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Clinical AlarmsPatient Safety Policy
MANUAL
Care of the Patient
SECTION
Patient Safety
POLICY CODE
and NUMBER
PS-6
PURPOSE:
The purpose of this policy is to appropriately adjust and respond to all clinical alarms to ensure patient
safety.
POLICY:
1.
2.
3.
4.
5.
6.
7.
8.
All clinical alarms will remain active at all times and will be documented in EMR .
It is the responsibility of all clinicians in this institution to respond immediately to all clinical alarms.
Clinicians will perform corrective action within their scope of practice to resolve the problem.
Failure to respond immediately to clinical alarms can be life threatening; therefore failure to comply
with this policy may result in termination of employment.
Pulse oximetry is a noninvasive method of monitoring the oxygen saturation of arterial blood. This
policy is to assure arterial oxygenation for all patients whether breathing spontaneously or on
mechanical support. It is indicated for the following clinical situations a)During continuous
mechanical ventilation, b)During ventilator or supplemental oxygen weaning or airway decannulation
trials, c) During exercise and physical therapy on patients receiving supplemental oxygen, d) During
transport of patients on mechanical ventilation or supplemental oxygen, e) During cardiac arrest,
f)During bronchoscopy, g)To document the appropriateness of supplemental oxygen, h) and other
invasive procedures as directed. This is monitored by Respiratory on a monthly basis.
The Medical Gas alarms/bulk oxygen pressure alarm is designed to visually and audibly alert
hospital staff to an irregularity in the system.
a) The alarm will activate at 40 psig (Low Pressure) or 60 psig (High Pressure).
b) This policy is applicable to all maintenance and plant operations personnel who have
responsibility in operation and maintenance of the medical gas system.
c) This is monitored by Maintenance on a quarterly basis and Respiratory internally on a
monthly basis.
The Ventilator Support System (invasive and non-invasive) provides respiratory support for a wide
range of adult patients for a wide variety of clinical conditions.
a) The ventilator’s mixing technique allows to ventilate critically ill patients.
b) All ventilator alarms will remain active at all times and will be documented in EMR ventilator
assessment
c) This is monitored by Respiratory and Maintenance on a monthly basis.
The Enteral Pump System is designed to deliver only a liquid enteral feeding product.
a) It is a micro-processor controlled pump that provides accurate, controlled enteral feeding.
b) The pump used is a volumetric pump that uses a specially designed feeding set, which
includes a cassette that delivers measured amounts of enteral products.
c) The monitoring by the manufacturer consist of flow calibration and alarms monitored by
Nursing.
d) This is monitored monthly by Maintenance and Nursing daily.
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9. The Intravenous Pump System is designed
10. The Telemetry System is intended for use in the ICU type of areas.
a) It is easy to operate with analog touch screen, high-resolution display review function such as
graphic trends.
b) Up to 16 patients can be monitored simultaneously from other areas of the hospital.
c) As integrated real-time patient data through bedside monitors of the telemetry receiver.
d) This is monitored by Monitor Technicians, ICU Nurses, and Respiratory and is part of EOC
Medical Equipment Plan.
11. The Fall Prevention System currently at this facility is the RN+ System.
a) It is a wireless system used primarily in hospitals to monitor and detect patient movement and
alert nurse to possible unassisted exits.
b) The RN+ utilities a bandwidth system.
c) Each employee will prioritize and assist with the prevention of patient falls and responds to
alarms immediately.
12. The Nurse Call System is designed as an integrating nurse call system with an in-building wireless
telephone system that can produce tremendous improvements in staff efficiency and thereby ultimately
improve response times to patients. This integrated health care communications products enables
caregivers to provide the best patient-focused care possible.
a)
This system has the ability for a handset delivery communication directly and indirectly with
the use of text paging.
b) This system also has a management software for tracking and organizing patient and staff
activity.
PROCEDURE:
1.
Pulse oximetry:
a.
b.
c.
d.
e.
f.
g.
h.
Plug pulse oximeter monitors power cables into a red electrical outlet and turn unit on.
Follow manufacturer's recommendations for appropriate setup.
Select appropriate monitoring site and secure probe on patient.
When using continuous pulse oximetry proper alarms setting should be set with HR low at
50 and HR high at 150, Sat O2 low at 85%, unless otherwise noted by physician.
Portable or bedside pulse oximetry may be used
Pulse oximetry will be monitored Q 12 hours on non-ventilated patients and with Q 2-hour
ventilatory checks.
Alarm settings and function along with site location will be documented during Q 12-hour
ventilator assessment.
Results and alarm settings will be charted in EMR.
Clinical AlarmsPatient Safety Policy
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Medical Gas alarms/bulk oxygen pressure alarm
The responding technician shall verify that the alarm is a result of the system being switched to the
standby sources due to the primary source being exhausted. If the above occurs during others then
normal duty hours and the reserve supply is adequate until the following morning, there will be no
need to call out a technician to replace the tanks.
Upon notification by PBX operator of any of the following alarm conditions
a.
b.
c.
d.
Oxygen pressure high
Oxygen Pressure low
Medical air pressure high
Medical air pressure low
During normal working hours, the responding engineer shall verify the alarm condition, attempt to
determine the malfunction and take appropriate action to repair. During other than normal
working hours, the responding maintenance person shall verify the alarm condition attempt to
determine the cause of the malfunction and notify the appropriate manager or contractor, who
shall respond accordingly. If the alarm is determined not to be a system malfunction, but an alarm
condition that can wait until the following morning, a contractor does not need to be called out.
BULK OXYGEN ALARMS (liquid oxygen) - The bulk oxygen level alarm is designed to visually
and audibly alert hospital staff to an irregularity in the system.
a.
b.
c.
d.
Locate all patients on mechanical ventilation and insure proper function of ventilator.
Utilize manual resuscitator to ventilate patient if ventilator is inoperable.
Silence the alarm by depressing the alarm silence button on the alarm system control panel.
Read the alarm indicator directly below the liquid oxygen level. If the indicator indicates
“Emergency Reserve In Use”, notify Plant Engineer, Respiratory Care, Nursing Manager,
Administration, and the oxygen supply company IMMEDIATELY. Contact area hospitals for
additional cylinders of oxygen if the Emergency Reserve is in use and it is known the supplier
cannot refill in adequate time.
e.
Read pressure and inches of water gauges on bulk oxygen system.
e.
Check and record readings for the bulk system emergency reservoirs or other back up system.
f.
Check line pressure downstream of zone valves located throughout the hospital.
g.
Notify House Supervisor, Respiratory Director Administration, Plant Engineer. Report all
current readings.
h.
Call the oxygen supply company. Inform them of the current alarm status.
i.
Use cylinder oxygen for resuscitators.
j. Assess all other patients receiving oxygen. Provide oxygen via cylinders until problem is
corrected.
k. Reassure patients.
l. Complete Incident Report Form.
Note: After the problem has been corrected, place patients back on the mechanical ventilator.
Check for proper ventilator and alarm function.
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Mechanical Ventilators (invasive)
Alarm settings will be set as follows:
a.
b.
c.
d.
e.
High-Pressure Alarm: Set 10-20 cm H2O above the highest documented peak inspiratory
pressure in the past twelve hours.
Low-Pressure Alarm: Set 10-20 cm H2O below the highest documented peak inspiratory
pressure in past twelve hours.
High-Rate Alarm:
Set at 10 breaths per minute above the patient's average stable rate.
This high-rate alarm will not be set higher than 40 breaths per minute unless otherwise
indicated by the patient's condition.
Low tidal volume: 100-200cc below the patient’s ordered
Low expired minutes ventilation is to be set 20% below last documented VE
If Respiratory Therapist finds it necessary to set alarms outside these parameters, this is documented and
the reason for the change each shift. These parameters need to be re-evaluated every shift and readjusted
according to patient’s condition as well.
BIPAP Vision (non-invasive)
Alarm setting will be as follows:
1.
2.
3.
4.
5.
High pressure limit (PIP) is to be set 50% above highest documented PIP in past twelve
hours not to exceed 10em H2O below.
Low-pressure delay is to be set at ten seconds.
Apnea – 20 or less seconds delay.
Low expiratory minute ventilation is to be set 20% below last documented VE.
High respiratory rate is to be set 10-15 above highest RR documented.
Listed below are the most frequent alarms of ventilators, probable cause and corrective actions
needed to resolve alarms. MANUALLY RESUSCITATE PATIENT UNTIL CAUSE OF
ALARM IS RESOLVED. Nursing personnel must notify Respiratory Care personnel of alarm
condition.
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6. Actions Required for the following:
ALARMS
Low Pressure
High Pressure Limit
PROBABLE CAUSE
Ventilator Circuit
disconnected
CORRECTIVE ACTION
Begin at patient end of circuit and scan
for disconnects.
Leak in ventilator circuit
Repeat above procedure
Cuff Leak
Check cuff for proper inflation
pressure.
Obstruction in patient airway
Clear obstruction (suction).
Obstruction in ventilator
tubing
Clear obstruction (drain
tubing)
Kinked ventilator tubing
Straighten ventilator tubing
Change in patient status
Re-evaluate patient.
Re-position artificial airway.
Low expired
volume
minute
Artificial airway
misplacement
Same as low pressure
High Expired
volume
minute
Change in patient status
Re-evaluate patient
Apnea
Change in patient status
Re-evaluate patient
High Rate
Change in patient status
Re-evaluate patient
Air Supply
Inadequate compressed
air supply to ventilator
Replace ventilator compressor. Provide
compressed air via cylinders. Notify
R.C. Manager.
Oxygen Supply
Inadequate oxygen supply
to ventilator
Check oxygen piping pressure and
supply. Provide O2 via cylinders.
Notify R.C. Manger.
Loss of Power
Loss of electrical power
Insure ventilator connected to
emergency electrical outlet.
Vent inoperative
Microprocessor failure
Manual resuscitate patient EST to be
done by RT. If necessary replace vent.
Same as low pressure
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Enteral Pump System
Intermittent audio alarms are accompanied by messages on the front panel indicating cause of the
alarm for all alarm conditions except LOW AUDIO (visual only), which indicates low alarm
volume has been selected.
Actions Required to be followed:
Visual Display
Occlusion – flow has stopped
Corrective Action
clear obstruction, check for kinked tubing, then
run
Empty – feed or flush bag empty
Dose Complete – volume fed is equal to
the set dose. Pump stops
Set Rate – dial turned to run without
entering rate
Turn to Run – pump dial in setting other
than run or off more than five minutes
Door/Cassette – door open, cassette not
properly loaded or excess foam or air in
cassette
Low Battery – pump has approximately
30 minutes of battery operation before
complete shutdown
Turn dial to hold; refill container; turn to run
Turn dial to set dose; press keypad arrows to set
dose; to silence alarm, turn to hold, then run.
Select flow rate (1 to 300 ml/hr); to slience
alarm, turn to hold, then run
Turn the dial to hold or run to reset
ERR-system malfunction
Flush Display Blank with Feed/Flush Set
in use – clamp is closed on flush bag
5.
Intravenous Pump System
Confirm cassette in place and close door;
manually reprime to remove foam or air; replace
set; if alarm persist, requires service
Complete shutdown is preceded by a continuous
alarm for one minute; plug power cord into AC
outlet, pump will operate normally while battery
is charging
Must turn pump off to reset, if persist requires
service
Turn pump off, fill flush bag, open clamp,
restart
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Telemetry System
The telemetry system incorporates a priority alarm system with different notifications for different
levels of alarm priorities. Levels of alarm priorities ranges from system failure, to life threatening,
to cautionary, to treatment needed, and message alarms. Individual parameter alarms consist of
ECG, respiration, blood pressure, temperature, and oxygen saturations, among other which
currently are not used in this facility. When setting an alarm at the central station, the network
function will set the bedside monitor for the same configurations. This applies to
ON/OFF/SUSPEND. When the system alarms are on and the alarm factor occurs the message
will be displayed and the alarm sound occurs. The measured values for each parameter are
displayed on the individual display. The alarm limits are set as follows:
Actions Required to be Followed:
Parameter
Heart rate
Respiration
Blood Pressure
Oxygen Saturation
CVP
7.
Alarm Limits
High limits: 150, Low Limits: 50
High limits: 40, Low limits: 10
Low limits: Systolic <85, Diastolic <100
High limits: Systolic >170, Diastolic >100
Low limit: <85%
High limits: 16-20, Low limits: 0-4
Fall Prevention System
Patients admitted to the hospital will be assessed by an RN for fall risk factors during admission,
daily and as his/her condition warrants. Every attempt will be made to safely support the patient¹s
rights for independence and self-determination by creatively activating the least restrictive
methods for fall prevention which are effective. Manufacturer recommends that staff conduct
system tests upon installation and on periodic basis. The system has three methods of alerting
staff battery needs recharging. Red charge battery light on signal unit will illuminate
approximately one week prior to dead battery. Signal unit will chirp every ten seconds
approximately 24 hours prior to dead battery, and finally console status review light will
illuminate approximately one week prior to dead battery. Select a signal unit to be programmed.
To test unit prior to placement on a patient, press unit button to determine battery status. Plug
sensor into signal unit sensor jack. Both console and signal unit will alarm. Press console silence
alarm button. Console will stop alarming, while signal unit will continue to alarm. Place hand flat
across sensor and apply pressure. After a short delay, signal unit alarm will stop.
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8.
Nurse Call System
9.
Monitoring of clinical alarm response times is through the Nurse Call System’s Database and reporting
System for the following:
a)
Ventilators
b)
Pulse Oximetry
c)
IV Pumps
d)
RN+ System
The data is reviewed monthly and reported quarterly.
References:
JC-HAS:
OTHER:
Original Date
Review/Revision Date
 Supersedes all Previous
Approved: _____________________
Date