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.
"We used a multimember interdisciplinary team, including nurses,
respiratory therapists, biomedical staff, and IT staff to formulate a
list of alarms that we felt were important," said Deborah Free, RN,
stroke program coordinator and quality manager at Wesley's Galichia
campus. "At the same time, our [alarm management vendor] sent us a list
of our most frequent alarms. We compared the two lists and prioritized
the alarms we wanted to address."
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.
By changing practice based on evidence, the staff of Wesley was
able to reduce the number of alarms caused by nonactionable, brief
physiologic changes. By collecting high-resolution physiologic data from
medical devices—not just the individual alarm data—the
interdisciplinary team was able to measure the potential impact on the
number of alarms before making adjustments to alarm settings.
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 |
SpO2: pulse oxygen saturation
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.
