Clinical Alarm Management

“Stop the Nuisance” Maria Carpenter MSN, RN, AG CNS-BC, CCRN

Laura Solano MSN, RN, CCNS, PCCN, CCRN K

Objectives

• Discuss aspects of alarm safety

• Discuss implications of alarm fatigue

• Discuss changing culture of alarm management

• Discuss tools and methods used to improve clinical alarm management

• Discuss widening default parameters in cardiac monitoring and the impact it has had at PPMC

Alarm Safety Recognized

2005-2009 linked 566 deaths to

monitor alarms

Research shows:

• Response rate improves with alarm reliability, low work load conditions and trust in the alarms

• 68 – 99% of all alarms are false or nonactionable

• Nurses spend 16-35% of their time answering alarms

Alarm Fatigue

• Occurs when device alarms sound frequently or without a sign of emergent patient danger.

▫ Nurses stop recognizing the alarm as a sign of emergent danger

▫ Alarm responders become desensitized delaying recognition and response to alarms

▫ Sentinel events have occurred

Clinically Relevant Alarm

• Definition:

▫ Alarm for which a diagnostic or therapeutic decision is required to be made. Actionable alarm

Nuisance alarm

• Definition

▫ an alarm that indicates a parameter has been violated, but does not require clinical intervention.

▫ “cry wolf” effect

Alarm Management

• Alarm committee

• Changing the culture

• Healthy work environment

• Consequences:

▫ Clinical effects on patients and families

▫ Affects quality and patient safety

▫ Effects staff

Stop the Nuisance

• Where to begin?

• Start with the basics

▫ Patient education

▫ Change electrodes daily

▫ Skin prep, lead selection, proper storage

▫ Proper fitting SpO2 finger sensors

▫ Stability of capnography cannulas

Education and Staff Competency

• Proactive use of pause

▫ Suctioning, Drawing blood from aline

• When to use ST segment detection

• When to turn off pacemaker detection

• When to turn off irregular alarms

• Alarm customization, individualization

• Clinical Alarm Management Policy

▫ Guide to safe practice

Inoperable Alarms

• INOP alarm (such as leads off)

▫ Sentinel events

▫ Considered a priority

▫ Treat with an immediate response!

▫ Change the culture!

Alarms must be audible

• Respond in a timely manner.

• All alarms must be ‘on’ and audible to staff.

• Does your technology allow for alarms to be turned off in the room yet audible at the desk?

• Can the volume be turned down in the room : sleep mode / comfort mode?

Alarm Customization

• Individualize to your patient’s condition

▫ Known afib – turn off irregular alarm / afib alarm

▫ Patient on a ventilator – turn off RR alarm

▫ Adjust parameters

Alarm Champions (staff)

• Involve all staff

• Seek out nuisance alarms and work to find solutions

• Assist coworkers to customize alarms

• Conduct huddles on alarm management

• Implement initiatives such as ‘no pass zone’

Effects of customization

Rethinking defaults

• Widen default parameters so that alarms are actionable • Add delay so that false alarms have a chance to

autocorrect prior to sounding • Eliminate duplicative alarms • Turn off alarms for conditions that we no longer treat • For some signals, a visual alarm can work better than

another beeping sound

Analyze your data

• Pareto diagram to determine highest areas of impact

• Evaluate where the violators lie within those areas

• Utilize unit level data to determine comfort level of default changes against their impact

What if:

Pre – 6/20/17 - 6/27/17 Post - 5/22/2017-5/29/2017

4/1/17-5/1/17 10/7/17- 11/6/17

Post default changes: RR in TSICU

Widen defaults

unit by unit

Previous Defaults HR 55 to 120 RR 8 to 30 SBP 90 to 160 Mean 60 to 90 SPO2 90 to 100% PVCs >10

References

.

Cvach, M., Monitor Alarm Fatigue: An integrative Review”, Biomedical Instrumentation & Technology, July/Aug 2012,

268-277.

Cvach, M., Graham, KC. (2010) Monitor alarm fatigue: standardizing use of physiological monitors and decreasing

nuisance alarms. Am J Crit Care. 19(1):28-34

Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. (2012) Daily electrode change and effect on cardiac alarms: an

evidence-based practice approach. J Nurs Care Qual. 28(3): 265-271

Cvach, M., Monitor Alarm Fatigue: An integrative Review”, Biomedical Instrumentation & Technology, July/Aug 2012,

268-277.

Cvach, M., Graham, KC. (2010) Monitor alarm fatigue: standardizing use of physiological monitors and decreasing

nuisance alarms. Am J Crit Care. 19(1):28-34

Cvach MM, Biggs M, Rothwell KJ, Charles-Hudson C. (2012) Daily electrode change and effect on cardiac alarms: an

evidence-based practice approach. J Nurs Care Qual. 28(3): 265-271

Gross, B., et al. “Physiologic monitoring alarm load on medical/surgical floors of a community hospital”, Biomedical

Instrument Technology, Spring 2011, Sppl., pp 29-36.

Gross, B., et al. “Physiologic monitoring alarm load on medical/surgical floors of a community hospital”, Biomedical

Instrument Technology, Spring 2011, Sppl., pp 29-36.

Hsu, T., Ryherd, E. Waye, K.P., & Ackerman. (2013) Noise pollution in hospitals: impact on patients. J Clin Outcomes

Manage 19(7): 301-309

Hsu, T., Ryherd, E. Waye, K.P., & Ackerman. (2013) Noise pollution in hospitals: impact on patients. J Clin Outcomes

Manage 19(7): 301-309