National Teaching Institute & Critical Care Exposition - 2015 Prep for 2014/2016 National Safety Goal on Alarm Management Lessons Learned Mary Baum NTI 2015
What I Will Share Agenda Define alarm fatigue Best practice and strategies to reduce alarm fatigue Methods to assure notifications of alarms- right time/right role Five recommendations for the alarm design of the future 2 32
Purpose of Clinical Alarms Enhance patient safety The perfect alarm system Never misses a clinically important event (100% sensitivity) Never alarms when there is no clinically important event (100% specificity) The reality high sensitivity and low specificity 3 32
Technology Hazard ECRI Institute- Top 10 technology hazard Staff overwhelmed Desensitized Missed alarms or delayed response 4 32
To Make Hospitals Less Deadly The Joint Commission 2014 National Safety Goal on Alarm Management Sentinel events still happening regularly A dose of data: 2005-2010- Hospital self-reported #216 deaths (Kowalczyk) 2005-2008- Hospital self-reported #566 deaths (FDA) 2013- The Journal of Patient Safety Preventable hospital errors reality #440,000 per year The goal for the new regulation: No patient will be harmed by adverse alarm events 5 32
The Basic Requirement + Best Practice NPSG.06.01.01 Phase One January 1,2014 Establish alarm safety as a priority Identify most important alarms Phase Two January 1, 2016 Develop and implement specific policies and procedures Educate staff Best Practice Leadership - active participation Annual inventory Understated default settings Identify what alarms to manage Establish policies and procedures for managing Educate staff Metrics Ongoing 6 32
Lesson One: A multi-disciplinary Task Force 7 32
Process for Success Assess Risk Measure alarms/high priority devices/great risk Assess unit environment Form a multi-disciplinary team Pilot and measure change Default alarms Messages vs. audible 24 hour lead change Customize alarms 8 32
Process Policy and procedures Redesign workflow to improve efficiency Staffing patterns and assignments Notification technology Communication technologies 9 32
A Workaround Culture Workaround defined An improvised method to circumvent an obstacle, but which does not eliminate the obstacle. --Merriam Webster In healthcare organizations Focus on current, immediate patient care needs rather than on improving system for future patients Vicious cycle: bad process > workarounds > bad process Reinforces (sometimes mistaken) belief that some other department is not doing its job > workaround 10 32
How We See Workflow 11 32
Clinical Challenge Effective inter-disciplinary collaboration among caregivers and support staff is imperative to ensure positive patient outcomes It does not happen automatically It does not happen easily It does not happen often 12 32
Root Cause The environment is uncertain and in constant flux Work is done in silos parallel play side by side with the semblance of collaboration Reality: little process or policy to support interdisciplinary or cross department work Results: sentinel events, inefficiency, poor use of resources, unnecessary patient suffering and missed diagnosis 13 32
What Supports That Effort? Organizational practice Programmed systems and standards Boundary spanners Performance metrics 14 32
Interdependencies Technology Standards Staffing Patient Environment Leadership Workflow 15 32
Patient Safety Dependent on FIVE components 1. Technology - Alarm Data acquisition/appropriate sensors 2. Communication system - Transmission of the alarm data to appropriate resources 3. Integration of the alarm data with the state of the patient (both nurse/physician) 4. Synthesis of an appropriate action/response/escalation (both nurse/physician) 5. Clinical Analytics - Associated storage and later use of data have we made a difference? Metrics 16 32
Conclusions Leadership clarity - Share Best Practice - Periodic alarm audit - Interaction physician and staff - System thinking - What gets measured gets improved - Collaboration and shared vision - Culture of continuous improvement Technology s role agreement Nursing responsibility - agreement 17 32
Cause of Most Sentinel Events 18 32
Lesson Two: Modest Changes Small CHANGES make a big difference ASYSTOLE CRISIS VFIB/VTAC CRISIS V TACH CRISIS VT > 2 CRISIS Message /Message V BRADY CRISIS COUPLET WARNING Message/ Message BIGEMINY WARNING Message/ Message ACC VENT MESSAGE PAUSE WARNING Message/ Message TRIGEMINY ADVISORY Message/ Message R ON T MESSAGE PVC MESSAGE TACHY WARNING Message/ Message BRADY WARNING Message/ Message IRREGULAR MESSAGE HR WARNING (limits 50 and 115 120) (50-120 limit change) PVC ADVISORY Message /Message ST ADVISORY Message (limits changed from -1 and 1 to -2 and 2) /change limits ART ADVISORY (limits Sys H-180 L-90; Mean H - 120 Lo-55; Dia H-110 Lo 40) SPO 2 ADVISORY (Limit - 89) 19 32
The Modest Changes Standardize Actionable Visual vs. audible Limit adjusted At 211 degrees, water is hot. At 212 degrees, it boils. And with boiling water, comes steam. And with steam, you can power a locomotive. One extra degree can make all the difference. 20 32
35-65% Reduction of Alarms General sources of alarms ECG - 83% We can reduce alarms by changing settings Gross et al, 2011 HR: 120 to 130 50% reduction Low SpO 2 : 90% to 85% - 35% reduction Low SpO 2 : 90% to 80% - 65% reduction 21 32
Five Second Pause Big Reduction Delay: reduce # of alarms by up to 70% - Welch, 2011: SpO 2 Alarms 5 second delay 32% decrease 10 second delay 57% decrease 15 second delay 70% decrease 22 32
Lesson Three: Right Alarm/Right Role/Right Time Monitor watch Pagers Split bedside screens View on alarms Screens/ Monitors Phones 23 32
The Best Practice + Technology = Patient Safety Crises alarms sent immediately to nurse Warning and system alarms paused for 60 seconds (allowing for auto corrections, or staff to silence) Right intelligent alarm escalation via middleware- routes alarm to specific devices (pagers or phones) to specified caregiver 24 32
Lesson Four: Reduce Artifact Technical alarms: reduced by proactivity Change the electrodes daily Proper skin prep and lead replacement Change or charge the battery daily Reduced average alarms/bed/day by Best Practice 46% Standards/protocol and practice 25 32
Lesson Five: Reduce Non-Actionable Alarms Customize alarm settings to individual patients De-activate default alarms to conditions you do not treat (PVCs) Avoid unnecessary monitoring- who should be monitored and for how long? AHA practice standards (Drew et al, 2004) Baseline Pulse Trial data (Funk et al, 2010) 85% of 783 patients- no indication for monitoring on monitoring 26 32
Viewpoint People Process Technology Technology must follow process not dictate However Automating inefficient process only multiplies the inefficiencies 27 32
What Supports That Effort? Organizational Practice Programmed systems and standards Performance metrics 28 32
Measure Everything 29 32
Summary Know your number Staff and executive involvement/commitment Best Practice Prioritize areas/alarms Small changes - Big difference Make sure changes are codified and translated into policy and practice Context is highly relevant - workflow Technology enables -does not drive Metrics 30 32
Questions? 31 32
Thank you for your attention. Mary A. Baum President/CEO Baum Arensmeier and Talent BA&T The Schleier Mansion 1665 Grant Street Denver, CO 80203 303 831-7692 DL 303 810-9780 Cell maryb@thinkbat.com