Wake Up!
From Alarm Fatigue
S. JILL LEY RN, MS, CNS, FAAN
CARDIAC SURGERY CNS
CALIFORNIA PACIFIC MED CENTER;
CLINICAL PROFESSOR, UCSF
SAN FRANCISCO, CA
Objectives
▪ Define the concept of “alarm fatigue” and factors that contribute
to it’s occurrence
▪ Discuss a comprehensive clinical alarm assessment, policy and
educational strategy that improve alarm safety while meeting
regulatory requirements
▪ Identify essential provisions and timelines for implementation of
The Joint Commission’s National Patient Safety Goal for alarm
management
Responding to Alarms
Alarm sounds . . . . . .
▪ Hear the alarm
▪ Determine meaning/interpret
▪ Prioritize if immediate action necessary
▪ Distinguish what action is appropriate
▪ Respond
▪ Patient care – resuscitation response, notifications
▪ Adjust monitor parameters/fix equipment
How Do Alarms Work?
▪ Current Designs
▪ High sensitivity – detect even minute changes = frequent alarms
▪ Low specificity – do not distinguish if real or important = frequent alarms
▪ Threshold Technology
▪ Each alarm has a threshold that must be breached for it to sound
(e.g., low HR at 50 bpm)
▪ Each alarm as a separate threshold (HR vs SBP vs SpO2)
▪ Thresholds may not be integrated (e.g., asystole alarm & A-line BP 110/72)
▪ Built in delays for “self correction” prior to alarm are possible
▪ Current Options to Reduce Alarms Include
▪ Disabling the parameter
▪ Changing the threshold
▪ Increasing the delay
The Problem With Alarms
▪ Ranked as #1 top technology safety hazard by ECRI
(Economic Cycle Research Institute)
▪ 86% - 99% of alarms are non-actionable
▪ Fire alarms work because they are a RARE event!
▪ When the same alarm sounds for a life threatening
arrhythmia versus brushing your teeth, then
“Nothing is an Emergency”
Question #1
A non-actionable alarm can be caused by all of the
following except:
a)
b)
c)
d)
Artifact
Self-correcting SpO2
Leads off
Narrow alarm limits
Question #1
A non-actionable alarm can be caused by all of
the following except:
a)
b)
c)
d)
Artifact
Self-correcting SpO2
Leads off
Narrow alarm limits
Alarm Fatigue Terminology
Actionable Alarm – Requires intervention
▪ to reverse or prevent patient deterioration
▪ to maintain appropriate monitoring, avoid missing critical events
Non-actionable [nuisance] alarm – Does not require intervention
▪ True: alarm was accurate but unimportant
▪ False: alarm error (e.g., artifact)
Number of Alarms
Baseline Alarm Assessment – 4 Units, 1 Campus, ONE Day
> 5000 Alarms/Day!
2000
1800
1600
1400
1200
1000
800
600
400
200
24 patients
16 patients
8 patients
0
YELLOW BED
RED BED
YELLOW ARRHYTHMIA
RED ARRHYTHMIA
4S
177
60
1534
56
TICU
422
125
444
9
12 patients
MSICU
437
25
661
36
Most common Yellow arrhythmias: Pair PVCs, PVC rate > 10/min, multiform PVCs
CCU
344
42
531
2
Internal Alarm Frequency Audit Strategy
3 campuses, 11 units
9,515 alarms/day
▪ Set up “event groups” at each central station (once then save groups)
▪ Event group = red arrhythmia, yellow arrhythmias (3), discharge (hi/lo HR), all alarms
▪ Patient window → all controls → unit settings → event groups → new group/name
▪ Review and collect individual patient data
▪ Patient window → alarm review → event review → select 24 hrs → select event group
▪ Tally by unit
Hallmark
Alarm Study
▪ High surveillance monitoring; 5 critical care units, 461 patients, 31-days
▪ Total number of alarms
2,558,760
▪ Arrhythmia alarms
1,154,201
▪ Parameter alarms
612,927
▪ Technological
791,632
▪ Audible alarms
381,560
Audible alarms per patient bed per day = 187!
Drew BJ, et al. PLoS ONE 9(10): e110274. doi:10.1371/journal.pone.0110274
Accuracy of ECG Arrhythmia Alarms
Drew BJ, et al. PLoS ONE 9(10): e110274. doi:10.1371/journal.pone.0110274
SBAR Plan For ECG Monitoring
Situation = too many alarms that don’t mean anything
Background = things were different when I trained
Assessment = we have to do something!
Recommendation = Alarm Makeover
California Pacific Medical Center - Alarm Management Plan
▪ Review detailed data from all
units, formulate multidisciplinary
approach RN, MD, biomed, admin
▪ Begin with evidence-based
monitor changes: add high
priority/RED alarm for leads off
▪ Incorporate changes in nursing
practice and culture through unitbased Alarm Champions
Form Alarm Fatigue Task Force
Use Data to Plan Approach
Phase I: Monitor Settings
Agreement
Evaluate
Approvals
Changes
Phase II: Change Clinical Practice
Nurse Champions
Evaluate
Culture & Protocols
Changes
Alarm Fatigue Task Force
▪ Funding by CPMC Foundation Grant
▪ Team Leaders
▪ Jill Ley & Robert Airoso
▪ Physician Champion: Rick Hongo, MD
▪ Biomed Champion: Dale Rose
▪ Nurse Champions:
▪
▪
▪
▪
▪
▪
▪
▪
▪
Flor Aguilar, Telemetry St Lukes
Danielle Burian, ICU Davies
Josie Buangan, St Lukes
Caitlin Carpenter, 6-south Pacific
Linda Chu, TICU3, Pacific
Eva DeLeon, St Lukes
Jeanne Ebuen, 4-south, Pacific
Julie Esposto, 4-south Pacific
Al Flores, ICU Davies
▪ Nurse Champions (con’t):
Elizabeth Foley, 4-south Pacific
Aaron Fong, 6-south Pacific
Mina Jackson, TICU Pacific
Wen Bei Jiang, MSICU, Pacific
Rasheda Jones, Education St Lukes
Mary Kazeminejad, 4-south, Pacific
Marvin Lai, St Lukes
Kayline Martinez, CCU Pacific
Barbara Morales, CCU Pacific
Shelly Petrie, 5-south Pacific
Hieu Pham, MSICU Pacific
Tonya Rozen, 5-south Pacific
Lauren Shinjo, CCU Pacific
Ann Soy, 5-south Pacific
Sasha Sunder, TICU3 Pacific
Ron Villanueva, St Lukes
Question #2
Evidence based resources regarding alarm management include:
a)
b)
c)
d)
AACN Clinical Toolkit for managing alarm fatigue
A Joint Commission National Patient Safety Goal
ERCI alarm safety resource center
All of the above
Question #2
Evidence based resources regarding alarm management include:
a)
b)
c)
d)
AACN Clinical Toolkit for managing alarm fatigue
A Joint Commission National Patient Safety Goal
ERCI alarm safety resource center
All of the above
Evidence-Based Monitoring Standards
ICU Drill Down: Yellow Arrhythmia Alarm by Type
Redundant Alarms
Recommendation: Implement Johns-Hopkins Best Practices
Remove “Nonactionable” Yellow Alarms
PREDICTED 65% REDUCTION eliminating: PVC pairs and runs, Multiform PVCs, Bi- and Tri-geminy
Additional change – leads off now a high priority alarm
Standardize HR
defaults to 135, 50
and SpO2 88%
Also eliminate
redundant alarms
Additional A Fib Alarm
Changing the Culture of Nursing Practice:
Phase II Implementation
▪ NEW: Electrode skin prep and change
frequency increased to q 24 hrs
TRUE
▪ Alarm settings now reviewed at handoff
▪ Adjust HR within 5-20 bpm from default
as appropriate to pt condition
▪ Disable irregular HR alarm for
All of these were false
chronic AF (no order required)
▪ Enable paced rhythm alarm for paced
patients (no order required)
▪ Proactive “pause” for leads off
▪ Assume any alarm is now “actionable”
FALSE DUE TO
ARTIFACT
21%
79%
Eliminate false alarms due to artifact
Results: Yellow Alarms/Patient Day Reduced
57-89% By Unit
# alarms/pt/day
200
180
160
140
120
100
80
60
40
20
0
77%
80%
57%
59%
60%
82%
85%
85%
88%
86%
89%
Before
After
Press-Ganey Patient Satisfaction Scores for Noise
Continued Improvement on Pilot Unit
Satisfaction Level
Project Implementation
Additional Solutions:
Criteria for Telemetry
Do we NEED to monitor everyone?
Potential Adverse Consequences of ECG Monitoring
▪ Alarm fatigue!
▪ Resource utilization
▪ Nursing hours and ratios
▪ Disposables
▪ Equipment maintenance and upkeep
▪ Reduced mobility for the patient
▪ Increased time in bed
▪ Potential delirium, PNA, etc.
▪ Patient & family concerns of being “critically ill”
▪ Misinterpretation of artifact as VT
Artifact Mimicking Ventricular Tachycardia
FROM: Knight BP, et al. NEJM 1999; 341(17):1270-1274.
This patient was treated with lidocaine
Drew showed that 86.8% of VT alarms are FALSE!
Evidence Based Criteria for Telemetry Monitoring
▪ Class I – Indicated for nearly all acute patients
▪ Potential for ischemia (ACS, high risk CAD)
▪ Potential for arrhythmia (post arrest, drug load, > Mobitz II heart block, etc)
▪ Procedural or critically ill (postop heart, PCI, conscious sedation, etc)
▪ Class II – Indicated for some patients
▪ Potential for instability (chest pain, syncope, hypotension, etc)
▪ Class III = Monitoring is not indicated
▪ Acute conditions (low risk surgery, terminal illness, atypical chest pain, etc)
▪ Chronic, stable conditions (atrial fib, asymptomatic PVCs or NSVT, etc)
Henriques-Forsythe MN, Ivonye CC, Jamched U, et al. CCJM. 2009;76(6):368-372.
Drew BJ, Califf RM, Funk M, et al. Circulation 2004;110:2721-2746.
Re-audit 1 year later: Yellow Alarms/Patient Day By Unit
# alarms/pt/day
70
60
50
Baseline
2014
2015
40
30
20
10
0
CCU - PAC TICU - PAC
5-south
MSICU
4-south
TICU-3
6-south
Audit Observations
▪ Excellent compliance with setting alarm parameters
▪ Customizing to patient
▪ Enabling/disabling alarms for pacers/Afib
▪ Maximum # alarms/patient/day fell from 349 to 173
▪ Reasons for high alarm frequency
▪ Patient with intermittent paced rhythm
▪ Bundle branch blocks
▪ Artifact
▪ Fewer patients on monitor despite similar census
Question #3
The Joint Commission National Patient Safety Goal for alarm safety
requires organizations to do all of the following by January 1, 2016
except:
a)
b)
c)
d)
Establish alarm safety as an organizational priority
Complete a detailed inventory of all audible alarms in the facility
Determine who can change or disable clinical alarms
Determine appropriate responses to alarm conditions
Question #3
The Joint Commission National Patient Safety Goal for alarm safety
requires organizations to do all of the following by January 1, 2016
except:
a)
b)
c)
d)
Establish alarm safety as an organizational priority
Complete a detailed inventory of all audible alarms in the facility
Determine who can change or disable clinical alarms
Determine appropriate responses to alarm conditions
Getting Ready for The Alarm Safety
National Patient Safety Goal
NPSG.06.01.01:
Improve the safety of clinical alarm systems
▪ Phase 1 – Effective January 1, 2014
▪ Establish alarm safety as an organizational priority and determine YOUR
facility’s most important alarms to manage
▪ Gather data – internal alarm history, adverse events (labor intensive but essential)
▪ Review and compare with best practices/guidelines
▪ Determine a plan for reducing unnecessary alarms
▪ Phase 2 – Effective January 1, 2016
▪ Establish policies & procedures for alarm management
▪ Staff educated about appropriate practices
This is not just for ECG alarms!
Warming
Devices
Foot Pumps
SpO2
Monitors
Infusion Pumps
Bed Alarms
Hemodynamics
Ventilators/CPAP
Alarm Management Policies and Procedures
▪ Should address the following areas:
▪
▪
▪
▪
▪
▪
▪
▪
▪
Clinically appropriate alarm settings
When alarms can be disabled
When alarms can be changed
Who can disable alarms
Who can set alarm parameters
Who can change alarm parameters
Appropriate monitoring practices
Appropriate response to monitor alarms
Processes for checking alarms for accurate settings, appropriate
operation, and detectability (audibility throughout unit)
Coming Soon
System-Wide Alarm Policy
POLICY AND PURPOSE
Alarm management is a Joint
Commission National Patient Safety
Goal (NPSG.06.01.01) that this
organization has identified as a priority.
Clinical alarm systems are intended to
alert caregivers to an important change
in the patient's physiologic condition or
a medical device equipment issue and,
if not managed properly, can
compromise patient safety.
Alarm Priority Levels
Risk/Priority
Criteria
Response Time
Level of Oversight
High
•
•
Potentially life-threatening, audible alarms
Inattention could result in permanent harm or
death
Immediate
Goal <2 minutes
Need for close observation of
patient and device all or most of
time*
Moderate
•
Not life-threatening, medium priority, audible
warning
Non-emergent; requires attention as quickly as
possible
Rapid
Goal 2-5 minutes
Need for close observation of
patient and device many times
throughout shift
No harm to patient if evaluated within short time
period
Audible advisory signal indicates need for
reassessment
As soon as
possible
Goal 5-7 minutes
No need for intervention throughout
shift anticipated or patient harm if
unattended
•
Low
•
•
Modified from policy graciously provided by Johns Hopkins Medical Center
Staff Responsibilities For Alarm Safety
▪ Critical clinical alarm systems will not be disabled. Patient care staff will check all
equipment with clinical alarms to ensure:
▪
▪
▪
▪
Settings are appropriate for each patient;
Alarm is active;
Alarm is not impaired in any manner;
Alarm is sufficiently audible to all staff with respect to distance and competing noise
▪ Caregivers and equipment users will verify, as appropriate, that critical alarms are in the
"On" position and sufficiently audible:
▪
▪
▪
▪
Prior to using the device on a patient;
When assuming care of a patient (i.e., at the start of shift);
Following removal and subsequent reapplication of the device on a patient;
Prior to transferring a patient with the device to another care area.
Alarm Fatigue Summary
▪ Alarm management is an important problem that creates
safety risks, leading to a new national patient safety goal
▪ Use of internal alarm data is essential to target highest
priority alarms and improve outcomes
▪ Implementation of evidence-based practices is effective in
reducing nuisance alarms while improving safety
▪ The Joint Commission NPSG will require us to do more in
2015 and beyond to address this issue