM, Draeger IS Senior Analyst IS Project Leader Clinical Engineering for NICU Clinical Engineering Clinical Engineering VP, Capital Projects IT Telecomm IT Telecomm

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16 Interfaces Inputs Nurse-call Rauland Responder 5 Draeger Infinity Acute Care System Ventilators Puritan Bennett 840 EPIC ADT data Cisco call manager Outputs Cisco VOIP phones SQL reporting server

17 Design NICU Draeger 13 Monitor alarms Covidien 48 Ventilator alarms Rauland 41 Nurse-call alerts Labor & Delivery Rauland 19 Nurse-call alerts Mother Baby Unit Rauland 2 Nurse-call alerts System Alerts Heartbeat function added to all servers 29 system monitoring alerts

18 Physiologic Monitors Ventilators Nurse Call Alarm Management and Notification Platform

19 Simulation-based Training Procedural skills Clinical decision-making Teamwork Communication Inter-professional team training Testing new facilities

20 TESTPILOT Transport Enhanced Simulation Technologies for Pre-Implementation Limited Operations Testing Rhode Island Hospital adult emergency department 2005 Rhode Island Women and Infant s Hospital NICU 2009 Rush NICU 2014

21 Goals of TESTPILOT Evaluate integration of new and existing systems and workflows Identify latent safety threats

22 TESTPILOT Multidisciplinary team Headed by Dr Beverley Robin Eight clinical scenarios 10 NICU patient rooms equipped In situ simulations, varying levels of fidelity 30 minute simulations, 60 minute debriefing Videotaping

23 TESTPILOT Participants Nurses (12) Neonatologists (2) Nurse practitioners (2) Residents (4) Respiratory Therapists (4) Patient Nursing Assistants (2) Clerks (2) Lactation consultant (1) Pharmacist (1) X-ray technician (1) Confederates (parents, L&D and transport nurses)

24 Threats to Patient Safety Identified by TESTPILOT 11% 6% 9% 31% Communication Equipment Ergonomics 14% Systems/Workflow 13% 16% Facilities Family-centered care Environmental Safety

25 Methods - Design Critical Alarms (Apnea/Asystole/Brady/Desat) go directly to phones with no delay Non-Critical and Advisory Alarms have delays before forwarding to phones to allow recovery of patient If no response, escalation to buddy and then to pod leader

26 Draeger Patient Monitor Alarms

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28 Methods - Modifications Ongoing evaluation and review of alarm transmission After 3 months review, changes made including blocking transmission of most non-critical alarms to phones After 8 months, additional safety measures implemented, including Split Screen and No Pass Zone policy was implemented.

29 Physiologic Monitor Alarms March-May 2015 Alarm Class Alarm Type Total Alarms Alarms % Critical Apnea 11, % Critical Asystole 1, % Critical Bradycardia (<60) 6, % Critical Desaturation (<78) 59, % Non-Critical High HR (>200) 35, % Non-Critical HR Low (<100) 4, % Non-Critical Sat High (>95) 22, % Non-Critical Sat Low (<88) 189, % Non-Critical Art BP Low % Non-Critical NIBP Low % Advisory Sat Ld off 32, % Advisory ECG Ld off 9, % Advisory Art Ld off % All Total 373, %

30 Monitor Alarms at Bedside

31 Alarm Fatigue Staff quickly complained of alarm overload Committee formed to evaluate alarm fatigue Staff surveys and online meetings List of main concerns created Team tasked with resolving issues

32 Alarm Modifications 3 months Decrease the volume of Draeger Central Station Decibel meter to measure volume at central and decrease sound Remove the Draeger yellow alarms for HI and LO Sat Yellow alarms of High and Low Saturation and High HR blocked to phone Right button should allow for both 'escalate' and 'acknowledge' Soft keys recustomized to allow easier use Can we allow '2' as a volume option? Phone volume limits lowered from 3 to 2 out of 7 Is it possible to allow users to select vibrate mode? Vibration decreased for all except 2 Life Threatening alarms

33 Alarm Modifications 3 months The Nurse-call sign in process takes a long time Re-education sessions for assignment sign-in Reduce the Nurse-call alerts coming into the duty station in the break room. All but codes and deliveries removed from other areas Versus: Lingering lights and no lights failures continue to be an annoyance on NICU and L&D Recalibrated Versus sensors, development for integration to Connexall Can alert auto-escalate if user is on the phone? Cisco phones can't autoescalate when in use Oncoming personnel should be able to take outgoing personnel off duty as part of report process Working with Rauland for improvement in user interface

34 Additional Safety Measures 8 months Split screen No pass zone for red alarms Large central monitor screens Vigilant staffing patterns: overall 1:2 staffing Proximity of room assignments Partial door opening to view alarms Buddy escalation of alarms Safety huddle- at report Safety huddle in the pod identifying concerning patients 2007 RUSH University Medical Center

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37 Heat Map

38 Physiologic Monitor Alarms Per Patient Per Day Transmitted to Phones by Period and Total Alarms Alarm Type Mar-May June-Oct Nov-Mar Total Apnea ,080 Asystole ,260 Bradycardia (<60) ,060 Desaturation (<78) ,278 High HR (>200) HR Low (<100) ,779 Sat High (>95) Sat Low (<88) Art BP Low ,520 NIBP Low Sat Ld off ,595 ECG Ld off ,263 Art Ld off Total ,027,573

39 Conclusions Use of a Alarm Management and Notification Platform created a virtual line of sight from providers to the patient in an SFR environment Review and modification of alarm algorithms reduced non-critical alarm burden Successful implementation requires a multidisciplinary team approach

40 Limitations Alarm Fatigue not easily quantifiable Changes to algorithms of alarm transmission was based on clinical judgement Further studies are needed to assess safety impact of alarm strategies

41 Ongoing Alarm Activities Alarm Management Committee Ongoing meetings to review alarm fatigue Process for Developing Policies Comprehensive Alarm Management Policy Compliance with 2016 TJC NPSG

42 The Future Comprehensive Data aggregation Allows direct population of Epic data from Draeger/other devices Many drivers for various devices Smart pump alarms Anesthesia carts Capnographs