Pulse Oximetry Alarm Reduction Strategy at Boston Medical Center

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Daniella Cannon
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1 Pulse Oximetry Alarm Reduction Strategy at Boston Medical Center July 30, 2014 Boston Medical Center Alarm Initiative Reduction in alarms Recent focus on Pulse Oximetry Data review for supporting change Technical Considerations Clinical Considerations Training to support change Strategies 7/30/2014 2

focus on Pulse Oximetry Data review for supporting change Technical

2 Pre Pilot Alarm Data Evaluate technology and processes to understand alarm issues Assess alarm data to pinpoint contributing factors to alarm fatigue Identify strategy to safely effect changes to reduce clinically insignificant alarms 7/30/ Post Pilot Alarm Data Data proved that changes were effective and safe Actionable Alarms = Better response Better display of events Many alarms were missed before changes 7/30/2014 4

clinically insignificant alarms 7/30/2014 3 Post Pilot Alarm Data Data proved that changes were effective

3 87,823 Total Audible Alarms Average Alarms per Week 9,967 Pre Pilot Pilot 7/30/ Data collected from alarm logs Area/Campus SPO2 Lo SPO2 Rate Lo SPO2 Rate Hi SPO2 Probe SPO2 Sensor Pulse Search Total Week Warning Warning Warning Warning Warning Message Menino Units 283,776 25, , , ,630 Newton Units 148, ,163 26,705 1,623 2, ,805 Data and workflow and Education suggest there are opportunities to improve Define the current problem/ reason for action Following the successful implementation of the cardiac monitor alarm reduction project we found that there remained a significant number of alarms contributing to alarm fatigue that stemmed from SpO2 alarms (O2 Sat alarms). On further review we found that standard policies, procedures and order sets governing application of this technology are lacking and there is significant opportunity for improvement in application of this technology across the organization. Provide baseline data to support the problem statement Currently SpO2 alarms constitute over 1/3rd (39%) of all audible alams on our medical surgical units. On Newton 8E our Pilot Unit again over 1/3 rd (32%) of all alarms comes from SpO2 alarms Discuss any potential barriers to success Achieving interdisciplinary consensus on application of O2 sat monitoring technology. 7/30/2014 6

Education suggest there are opportunities to improve Define the current problem/ reason for action Following the successful implementation of the cardiac monitor alarm reduction project we found that

4 Technical Considerations Signal averaging In general terms, oximeters average the signal output over a number of seconds allowing the user to change the settings within the service/operating menu. Generally, a short averaging time, e.g. 2 s, will accurately record all data, but may be prone to increased levels of motion artifact, whereas a longer averaging time, e.g. 12 s, will reduce the presence of artifact, but reduce the quality of the signal so that rapidly changing events may be missed. Delay A feature that requires additional time to detect hypoxemia (SpO 2 less than 90 percent). The length of delay can be affected by poor sensor site perfusion and vasoactive drugs. (Pulse Search alert) Probe considerations Probe type and positioning can influence accuracy of readings. There are Several types of probes available and finding the proper site and signal strength is an important feature in ensuring accurate information. Images courtesy of Google. 7/30/ Clinical Considerations Patient Populations Patient populations will require consideration for probe and site selection and sampling rate/delay. NICU is especially critical due to potential issues associated with hyperoxemia. Continuous vs. Intermittent Pulse Oximetry should be used as a clinical tool and matched to the patient s acuity. Baselines and alarm settings While typical settings are , you will alarm at threshold set. Our data showed a high number violations because patients were hitting the threshold. Supporting Documentation + CPOE Our policies and order sets did not delineate proper utilization for patient needs. Managing the patient requires order sets and policies that reinforce optimal care and not allow for misuse of technology. Leverage 2 Nurse identifier for patient specific changes Using data to support individual changes to settings is an in situ management tool used to allow for alarm changes in advance of a physicians order. 7/30/2014 8

Delay A feature that requires additional time to detect hypoxemia (SpO 2 less than 90 percent). The length of delay can be affected by poor sensor site perfusion and vasoactive drugs.

5 Educational Considerations Data review Data is an important component to change management. Leverage data to pinpoint opportunities. Definitions As we create changes, define the current state and what the changes should bring. Providing data and rationale is an important component of change acceptance. Cart As we create a change model, our training cart provides a means to both test our assumptions as well as demonstrate to staff what the changes will look and sound like. It is a well used method to allow staff to visualize changes on a live system. Tip for our staff When taking probe off for eating or ambulating actually disconnect probe from the monitor. This will take away alarm. This would be important for you to ask your Physical Therapy colleagues to do to and they have been made aware of this. For patients who are agitated because of probe slipping off change to disposable sticky probes so probe will stay on more securely and ensure safety. 7/30/ Strategies Data Identify opportunities for change through data review Verify technical features (Sampling/Delay) to help frame discussions Define scope and limitations Continuous versus intermittent Patient populations, risks, alarm thresholds Investigate use models Educate and Disseminate CPOE and procedures should support workflow Identify methods to reduce system alarms Share with all stakeholders Demonstrate changes using available tools Share information in the moment 7/30/

Cart As we create a change model, our training cart provides a means to both test our assumptions as well as demonstrate to staff what the changes will look and sound like.

A Novel Approach to Cardiac Alarm Management on Telemetry Units. Medical Device Alarm Safety in Hospitals Joint Commission Webinar May 1, 2013

A Novel Approach to Cardiac Alarm Management on Telemetry Units Patricia Covelle, RN, MMHC Director of Critical Care Nursing James Piepenbrink, BS Director, Department of Clinical Engineering Deborah Whalen