Understanding the challenges in alarm management
Inhel Rekik George Reed Shock Trauma Anesthesiology Research Alarm Management 2013 NPSG Clinical alarm safety for hospitals and critical access hospitals 2014 Establish alarms as an organization priority and identify the most important alarms to manage. 2016 Hospitals will be expected to develop and implement specific policies and procedures for managing alarms as well as educate staff and independent licensed practitioners in the organization about alarm system management. Alarm Management Extension Healthcare performed a marked survey: 90% of hospitals interviewed havent developed a comprehensive alarm management program 80% of hospitals interviewed are NOT collecting, reviewing and/or analyzing alarm data on a regular basis EXCEPT to address sentinel events. Alarm Management What do we know?
Small percentage of Alarms are actionable Large percentage of Alarms are non-actionable What does this mean to the Clinician? Nothing! Whats happened in our institution
University of Maryland Medical Center / Shock Trauma Center We didnt hear it We couldnt tell what was alarming We just got too busy Things were just crazy that day The place is like a casino with so many bells and whistles Alarm Management Alarm Recognition Cropp et al tested 100 ICU staff (25 physicians, 41 nurses and 34 respiratory therapists) with various degree of ICU experience with an audiotape of 33 different ICU alarms 3 yr experience correctly identified 46% of alarms So whats the issue? Lack in education and training Name that tone. The proliferation of alarms in the intensive care unit by Cropp AJ Alarm Identification and Response Simulation Study
Jennifer at UMMC identified a gap in the literature in training new hired nurseson how to recognizeand respond to different alarms in a timely manner. Methods: Alarms from multiple devices were recorded in their natural milieu with multiple alarms captured per recording and played back to new hires in random order Results: After 14 weeks of training, new hires were able 81 % of alarms Alarm identification and response simulation study by Jennifer Tumulty Alarm Management How UMMC began to Manage Alarms?
To manage alarms, have to understand what those are. What are the defaults and why? Does the department understand the default impact? We created a mobile lab to understandthe alarms and the impact of the defaults setting Are the clinicians familiar with standard monitor features such as alarm levels, sounds and display Our next step after evaluation of all areas We developed an alarm estimation software and vital signs dashboards to help clinicians adjust their setting Understanding the challenges in alarm management
High resolution vital signs and alarm collection Alarm estimation software and results Next steps Vital signs viewer UMMC alarm task force recommendation High resolution vital signs and alarm collection System
Allow real time capture and long term recording of patient vital signs, waveforms and alarms Unlimited full disclosure Can capture and record data from other medical devices such as ventilators, cerebral oximeters, cardiac output monitor Provides an analysis tool for the patient vital signs and recorded alarms. High resolution vital signs and alarm collection System Continuous streaming of patient vital signs Neuro ICU Vital Sign Collected From 10/31-01/29
Percent of time having VS Total alarms in Neuro ICU each bed, each month
Our Goal: Reduce 30% Unnecessary Alarms in 12 Month Neuro ICU 22 Bed Oct to Jan Recorded all alarms (type and duration) and Vital Signs (Trends 0.5Hz), Waveforms (240 Hz) Total 610,569 alarms in 3 Month308 alarms /day/bed 833 alarms/bed/day Total alarms in Neuro ICU each bed, each month Alarms Categories of alarms : patient crisis : (Asystole, VTACH, VFIB)
3 beeps, red patient warning: (HR HI, VT>2, HR LO, Brady...) 2 beep, yellow patient advisory: (RSP HI, TACHY, SPO2 L, ART S HI ) 1 beep Patient message System alarms: (SPO 2 Probe, Connect Probe, lead fail, No ECG) warning 1 beep continuous advisory 1 beep on time Top 10 Reasons for Alarm in each of 4 Categories
Our Goal: Reduce 30% Unnecessary Alarms in 12 Month Total 610,569 Alarms (3588 types of Alarm messages) in 3 Month in 22 Bed Neuro ICU Top 10 Reasons for Alarm in each of 4 Categories Alarm N 1 2 3 4 5 6 7 8 9 10 Level Categories System Alarms 39102 (6.4%) SPO2 PROBE CONNECT PROBE ARRHY SUSPEND LEADS FAIL NO ECG RR LEADS FAIL NBP MAX TIME SENSOR SPO2 SENSOR WRONG CABLE 43.6% 18.2% 14.8% 13.1% 2.8% 2.5% 1.6% 0.6% 0.3% 5 Patient Advisory (88.8%) CHECK ADAPTER RSP HI TACHY SPO2 LO ART S HI NO BREATH RSP LO ART D LO ART S LO EXP CO2 LO 18.3% 18.0% 10.0% 7.5% 6.9% 4.6% 3.6% 3.2% 2.4% 6 Patient Warning 27675 (4.5%) HR HI VT>2 HR LO ART DISCONN PVC BRADY ART D HI ART M HI V BRADY 38.1% 29.7% 23.0% 2.3% 0.7% 0.5% 0.4% 0.2% 7 Patient Crisis 1801 (0.3%) ASYSTOLE V TACH VFIB/VTAC 20.9% 69.5% 9.6% Can we wait 2s to reduce 45% Or 4s to reduce 56% of alarms? Alarm Estimation Software
Vital signs Pre-processing Retrieve data from BedMaster Import data into Matlab Retrieve Alarms Query alarms from BedMaster DB Query alarm settings from BedMaster DB Mimic GE Alarm Alarm Estimation Software
Analyzed SpO2 LO, HR HI, ART S HI, NIBP HI For each alarm, we reported to clinicians Comparison of real alarm and mimic alarm (VS-based) Alarm limits and statistics % of change in frequency and duration of alarmswith different limit settings SPO2 LO Real Alarm Setting Real SPO2 low limit SPO2 LO limit level change in Bed C7E_C752
SPO2 LO alarms # Time SPO2 LO: % Change (Baseline = 90) HR HI Limit Setting C7E-C752 All beds HR HI: % Change (Baseline = 130) ART1 S HI Limit Setting C7E-C766 All beds ART1 S HI: % Change (Baseline = 180) NIBP HI Alarm Setting C7E-C752 All beds NIBP HI: % Change (Baseline = 100) Results (Alarms >1h)
Technical Alarms: majority can be reduced with proper training Type Message Frequency % Freq(for type #) Duration % Dur(for type #) Dur/event 1Q 3Q 3 CHECK BATT ST 18 10.91% 66.87% 6842.5 SERVICE PDM 1.82% 42138 1.15% 14046 10715 17463 NO ECG 28 16.97% 352948 9.64% 6026.5 5 CHECK ADAPTER 157 49.68% 62.00% 5047 10355 LEADS FAIL 10 6.06% 88157 2.41% 8815.7 9970.5 SPO2 SENSOR 11 6.67% 89416 2.44% 4592.5 7481.5 CAL SENSOR 26 8.23% 200539 8.17% CONNECT PROBE 21 12.73% 159087 4.34% 4480 12228 RR LEADS FAIL 22586 0.62% 6726 8629 CAL CO2 4 1.27% 29514 1.20% 7378.5 6561 8471.5 SPO2 PROBE 49 29.70% 333631 9.11% 4445 6846 NBP MAX TIME 109022 2.98% 4166 5909 Technical Alarms CO2 technical alarms: Check Adapter , CAL sensor and CAL CO2: Nurses lack training on CO2. Medical Center is training nurses on calibrating CO2 instead of waiting for the respiratory therapist to do it. ECG technical alarms: Proper skin prep for ECG electrodes Change ECG electrodes daily What weve learned Crisis alarms are lowest percentage of all alarms - actionable All other alarms equal the greatest impact and are non- actionable Adjusting thresholds should limit alarms Clinicians do not look at collective data they need acuity or patient specific. Next steps Should we have individual alarm setting? Vital Signs Unit dashboard. Do sick patient produce more alarms? Can we use alarms to predict mortality? Unit Vital Signs Dashboard Unit Vital Signs Dashboard Target: Reduce 30% alarms in 12 Month
ICU Team ViewerPatent Pending Are Sick Patient Associated with more Alarms?
610,569 Alarms in 3 Month in 22 Bed Neuro ICU Patients, 28 Expired Could Alarm status been used in predicting patient outcomes? GCS UMMC Alarm Task Force Recommendation (ICU/IMC and telemetry Groups)
Get rid of warning and advisory alarms Default all monitors to full and not lethal for the arrhythmia alarms Eliminate duplicate alarms: Use HR high/low instead of bradycardia and tachycardia Develop a comprehensive education program for all providers Empower clinicians to customize alarm limits Questions irekik@umm.edu greed@umm.edu