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The Institute for Johns Hopkins Nursingwww.ijhn.jhmi.edu, [email protected]

5/2/2014

Managing Clinical Alarms

Maria Cvach, DNP, RN, CCRNAssistant Director of Nursing, Clinical Standards

Sharon Allan RN, MSN, ACNS‐BC, CCRCClinical Nurse Specialist, CVSICU

Matt Trojanowski, MSc, RRTManager, Adult Respiratory Care Services

Why did we initiate alarm management at JHH?

Alarming Situation

Alarms not set to

actionable limits Too many

alarming devices: duplicate

alarms

Low specificity results in

frequent false alarms

Alarm desensitization

Unclear alarm

responsibility

Large units with inability to hear

alarms

No back-up/ escalation

plans

Competing Priorities

2-May-14 3

Barriers to Accurate, Actionable Alarms

What changes were made?

© ECRI Institute 2013

System’s Approach

• Assemble a multidisciplinary team

• Review recent events and near misses

• Ask staff about their concerns

• Review unit alarm data

© adapted from ECRI Institute 2013

Text 2 Tex3

CUSP TEAMInterdisciplinary Alarm Committee

Support from Hospital Administration

Nursing Biomedical and IT

HospitalVendors

Human Factors

RT

Risk Management

Physicians Patient Rep

UNIT NAME CVSICU Ave Beds Reporting Alarms/ Day 14High Priority 186 (1%)Medium Priority 1972 (9%)Low Priority 16080 (77%)Technical 2603 (12%)TOTAL ALARMS 20841Ave Alarms/Bed/Day 208Ave Alarms/Bed/Day High Priority 2Ave Alarms/Bed/Day Medium Priority 20Ave Alarms/Bed/Day Low Priority 161Ave Alarms/Bed/Day Technical 26Ave High Priority Duration (sec) 27Ave Medium Priority Duration (sec) 15Ave Low Priority Duration (sec) 19Ave Technical Duration (sec) 56

CVSICU Monitor Alarm Assessment

6

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

CVSICU Weekly Report by Alarm Type

System’s Approach (cont.)

• Identify patient safety vulnerabilities and potential failures

• Review unit alarm coverage

• Determine underlying causes of potential failures

© adapted from ECRI Institute 2013

Missed Alarm: Results of Fault Tree Analysis

Alarms not recognized

(detected)

Nurses desensitized (auditorilly

or conceptually)

Insufficient monitor

skills

Late response time

Inadequate interface design

Staffing challenges

Equipment failure

Failure to respond to a critical

alarm in a timely manner

OR

Copyright © The Johns Hopkins Health System Corporation. All rights reserved.

JHH Measures to Reduce Quantities of Alarms

• Minimize recurring alarms; standardize alarms across similar units/settings (e.g., pediatrics, telemetry, ICU)

• Enable actionable alarms

• Reprioritize auditory and visual alarms Auditory: Higher priority

Visual: Low priority

• Adjust parameter limits appropriately for patient population

• Assure alarm audibilityMaria Cvach DNP, RN, CCRN

Sample JHH Monitor Alarm Inventory Default Parameter Grid

Parameters

Departments

PULSE OX %

HEART RATE BPM

BP SYSTOLIC mmHg

BP DIASTOLICmmHg

BP MEANmmHg

Low High Low High Low High Low High Low HighMedical ICU 88 105 50 140 90 180 40 110 65 120Surgical ICU 88 105 50 120 90 180 40 110 55 120Coronary Care 88 105 45 120 90 180 40 110 55 120Cardiac Surgical ICU 88 105 50 120 80 150 40 110 55 120Neurologic ICU 88 105 50 120 90 180 40 110 55 120Weinberg ICU 88 105 50 120 90 180 40 110 55 120Oncology Department 88 105 50 130 90 180 40 110 55 120Surgical Progressive Step-down Care unit

88 105 50 140 90 180 40 110 60 120

Sample JHH Alarm Risk InventoryClinical Equipment AlarmInventory

Risk to Patient and Response

Level of oversighttypically available

Secondary AlarmNotification

High priority cardiac monitor alarms

A Varies by unit Varies by unit; includes beside split screens, auto-

view on alarm, hallway waveform screens, acknowledgement

pagers/phones, unit-based monitor watch

Medium/technical cardiac monitor alarms

B Varies by unit

Low priority cardiac monitor alarms

C Varies by unit

Ventilator A Varies by unit Nurse call auxiliary outletECMO A High Direct supervisionBed/chair exit alarm A Low Nurse call auxiliary outletSequential compression device C Low None identified

Central Monitor Station

• Unit floor plan• Unit workflow• Unit staffing• Redundancy

Monitor Alarm

NotificationMethods

HallwayWaveform

Screens

Monitor watch

Phones

Pagers

View on alarm

Split Bedside Monitor

Screens

Zoning

Use of Middleware

Routes the alarm to the proper person/device following an algorithm

Strategies that Worked

Alarm Reduction Strategy Potential Benefit Sustainability Challenges

Parameter limits and alarm level changes

25%- 74% reduction in frequency of alarms (varied by unit)

Agreement of group on what is an actionable alarm

Daily electrode change46% reduction in frequency of alarms in MPCU and CCU

Behavior may diminish over time; patient discomfort; cost

Alarm escalation notification (each nurse carries acknowledgment pager)

53% reduction in frequency of alarms on a surgical IMC; 23% reduction in time to respond to alarm

Cost of acknowledgement pagers; Using two different devices to communicate alarms

Strategies Resulting in Varying Degrees of Success

Alarm Reduction Strategy Potential Benefit Sustainability ChallengesCharge nurse (CN) reminds each nurse to customize alarms each shift

24% reduction in frequency of alarms in CCU

Once CN stopped reminding staff, behavior diminished over time.

New SPO2 sensor tested 2% reduction in frequency of alarms in CCU

None identified

Unit-based monitor watcher 47% reduction in frequency of alarms in CCU

Cost; staffing

Use of disposable leads34% reduction in frequency of alarms in CCU; no change in frequency of alarm in PICU

Cost of disposable leades

Alarm escalation notification (Charge nurse carries acknowledgment pager)

No reduction in frequency of alarms on a surgical IMC; 13% reduction in time to respond to alarm

Cost of acknowledgement pagers

Maria Cvach DNP, RN, CCRN

Impact of Cardiac Alarm Management Strategies

UNIT Pre-interventionsAverage Alarms/

Monitored Bed/Day

Post-interventionsAverage Alarms/

Monitored Bed/Day

% Reduction in Cardiac Monitor

Alarms

MICU 215 68 68%CCU 515 194 62%WICU 771 151 81%IMC 240 50 79%

Telemetry 90 17 81%

JHH Alarm Management Initiatives

• Nurse‐Managed Telemetry Discontinuation Protocol

• Audible Alarms and Alerts in an ICU Setting – Are they recognizable?

•Management of Ventilator Alarms: Evaluation of Current Practice

Nurse Driven Telemetry Discontinuation Protocol

Audible Alarms and Alerts in an ICU Setting –Are they recognizable?

1) Assess discriminability of current audio alarm signals and determine if these signals cue nurses appropriately

2) Assess nursing staff clinical alarm attitudes and perception of effectiveness of alarm notification prior to and after implementation of a bundled set of interventions

3) Assess alarm frequency per monitored bed and mean alarm duration time prior to and following implementation of a bundled set of interventions

Audible Alarms and Alerts in an ICU Setting –Are they recognizable?

• Tone tests (17 common sounds) pre/post• Staff alarm attitude survey pre/post• Bundled set of interventions

– Staff education– Parameter changes– Revised alarm notification process

• Timeframe – pre/2months post/4 months post

Review of patient charts to compare alarm settings vs. ventilator parameters

Observing clinician responses to alarms in

real-time

Review of ventilator data logs

Observing alarms requiring intervention vs.

self-resolving alarms

What’s actually happening?

Management of Ventilator Alarms: Evaluation of Current Practice

May 2, 2014 25

Equipment Alarm

Nurse

Call

Weekly Report

• Alarm source location• Time of alarm activation• Duration of alarm

How Data is Obtained What Information is Included in the Data

• # of alarms per vent/per day• Time distribution of alarms• Average duration of alarms

What can be concluded from analyzing the data

• Specific alarm condition• Alarm priority• Actionable vs. not actionable

What cannot be concluded from analyzing the data

Understanding Current

Practices & Perceptions

What alarms are important?

Utility of secondary notification systems?

Alarm duration

influence on provider response

How do you set alarms?

National Survey of Respiratory Therapists

Summary: What Works?

• Alarm delays for alarm‐auto correction• Multi‐parameter alarms to increase alarm specificity• Good skin/electrode practices• Alarms set to actionable levels• Customization of alarms based on patient need• Discontinuing monitoring when no longer necessary• Limited recognizable alarm sounds • Alarm notification to the responsible person using an escalation process

The Institute for Johns Hopkins Nursingwww.ijhn.jhmi.edu, [email protected]

5/2/2014

managing clinical alarms - amazon s3s3.amazonaws.com/.../slides_jhu_cvach_allan_trojanowski.pdf ·...

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