Alarm Management Michelle Bell, RN, BSN, FISMP, CPPS Kelly Graham, BS, RN Objectives 1. Discuss the importance of appropriate alarm use 2. Describe strategies for improving alarm safety and how to begin implementation 3. Identify challenges of alarm management 2015 Pennsylvania Patient Safety Authority 2 1
Importance 2015 Pennsylvania Patient Safety Authority 3 Case Studies Child admitted to hospital with respiratory distress. Child found with no heart rate and no respiratory effort. Child was on a monitor but the alarms were suspended. PA-PSRS 2015 Pennsylvania Patient Safety Authority 4 2
Case Studies Patient admitted for arrhythmia. Nurse was told by the monitor tech that the patient s leads were off. Went to get more leads. Distracted by another patient alarm. Staff found patient unresponsive. PA-PSRS 2015 Pennsylvania Patient Safety Authority 5 Drawing attention to the problem Strong media attention began in 2010 with reports of patient deaths linked to monitor alarms http://www.boston.com/news/local/massachusetts/articles/2010/04/03/alarm_fatigue_linked_t o_heart_patients_death_at_mass_general/ 2015 Pennsylvania Patient Safety Authority 6 3
Case Studies Patient admitted for chest pain and pneumonia. Nurse found patient unresponsive, still wearing monitor next morning. It appears that, although the patient was wearing the monitor, he had been taken out of the heart monitoring system. PA-PSRS 2015 Pennsylvania Patient Safety Authority 7 Case Studies Patient with several chronic conditions admitted. Respiratory status deteriorated and she arrested. Code called. On further investigation it was determined that the alarm volumes were not adequate. PA-PSRS 2015 Pennsylvania Patient Safety Authority 8 4
Drawing attention to the problem Sometimes I would hear alarms in my sleep. Follow up from media shows many medical centers working to decrease the number of alarms in hopes to prevent alarm fatigue. One facility in New England reduced their alarms by removing those that were of lower priority. http://www.bostonglobe.com/lifestyle/health-wellness/2013/12/23/boston-medical-centerreduces-monitor-alarms-says-care-safer-for-patients-less-stressful-forstaff/szqfan1se7cghnfsut2fel/story.html 2015 Pennsylvania Patient Safety Authority 9 Why is this important? The Joint Commission National Patient Safety Goal 2015 #6 Reduce the harm associated with clinical alarms. Improve the safety of clinical alarm systems. 2015 Pennsylvania Patient Safety Authority 10 5
The Joint Commission Data It is estimated that between 85% and 99% of alarm signals do not require clinical intervention. The Joint Commission s Sentinel Event database includes reports of 98 alarm-related events between January 2009 and June 2012. From: Joint Commission Sentinel Event Alert, Issue 50, April 8, 2015 2015 Pennsylvania Patient Safety Authority 11 The Joint Commission Data For the reported events, among the major contributing factors were: Absent or inadequate alarm system Improper alarm settings Alarm signals not audible in all areas Alarm signals inappropriately turned off 2015 Pennsylvania Patient Safety Authority 12 6
Case Studies Nurse observed low oxygen saturation and called a code. All alarms were off except heart rate. Hit the button to reset alarms to default, and alarms remained off. No visual indicated that alarms were off. PA-PSRS 2015 Pennsylvania Patient Safety Authority 13 Alarm Events Reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) 2010-2014 2015 Pennsylvania Patient Safety Authority 14 7
Case Studies Patient admitted for chest pain. When responding to IV pump alarm, patient was found unresponsive and pulseless. Cardiac leads were disconnected from the monitor cable. PA-PSRS 2015 Pennsylvania Patient Safety Authority 15 ECRI Institute PSO Database Sources of alarms: Physiologic Monitors Ventilators Intravenous Pumps Bed Alarms Chair Alarms Tube-feeding Pumps Infant Security Systems Intra-aortic Balloon pumps Medical Gas Systems Fire Alarms 2015 Pennsylvania Patient Safety Authority 16 8
ECRI Institute PSO Database Common Themes: Alarms did not sound Alarms not addressed Miscommunication Say what? 2015 Pennsylvania Patient Safety Authority 17 Strategies & Implementation 2015 Pennsylvania Patient Safety Authority 18 9
Systems Approach Assemble a multidisciplinary team Determine underlying causes of potential failures Develop realistic, implementable strategies Review recent events and ask staff about concerns Identify potential failures Implement strategies and evaluate effectiveness Determine alarm focus Observe alarm coverage process Monitor effectiveness and provide feedback 2015 Pennsylvania Patient Safety Authority 19 Multidisciplinary Team Administrative sponsor Key medical staff Nurse managers Front-line nurses Monitor technicians Patient safety/risk manager Clinical engineering staff IT staff Consult with others, as appropriate 2015 Pennsylvania Patient Safety Authority 20 10
Case Studies Unwitnessed inpatient code. Was on telemetry, leads-off alarm followed by cannot analyze ECG and then the telemetry pack turned off. RN replaced disconnected leads to chest not realizing the telemetry pack powers down to conserve battery after 10 minutes of no usable waveform. Routine assessments throughout night, ECG leads confirmed upon visual inspection of chest. Staff at bedside for blood draw recognized pulseless/ apneic, code called, patient expired. PA-PSRS 2015 Pennsylvania Patient Safety Authority 21 Review Events and Staff Concerns Identify all potential alarm sources Audit frequency of alarm types Aggregate alarm types per care area/shift Identify trends in data Review remediation/results Identify root causes of alarm events (E.g. delayed response) 2015 Pennsylvania Patient Safety Authority 22 11
Determine Alarm Focus 2015 Pennsylvania Patient Safety Authority 23 Observe Alarm Coverage Process Listen to staff concerns/problems Map processes for alarm notification and response Identify obvious problems Failures within communication process Excessive alarms Audibility of alarms Delayed alarm response 2015 Pennsylvania Patient Safety Authority 24 12
Identify Potential Failures and their Causes FMEA March 2008 277 reports submitted through PA-PSRS between June 2004 and October 2006 relevant to physiologic alarm management Follow up article September 2011 35 deaths reported through PA-PSRS between June 2004 and December 2010 related to physiologic alarm management http://www.patientsafetyauthority.org/advisories/advisorylibrary/2008/mar 5(suppl_rev)/Documents/mar5(supplrev).pdf 2015 Pennsylvania Patient Safety Authority 25 PA-PSRS Breakdown Telemetry transceiver not connected Physiologic data not received Physiologic data inaccurate Battery issues Leads off Lacking or missed communication Alarm limits changed, alarm off, or alarm volume turned down or off Monitor in standby mode Delayed clinical response 2015 Pennsylvania Patient Safety Authority 26 13
Identify Failures and Determine Causes Failure Causes Delayed alarm response Diffuse responsibility for alarm response Competing priorities Assumptions that someone else will respond No back-up plan/escalation 2015 Pennsylvania Patient Safety Authority 27 Case Studies Patient presented to ED with abdominal pain. Patient was being worked up for possible kidney stone. Patient was found unresponsive and code blue was called. The patient did not survive the code. Retrospective review of monitor strips indicated that the patient experienced v-fib with monitor alarm for 18 minutes prior to patient being found unresponsive and CPR being initiated. PA-PSRS 2015 Pennsylvania Patient Safety Authority 28 14
Develop and Implement Strategies Create action plan Who Date Resources Measurement 2015 Pennsylvania Patient Safety Authority 29 Description of Event: Event Date: Sample Action Plan Investigation Date: Issue Identified Risk Reduction Strategy Responsible Person Due Date Measurement Date Completed Delayed Physiologic Alarm Response Delayed Physiologic Alarm Response Delayed Physiologic Alarm Response ICU Team will determine new default limits Monitor units set with new volume requirements based off environmental study Notification process revised to escalate to charge nurse and then all nurses ICU Manager BioMed ICU Manager/ Central Monitor Manager Alarms triggered in ICU/ patient day Goal: 25% reduction Units reset/ total units Goal: 100% Time from alarm to intervention Goal: <60 seconds average Delayed Physiologic Alarm Response Eliminate harm events related to delayed physiologic alarm response ICU Manager/ Central Monitor Manager Review events with alarm to intervention time >60 seconds Goal: Zero patient harm from delayed alarm response 2015 Pennsylvania Patient Safety Authority 30 15
Case Studies Nurse noticed that patient did not have a good wave form on monitor. Went into patient room and found patient in arrest. All nurses were in rooms with door closed. Did not hear alarms at central station. PA-PSRS 2015 Pennsylvania Patient Safety Authority 31 Evaluate, Monitor and Provide Feedback Determine appropriate measurement strategy Monitor for effectiveness Modify strategies as needed Provide feedback to all -> Ensure the feedback gets to frontline staff 2015 Pennsylvania Patient Safety Authority 32 16
Challenges 2015 Pennsylvania Patient Safety Authority 33 Datacide Barriers Team/Approval Process Resource Limitations: Money, Time, Frontline staff non-clinical time Buy-in (to solution and problem) 2015 Pennsylvania Patient Safety Authority 34 17
No Single Cause Alarm Fatigue Competing Priorities Lack of Understanding/ Apathy No Back-up/ Escalation Plans Common Problems Communication Breakdown Unable to hear and/or distinguish alarms Diffuse Responsibility 2015 Pennsylvania Patient Safety Authority 35 No Single Answer Alarm Fatigue Competing Priorities Leads-off Apathy No Back-up/ Escalation Plans Common Solution Communication Breakdown Unable to hear and/or distinguish alarms Diffuse Responsibility 2015 Pennsylvania Patient Safety Authority 36 18
Reducing the Frequency of Nuisance Alarms Make alarms actionable Analyze unit default settings Tailor alarms per patient Develop alarm escalation plan Implement Preventions Skin Prep Electrode Placement Routine battery replacement Changing electrodes Reinforce high-urgency of correcting the alarms Hold staff accountable Track progress and provide feedback to staff 2015 Pennsylvania Patient Safety Authority 37 Culture 2015 Pennsylvania Patient Safety Authority 38 19
Key Lessons Form a multidisciplinary task force Analyze your current system Identify patient safety vulnerabilities Develop strategies to minimize risk Utilize shared strategies to address common problems and adapt per your unique set of variables Carefully plan for implementation Monitor the effectiveness of strategies and modify, as needed Provide feedback to staff 2015 Pennsylvania Patient Safety Authority 39 Resources The Joint Commission. Sentinel Event Alert #50 http://www.jointcommission.org/assets/1/18/sea_50_alarms_ 4_5_13_FINAL1.PDF Patient Safety Authority. Alarm Interventions during Medical Telemetry Monitoring: A Failure Mode and Effects Analysis http://www.patientsafetyauthority.org/advisories/advisorylib rary/2008/mar5(suppl_rev)/pages/mar5(supplrev).aspx Patient Safety Authority. Physiologic Alarm Management http://www.patientsafetyauthority.org/advisories/advisorylibrary/2 011/sep8(3)/Pages/105.aspx 2015 Pennsylvania Patient Safety Authority 40 20
Questions? 2015 Pennsylvania Patient Safety Authority 41 21