Note from Nurse Kim:
This is a huge issue right up there with compassion fatigue and violence in the workplace. Patient Safety is a priority strategy for healthcare providers. Our vigilance will reap great rewards for patients and staff when we make sure to not let this issue fall by the wayside.
Alarm Management Goes Into High Gear
"The failure to recognize and respond to actionable clinical alarms... in a timely manner" was the second highest-ranked patient safety risk identified in the ECRI Institute's Top 10 Health Technology Hazards for 2016.[1] These threats include actionable alarms that are not detected, as well as alarms that are not handled appropriately by clinical staff owing to miscommunication and alarm fatigue.The lack of hospital-wide clinical alarm management policies and procedures, and the dangers inherent to alarm mismanagement, achieved prominence in 2013 with the release of the Joint
Commission's National Patient Safety Goals on clinical alarm safety.[2] This initiative mandates that hospitals must identify and prioritize alarms based on internal considerations by January 1, 2016. In phase 2, which also begins in January, "hospitals will be expected to develop and implement specific components of policies and procedures. Education of those in the organization about alarm system management will also be required."[2]
Although hospitals and health systems have made progress in solutions development, missed alarms resulting from poor communication or alarm fatigue continue to pose clear and present threats to patient safety. The increase in the number of medical devices with alarm capabilities has only exacerbated the problem, as has the lack of standards on the proper configuration of alarm parameters.
Technology will play a critical role in getting alarms under control, but it is not enough. Without input from the workforce, technology solutions can fail owing to lack of adoption. Nurses and nursing leaders must get out ahead of this issue or solutions will not have representation from the correct stakeholders. Clinical and information technology (IT) leadership, including nurses, respiratory therapists (RTs), biomedical engineers, and IT staff, must come together to develop the policies and standards necessary to prioritize and reduce the number of alarms, as well as to establish protocols for altering current or default alarm parameters.
This article describes how two different hospitals achieved their alarm management goals using both technology and interdisciplinary expertise.
An Interdisciplinary Approach
In explaining why technology alone is not enough to solve the riddle of clinical alarm management, The Joint Commission said, "It is important for a hospital to understand its own situation and to develop a systematic, coordinated approach to clinical alarm system management. Standardization contributes to safe alarm system management, but it is recognized that solutions may have to be customized for specific clinical units, groups of patients, or individual patients."[2]In other words, each hospital has its own unique characteristics and needs. Identifying and documenting those attributes is critical to a successful alarm management program. Achieving measurable progress in clinical alarm management requires hospitals to identify direct clinical staff as internal champions.
Wesley Medical Center (Wichita, Kansas) surveyed every nurse in the facility to determine which alarms they considered "clinically relevant" and which they considered "nuisance alarms." On the basis of 200 responses, the hospital was able to evaluate which alarms were most important to them as providers of care and compare findings with the most frequent alarms that occurred in a baseline study.
Wesley Medical Center was able to reduce and prioritize more than 10,000 daily alarms, reduce alarm incidence in its coronary care unit by 78%, and capture and distribute data from more than 600 medical devices for enhanced clinical surveillance by leveraging a combination of interdisciplinary input and alarm management technology.[3] The baseline evaluation enabled Wesley's clinical leadership to begin the process of mapping alarm trends, as well as classifying alarms by:
- Frequency, alarm type, and device;
- Variations by time and day as well as by rooms and units;
- Alarm parameters and thresholds; and
- Physiologic vs technical alarms.
The highly specific data generated by the baseline study and analysis helped Wesley's clinical staff develop a more effective alarm management system that will reduce the number of nuisance alarms requiring no action and will allow them to measure improvement over time to meet patient safety goals. An evaluation was conducted using a variety of factors, including:
- Setting a predetermined number of days (eg, 30 days or 90 days) for analysis;
- Analyzing alarm type by alarm category;
- Identifying which alarms are most frequent;
- Identifying changes in type and frequency of alarms by unit;
- Identifying variations in alarm type and frequency by device (eg, patient monitor, ventilator, infusion pump, etc.);
- Analyzing variations in alarm response behavior based on technical and physiologic categories, including time, day of week, room, and unit; and
- Analyzing common alarm limit violations to determine how potential changes in current limits may alter alarm frequencies.
For example, Wesley now has the flexibility to determine which events will trigger alarms as well as where and how clinicians will be notified. Uniquely, Wesley's system provides staff with high-fidelity, real-time, intelligent data from myriad devices to improve patient monitoring and allow staff to intervene before a patient's condition turns critical—offering point-of-care clinical decision support and enhancing patient outcomes.
Nuisance Alarms
A major challenge in alarm management is sorting clinically relevant alarms from nuisance alarms (for example, an alarm caused by a sensor on a patient being momentarily detached or the Wi-Fi connection being momentarily lost). Hospitals need to develop a standard approach to alarms and have a strategy to reduce alarm frequency, alarm noise, and alarm fatigue. Moreover, providers must guard against the overuse of monitoring when it is not indicated, because this just adds to the number of nonactionable alarms.The problem with attenuating alarm data is achieving the balance between communicating the essential, patient-safety specific information that will provide proper notification to clinical staff while minimizing the excess, spurious and nonurgent events that do not threaten patient safety. In the absence of contextual information, the option is usually to err on the side of excess because the risk of missing an alarm or notification carries with it the potential for high cost in terms of patient harm or death.[4]
Wesley's clinical leadership was able to establish separate alarm thresholds as well as combination, trending, and frequency alarms to eliminate nonactionable alarms from being sent to the clinicians carrying phones outside of patients' rooms. For example, instead of an alarm based on a single vital sign, such as the ECG heart rate, a combination alarm might also look at the heart rate from the pulse oximeter or an invasive blood pressure wave to make sure the alarm is real and not just artifact. Overall, Wesley was able to reduce the number of these alarms daily in the coronary care unit from 1285 to 281—a 78% reduction.
The Table shows the reduction in the number of alarms sent to the nurses' phones. The "device alarms" column represents alarms generated by bedside devices and sent to nurses' phones. The "smart alarms" column shows the number of alarms that actually passed to the phones after implementing the smart alarm solution.
Table. Reduction in Number of Alarms With Smart Alarm Platform
| Alarm Type | Device Alarms | Smart Alarms | Reduction |
|---|---|---|---|
| Respiratory rate - low/high | 428 | 212 | 50% |
| SpO2 - low | 508 | 61 | 88% |
| Heart rate – low/high | 349 | 8 | 98% |
| Asystole | 15 | 15 | 0a |
| V-tach | 13 | 13 | 0a |
| V-fib | 2 | 2 | 0a |
V-tach: ventricular tachycardia
V-fib: ventricular fibrillation
aCritical pass-through alarms from the device
Medical Device Connectivity
In a 2013 survey, 9 of 10 hospitals indicated that they would increase their use of patient monitoring, particularly of capnography and pulse oximetry, if false alarms could be reduced.[5] A tremendous amount of data is being generated by monitoring technology and needs to be viewed across the entire continuum of patient care.The Hospital for Special Care (HSC), located in New Britain and Hartford, Connecticut, is nationally recognized for advanced care and rehabilitation in pulmonary care, acquired brain and spinal cord injury, medically complex adults and pediatrics, neuromuscular disorders, and cardiac disease. In addition to reducing or eliminating nonactionable alarms, HSC's goals for alarm management included collecting and distributing real-time data from more than 100 ventilators (each with its own set of alarms), as well as pulse oximeters, for enhanced, continuous patient surveillance, and analyzing objective, comprehensive clinical data after any patient incident to assess response processes and preventive measures.[6]
The critical nature of ventilators as life-support devices and the number of alarms they produced were major drivers in HSC implementing a solution that would enable HSC's team of RTs to provide continuous surveillance monitoring of patients while reducing nonactionable alarms and enhancing patient safety. The solution allows HSC's team of RTs to provide continuous monitoring of vital patient information and intervene before a situation becomes critical, enhancing patient safety.
Networked laptop and desktop computers, as well as scrolling message bars, were deployed at key locations throughout the pediatric unit, providing RTs with access to data and alarms from all ventilated patients. In addition, ventilator alarms were routed through pagers to the specific RT assigned to each patient. The system also automates processes that were previously done manually, such as manual ventilator checks, which frees up the RT to focus on the patient rather than the ventilator.
HSC's platform achieved real-time surveillance of patients on ventilation support and reduced the number of ventilator alarms by an estimated 80%, helping achieve compliance with The Joint Commission National Patient Safety Goals on alarm management. Clinical alarm management also helped HSC with quality and reporting data. Before implementing the platform, HSC was dependent on individual recollections from the clinical responders after an alarm incident. Today, HSC has a clearer picture of every event. HSC can use the data provided by its platform to sort out the story behind any incident, increasing accuracy on occurrence reporting and resolution. Moreover, the data collected are used by the performance management audit committee, which monitors ventilator management performance and helps identify potential areas of need.
"Alarm management is already a fundamental part of what we do," said Connie Dills, MBA, RRT, RPFT, respiratory practice manager for HSC. "It's made a big difference in our staff's efficiency and effectiveness, and has reduced stress for our patients and their families."
Lessons Learned
Alarm management is constantly changing. It must evolve with the needs of the hospital's patients and clinical staff. The nursing leadership and staff at Wesley continue to make adjustments to the alarm management process and configuration. "Alarm parameters should be part of our nurses' practice, and setting actionable alarms will increase their ability to care for patients," said Free. "Alarm management—and the parameters—have to be based on an individualized approach to your patient. Attention to this process have given us ownership."Wesley is also looking at how it can use alarm data for predictive analytics, collecting physiologic data from multiple devices to create a holistic picture of a patient's condition. For example, taken individually, a slight drop in heart rate, a gradual rise in end tidal CO2, or a slight reduction in respiratory rate may not indicate anything critical in a patient's condition. However, data aggregated from those individual parameters could provide the caregiver with a more accurate, predictive picture of the patient's condition—in this case, an emerging risk for respiratory depression.
Addressing clinical alarm hazards in all their forms requires a comprehensive approach, free of the well-known departmental and data silos that hinder patient care and optimal clinical workflows. Technology certainly plays a critical role in alarm reduction and prioritization, but alarm management is a classic example of interdisciplinary leadership, involving clinical, IT, biomedical engineering, and other departments.
References
- ECRI Institute. Top 10 Technology Hazard for 2016. November 2015. https://www.ecri.org/press/Pages/Dirty_Endoscopes_Top_ECRI_Institutes_2016_Technology_Hazards_List.aspx Accessed January 7, 2016.
- The Joint Commission. The Joint Commission announces 2014 National Patient Safety Goal. http://www.jointcommission.org/assets/1/18/jcp0713_announce_new_nspg.pdf Accessed January 7, 2016.
- Wesley Medical Center. Beyond Alarm Management. Bernoulli. October 2015. www.cardiopulmonarycorp.com/wp-content/uploads/2015/10/Bernoulli-Wesley-Case-Study-AM-01-vA-10-15.pdf Accessed January 7, 2016.
- Zaleski JR. Alarm fatigue? What a nuisance! [Blog post]. October 4, 2014. www.medicinfotech.com/2014/10/mathematical-techniques-mitigating-alarm-fatigue Accessed January 7, 2016.
- Wong M, Mabuyi A, Gonzalez B. First National Survey of Patient-Controlled Analgesia Practices. March-April 2013. A Promise to Amanda Foundation and the Physician-Patient Alliance for Health & Safety. http://www.premiersafetyinstitute.org/wp-content/uploads/PPAHS-national-survey-patient-controlled-analgesia.pdf Accessed January 7, 2016.
- Hospital for Special Care. Achieving Clinical Clarity from Ventilator Overload. Bernoulli. October 2015. www.cardiopulmonarycorp.com/wp-content/uploads/2015/10/Bernoulli-HSC-Case-Study-LT-01-vA-10-15.pdf Accessed January 7, 2016.
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