Alarm management: The Abbott Northwestern Experience A quality improvement project

Transcription

1 Alarm management: The Abbott Northwestern Experience A quality improvement project Stacy Jepsen, APRN, CNS, CCRN Sue Sendelbach, PhD, RN, CCNS, FAHA, FAAN September 3 rd, 2014

2 Abbott Northwestern Hospital Minneapolis, MN Abbott Northwestern Hospital Staffed for 627-beds 38,168 in-patient admissions per year Heart transplant/ventricular assist device program Three intensive care units: 16-beds cardiovascular medical; 16-bed cardiovascular surgical; and 30-bed medical/surgical/neuro 2

3 Objectives 1. Describe the use of a champion to facilitate the project. 2. Explain the process of the implementation of interventions to decrease nuisance alarms. 3. Identify the bundled approach utilized to decrease nuisance alarms. 3

4 Rapid Improvement Process Workshop Stakeholder Stake in Project Potential impact on Project Power / Interest [See Fig I] What is needed from the Stakeholder? Perceived attitudes and/or risks of the Stakeholder? Stakeholder Management Strategy [See Fig I] Name / Function or Role What part of the process or outcome does stakeholder own? Are there other interdependencies to be considered? Power: High Interest: High What will stakeholder need to stop / start / do differently? (Ex: Staff to help with project; Data or other information; Commitment to implement change) What will stakeholder win / lose? How might they react? (Ex: Lack of interest in project; Impact to workload; Training needs, etc.) How to get and/or keep stakeholders on board? Who will take the lead on what key tactics? 4

5 5 Research and quality improvement projects

6 Research and quality improvement projects N Engl J Med Aug 10;321(6): % of alarm conditions indicated non critical and generally non actionable, events; 38 percent of alarm conditions indicated premature ventricular complexes (PVCs), which, since a landmark 1988 Cardiac Arrhythmic Suppression Trial (CAST) study, are no longer treated. AAMI. Dr. Barbara Drew. Clinical Alarms: 2011 Summit. Pg. 11 6

7 Research and quality improvement projects Whilst many of the respondents set alarm limits individualised of their patient, there appeared to be no consistency as to what these meant. For example.heart rate limits there were often set 10 beats/minute above and below the current rate. pg. 208.Intensvie & Critical Care Nursing: The Official Journal of the British Association of Critical Care. Aug 2014;30(4):

8 Policy/Procedure for Alarm Management Clinical policies and procedures regarding alarm management are effectively used in my facility (n=4915) Percentage P for χ 2 Median score (interquartile range) P for Mann Whitney U <.001 2(2 3) 2(2 3) <.001 Strongly agree Agree Neutral Disagree Strongly disagree Funk M et al. (2014). Attitudes and practices related to clinical alarms. AJCC. 23:e9 e18. 8

9 Policy/Procedure for Alarm Management There is a requirement in your institution to document that the alarms are set and area appropriate for each patient (n=4886) Percentage P for χ 2 Median score (interquartile range) P for Mann Whitney U (1 2) 2 (1 3) <.001 Strongly agree Agree Neutral Disagree Strongly disagree Funk M et al. (2014). Attitudes and practices related to clinical alarms. AJCC. 23:e9 e18. 9

10 Changing practice - Champions Effective strategies to change practice Reminders (manual or computerized) 1 The use of local opinion leaders (practitioners identified by their colleagues as influential) 1 3 Interactive educational meetings (participation of healthcare providers in workshops that include discussion or practice) 1 Ineffective strategies to change practice Didactic education meetings 1,2,4 Educational materials (distribution of recommendations for clinical care, including clinical practice guidelines, audiovisual materials, and electronic publications) Bero LA et al Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ; 317: Weingarten S Translating practice guidelines into patient care: Guidelines at the bedside. 118(2):4S 7S. 3 Titler MG. (2004). Translation science: quality, methods, and issues. Communicating Nursing Research. 37:15, Smith WR Evidence for the effectiveness of techniques to change physician behavior. Chest. 118(2)Supp. 8S 17S.

11 Clinical Nurse Specialist Champions Key inteprofessional teams members biomed, respiratory therapist, RNs including clinical nurse specialists and staff nurses, physicians, information technology specialists 11

12 Initial Work Know & understand default alarm settings Scope of work Limited to ECG, SpO2 Analysis of default alarm setting Evaluate and understand priority levels and how being used Unit thresholds versus critical care thresholds How were limits decided? Hospital policy versus unit/department specific Setting individual alarm limits per unit/ patient needs 12

13 Duplicate alarms Nuisance alarms Bradycardia low heart rate Tachycardia high heart rate Bigeminy & Couplets Daily ECG patch changes, skin prep 13 Cvach M., et al., (2012). Daily electrode change and effect on cardiac monitor alarms: An evidence based practice approach. J Nurs Care Qual

14 Reduce duplicate alarms, make alarms meaningful Alarm type Current setting Change being made Type of alarm (alert on monitor) High HR Serious (yellow alarm) Low HR Serious (yellow alarm) Brady Life Threatening (red alarm) V tach (VT) Life Threatening (red alarm) Bigeminy On Off Advisory (white alarm) Widening out the serious high/low HR alarms will make the life threatening alarms the primary alert and reducing duplicate alarms. Couplet On Off Advisory (white alarm) SpO2 Lower Limit 89% 88% Serious (yellow alarm) 14

15 Review and changing of alarms When these settings need to be reviewed/ changed and who can change them (e.g., during transport) Transport: SCCM 1, ARC 2, ESICM 3, SIAARTI 4, ACEM 5 guidelines Not specific to what, how often SCCM recommends same level of physiological monitoring as in ICU Critical monitoring pieces (pulmonary artery catheter) Orders to transport off monitor Unique areas/patient situations: Comfort care patient Pre operative/cath lab areas where there can be 3 patients within an hour 15 1 Warren J, et al. (2004). Guidelines for the inter and intrahospital transort of critically ill patients. Crit Care Med; 32: Stevenson VW, et al. (2002). Intrahospital transport of the adult mechanically ventilated patient. Respir Care Clin 8: Ferdinande P. (1999). Recommendations for intrahospital transport of the severly head injured patient. Intens Care Med. 25: Torri G. (2006). Recommendations on the transport of critically ill patients. Minerva Anestesiol. 72(10:I XLVI. 5 ACEM (2003) Minimal standards for intrahospital transport of critically ill patients. Emerg Med. 15:

16 Results Average number of alarm signals per patient per day 16 Limitations: Quality improvement project with the use of a bundled approach. We can not say for certain which intervention made the difference. Results not generalizable.

17 thank you!