Focus on Respiratory Care & Sleep Medicine Irvine, CA Alarm Management September 14-15, 2018 ECRI INSTITUTE 1
Speaker Information Marc Schlessinger, RRT-NPS, RPFT, MBA, FACHE Senior Associate/Consultant, ECRI Institute 38 years experience as a RT 34 years management experience 15 years Senior Director of Ancillary Services ECRI INSTITUTE 2
Conflict of Interest I have affiliations with, special interests, or have conducted business with the following companies that in context with this presentation might possibly constitute a real or perceived conflict of interest: ECRI Institute ECRI INSTITUTE 3
Objectives Learning objectives for this presentation: The attendee will be able to identify the major causes of alarm fatigue as it effects your workflow. Attendees will have the ability to develop a new or modify an existing policy intended to minimize nuisance ventilator alarms while maintain compliance with regulatory agencies. The attendee will have the knowledge following the presentation to determine which ventilator alarms contribute most to alarm fatigue and how to develop an action plan to decrease these alarms. ECRI INSTITUTE 4
Agenda The Joint Commission National Safety Patient Goals (NPSG) Alarm Fatigue and Patient Safety Alarm Management Middleware ECRI INSTITUTE 5
Legal Disclaimer Throughout this presentation, there may be images of specific manufacturer technologies. These images are used only as an example of the technology being discussed and in no way are a endorsement by either ECRI Institute or the speaker. ECRI INSTITUTE 6
The Joint Commission's National Patient Safety Goal (NPSG).06.01.01 ECRI INSTITUTE 7
NPSG.06.01.01 Does your hospital / department meet the goals? Training? Audits of all medical devices that alarm? Review of past events involving alarms? Near misses? Customize ventilator alarm parameters to meet individual patient needs? Do policies specify who may adjust alarms? ECRI INSTITUTE 8
Specific Recommendations for Joint Commission Compliance Start a hospital wide alarm committee with multidisciplinary representation. Alarm safety must be established as a priority on all levels with Senior Leadership sponsorship and top-down engagement. Develop clear policies regarding alarm management including response to alarms, customizing alarm limits, etc. Every RN, RT, PCT, MD, etc. should be able to speak to at least one thing their unit is doing to improve alarm fatigue. ECRI INSTITUTE 9
Despite The Joint Commission s emphasis on alarm safety and improving alarm fatigue, multiple incidents surrounding medical alarms continue to occur that lead to patient harm, including death. ECRI INSTITUTE 10
ALARM FATIGUE and PATIENT SAFTEY ECRI INSTITUTE 11
Ventilator Alarms 3 Alarms Past and Present 100+Alarms! ECRI INSTITUTE 12
Ventilator Alarms Non-Connected ECRI INSTITUTE 13
Ventilator Alarms Connected via Nurse Call ECRI INSTITUTE 14
Ventilator Alarms Connected via Central Station ECRI INSTITUTE 15
Ventilator Alarms Fully Integrated ECRI INSTITUTE 16
Culture Conundrum of Alarms It s not my job! We don t have any problems. We ve never had an alarm event. It s the vendor s fault! ECRI INSTITUTE 17
Underlying Causes of Alarm Fatigue Units have high noise level and too many alarms Monitors, infusion pumps, ventilators, call bells, phones, etc. False alarms vs nuisance alarms Decrease/elimination of non-actionable alarm Alarm limits are not tailored for individual patient All alarms to clinicians Redundancy of alarms (low Vt and Ve) ECRI INSTITUTE 18
The Perfect Alarm ECRI INSTITUTE 19
Some Recent Alarm Related Sentinel Events Large Academic Teaching Hospital Christmas day patient death due to monitor speakers being unplugged. On another day, in another unit, the speakers were covered with towels. Nursing staff, including managers oblivious to alarms sounding for over 20 minutes during our visit. ECRI INSTITUTE 20
Some Recent Alarm Related Sentinel Events 5-hospital system Invested in a elaborate middleware solution Patient became disconnected from a vent while in the ED for 16 minutes 7 RN s 2 MD s, plus residents in immediate area. No one responded. The ventilator monitoring system worked and sent multiple pages, but the pagers were off, in the department, some without batteries. The patient died. ECRI INSTITUTE 21
Some Recent Alarm Related Sentinel Events Pediatric LTC Facility Installed elaborate oximetry monitoring system Ventilators not remotely monitored and difficult to hear outside of room. 1 RN/4 patient room. 1 RT/4 rooms (quad) RN left room for bathroom break and didn t inform covering nurse Patient became disconnected from ventilator. Pulse oximetry alarm did alarm, but patient sustained additional brain damage from being disconnected from ventilator. ECRI INSTITUTE 22
Some Recent Alarm Related Sentinel Events 250 Bed Community Hospital 28 bed ICU RN complained to RT about numerous alarms occurring on a particular patient and how they disturbing her RRT decreased alarm on ventilator to 10% volume (lowest available setting) Patient found unresponsive by RN and unsuccessfully coded Alarm log on ventilator showed patient was disconnected for 16 minutes ECRI INSTITUTE 23
ALARM MANAGEMENT ECRI INSTITUTE 24
Alarm Management Alarm management is the application of human factors (or 'ergonomics') along with instrumentation engineering and systems to manage the design of an alarm system to increase its usability and effectiveness. ECRI INSTITUTE 25
ECRI INSTITUTE 26
Ventilator Alarms Contributing Factors Ventilator Malfunctioned 2% 5 YEAR PATIENT DEATHS FACTORS Caregiver Wasn't Sure If Alarm Sounded 5% Alarm Improperly Set 13% Caregiver Didn't Hear Alarm 23% Caregiver Said Alarm Didn't Sound 45% Caregiver Silenced Alarm 3% Unclear What Happended 9% ECRI INSTITUTE 27
Issues With Ventilator Alarms Configuration of priorities by user/facility not possible Alarms may or may not latch and are not configurable Some alarms may have fixed limits or limits that are linked to settings Alarm escalation by ventilator not possible (need middleware) Alarm volume can be lowered to unsafe limits Ventilators usually do not allow for alarm delays ECRI INSTITUTE 28
Random Thoughts Default settings are just your starting point. Every alarm needs to be tailored to the individual patient. Can you make non-actionable alarms visual only? Can a delay be programed, as 90% of all alarms selfcorrect in under 7 seconds. What parameters are on and why? Are they all necessary? Education alone does not change practice. Staff must be accountable. If everybody is responsible, nobody is responsible. ECRI INSTITUTE 29
Magnitude Challenges More devices that alarm More patients connected to these devices More high-acuity patients = increased alarm load Limitations of Devices and Alarm Systems May not satisfy workflow demands across all care settings Alarm system designs are not standard Excessive false positive and non-actionable alarms Duplicate alarm conditions Inaudible alarms Indistinguishable alarms ECRI INSTITUTE 30
Challenges (continued) Limitations of Devices and Alarm Systems Lack of actionable intelligence Challenges in implementing middleware Alarm Burden and Fatigue Too many and/or too frequent alarms many are non-actionable, resulting in staff taking inappropriate actions (silencing or ignoring) Alarm noise unpleasant environment leading to distractions, delayed response time, and desensitization Effects of noise on patients, family and staff physiological effects on patients recovery, families loose trust in caregivers, etc. ECRI INSTITUTE 31
Challenges (continued) Lack of Accountability Related to Alarms Who is responsible for creating and managing policies? Who is responsible for responding to alarms, on every shift/unit? Inconsistent response to alarm/lengthy response times Lack of a backup/escalation plan Too much trust/lack of trust in alarm systems Inconsistent System Management Lack of standardization of alarm system defaults Inconsistent use of alarm system features Alarm system limits set incorrectly ECRI INSTITUTE 32
Alarm Management Staff Surveyed If They Would Respond To an Alarm Lasting 5 Seconds or Less Copyright AAMI Foundation / Johns Hopkins Medicine ECRI INSTITUTE 33
Alarm Management Copyright AAMI Foundation / Johns Hopkins Medicine ECRI INSTITUTE 34
Alarm Management Copyright AAMI Foundation ECRI INSTITUTE 35
MIDDLEWARE ECRI INSTITUTE 36
Middleware Middleware is a term most commonly used for software that enables communications and the management of data in a distributed application. ECRI INSTITUTE 37
Middleware Critical Functions of Middleware Prioritization of alarms Staff assignments Alarm escalations Routing assignments Individual Group Report generation and information logs Complex event processing ECRI INSTITUTE 38
Middleware Reports ECRI INSTITUTE 39
Middleware Reports ECRI INSTITUTE 40
Middleware Reports ECRI INSTITUTE 41
Alarm Integration Middleware System Design Alarm Integration systems are complex Require a multidisciplinary approach Unique to each organization Should fit into the alarm management model of the hospital ECRI INSTITUTE 42
Alarm Integration System Design Alarm Source Physiologic Monitors Pulse Oximeters ETCO2 Monitors Ventilators BiPAP s Nurse Call Infusion Pumps Middleware Systems that collect the alarm information from the primary alarming devices Prioritization of incoming alarms/alerts Customizable by the hospital to fit their needs Reporting abilities Nursing assignments Escalation schemes ECRI INSTITUTE 43
Alarm Integration System Design The building blocks End Devices Middleware Alarm Source Communication Engine ECRI INSTITUTE 44
Alarm Escalation Patient Monitor Crisis Alarm Escalation Scheme Things to consider Points of delays Crisis Alarm Acknowledgement of time delays Silencing alarms at primary alarming devices Alert Primary Nurse Via Phone (no delay) Nurse Acknowledges page within 30 seconds NO Alert Buddy Nurse Via Phone Nurse Acknowledges page within 30 Seconds NO Alert Charge Nurse Pulse Oximetry Escalation Scheme can be different if not considered a highpriority alarm Add an initial delay to primary nurse to see if alarm resolves Silencing delays to primary device may be longer No Further Escalation/Primary Nurse Addressed Alarm YES Some time delay established by the hospital for nurse to take action and silence alarm on primary alarming device (120 seconds-200 seconds) YES Nurse Addresses/ Silences Alarm NO No Further Escalation Nurse Addressed Alarm YES YES Some time delay established by the hospital for nurse to take action and silence alarm on primary alarming device (120 seconds-200 seconds) Nurse Addresses/ Silences Alarm NO Addresses Alarm or ensures one of the nurse addresses the alarm No Further Escalation ECRI INSTITUTE 45
Design Team Get the right team together A good team will incorporate both internal and external team members Internal - Facilities, Clinical Engineering (CE), Nursing, Clinical staff, IT External Staff from middleware, medical device vendor, communication systems vendor ECRI INSTITUTE 46
End User Alerting Devices ECRI INSTITUTE 47
Thinking of Implementing? Issues to Consider Architectural layout Nurse to Patient ratio Technology limitations Testing, testing and testing Possible Vendors Amcom Amplion Ascom Cardiopulmonary Corp Cerner Connexall Extension Philips/Emergin Vocera ECRI INSTITUTE 48
ECRI INSTITUTE 49
Questions? Marc Schlessinger Senior Associate Applied Solutions (610) 825-6000 ext. 5420 mschlessinger@ecri.org ECRI INSTITUTE 50