1. Alarm Fatigue and other EC/LS Hot Spots for Clinical Managers
October 2011
Jennifer Cowel, RN MHSA

2. Speaker Jennifer Cowel, RN MHSA
TJC Experience: Former TJC Hospital Surveyor and former Director of Service Operations in Accreditation in Central Office
Accreditation and regulatory compliance consultant
Vice President and Principal Patton Healthcare Consulting

3. Alarm Fatigue & Top Scored What, Me Worry?
Alarm Fatigue – JC Online Aug 2011
Issue highlighted at TJC Executive Briefings
4 of the top 5 scored standards were in EC or LS
In LSC days increased
Surveyor Focus on industry trends
Alarms have led to Immediate Threat

4. 2012 Decision Categories PDA Contingent Accreditation
Accreditation with Follow-up Survey (AFS)
Accredited
Ex: Immed Threat to Life or falsification or fail to clear RFIs after two tries when in CONT
Ex: Failed AFS after 2 tries, or No License, etc
Ex: Too many RFI’s
CoPs non compliant.
Ex: Compliant or cleared all RFIs w/ ESC
Perspectives 11/2010

5. Alarm Fatigue A Growing Problem
FDA article reports 566 patient deaths between 2005 – 2008, related to alarms
The numbers are self reported and are likely to be higher
Twenty-five years ago, few, if any alarms on equipment
Today – increasing equipment and increase in type & # of alarms
566 reports of patient death related to the alams on monitorin gdevices.

6. Alarm Fatigue A high-profile Problem
A patient on cardiac monitor died after V-Fib, dysrhythmia processing turned off
Perinatal monitor did not audibly alarm fetal distress, only visual, went unnoticed
A patient stopped breathing but staff just didn’t hear the monitor
The monitor detected it, but neither v-fib or asystole would have sounded an alarm as that aspect of monitoring had been suspended

7. 10 Years of TJC Focus
Sentinel event alert in 2002 focus on clinical ventilator alarms
Introduced NSPG
Moved clinical alarms to standards ‘05
Participating in fall summit by AAMI, ACCE, ECRI
Problem continues to grow
The summit is to identify specifi actions

8. What is Alarm Fatigue? Or Crying Wolf
Alarm fatigue occurs when clinical personnel fail to respond appropriately to alarms due to inability to understand the critical nature or priority of the alarm. Staff become desensitized after experiencing and handling so many. Alarms are ignored or turned off.

9. Taking a Good Thing Too Far
Go beyond the visual/audible alarm, to cell phone, pager alerts, dashboards, nurse call systems
Beyond the basics – bed alarms, chair alarms, IV, call button, hand sanitizer.
Study of alarms in critical care units
900 to 1300 alarms per day, per unit.
Alarms every 66 seconds
Study conducted by childrens national medical center and vendors published in AAMI. Recorded tens of thousands of alarms in in 30 day period. Johns hopkins study in observed 16,934 alarms on one unit in 18 day time period.

10. Understanding the Issues
FDA published results of 216 manufacturer reports on monitor related deaths
TJC analyzed sentinel events for monitor related causes

11. Common Causes Staff are overwhelmed by the # of alarms
Staff don’t respond or hear alarms
Staff turn-off or turn down alarms
Alarm settings not returned to original setting after a patient move
Alarm not properly relayed to wireless or paging system

12. Common Causes Nuisance Alarms reduce sensitivity
As many as 99% of ICU alarms are false, or non-critical alarms
No routine replacement of batteries, leads to excessive “low battery” alarms
Put a “ring” on it - The solution to many problems or RCAs is to add an alarm on it to prevent recurrence.
Alarms just become back ground noise
Children’s national hospital demonstrated that 85 – 99% of alarms were false positive. We are inundated with information and alarms, most of which is meaningless.
Put a ring on it – alarms for call bells not answered, for chairs, for hand sanitizer,

13. Causes – Cont. The Sound of the Alarm
Med Equipment companies create their alarm to fetch attention, the beeping is intended to irritate
Sounds of alarms do not differentiate a ‘notification’ from a critical event.
Sounds are difficult to learn, differentiate which alarm
Difficulty learning > 6 alarm signals

14. Causes – Cont.
Alarm noise contributes to sound level in unit, disrupts sleep and environment of healing
Users can turn alarms off, change parameters, reduce volume.
Alarms are not tailored to the individual patient
Nurses block out noise to focus on task
Medication mangement – don’t want disrutions, nurse tune out to improve complex tasks.
FDA report on device related deaths

15. Concrete Steps to Improving Safety/Effectiveness of Alarms
How many alarms are tolerable to staff to avoid fatigue? Anesthesiology Today study suggests 2 – 4 per patient/day
Reduce Thresholds for alarms, use evidence based approach.
Define when a clinician needs to go to bed side

16. Reducing False Positives
A Johns Hopkins Study: lower SpO2 alarm from 90& to 88% reduced alarms by more than 50%
Place delays on alarms, delay alarm by 15 seconds. Journal of Emergency Medicine (JEM) study. Reduced false positives by 80%
Get to only the alarms staff care about

17. Improving Safety of Alarms Cont.
Equipment maintenance
Reduce low battery alerts by replacement
Deactivate or limit overrides
Routine testing of alarms
Selection of equipment
Vendors with meaningful alarm sounds
Implement intelligent escalation of alerts
Involve staff in equipment selection
Test alarms, are they audible? Alarm when disconnected? Have appropriate parameters?

18. Improving Safety of Alarms Cont.
Alarm Notification Alternatives
Consider central surveillance room with monitor watchers than notify care givers
Consider alarm integration systems that directs alarms to devices worn by staff

19. Improving Safety of Alarms Cont.
Staff Training
Train staff on meaning of all alarm sounds
Train staff to check patient before silencing any alarm
Train staff on new equipment
Train staff on proper alarm placement, skin preparation, ensure competence
In a january 2011 publication “preventing medical errors, FDA recommende several thing to avoid alarm-related injuries.

20. Improving Safety of Alarms Cont.
Develop and implement policies
Who can change alarm settings
Who needs to be monitored
What are default settings
Who is responsible for performing clinical alarm monitoring rounds
Develop audit tool to measure compliance with established policies
Develop and complete check list at shift change for patient alarm settings
In a january 2011 publication “preventing medical errors, FDA recommende several thing to avoid alarm-related injuries.

21. Top Scored EC & LS Standards
Surveyors see these everywhere, low hanging fruit
These are seen by both the LSC surveyor and the clinical surveyors
Prevent them from seeing these at your organization and create an impression on day 1

22. Exits and Cluttered Corridors (LS.02.01.20 -57%)
Hospital maintains means of egress
Easy to find issues, educate on:
Blocked or locked egress doors
Corridor clutter, storage in hallways
Linen carts and latex carts will be scored
Exit signs – burned out, enough, proper location,
“No Exit” signs posted

23. Fire Protection Features (LS.02.01.10 - 57%)
Building & fire protection features minimize the effects of fire, smoke and heat.
Fire and smoke doors labeled, correct type, close, label visible, under cut, door gaps, adhesive tape over latch
Penetrations are sealed with correct material – IT cables biggest offender. Consider a work permit and inspection

24. Fire Doors, cont Inspect and maintain fire doors
Appropriate fire rating on doors and frame
Door positively latches
Door had a closure
No gaps > 1/8 inch, or undercut >3/4 inch
Resulted in ITL if multiple problems

25. Fire Protection Equipment (EC.02.03.05 – 42%)
Hospital inspects, tests & maintains
fire safety equipment.
Includes testing of: fire alarms boxes, smoke detectors, sprinklers, portable extinguishers, magnetic release devices, tamper switches
& water flow devices.
If outsourced to a vendor keep the report, read the report and act on problems!
Make sure reports are tied to an inventory of devices
Check closed areas of the building as well when doing all tests.

26. Fire Extinguisher Dating (EC.02.03.05 cont.)
Month, day, year and initials of inspector required per NFPA
They will review the tag
If bar coded, they will review documentation
Required monthly
Check closed areas of the building as well when doing all tests. – this means every 30 days!!!! Not during the month *** jkc check!!!

27. Fire Protection Equipment (EC.02.03.05 – 42%)
Hospital inspects, tests & maintains
fire safety equipment.
Includes testing of: fire alarms boxes, smoke detectors, sprinklers, portable extinguishers, magnetic release devices, tamper switches
& water flow devices.
If outsourced to a vendor keep the report, read the report and act on problems!
Make sure reports are tied to an inventory of devices
Check closed areas of the building as well when doing all tests.

28. Medical Gas (EC – 20%)
Hospital inspects, tests & maintains medical gas and vacuum systems.
Get vendor reports, fix problems noted
Gas shut off valves must be labeled with rooms they shut off. Staff must know who can shut these off and when.
Alarms must be working. Has led to ITL

29. Provide/Maintain Fire Systems and Equip (LS.02.01.35 33%)
Sprinklers
18 inch rule
Sprinkler pipes can not support other items like cables or wires
Sprinkler head clean and free of obstruction, collar flush

30. Medical Gas (EC.02.05.09 – 20%) No parking zone!
Get vendor reports, fix problems
Gas shut off valves must be labeled with rooms they shut off.
Staff know who can shut these off
Alarms must be working. Led to ITL
Test & inspect & maintain medical gas and vacuum per policy

31. Safe, Functional Environment (EC.02.06.01 – 20%)
Areas scored here: furnishing and equipment are in good repair, the environment meets needs of patient.
Ripped mattresses, cracked ceiling tile, mold, broken wheel chair
In behavioral health units do environmental risk assessment for suicide risks. Either fix or implement other safety interventions such as increase monitoring. Document and keep your risk assessment. ( or scored at EC )

32. Safety and Security (EC.02.01.01 – 15%)
Hospital manages safety and security risks
Complete risk assessments on areas of potential risk
Scored in sensitive areas such as Labor and Delivery, Pediatrics
Trace your own policies, do staff stop you or surveyor when they enter area?
See unsecured O2 scored here JKC

33. Strategies for Success Preparing Clinical Areas
Rollout the Clinical Area Checklists
them out, assign, implement, collect them back, analyze compliance
Involve/educate clinical & frontline staff
Everyone knows who to call to get fixed
Identify areas to improve, fix it, then reassess
Make LS an every day expectation!

34. Strategies for Success Do Mock Surveys
Conduct mock tracers in clinical areas
Do EOC System Tracer during your Mock survey
Use the documentation checklist
“show me where this is documented”
Look for missing dates, think medication refrigerators when doing this!

35. Strategies for Success
Review your eSOC quarterly for updates, completion of projects
Validate that ILSM evaluations exist on paper for each PFI on the eSOC
Work with facilities staff and learn the language

36. Strategies for Success
Make use of the PPR to document compliance
Record the name and location of each report that documents compliance
Helps during on-site survey!
When in doubt, get clarity from SIG

37. Survey Process Preparation
Before your next survey prepare for and/or practice the following:
Day one documents – surveyor planning session
Environment of Care system tracer
Document Review session *
Emergency Management system tracer
LSC building tour *
Tools and check lists for the document review session and check list for the building tour are in your packet and will be described at the end

38. Now That You Know… fix it
Options for managing self identified deficiencies in LS.02.xx.xx – LS.04.xx.xx
Correct it immediately
Fix in 45 days in corrective maintenance – document it.
If it takes >45 days, create a Plan for Improvement (PFI) in your e-SOC
Consider equivalency request to TJC
waiting until they announce how the data will be used will be too late.  You will have a tail wind of 12 or months of outliers you will have to live with.
Overview: When an [organization] finds that it is out of compliance with Standards LS – LS the hospital either resolves the deficiencies immediately or manages it through one of the following options:␣ A maintenance management process that documents the deficiency and corrective resolution within 45 days␣ A Plan For Improvement derived from the Statement of ConditionsTM␣ A Life Safety Code Equivalency approved by The Joint Commission

39. Validate ID on the extranet Institute your calling tree
Managing the Onsite Survey … GOOD MORNING, WE ARE HERE FROM THE JOINT COMMISSION
Validate ID on the extranet
Institute your calling tree
Everyone or their back up initiates the pre-planned action.
Rooms are freed up,
Documents are rolled in, opening conference starts. Optional information shows great things only

40. Institute the Action Plan Everyone in Position

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