Managing Clinical Alarms Maria Cvach, DNP, RN, CCRN Assistant Director of Nursing, Clinical Standards Sharon Allan RN, MSN, ACNS BC, CCRC Clinical Nurse Specialist, CVSICU Matt Trojanowski, MSc, RRT Manager, Adult Respiratory Care Services The Institute for Johns Hopkins Nursing www.ijhn.jhmi.edu, IJHN@jhmi.edu 5/2/2014
Why did we initiate alarm management at JHH? Competing Priorities Alarms not set to actionable limits Too many alarming devices: duplicate alarms No back-up/ escalation plans Alarming Situation Low specificity results in frequent false alarms Large units with inability to hear alarms Unclear alarm responsibility Alarm desensitization Slide 2
Barriers to Accurate, Actionable Alarms 2-May-14 3
ECRI Institute 2013 What changes were made?
System s Approach Assemble a multidisciplinary team Review recent events and near misses Ask staff about their concerns Review unit alarm data adapted from ECRI Institute 2013
Nursing Human Factors CUSP TEAM Interdisciplinary Alarm Committee Support from Hospital Administration Physicians Patient Rep RT Biomedical and IT Slide 6 Hospital Vendors Text 2 Tex3 Risk Management
Slide 7 CVSICU Monitor Alarm Assessment UNIT NAME CVSICU Ave Beds Reporting Alarms/ Day 14 High Priority 186 (1%) Medium Priority 1972 (9%) Low Priority 16080 (77%) Technical 2603 (12%) TOTAL ALARMS 20841 Ave Alarms/Bed/Day 208 Ave Alarms/Bed/Day High Priority 2 Ave Alarms/Bed/Day Medium Priority 20 Ave Alarms/Bed/Day Low Priority 161 Ave Alarms/Bed/Day Technical 26 Ave High Priority Duration (sec) 27 Ave Medium Priority Duration (sec) 15 Ave Low Priority Duration (sec) 19 Ave Technical Duration (sec) 56 6
5000 CVSICU Weekly Report by Alarm Type 4500 4000 3500 3000 2500 2000 1500 1000 500 0
System s Approach (cont.) Identify patient safety vulnerabilities and potential failures Review unit alarm coverage Determine underlying causes of potential failures adapted from ECRI Institute 2013
Missed Alarm: Results of Fault Tree Analysis Failure to respond to a critical alarm in a timely manner OR Alarms not recognized (detected) Nurses desensitized (auditorilly or conceptually) Insufficient monitor skills Late response time Inadequate interface design Staffing challenges Equipment failure Copyright The Johns Hopkins Health System Corporation. All rights reserved. Slide 10
JHH Measures to Reduce Quantities of Alarms Minimize recurring alarms; standardize alarms across similar units/settings (e.g., pediatrics, telemetry, ICU) Enable actionable alarms Reprioritize auditory and visual alarms Auditory: Higher priority Visual: Low priority Adjust parameter limits appropriately for patient population Assure alarm audibility Slide 11 Maria Cvach DNP, RN, CCRN
Sample JHH Monitor Alarm Inventory Default Parameter Grid Parameters PULSE OX % HEART RATE BPM BP SYSTOLIC mmhg BP DIASTOLIC mmhg BP MEAN mmhg Departments Low High Low High Low High Low High Low High Medical ICU 88 105 50 140 90 180 40 110 65 120 Surgical ICU 88 105 50 120 90 180 40 110 55 120 Coronary Care 88 105 45 120 90 180 40 110 55 120 Cardiac Surgical ICU 88 105 50 120 80 150 40 110 55 120 Neurologic ICU 88 105 50 120 90 180 40 110 55 120 Weinberg ICU 88 105 50 120 90 180 40 110 55 120 Oncology Department 88 105 50 130 90 180 40 110 55 120 Surgical Progressive Stepdown Care unit 88 105 50 140 90 180 40 110 60 120 Slide 12
Sample JHH Alarm Risk Inventory Clinical Equipment Alarm Inventory Risk to Patient and Response Level of oversight typically available Secondary Alarm Notification High priority cardiac monitor alarms Medium/technical cardiac A B Varies by unit Varies by unit Varies by unit; includes beside split screens, autoview on alarm, hallway monitor alarms Low priority cardiac monitor C Varies by unit waveform screens, acknowledgement alarms pagers/phones, unit-based monitor watch Ventilator A Varies by unit Nurse call auxiliary outlet ECMO A High Direct supervision Bed/chair exit alarm A Low Nurse call auxiliary outlet Sequential compression device C Low None identified
Central Monitor Station Unit floor plan Unit workflow Unit staffing Redundancy Slide 14
Monitor watch Split Bedside Monitor Screens Monitor Alarm Notification Methods Pagers View on alarm Slide 15 Hallway Waveform Screens Zoning Phones
Use of Middleware Routes the alarm to the proper person/device following an algorithm Slide 16
Strategies that Worked Alarm Reduction Strategy Potential Benefit Parameter limits and alarm level changes Daily electrode change Alarm escalation notification (each nurse carries acknowledgment pager) 25%- 74% reduction in frequency of alarms (varied by unit) 46% reduction in frequency of alarms in MPCU and CCU 53% reduction in frequency of alarms on a surgical IMC; 23% reduction in time to respond to alarm Sustainability Challenges Agreement of group on what is an actionable alarm Behavior may diminish over time; patient discomfort; cost Cost of acknowledgement pagers; Using two different devices to communicate alarms Slide 17
Strategies Resulting in Varying Degrees of Success Alarm Reduction Strategy Potential Benefit Sustainability Challenges Charge nurse (CN) reminds 24% reduction in frequency of alarms Once CN stopped reminding each nurse to customize alarms each shift in CCU staff, behavior diminished over time. New SPO2 sensor tested 2% reduction in frequency of alarms in CCU None identified Unit-based monitor watcher 47% reduction in frequency of alarms Cost; staffing in CCU 34% reduction in frequency of alarms Cost of disposable leades Use of disposable leads in CCU; no change in frequency of alarm in PICU Alarm escalation notification (Charge nurse carries acknowledgment pager) No reduction in frequency of alarms on a surgical IMC; 13% reduction in time to respond to alarm Cost of acknowledgement pagers Slide 18
Impact of Cardiac Alarm Management Strategies UNIT Pre-interventions Average Alarms/ Monitored Bed/Day Post-interventions Average Alarms/ Monitored Bed/Day % Reduction in Cardiac Monitor Alarms MICU 215 68 68% CCU 515 194 62% WICU 771 151 81% IMC 240 50 79% Telemetry 90 17 81% Maria Cvach DNP, RN, CCRN Slide 19
JHH Alarm Management Initiatives Nurse Managed Telemetry Discontinuation Protocol Audible Alarms and Alerts in an ICU Setting Are they recognizable? Management of Ventilator Alarms: Evaluation of Current Practice Slide 20
Nurse Driven Telemetry Discontinuation Protocol
Audible Alarms and Alerts in an ICU Setting Are they recognizable? 1) Assess discriminability of current audio alarm signals and determine if these signals cue nurses appropriately 2) Assess nursing staff clinical alarm attitudes and perception of effectiveness of alarm notification prior to and after implementation of a bundled set of interventions 3) Assess alarm frequency per monitored bed and mean alarm duration time prior to and following implementation of a bundled set of interventions Slide 22
Audible Alarms and Alerts in an ICU Setting Are they recognizable? Tone tests (17 common sounds) pre/post Staff alarm attitude survey pre/post Bundled set of interventions Staff education Parameter changes Revised alarm notification process Timeframe pre/2months post/4 months post Slide 23
Management of Ventilator Alarms: Evaluation of Current Practice Review of patient charts to compare alarm settings vs. ventilator parameters Observing clinician responses to alarms in real-time What s actually happening? Review of ventilator data logs Observing alarms requiring intervention vs. self-resolving alarms Slide 24
How Data is Obtained What Information is Included in the Data Equipment Alarm Alarm source location Time of alarm activation Duration of alarm Nurse Call Weekly Report What can be concluded from analyzing the data # of alarms per vent/per day Time distribution of alarms Average duration of alarms What cannot be concluded from analyzing the data Specific alarm condition Alarm priority Actionable vs. not actionable May 2, 2014 25 Slide 25
National Survey of Respiratory Therapists What alarms are important? How do you set alarms? Understanding Current Practices & Perceptions Utility of secondary notification systems? Slide 26 Alarm duration influence on provider response
Summary: What Works? Alarm delays for alarm auto correction Multi parameter alarms to increase alarm specificity Good skin/electrode practices Alarms set to actionable levels Customization of alarms based on patient need Discontinuing monitoring when no longer necessary Limited recognizable alarm sounds Alarm notification to the responsible person using an escalation process Slide 27
The Institute for Johns Hopkins Nursing www.ijhn.jhmi.edu, IJHN@jhmi.edu 5/2/2014