1. What is it? Alarm Fatigue Alarm fatigue occurs when clinical personnel fail to respond appropriately to alarms due to excessive or inability to understand the priority or critical nature of alarms. As a result, clinical personnel will be desensitized to alarms, and will ignore them and even turning them off.

2. Alarm Fatigue Why is it important? 2004 study showed 1,511 undetected status changes ending in death or rescue activities per 10,000 admissions JCAHO recognized Alarm Fatigue as critical and integrated such into their accreditation standards The number of deaths caused by alarm fatigue has increased from 189 in 2001 to 449 in 2004

3. Alarm Fatigue Causes? Studies have shown as many as 99% of ICU alarms are false or non-critical alarms. These are called nuisance alarms and are the leading contributor to alarm fatigue

4. Alarm Fatigue Causes? Alarms fail to function as expected It is difficult to distinguish which machine's alarm is going off Nurses may block out noise in order to concentrate on current task.

5. Alarm Fatigue Nurses Problems? Nurses have an overabundance of notifying devices (nurse calls, pagers, phones, overhead pagers, and monitor alarms) Lower patient to nurse ratios increase the number of relevant alarms per nurse Monitors with undirected alarms alert all nurses instead of specific nurses

6. Alarm Fatigue Nuisance Alarms? Many nuisance alarms can be avoided by maintenance and adjustments such as battery changes and new sensors 2005 John Hopkins Hospital study observed 16,934 alarms over 18 days in one unit Maintenance was performed and settings were adjusted resulting in 43% decrease

7. Alarm Fatigue How can we Improve? Tiered response system would allow for quicker response time and delegation Actionable/tailored alarms would create less nuisance alarms The combination of all alerts to one device, "Smart alarms" to monitor multiple device in relation to each other

8. Alarm Fatigue What are the Obstacles? There is little or no coordination between manufacturers including limited standards Manufacturers prefer a proprietary product Alarm acoustics bare no relationship to type of alarm Most alarms are on or off with no variation in level for type of alert

9. Alarm Fatigue Current Efforts? Third party vendors are pushing for FDA regulation on monitor interface iTouches and iPhones have been used to integrate alarms and notifications along with communication between nurses Devices have been developed to provide data to specific nurses about specific patients from multiple devices allowing real- time use.

10. Alarm Fatigue Action? Evaluate equipment with excessive alarms that desensitize staff Standardize alarm management Gage the reliability of secondary notification devices and assess new systems of alarm management Determine staff educational needs on alarm devices

11. Central Line Infection Also called Central venous catheter (CVC) Placed into large vein in neck, chest, or groin Used mainly to administer drugs or obtain blood tests

12. Central Line Infection Why it is important 2006 study showed that 48% of the 4 million ICU patients that year received indwelling catheters Approximately 200,000 contract bloodstream infection 15-20% mortality rate Cost $3,700 to $29,000 per infection

13. Central Line Infection Causes (Procedural) Because of routine nature of procedure, physicians only think partial drapes are needed over full-sized drapes In a study, the perceived need for full-sized drapes was 22%. Documented use of full-sized drapes was 44%

14. Central Line Infection Causes (Infections) Catheter insertion breaks the skin, creating an open pathway for organisms to enter bloodstream Accessing the catheter for medication admin, flushing, and tubing changes introduces microorganisms into the lumen Infection elsewhere can also lead to bloodstream related infection Contaminated fluid or medications

15. Central Line Infection How can we Improve? Integrating a guideline for surgery procedures Apply minimum guidelines for sterilizing catheters and surgical areas Utilize nurses to run down a checklist to make sure all personnel and procedures abide by these guidelines

16. Central Line Infection Specifics Hand Hygiene Maximal barrier precautions upon insertion and effective protective dressing Chlorhexidine skin antisepsis Optimal catheter site selection Daily Review of central line necessity

17. Alarm Fatigue What are the Obstacles? Not enough evidence-based data to create guidelines Difficult to empower nurses with the final verdict of guidelines Constant replacement of CVCs doesn’t necessarily reduce risk of infection

18. Central Line Infection Current Efforts Development of evidence-graded guidelines for prevention Implement instructional courses given to physicians and staff to refresh importance of reducing infection Hands on approach with courses bundled with multiple modules covering all aspects of improvement

19. Central Line Infection Action? Develop well-defined procedural guidelines using evidence-based data Continue to keep physicians informed with courses to refresh techniques for surgical procedures Find new ways to reduce infection, such as alternative insertion sites

20. Central Line Infection Outcomes After multifaceted intervention study, rate of infection decresed from 11.3/1000 to 0/1000 from 1st Estimated cost savings of $63,000 and up to $800,000 Use of full-sized drapes increased from 44% to 65%