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Sound the Alarm!
Strategies for Alarm
Management in the
Rush NICU
Steven B Powell MD
John E Overby BSN
Connie L Weissman MS
Carol A Squires BS
Jean M Silvestri MD
October 21st, 2015
Background
• The Joint Commission has issued National Patient Safety Goal on Alarm Management
• Over-exposure to multiple alarms can result in alarm fatigue
• Devices at bedside have grown significantly
• Safe alarm management is a challenge for NICUs transitioning from open bay to single family room (SFR) environments
The Joint Commission NPSG 2015
• Identify the most important alarm signals to manage based on the following:• Input from the medical staff and clinical
departments
• Risk to patients if the alarm signal is not attended to or if it malfunctions
• Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
• Potential for patient harm based on internal incident history
• Published best practices and guidelines
©2007 RUSH University Medical Center
The Joint Commission NPSG 2016
• Establish policies and procedures for managing the previously identified alarms and address the following:• Clinically appropriate settings for alarm signals
• When alarm signals can be disabled
• When alarm parameters can be changed
• Who in the organization has the authority to set alarm parameters
• Who in the organization has the authority to change alarm parameters
• Who in the organization has the authority to set alarm parameters to “off”
• Monitoring and responding to alarm signals
• Checking individual alarm signals for accurate settings, proper operation, and detectability
©2007 RUSH University Medical Center
Workflows
• For existing workflows to work, nurses must
be able to receive alerts from both the
patients’ systems and from other staff
• Alerts must have assigned priority to
differentiate important alerts from less
important to avoid alarm fatigue
• Escalation required if busy or no response
Alarm Fatigue
• Over-exposure to alarms can result in alarm fatigue– Ignoring critically important alarms
• Devices at bedside have grown significantly– Vital sign monitors, ventilators, infusion pumps, pulse
oximeters, capnographs, feeding pumps
• Can generate hundreds of alarms per patient per day, overloading staff
• Risk recently rated first in patient safety threats by ECRI Institute
• Joint Commission has issued National Patient Safety Goal on Alarm Management and Sentinel Event on Medical Device Alarm Safety
Hospital Leadership
“Default alarms are
my safety net against
Sentinel events.”
“When in doubt –
turn on the default
setting.”
Bedside Nurse
“Responding to alarms is
just one task on a huge
and growing list.”
“All these alarms don’t
help keep patients safe.”
“Alarm management
is a technology problem
to be fixed.”
Alarm
Fatigue
Objective
• Integration of physiologic monitors,
ventilators, and nurse-call to wireless
phones to create virtual “line of sight” to
patients after transitioning from open-
bay to SFR environments
• To mitigate alarm fatigue by adjusting
parameters of alarm management and
notification platform
The process
• Create a team – multidisciplinary
– Hospital Leadership
– Physicians
– Nurses and Nursing Administration
– Respiratory Care
– Biomed/Clinical Engineering
– Information Technology
– Risk/Legal
June 2014 RUSH Team of the Quarter
Steven Powell NICU Attending-Team Leader
Jean M. Silvestri Director of the NICU
David Vines Chair/Program Director Respiratory Care Program
Keith Roberts Director, Respiratory Therapy
Sara Murphy Respiratory Therapy
John E. Overby NICU RN
Melinda D. Noonan Project Sponsor- AVP Children’s Hospital
Natasa Djukic Project Coordinator, Women’s and Children’s Services
Patty Nedved AVP, Prof. Nursing Practice
Debbie Gist Unit Director, NICU
Jody Selenica AUD, NICU
Elizabeth Myers Risk Management
Karen M. Silvestri Risk Management
Bonnie Macius Risk Management
Amanda McGee Risk Management
Susan O’Leary Risk Management
Lisa Swiontek AVP, Clinical Information Systems
Scott Finkle IS Director, Systems Development & Integration
Christopher J. Kaspar IS Director, Systems Integration
Carol Squires IS Project Leader
Robert Elder IS Director, Capital Projects
Susan Kovach IS PM, Nurse-call
Scott Simon IS PM, Draeger
Connie L. Weissman IS Senior Analyst
Cheryl M. Liggett IS Project Leader
Randy Johnson Clinical Engineering for NICU
Jonathon Arrington Clinical Engineering
Gene Ward Clinical Engineering
Mike Lamont VP, Capital Projects
Tito Luna IT Telecomm
Alden Brugada IT Telecomm
Interfaces
• Inputs
– Nurse-call – Rauland Responder 5
– Draeger Infinity Acute Care System
– Ventilators – Puritan Bennett 840
– EPIC ADT data
– Cisco call manager
• Outputs
– Cisco VOIP phones
– SQL reporting server
Design
• NICU– Draeger – 13 Monitor alarms
– Covidien – 48 Ventilator alarms
– Rauland – 41 Nurse-call alerts
• Labor & Delivery– Rauland – 19 Nurse-call alerts
• Mother Baby Unit– Rauland – 2 Nurse-call alerts
• System Alerts– Heartbeat function added to all servers
– 29 system monitoring alerts
Simulation-based Training
• Procedural skills
• Clinical decision-making
• Teamwork
• Communication
• Inter-professional team training
• Testing new facilities
TESTPILOT
• Rhode Island Hospital adult emergency
department 2005
• Rhode Island Women and Infant’s
Hospital NICU 2009
• Rush NICU 2014
Transport Enhanced Simulation Technologies for
Pre-Implementation Limited Operations Testing
Goals of TESTPILOT
• Evaluate integration of new and existing
systems and workflows
• Identify latent safety threats
TESTPILOT
• Multidisciplinary team
– Headed by Dr Beverley Robin
• Eight clinical scenarios
• 10 NICU patient rooms equipped
• In situ simulations, varying levels of
fidelity
• 30 minute simulations, 60 minute
debriefing
• Videotaping
TESTPILOT Participants
• Nurses (12)
• Neonatologists (2)
• Nurse practitioners (2)
• Residents (4)
• Respiratory Therapists (4)
• Patient Nursing Assistants (2)
• Clerks (2)
• Lactation consultant (1)
• Pharmacist (1)
• X-ray technician (1)
• Confederates (parents, L&D and transport nurses)
Threats to Patient Safety
Identified by TESTPILOT
31%
16%13%
14%
11%
6%9%
Communication
Equipment
Ergonomics
Systems/Workflow
Facilities
Family-centered care
Environmental Safety
Methods - Design
• Critical Alarms
(Apnea/Asystole/Brady/Desat) go
directly to phones with no delay
• Non-Critical and Advisory Alarms have
delays before forwarding to phones to
allow recovery of patient
• If no response, escalation to “buddy”
and then to pod leader
Methods - Modifications
• Ongoing evaluation and review of
alarm transmission
• After 3 months review, changes made
including blocking transmission of most
non-critical alarms to phones
• After 8 months, additional safety
measures implemented, including Split
Screen and No Pass Zone policy was
implemented.
Physiologic Monitor Alarms March-May 2015
Alarm Class Alarm Type Total Alarms Alarms %
Critical Apnea 11,779 3.1%
Critical Asystole 1,828 0.5%
Critical Bradycardia (<60) 6,151 1.6%
Critical Desaturation (<78) 59,230 15.8%
Non-Critical High HR (>200) 35,871 9.6%
Non-Critical HR Low (<100) 4,503 1.2%
Non-Critical Sat High (>95) 22,445 6.0%
Non-Critical Sat Low (<88) 189,808 50.8%
Non-Critical Art BP Low 192 0.1%
Non-Critical NIBP Low 199 0.1%
Advisory Sat Ld off 32,158 8.6%
Advisory ECG Ld off 9,767 2.6%
Advisory Art Ld off 13 0.0%
All Total 373,944 100.0%
Alarm Fatigue
• Staff quickly complained of alarm
overload
• Committee formed to evaluate alarm
fatigue
• Staff surveys and online meetings
• List of main concerns created
• Team tasked with resolving issues
Alarm Modifications – 3 months
• Decrease the volume of Draeger Central Station– Decibel meter to measure volume at central and decrease
sound
• Remove the Draeger yellow alarms for HI and LO Sat– Yellow alarms of High and Low Saturation and High HR
blocked to phone
• Right button should allow for both 'escalate' and 'acknowledge'– Soft keys recustomized to allow easier use
• Can we allow '2' as a volume option?– Phone volume limits lowered from 3 to 2 out of 7
• Is it possible to allow users to select vibrate mode?– Vibration decreased for all except 2 Life Threatening alarms
Alarm Modifications – 3 months
• The Nurse-call sign in process takes a long time– Re-education sessions for assignment sign-in
• Reduce the Nurse-call alerts coming into the duty station in the break room. – All but codes and deliveries removed from other areas
• Versus: Lingering lights and no lights failures continue to be an annoyance on NICU and L&D– Recalibrated Versus sensors, development for integration to
Connexall
• Can alert auto-escalate if user is on the phone?– Cisco phones can't autoescalate when in use
• Oncoming personnel should be able to take outgoing personnel off duty as part of report process– Working with Rauland for improvement in user interface
Additional Safety Measures – 8 months
• Split screen
• No pass zone for red alarms
• Large central monitor screens
• Vigilant staffing patterns: overall 1:2 staffing
• Proximity of room assignments
• Partial door opening to view alarms
• Buddy escalation of alarms
• Safety huddle- at report
• Safety huddle in the pod identifying concerning patients
©2007 RUSH University Medical Center
Physiologic Monitor Alarms Per Patient Per Day Transmitted
to Phones by Period and Total Alarms 2014-2015
Alarm Type Mar-May June-Oct Nov-Mar TotalApnea 3 3 3 46,080Asystole 1 0 1 8,260Bradycardia (<60) 2 3 2 39,060Desaturation (<78) 17 37 27 451,278High HR (>200) 10 0 0 0
HR Low (<100) 1 1 1 18,779Sat High (>95) 6 0 0 0Sat Low (<88) 53 0 0 0Art BP Low 0 0 0 1,520NIBP Low 0 0 0 498Sat Ld off 9 11 10 159,595ECG Ld off 3 3 4 54,263Art Ld off 0 0 0 116Total 105 59 49 1,027,573
Conclusions
• Use of a Alarm Management and
Notification Platform created a virtual “line
of sight” from providers to the patient in an
SFR environment
• Review and modification of alarm
algorithms reduced non-critical alarm
burden
• Successful implementation requires a
multidisciplinary team approach
Limitations
• Alarm Fatigue not easily quantifiable
• Changes to algorithms of alarm
transmission was based on clinical
judgement
• Further studies are needed to assess
safety impact of alarm strategies
Ongoing Alarm Activities
• Alarm Management Committee
• Ongoing meetings to review alarm fatigue
• Process for Developing Policies
• Comprehensive Alarm Management Policy
• Compliance with 2016 TJC NPSG
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