4 An Alarming Challenge More and more devices with alarms More and more patients are connected to one – or many alarm-based devices 150-400 alarms per patient per day can be typical in a critical care unit Alarm-based devices are not standardized in many institutions Flexible alarm setting features allow for inconsistent use of alarms
5 Alarm Management is Complex
6 Culture Conundrum If the nurses would just do their job, we wouldn’t have a problem. We don’t have any problems. We’ve never had an alarm event. Why should I rush to put the leads back on? They’re just going to come off again. It’s not my job! I’m too busy to deal with this ! What’s the use? Nothing is ever going to change. It’s the vendor’s fault! This is the way we’ve always done things. No foundation for improvement
7 ALARM FATIGUE Why is it important? The Food and Drug Administration (FDA) received 566 reports of patient deaths related to alarms on monitoring devices from 2005 through 2008 The ECRI Institute has identified alarm hazards as their number 1 top hazard for 2012 JCAHO recognized Alarm Fatigue as critical and integrated this into their accreditation standards
8 The Consequences are Alarming “Alarm Fatigue” a Concern for New Haven Hospitals. New Haven Register, June 11, 2011 And Still in the News
9 A Typical Event “ Patient admitted with chest pain and shortness of breath---Was on a monitored unit. At 3:25 am, patient’s nurse noticed the leads were off and on checking on the patient found him in the bathroom unresponsive. Resuscitation efforts were unsuccessful. Monitor showed the leads had come off at 2:32 am …” Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis, A Pennsylvania Patient Safety Advisory Supplemental Review, March 2008
10 Example of Alarm Fatigue Ventilator-dependent patient – frequent coughing Coughing triggers high-pressure alarm Frequent response to alarm by nurse with no real problem Pressure alarm limit increased to minimize the number of false-positive alarms An accident waiting to happen Patient movement crimps breathing circuit Secretions clog the endotracheal tube Inadequate ventilation (inhalation or expiration)
11 Some Questions to Ask Does the nurse understand the purpose of the high-pressure alarm? Was the nurse’s competence in ventilator use validated? Does the hospital have a policy for who can and cannot set ventilator alarms? Is there a policy on how ventilator alarms should be set? If so, is it generic or does it consider specific circumstances? Does the hospital have ventilator responsive-valve features, which can reduce nuisance high-pressure alarms?
12 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 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.
13 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 NURSES PROBLEMS?
14 Underreporting Some estimates suggest that the actual number of alarm-related deaths is ten-fold higher or more than what problem data shows Ability to do analytics on data is very limited I literally had to read every report (around 20) in a recent problem reporting analysis Actual reports often don’t have much information Typical language (paraphrased) - During use of device alarm did not sound and patient died Problem Reporting Data
Assess if sufficiently staffed with enough nurses How many nuisance/false-positive alarms are there in the unit per day Tiered response system would allow for quicker response time and delegation Set individual parameters 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 Centralized monitoring with allocated staff member to alarm personnel Pop up screens EDUCATION & TRAINING!!! How can we improve?