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Presentation Title Sub Information Strategies for Managing Alarm Fatigue An Evidence-Based Approach for Understanding and Managing Alarm Fatigue in the Acute and Critical Care Environment May C opyright © 2013 American Association of Critical-Care Nurses

Presentation Title Sub Information Learning Outcomes  Describe the causes and impact of alarm fatigue.  Outline the causes of nuisance and false-positive alarms.  Explain the impact of alarm fatigue on patient safety.  Summarize the impact of false-positive and nuisance alarms on patient safety.  Examine the evidence-based implementation strategies for improving patient safety.  List nurse-led strategies for individualizing patients’ alarm parameters. Copyright © 2013 American Association of Critical-Care Nurses 3

The Extent of the Problem Copyright © 2013 American Association of Critical-Care Nurses4

Unintended Consequences—Patient Death 2007  77-year old was admitted to a telemetry unit.  Alarms for “low battery” went unanswered.  Patient had cardiac arrest and died. January 2010  89-year-old patient was in the ICU.  Bedside alarm was turned off.  Alarmed sounded at the central nurses’ station.  Nurses on duty said they did not hear the alarm or see the digital display. Since 2005, more than 216 patient deaths have been directly attributed to alarm fatigue. Copyright © 2013 American Association of Critical-Care Nurses5

Unintended Consequences—Patient Death (cont’d) August 2010  60-year-old man was admitted to the ICU after a tree fell on him, resulting in facial trauma and head injury.  He was agitated and received lorazepam 5 mg IV push. The order was for “small doses up to 5 mg.”  An hour later, tachycardia and low oxygen saturation (SpO 2 ) alarms went unanswered for an hour.  Respiratory arrest was called. Patient was resuscitated and placed on a ventilator.  CT scan showed an anoxic injury of the brain.  Family withdrew the patient from life support after several days. Copyright © 2013 American Association of Critical-Care Nurses6

Defining the Problem Alarm Fatigue  Occurs when staff members are exposed to an excessive number of alarms.  Staff become desensitized to alarms.  Results in sensory overload: —Staff frustration —Delayed alarm response —Missed alarms —Patient safety events Copyright © 2013 American Association of Critical-Care Nurses7

Contributing Factors Nuisance Alarms  May interfere with patient care.  Are perceived as annoying.  Are not the result of adverse patient conditions.  Distract from other tasks or focus. False Alarms  Are detected by a medical device.  Indicate the need for a response.  Are triggered without a true patient event.  Are usually the result of: —Parameters not set to actionable levels —Too tight thresholds Copyright © 2013 American Association of Critical-Care Nurses8

The Reality Technology  Natural part of the environment Physiologic monitoring  Standards of care and practice Devices  Only as reliable as the clinicians who use them Alarms  Inherent in the clinical environment  Intended to alert clinicians to deviations from a predetermined “normal” status  Compromise patient safety if ignored Copyright © 2013 American Association of Critical-Care Nurses9

Staff Perceptions  Alarms are a necessary evil.  May not view alarm fatigue as a problem or real threat to patient safety.  Alarms may be used as a stop-gap measure for a lack of monitoring.  Use of alarms is a possible means to eliminate and/or replace staff or clinicians with technology. Copyright © 2013 American Association of Critical-Care Nurses10

Rethinking What We Do 11Copyright © 2013 American Association of Critical-Care Nurses

Rethinking What We Do Alarm fatigue is a complex issue:  Unique set of circumstances and vulnerabilities —Hospital and organizational culture —Nuisances specific to patient unit  Many variations of common problems —Apathy for “leads off” and “low battery” alarms —Communication breakdowns —Competing priorities  Alarm data are difficult to obtain Copyright © 2013 American Association of Critical-Care Nurses12

Rethinking What We Do (cont’d) 2011 ECRI Institute Report  Staff overloaded with alarms will improperly modify alarm setting.  Alarm settings should be modified only after careful consideration of each patient’s condition. Copyright © 2013 American Association of Critical-Care Nurses13

Proactive Response The best way to prevent alarm fatigue is through proactive alarm management.  Inquire whether you have the ability and authority to adjust alarms of physiologic monitoring systems  Tailor alarm parameters to the: —Individual patient —Specific patient population  Evaluate whether the: —Alarms are audible and visually displayed. —Critical alarm sound is distinguishable over unit noises and other alarms. 14Copyright © 2013 American Association of Critical-Care Nurses

Proactive Response (cont’d) Decrease false-positive alarms.  Degrade the clinician’s ability to decipher priority alarms.  Ensure proper skin preparation technique before placing ECG electrodes.  Troubleshoot false alarms when they occur. —Avoid ignoring them. —Avoid alarm work-arounds. 15Copyright © 2013 American Association of Critical-Care Nurses

Proactive Response (cont’d)  Do not overuse physiologic monitoring. —Avoid keeping the patient on telemetry monitoring longer than necessary. —Consider the American Heart Association and American College of Cardiology’s evidence-based Practice Standards for Electrocardiographic Monitoring in Hospital Settings.  Never turn off an alarm. —Consider silencing while you troubleshoot. —Assess the reason for the alarm. —Intervene as appropriate. 16Copyright © 2013 American Association of Critical-Care Nurses

Managing Environmental Alarms Copyright © 2013 American Association of Critical-Care Nurses17

Laser Sharp Focus Alarm Management  Orchestration —Culture —Staff responsibilities —Technology —Policies and procedures —Processes  Must support: —Prompt and efficacious alarm verification —Notification —Response —Documentation Copyright © 2013 American Association of Critical-Care Nurses18

Alarm Management Models Alarm Prioritization  Visual and audible distinctions of alarms are provided.  Indicates the level of urgency of the response. Alarm Escalation Plan  Designates the caregiver to receive initial alarm notification.  Identifies an additional caregiver as a backup in case no response to the alarm occurs.  Time intervals for escalation are defined. Copyright © 2013 American Association of Critical-Care Nurses19

Alarm Management Models (cont’d) Decentralized Alarm Coverage Model  Direct alarm notification —From central station —From remote displays —From devices themselves  Unit-based monitor watchers —Continuous watch central station displays —Notification directly to a patient’s nurse Copyright © 2013 American Association of Critical-Care Nurses20

Alarm Management Models (cont’d) Remote Centralized Monitoring Surveillance Model  Room is separated from the care area.  Dedicated monitor watchers are provided.  Alarm notification is provided to the nurse via telephone or pager.  Reduces patient and caregiver exposure to the noise and demand of nuisance alarms. Alarm Integration Model  Clinical device alarms are transmitted to a central system.  System communicates with caregiver via devices such as a pager or telephone.  System has potential to: —Relay alarms only —Attempt to filter out nuisance alarms Copyright © 2013 American Association of Critical-Care Nurses21

Alarm Management Strategies Copyright © 2013 American Association of Critical-Care Nurses22

Alarm Management Strategies Must involve multidisciplinary team:  Chief Nursing Officer  Director of Quality  Key Medical Staff  Clinical Engineering  Nurse Managers  Clinical Nurse Specialists and Educators  Frontline Nurses  Information Technology Staff Analyze:  Adverse events  Near misses  Did alarms contribute to the patient event? Observe alarm coverage. Survey staff regarding alarm concerns. Copyright © 2013 American Association of Critical-Care Nurses23

Alarm Management Strategies (cont’d) In collaboration with frontline staff, develop policies that will:  Define specific alarm levels.  Describe the expected response to each level.  Identify the back-up plan, should the responsible person be unable to respond. —Expectations and accountability must be aligned with the principles of a blameless culture. —Reporting of issues is encouraged and transparent. Develop reports that will:  Provide a benchmark.  Provide ongoing data about predefined quality parameters.  Measure the progress.  Identify areas of focus and work to attain high levels of staff compliance. Clinicians must immediately address alarms:  Alarms should never be turned off. Copyright © 2013 American Association of Critical-Care Nurses24

Alarm Management Strategies (cont’d) Organizations should communicate to patients and visitors that prompt responses to alarms are a top priority in keeping patients safe. Make all alarms actionable:  Clinicians only alerted to clinically significant alarms that require response  Addressed by analyzing default alarm parameters and ensuring parameters are appropriate for the individual patient  On-going education and validation of staff competency on customizing alarm parameters Copyright © 2013 American Association of Critical-Care Nurses25

Alarm Management Strategies (cont’d) Consider a brief delay in alarm notification (5 to 10 seconds).  Avoids alarm notification for a problem that quickly resolves.  Important: Incorporated delay must not jeopardize quick access to emergent care. Implement preventive maintenance.  Prepare the skin before applying ECG electrodes.  Routinely replace ECG electrodes every 24 hours to prevent them from drying out.  Consider setting a 5- to 15-second delay for SpO 2 alarms.  Individualize SpO 2 alarm threshold to the patient’s condition.  Consider upgrading to the next-generation pulse oximetry.  Use disposable, adhesive pulse oximetry sensors, and replace them when no longer properly adhering to the patient’s skin. Copyright © 2013 American Association of Critical-Care Nurses26

Alarm Management Strategies— Ventilator Alarms  Collaborate with Respiratory Care Practitioners.  No standard default alarm settings exist for ventilators.  The American Association of Respiratory Care Practitioners published a consensus statement regarding alarms: —Level 1: Events that are immediately threatening if left unattended for short periods (e.g., power failure, apnea) —Level 2: Events that are potentially life threatening if left unattended for longer periods (e.g., circuit leak, positive-end expiratory pressure [PEEP] alarms) —Level 3: Nonventilator events that are not likely to be life threatening but a possible source of patient harm if not addressed.  Consider using a 360-degree visual display screen on all high-priority ventilator alarms. High-priority alarms are displayed in red; medium-priority alarms are displayed in yellow. Copyright © 2013 American Association of Critical-Care Nurses27

Core Alarm Management Strategies— Infusion Pumps IV Infusion Pumps  No replacement for nursing assessment  Proactively identify any problems that might interfere with the prescribed infusion rate Copyright © 2013 American Association of Critical-Care Nurses28

Core Alarm Management Strategies— Bed Alarms Bed-Exit Alarms  Widely used as a fall prevention strategy  Used only in these clinical scenarios: —Patients with delirium and cognitive impairment —Patients who are unable to walk without support or who have an unsafe gait Copyright © 2013 American Association of Critical-Care Nurses29

Return on Investment Organizational focus likely to yield positive improvements in: Patient satisfaction Clinical outcomes Clinical documentation relevance Staff morale Effectiveness of the care team Copyright © 2013 American Association of Critical-Care Nurses30

Real World Success Stories: Examples of Successful Alarm Management and Patient Safety Efforts Copyright © 2013 American Association of Critical-Care Nurses31

Johns Hopkins Hospital Experience  Demonstrated that the number of nonactionable alarms can be reduced: —Thereby decreasing caregivers’ alarm burden without compromising patient safety by making modest default parameter changes; —Standardizing care policies and equipment; and —Providing reliable secondary alarm notification.  The organization invested the time to understand the problem. —Studied and tested various solutions —Shared knowledge among various staff and departments  The project was a collaborative effort, involving contributions from nurses, physicians, clinical engineers, and IT personnel, as well as the cooperation of the hospital’s monitor vendor. Copyright © 2013 American Association of Critical-Care Nurses32

Massachusetts General Hospital Experience  The hospital approached the incident in a transparent manner and conducted a thorough system review that led to improvements in care delivery including: —Holding monthly drills in the ICUs, and timing how long it takes members of the health care team to respond to alarms —Arranging seminars and webinars on reducing false alarms, as well as identifying proactive ways to safeguard against alarm fatigue —Disabling the “off” switches on 1,100 cardiac monitors —Installing more speakers to ensure alarms are clearly heard —Sending low-battery warnings, as well as alarms for many potential life- threatening changes in a patient’s condition, directly to nurses’ cell phones and pagers Copyright © 2013 American Association of Critical-Care Nurses33

NorthShore University Health System Experience Four-hospital system reviewed the status of clinical alarms on medical- surgical telemetry units.  Multidisciplinary team consisted of staff nurses, clinical nurse managers, clinical coordinators, physicians, risk management, nurse educators, and biomedical engineering.  Two different monitoring companies were in the system; one unit from each monitoring company was chosen for pilot testing. —First pilot unit was a 24-bed progressive care unit. After intervention, alarms dropped from 27,000 per month to less than 12,000 (56% reduction). —Second pilot unit was a 40-bed unit with alarms exceeding 114,332 per month. After intervention, alarms dropped to approximately 15,000 (87% reduction). Copyright © 2013 American Association of Critical-Care Nurses34

Christiana Health System Experience Developed system-wide alarm policy and protocols:  Defined its alarm management strategy for alarmed medical equipment, including remote continuous ECG monitors, standard cardiac monitors, pulse oximeters, and infusion pumps Resulted in:  Improved patient safety and environment of care  Shared sense of responsibility and additional support for nurses  Improved patient throughput Key learnings:  An organizational approach to alarm standardization is important: —Clinical staff work on multiple units and of various shifts —Clinical staff must know what to expect from an alarm system —Prevention of over-monitoring on one unit versus under-monitoring on another Copyright © 2013 American Association of Critical-Care Nurses35

Toolbox of Alarm Management Resources  AACN Practice Alert (  The Joint Commission proposal: 2014 National Patient Safety Goal on Alarm Management  ECRI Institute (  Healthcare Technology Foundation (  U.S. Food and Drug Administration Medical Devices (  Advancing Safety in Medical Technology Healthcare Technology Safety Institute (  Industry partners —Physiologic monitoring system manufacturers —Ventilator manufacturers —Infusion pump manufacturers —Pulse oximetry device manufacturers —Bed manufacturers —Wired and wireless communication systems manufacturers Copyright © 2013 American Association of Critical-Care Nurses36

Bibliography ECRI Institute. Top 10 health technology hazards for Health Devices. 2012; 41(11):1-23. Available at: Top-10-Hazards.aspx. Accessed December 2, Top-10-Hazards.aspx Association for the Advancement of Medical Instrumentation Foundation/Healthcare Technology Safety Institute (AAMI Foundation/HTSI). Safety innovations: using data to drive alarm improvement efforts. The Johns Hopkins Hospital experience. Available at: Accessed January 9, AAMI Foundation/HTSI). Safety innovations: recommendations for alarm signal standardization and more innovation. The Christiana Care Health System experience. Available at: Accessed March 7, American Association for Respiratory Care (AARC). Consensus statement on the essentials of mechanical ventilators—1992. Respir Care 1992; 37(9): Copyright © 2013 American Association of Critical-Care Nurses37

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