Evolution of an Integrated System for Alarm and Call Management March 19, 2014

Transcription

1 Evolution of an Integrated System for Alarm and Call Management March 19, 2014 Peter Doyle, Andrew Currie, Robert Frank, Adam Sapirstein and Maria Cvach

2 Objectives: Ensure patient safety through alarm and call management in a new clinical building Improve notification of alarm and call information Reduce alarm fatigue/desensitization to improve response times Reduce false alarms and noise Facilitate task prioritization Improve nursing workflow 2

3 Stepwise Overview of Integration Activity Conduct physiological monitor/cardiac alarm studies Plan and pilot new nurse call system in orthopedics Real Time Locating System (RTLS) One-way paging Wireless phones Middleware Acknowledgement pagers Plan custom notification configurations for new units Deploy and test systems (560 beds, 33 ORs) Evaluate, improve and customize system capabilities 3

4 Cardiac Alarm Studies Alarm management committee Reduce cardiac alarms while improving notification Fault tree analysis Equipment studies Education & policy changes Defaults and customization (threshold limits and levels) Notification tools (pagers) and delay and escalation schemes Physician-led alarm management group 4

5 Sample Cardiac Alarm Studies ALARM REDUCTION STRATEGY Parameter limits and alarm-level changes (varies by unit) DECREASE 25-74% Unit-based monitor watch in CCU 47% Daily electrode change CCU / MPCU 1 46% / 46% Use of disposable leads in CCU / PICU 34% / 0% New electrodes in CCU 31% 2 Remind staff to customize alarms (CCU) 24% 2 New SpO2 sensor in CCU 2% 2 1 Cvach et. al. Daily Electrode Change and Effect on Cardiac Monitor Alarms: An Evidence- Based Prac@ce Approach. Journal of Nursing Care Quality, Published online before print, Oct, Not sustained 5

6 UNIT Benefits of All Cardiac Alarm Strategies ALARM REDUCTION MEAN ALARMS / BED / DAY ICU A 68% 215 vs. 68 ICU B 58% 317 vs. 132 ICU C 74% 771 vs. 203 IMC 79% 240 vs. 50 TELEMETRY 37% 90 vs. 57 Cvach et. al. Managing Clinical Alarms: Using data to drive change. Safety Solu@ons, November,

7 Nurse Call System Pilot Nurse call system committee participants Clinical engineering, facilities, nursing and unit staff, IT, vendor reps Customized commercial product for better notification and to improve workflow Selected visual and auditory signals Determined use and placement of equipment / features Installed test system in orthopedics unit Conducted verification & validation activity Real Time Locator System (RTLS) Integration with phones via middleware 7

8 Nurse Call Sub- Assemblies Domelight Staff Console Annunciator Wireless Phone (added later) Staff/Duty 8

9 Nurse Call Signaling ALARM STATE CODE BLUE LAV/STAFF EMERG EQUIPMEN T/ BED EXIT LAV ASSIST PATIENT NORMAL STAFF NORMAL/ EQUIP DISCONNECTS ROOM CHANGE DOME LIGHT FLASH RATE FAST FAST FAST FAST STEADY STEADY STEADY TONE WARBLE VERY FAST PULSE FAST PULSE FAST PULSE FAST PULSE ON/OFF SLOW PULSE NONE PHONE MESSAGE UNIT ID RM # CODE BLUE PT. NAME UNIT ID RM # STAFF (OR LAV) EMERGENCY PT. NAME UNIT ID RM # EQUIPMEN T ALARM OR BED EXIT PT. NAME UNIT ID RM # LAV ASSIST PT. NAME UNIT ID RM # PATIENT NORMAL PT. NAME UNIT ID RM # STAFF NORMAL OR BED DISC OR PILLOWSPKR DISC OR EQUIP DISC PT. NAME N/A 9

10 New Real Time Locating System (RTLS) Indicates staff presence in rooms Provides list and map views of staff locations on monitors Equipment tagged later 10

11 V & V Results Verification 115 test items in each of 28 rooms Validation Time-based data difficult to compare to previous^ Judged equally easy to use as previous, simpler system Patient intercom can be accessed via phones Nursing confident overall response to calls had improved 11

12 One-Way Paging Test unit (orthopedics) Nurse calls linked to specific pagers via nurse call software Escalation scheme used Pinpointing messages to specific nurses had many benefits Well-received except cannot close the loop by acknowledging receipt of messages 12

13 Wireless Phones as Notification Devices Two-way interactive messaging^ 4 different ringtones used Improved wireless capability Needed multiple systems with paging bridges to support call load Complexity: 71training slides 13

14 Incorporate Middleware to Integrate Notification Devices Enables: Alarms & texts from multiple monitoring systems Two-way communication between nurse call system, wireless phones and pagers Customization of notification schemes Delay notification for self-clearing alarms/calls Escalate notifications to backup staff Time-based notifications e.g. glucose and wound care assessments Provides activity logs 14

15 Introduce Acknowledgment Pagers Acknowledgment pagers enable closing the loop Dedicated paging system for physiological monitor pagers Tested on adolescent care unit Access to data logs for forensic and system evaluation purposes Well received for ease of use, accuracy, timeliness, clinical value 15

16 Plan New Building Installations Alarm and call system configurations New middleware product Device assignments Escalation schemes Notification devices Bedside physiological monitors Central monitors Hallway cardiac monitor display Nurse call system Acknowledgement pagers and wireless phones 16

17 Alarm Management Steps for New Buildings Alarm management committee Physician-led group ECRI recommendations Nursing administration Changes to Monitor policy Cardiac policy Unit configurations for alarm notification Staff coverage Zoning Allocation & location of notification tools Alarm settings Delays/escalation Provide input to training developers Document and train 17

18 Zoning Developed zoning in view of staff ratios, care area and physical environments Physiological monitor zones Bedside and central monitors, auto view on alarm Hallway cardiac monitor displays Nurse call zones - placement and allocations of: Staff consoles Hallway annunciators and Zone lights Notification devices (type and escalation scheme) 18

19 PICU Zoning of 32 Rooms Central Monitors HM Hallway Monitors SC Staff Consoles Staff/Duty Stations SD No Annunciators Z Zone Lights CIC Z CIC Z SC ZONE 3 Z HM HM CIC CIC SC SD HM Z Z SD SC Z ZONE 1 ZONE 2 19

20 Unit Alarm Settings Determine monitor default settings Alarm levels for specific parameters Parameter thresholds Identify alarms to be communicated to pagers (Monitor watch, non-monitor watch, charge nurse only) Determine which alarms initiate AVOA displays Determine which audio alarm levels sound on hall displays 20

21 Monitor Alarm Delay/Escalation (Non-Monitor Watch) 21

22 Triaged Pt. Normal Call CCSR 0s Primary RN 120s RN Buddy 240s Charge RN 300s

23 Escalation Pattern for Triaged Messages 0 secs Call sent to CA/CT Call sent to RN 2 min or O sec if nurse only task Call rings at staff console, CCSR triages, and sends message 5 min Call sent to charge nurse 3 min 4 min CCSR will call initial messaging recipient via Ascom to follow-up on request Call sent to RN buddy 23

24 Deploy and Test in New Building Nurse call, RTLS, phone and middleware verification for all rooms >160k test items Assess whether zoning approach satisfied clinical unit objectives for zoning alarms and calls for all events 24

25 Acknowledgment Pager Escalation Results Each surgical IMC unit nurse carries pager 53% reduction of physiological monitor alarms 23% reduction in time to respond Charge nurse only carries pager No reduction of alarms 13% reduction in time to respond to alarm Cvach et. al. Managing Clinical Alarms: Using data to drive change. Safety November,

26 Transition from Pagers to Phones for Monitor Alarms Piloted phone use on units where charge nurse had pager as backup to assure phone reliability 26

27 Establish Change Committee Co-chaired by nursing and clin. engineering Nursing (unit staff) Clinical engineering IT / Telephony Respiratory Therapy Meet monthly to review change requests from units Use data to drive change Committee approves and tracks requests 27

28 Summary of Results Reduced unnecessary alarms and noise Parameter limits, daily electrode change, escalation of notification Assume alarm fatigue/desensitization is reduced Improved direct notification of alarm and call information and provided backups Facilitate task prioritization Improved nursing workflow 28

29 Alarm and Call Integration Thank You 29