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

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 630-664-8401 JenCowel@PattonHC.com

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 2011 - LSC days increased Surveyor Focus on industry trends Alarms have led to Immediate Threat

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

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.

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

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

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.

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 2005 observed 16,934 alarms on one unit in 18 day time period.

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

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

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,

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

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

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

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

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?

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

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.

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.

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

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

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

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

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.

Fire Extinguisher Dating (EC.02.03.05 cont.) Month, day, year and initials of inspector required per NFPA 10-1998 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!!!

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.

Medical Gas (EC.02.05.09 – 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

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

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

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.01.01.01)

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

Strategies for Success Preparing Clinical Areas Rollout the Clinical Area Checklists Email 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!

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!

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

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

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

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.02.01.10 – LS.04.02.05 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

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

Institute the Action Plan Everyone in Position

Please visit and bookmark www.pattonhc.com QUESTIONS? JenCowel@PattonHC.com Please visit and bookmark www.pattonhc.com