Sound the Alarm: Alarm System Management for Patient Safety

Transcription

1 Sound the Alarm: Alarm System Management for Patient Safety Chris Baker RN, PhD, MBA, FACHE Administrative Director Center for Professional Practice & Development St. Mary s Hospital Chris Baker has no conflicts of interest to disclose 1

2 Purpose & Objectives Purpose: Explore how a comprehensive alarm management system is an integral element of your patient safety plan Objectives: After attending this presentation the participant will be able to Discuss why alarm system management is a patient safety issue Summarize the causes and impact of false and nuisance alarms on patient safety Explore empirical evidence supporting a robust alternative to alarm fatigue that can lead to solutions Why is Alarm Management a Patient Safety Issue? In the clinical environment multiple devices are alarm enabled Physiological alarms Ventilators Bed/chair exit detection devices Key questions Do what extent does alarm availability drive alarm utilization? What are the unintended consequences of having alarm technology widely available? How sophisticated is the alarm technology? Auto reactivation Lag times Alarm Management scenarios 2

3 Why is Alarm Management a Patient Safety Issue? Why is Alarm Management a Patient Safety Issue? 3

4 Why is Alarm Management a Patient Safety Issue? Why is Alarm Management a Patient Safety Issue? 4

5 Clinical Alarms: Foundational Principles Clinical alarms are intended to alert caregivers to conditions that are at variance with a predetermined normal Patient conditions Device condition Users rely on clinical alarms to alert them to developing patient safety events Clinical alarms are effective when They alert caregivers to an adverse situation Caregivers identify source and meaning of the alarm Caregivers are able to correct the problem before harm occurs Impact of Clinical Alarms on Patient Safety ECRI published first report of a sentinel event related to an alarm in 1974 By 1982 researchers recognized the increasing number of alarm-enabled devices in the clinical environment One patient might have 6 or more alarm enabled devices at any one time Caregiver confusion Disruptive to the patient By different types of critical alarms in routine use Research suggested that ICU staff could identify only 50% of the critical alarms and 40% of the non-critical alarms Research indicated that the majority of alarms have no clinical significance As early as 1997 researchers were investigating the concepts of false and nuisance alarms and contribution to what was conceptualized as alarm fatigue 5

6 Alarm Fatigue Sensory overload that occurs when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarms, delayed response to alarms, and missed alarms When the majority of alarms are false or nuisance alarms (the devices cry wolf ) caregivers may Turn down volumes of audible alarms Adjust alarm parameters outside of what is safe for the particular patient Slow reaction time or even ignore the alarm Deactivate the alarm The Call to Arms In 2003 the Joint Commission made improving the overall effectiveness of clinical alarms a National Patient Safety Goal Healthcare Technology Foundation initiated a clinical alarm improvement initiative in 2004 The ECRI Institute consistently identifies alarm hazards as one of the Top 10 Hazards for the year Joint Commission Sentinel Event Alert published in 2013 Joint Commission 2014 NPSG on Alarm Management By July 1, 2014 leaders identify alarm system safety as a hospital priority and identify the most important alarms to manage By January 1, 2016 develop and implement policies & procedures for managing alarms and educate staff 6

7 Definitions Alarm/alert: An audible or visual signal intended to alert staff to an issue Critical Alarm: Any alarm for a clinical condition/medical device issue for which a timely response is important to determine if the alarm requires intervention to save the patient s life and/or prevent serious harm Alarm Fatigue: An umbrella term meant to encompass all phenomena that are responsible for clinicians increased response time and decreased response rate to alarms/alerts. Informativeness: The proportion of total alarms that successfully conveys a specific event and the extent to which it is a hazard Actionable Alarm: Any valid alarm for a clinical condition that either: a) leads to a clinical intervention; or b) leads to a consultation with another clinician Making Our Understanding of Alarm Fatigue More Robust & Actionable Rayo & Moffatt-Bruce (2015) The purpose of an alarm system is direct our attention from the less to the more important Cite lack of descriptive or comparative studies supporting the concept of alarm fatigue Informativeness is supported in the literature Informativeness drops off sharply when alarm systems notify caregivers of events that are not occurring or of events that are occurring but do not represent a hazard Decreased informativeness is associated with decreased response rate and increased response time 7

8 Making Our Understanding of Alarm Fatigue More Robust & Actionable Bonafide, et. al (2015) Observation research conducted in a children s hospitals 210 hours observing 40 patients and 36 nurses 5070 alarms noted during that time Determined that only 12.9% of alarms on PICU actionable and only 1% on general inpatient unit actionable When the nurse was out of the patient room, response times increased in proportion to the number of nonactionable alarms over the preceding 120 minutes To Increase Informativeness & Decrease Nonactionable Alarms Change default alarm thresholds Promote clinician discretion in individualizing thresholds based on individual patient assessment Utilize sensors with enhanced power to discriminate Utilize software that can analyze data across multiple parameters, trends over time, and signal quality to reduce the incidence of non-informative alarm signals Procure physiological monitoring systems that include a physiological lag 8