Addressing Alarm Fatigue. Todd Hazzard CBET October 2014

Transcription

1 Addressing Alarm Fatigue Todd Hazzard CBET October 214

2 What is Alarm Fatigue? Agenda Understand The Joint Commission NPSG # 6 Share some best-practices Discuss Alarms Analysis

3 Alarm Fatigue Reliance on Physiological monitors to continually watch patients and to alert the nurse when a serious rhythm problem occurs is standard practice. Alarms are intended to alert clinicians to deviations from a predetermined normal status. However, alarm fatigue may occur when the sheer number of monitors alarms overwhelms clinicians, possibly leading to alarms being silenced or ignored. (AACN 21)

4 What is Alarm Fatigue? Alarm fatigue is when a nurse or other caregiver is overwhelmed with 35 alarm conditions per patient per day. Alarm fatigue is when a patient can t rest with the multitude of alarm signals going off in the room. Alarm fatigue is when a true life-threatening event is lost in a cacophony of noise because of the multitude of devices with competing alarm signals, all trying to capture someone s attention, without clarity around what that someone is supposed to do. Alarm fatigue is compounded by inconsistent alarm system functions (alerting, providing information, suggesting action, directing action, or taking action) or inconsistent alarm system characteristics (information provided, integration, degree of processing, prioritization). Alarm fatigue is a systems failure that results from technology driving processes rather than processes driving technology. Per the AAMI Clinical Alarms-211 Summit support the healthcare community in the development, management and use of safe and effective medical technology. 4 Do No Harm, June, 212

5 Alarm Fatigue at the Federal Level In 212, Alarm management was named top IT hazard by ECRI (Emergency Care Research Institute) In 212, alarm fatigue becomes a focus for the FDA In April 213, Joint Commission issued a Sentinel Event on alarm fatigue Alarm Fatigue becomes a NPSG for 214

6 The Joint Commission Sentinel Event Database 98 alarm related events during this period (1/21 thru 12/212) 8 of these resulted in death 13 of these resulted in permanent harm 5 of these resulted in unexpected additional care or extended stay Retrieved from Joint Commission webinar on Alarm Safety transcript from May 1, 213

7 Alarm-Related Adverse Events

8 Framework for Alarm Management (ECRI Institute (211); Reprinted with permission)

9 In The News Patient Alarms Often Unheard

10 Alarm Fatigue Contributors Stocking Pump Continuous CO Ventilator What is Alarm Fatigue? Alarm fatigue occurs when clinicians are exposed to a large volume of alarms and as a result, they become desensitized to those alarms. Air Mattress Pump Ventricular Assist Device Desensitization can lead to longer response times or missing important alarms which can lead to patient injury and or death. Dialysis Patient Cooling Balloon Pump IV Pumps Bed Alarms Warmers 1 Do No Harm, June, 212

11 How did we get here? Do No Harm, June, 212

12 Alarm Management The Joint Commission Phase 1 (214) NPSG During 214 Joint Commission Deliverables Input from the medical staff and clinical departments Hospital Tasks Develop an alarms task force to review: -Current alarm policy & procedure -Review current alarm default settings Risk to patients if the alarm signal is not attended to or if it malfunctions. Determine which alarm signals are needed or unnecessarily contribute to alarm noise & alarm fatigue Published best practices and guidelines Develop or revise alarms-based risk assessment. Review internal incidents surrounding alarms. Alarm priority should be determined by risk assessment Should be determined by: -Risk Assessment -Alarms Analytics -Default Assessment -Alarms Workflow Assessment Evidenced based practice solutions based on current alarms literature. Best practice sharing 12 Do No Harm, June, 212

13 The Joint Commission Phase II by Jan. 1, 216 Joint Commission Deliverables by Jan Hospital Tasks Clinically appropriate settings for alarm signals. When alarm signals can be disabled. (Disabled=Paused) Who in the organization has the authority to SET*alarm parameters. * Per Joint Commission customer must define terminology. Who in the organization has the authority to CHANGE* alarm Parameters Alarm Limits Parameter / Arrhythmia Priorities. * Per Joint Commission customer must define terminology. Who in the organization has the authority to SET* alarm parameters to off. Changes based on data collected and analyzed via phase I Identify alarm pause default settings (2 vs. 5) Identify activity when alarms can be disabled. Example bathing, suctioning etc. Define who in the organization will have authority to set default settings. Define who in the organization will have the authority to make changes via the bedside/cic. Same as above Same as above Monitoring and responding to alarm signals. Checking individual alarm signals for accurate settings. Educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible. Define policy for addressing alarms Include primary and secondary alarm notification Consider the following: -Beginning each shift -Clinical training sign-off -Preventive Maintenance Define policy for new hire training and yearly competency training. 13 Do No Harm, June, 212

14 What are we doing at McLeod? Collecting Data to assess risk Getting Clinicians involved in collecting the data to create a sense of urgency Reviewing the data for opportunities Creating pilots of change using PDSA format

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18 Alarm Volume Current 6% Minimum 4% Example B (Alarm Control) Parameter Limits and Alarm Levels Physiological Monitors - CVRU Parameter Low High Level HR BPM 5 15 WARNING PVC # / min 1 ADVISORY NBP-S mmhg 8 2 ADVISORY NBP-D mmhg 4 1 ADVISORY NBP-M mmhg ADVISORY RR-Apnea Seconds 2 MESSAGE RR # / min 8 4 MESSAGE ST- I mm -2 2 MESSAGE ST- II mm -2 2 MESSAGE ST- III mm -2 2 MESSAGE ST- V1 mm -2 2 MESSAGE ST- V2 mm -2 2 MESSAGE ST- V3 mm -2 2 MESSAGE ST- V4 mm -2 2 MESSAGE SPO2 % N/A N/A N/A N/A Arrhthmia Alarm Levels Arrhythmia ASYSTOLE VFIB/VTAC ATRIAL FIB V TACH V BRADY PAUSE VT > 2 BIGEMINY ACC VENT TACHY BRADY R on T COUPLET TRIGEMINY PVC IRREGULAR Levels CRISIS CRISIS N/A CRISIS CRISIS WARNING ADVISORY ADVISORY ADVISORY ADVISORY ADVISORY MESSAGE MESSAGE MESSAGE MESSAGE MESSAGE

19 Alarm Default Sampling

20 Example A (Clinician Survey)

21 Severity Occurrence Detection Severity Occurrence Detection PFEMA by medical device type Potential Failure Mode and Effects Analysis (Design FMEA) System: McLeod Health Subsystem Page 1 of 1 Component Model: Core Team: Alarm Safety Committee Medical Device Re sp on sibi lity: Alarm Safety Committee Prepared by: Todd Hazzard Da te: 2/6/214 Date: 2/6/214 A c t i o n R e s u l t s Potential Failure Mode to create an Alarm Potential Effect(s) of Failure to Alarm Potential Cause(s) / Mechanism(s) of Failure Current Design Controls Prevention Current Design Controls Detection R. P. N. Recommended Action(s) Responsibility & Actions Taken & Target Completion Date Completion Date R. P. N. Function Medical Device Manner in which medical device could alarm Consequences on staff to react to or not react to alarm List every potential cause and/or failure to create an alarm, improper maintenance, fatigue, wear, etc. List prevention List detection activities to assure activities to assure design adequacy and design adequacy prevent or reduce and prevent or alarm occurrence. reduce occurrence. 3 Design actions to reduce severity, occurrence and detection ratings. Severity of 9 or 1 requires special attention. Name of organization or individual and target completion date Actions and actual completion date Anesthesia Ventilation System Low/High O2, tidal volume alarms, pressure alarms, leak, low supply gas, no power, ventilator error codes patient not receiving appropriate ventilation 9 lose of electric or supply gas, bad flow sensor, O2 cell, breathing circuit, ventilator control system, leak in breathing system 5 CRNA perform FDA ventilator controls daily checklist, proper sound at adequate planned level, FDA checklist maintenance, replace is performed daily, reusables IE O2 cell, PM preformed timely flow sensor, bellows, and parts replaced at batteries OEM intervals 1 Audit FDA checklist Biomed by being performs, audit 4/214 PM being performed correctly Ensure all anesthesia machines have a posted FDA checklist 4/214 Automatic Rotating Tourniquet leak detected in circuit tourniquet does not hold pressure and blood flows back to surgical site 5 leak in circuit, device internal check valve failure, loss of power 2 system has pressure sensors and low battery alarm replace cuff at OEM intervals, inspect device prior to use, inspect tubing, OEM PM procedure and intervals 1 45 verify PM procedure, Todd Hazzard by Todd Hazzard by verify staff competency 4/214 4/214 1

22 Any questions or concerns using this tool, please contact Debby at Biomedical Services at Alarm Assessment Tool By Department 1. Locate your unit/floor on the COMPASS under Life Safety. 2. Print out the map of your department. 3. Document the location of every device that has an audible and/or visual alert using numbers to identify location. (See example of red numbers 1, 2, 3 on map). If device is mobile, use identifying number at different locations. Those items will be documented by number on spreadsheet in Step Complete Step 2 - Department Alarm Assessment Spreadsheet. 5. Return to Biomedical Services-McLeod Florence via interoffice mail, dmays@mcleodhealth.org, or fax

23 NCIC Alarm Management Discussion Need to discuss clinical alarms, review policy and practice. Need to be able to answer the following questions. To be answered in context of physiological monitors we determined to be highest risk for McLeod Health concerning Alarm Fatigue based on results of FMEA. QUESTION POLICY PRACTICE 1. When alarm signals, can alarm be disabled? YES PC/C - 28 III What are the clinical appropriate settings for alarms? PC/C - 28 II1 Add-Clinical team evaluates, reviewed and signed off by CNO 3. When can alarm defaults be PC/C-28 II - III 1. changed? 4. How do we document this change? NONE PC/C-28 III How do we communicate this alarm setting change at hand off of NONE care? 6. Who in the organization has the NO- Default authority to set alarm parameters? 7. Who in the organization has the YES - PC/C-28 II authority to change alarm defaults? 8. Who in the organization has the authority to set alarm defaults to NO - end of life care "off"? 9. What is monitoring and NO responding to alarm signals? -Check patient -Responding 1. How do we check the individual alarm signals for accurate settings, proper operation and detect ability? Biomed - AIMs / Planned Maintenance NO Educate difference silence/disable ETCO-Alaris End of Life Care YES - Defaults NO - need to develop MD order - need to change alarms NO NO NO - default YES NO NO Work on educating staff

24 False Positive Alarms/Clinically Insignificant Alarms Source Setting % False Alarms Lawless, 1994 PICU 95%* Tsien & Facklet, 1997 PICU 86% Chambrin et al, Adult ICUs 72% Atzema et al, 26 ED 99% Görges et al, 29 MICU 77% Siebig et al, 21 MICU 85% *Includes false alarms & insignificant alarms induced by staff/patient/motion manipulation - False and/or Clinically Insignificant alarms may account for 8-99% per JHH Maria Cvach, Asst. DON at JHH 24 Do No Harm, June, 212

25 Asystole? 25 Do No Harm, June, 212

26 Monitors should be capable of simultaneously displaying and analyzing two and preferably three or more leads of ECG AHA Special Report, Circulation, Vol. 79, No. 2, Feb Do No Harm, June, 212

27 JH Study showing dramatic results 27 Do No Harm, June, 212

28 Best Recommended Practice for Applying Disposable Electrodes The stratum corneum of the epidermis has high impedance. Removal of the stratum corneum at the electrode site will dramatically reduce the skin impedance. The following is a technique that can be followed and will reduce skin impedance. 1. Select electrode application sites without bony prominence, avoiding fatty areas and major muscles. This placement method will help reduce motion-related artifact and maximize the ECG signal strength. 2. If the patient has a fair amount of hair at the electrode application site, the hair should be clipped. Shaving is not necessary and may actually cause some skin irritation. 3. The electrode application site should be clean and dry. The preferred method of cleaning is with soap and water plus drying the skin with a dry cloth or gauze. In emergency situations, this may be difficult. However, clean and dry skin does contribute to good electrode adhesion and good trace quality. 4. Cleaning with isopropyl alcohol should be avoided or limited to situations which electrode adhesion is an issue (diaphoresis, excessively oily or lotion-covered skin), since it may dehydrate the skin, thus causing skin impedance to increase. If alcohol is used, allow it to dry prior to the electrode application. 5. Attach the lead wires to the electrode prior to placing the electrode on the patient. This will eliminate the potential for patient discomfort if snap lead wires are pressed onto the electrode, after the electrode has been placed on the patient. Optimum patient comfort can be obtained if squeeze clip or pinch clip lead wires are used. 6. Electrode application sites should be abraded to lower the skin impedance. The Red Dot Trace Prep 2236 used in this clinician survey has proven to be an effective tool for lowering skin impedance.

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30 Robust Data Summary June 213 Excel Medical data mined 3 days of alarms on physiological monitors for ED, CCU, MICU, and TSCU

31 Alarm Study Overview Scope Unit Number of beds): 126 Total CCU -23 EM -48 MICU -22 OR -17 TSCU -16 Date: 6/1/14 6/25/14 = 25 Days Total # of Alarms: 242,266 Alarms/Day: 9,699 (based on 1% occupancy)

32 All Units, 126 Beds, 25 Days Total: 242,266 Occupancy 68% Crisis: 3,135 Warning: 23,256 Advisory: 157,354 System: 58,721 16, 14, 12, 1, 8, 6, TOTAL CRISIS TOTAL WARNING TOTAL ADVISORY TOTAL SYSTEM 4, 2, 1

33 All Units Crisis Alarms VTACH: 1,431 ASYSTOLE: 1,7 VFIB/VTAC: 473 V BRADY: 115 VT>2: 37 Other: Total: 3, VTACH ASYSTOLE VFIB/VTAC V BRADY VT > 2 Other 2 TOTAL CRISIS

34 By Unit CCU EM SPO2 LO APNEA BRADY TACHY PVC SPO2 PROBE SPO2 LO PVC HR LO LEADS FAIL Crisis Warning Advisory System Crisis Warning Advisory System

35 By Unit 9343 MICU 2546 OR SPO2 LO BIGEMINY APNEA RR LEADS FAIL PVC NO BREATH EXP CO2 HI ST-I SPO2 LO VT > Crisis Warning Advisory System Crisis Warning Advisory System

36 By Unit 196 TSCU SPO2 LO RR LEADS FAIL TACHY LEADS FAIL APNEA Crisis Warning Advisory System

37 All Units Most Frequent Alarms (MRMC Sample) SPO2 LO 515 SPO2 PROBE PVC 1522 APNEA HR LO 9962 PVC, 1522 APNEA, HR LO, 9962 SPO2 LO, 515 SPO2 PROBE, 28668

38 Most Frequent Alarms Per Unit (MRMC Sample) SPO2 LO SPO2 PROBE PVC APNEA HR LO 5 CCU EM MICU OR TSCU

39 CVICU Alarm Study Overview Scope (Unit Number of beds): CVICU -15 Date: 5/1/214 5/14/214 = 14 Days Total # of Alarms: 137,86 Alarms/Day: 9843 (based on 1% occupancy)

40 APNEA ART D HI ART D LO ART M HI ART M LO ART S HI ART S LO HR HI HR LO NBP D HI NBP D LO NBP M HI NBP M LO NBP S HI NBP S LO PVC HI SPO2 HI SPO2 LO CVICU Alarms by Types # of Parameter Alarms # of Arrhythmia Alarms ACC VENT ASYSTOLE BIGEMINY BRADY PAUSE TACHY V TACH VFIB/VTAC VT > 2 # of Technical Alarms Total Alarms Summary For This Report ARRHY SUSPEND ART DISCONN LEADS FAIL NBP FAIL NBP MAX TIME NBP OVER PRES RR LEADS FAIL SENSOR SPO2 SENSOR Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms % Other Alarms.%

41 Move to New CIC Tower/ New Technology/ New Alarms CIC Alarm Study Overview Scope Unit Number of beds): 6 Total CCU -2 MICU -2 TSCU -2 Date: 5/1/214 5/14/214 = 14 Days Average Alarms/Day: (based on 1% occupancy)

42 Increase in Technical Alarms Hospital Unit Duration MRMC TSCU 14 days Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms % Other Alarms % 9119 Hospital Unit Duration MRMC MICU 14 days Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms % Other Alarms % 1851 Hospital Unit Duration MRMC CCU 14 Days Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms % Other Alarms % 1283

43 Sample of McLeod Tele Alarms 14D 12 # of Technical Alarms # of Parameter Alarms 12 ARR SUSPEND LEADS FAIL NO TELEM # of Arrhythmia Alarms HR HI HR LO PVC HI Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms %

44 Sample of McLeod CVICU Alarms 14D Parameter Alarms Arrhythmia Alarms Technical Alarms Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms %

45 Sample of ED Alarms 13D Parameter Arrhythmia Technical Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms %

46 Sample of Hemodialysis Alarms 14D # of Technical Alarms # of Arrhythmia Alarms # of Parameter Alarms Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms %

47 Snapshot of CCU Alarms-inconclusive Parameter Alarms # of Arrhythmia Alarms Technical Alarms Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms %

48 Snapshot of TSCU Alarms-inconclusive Total Alarms Summary For This Report Category Count Percent Parameter Alarms % Arrhythmia Alarms % Technical Alarms %

49 Maria Cvach Alarm Settings - Solars 49 Do No Harm, June, 212

50 Noise Studies/Alarm Sounds Are Patient s room doors open? Consider floor plan. If closed, is there another location for the alarm to be heard? Secondary alarm notification systems? Pagers or phones? According to (WHO) the day time noise level of a hospital should be about 35 decibels during daytime hours and 3 decibels for the night time hours. Noise contributes to staff/patient/families/physician/etc. stress, disruption, fatigue, and concentration. Noise studies could be conducted. Reimbursement tied to Patient Satisfaction Surveys. 5 Do No Harm, June, 212

51 Next Steps Continual Process Improvement Culture We need to engage Physicians to ensure alarm defaults are clinically significant Clinicians must change alarms to the patients Norm We must consider appropriate use of device with alarms Alarm Champions monitoring progress and challenging the staff to actionable vs. non-actionable alarms. Practice Changing electrodes daily Proper skin preparation Changing telemetry batteries prior to failure Technology Evaluate secondary alarm notification Determine capabilities and limitations (smart alarms) Education/ Resources Develop quick reference guide Develop CBTs Tech Tips/ Nursing Newsletter/ Huddles

52 Questions