Presentation on theme: "Alarm Fatigue and other EC/LS Hot Spots for Clinical Managers"— Presentation transcript:
1 Alarm Fatigue and other EC/LS Hot Spots for Clinical Managers October 2011Jennifer 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 OfficeAccreditation and regulatory compliance consultantVice President and Principal Patton Healthcare Consulting
3 Alarm Fatigue & Top Scored What, Me Worry? Alarm Fatigue – JC Online Aug 2011Issue highlighted at TJC Executive Briefings4 of the top 5 scored standards were in EC or LSIn LSC days increasedSurveyor Focus on industry trendsAlarms have led to Immediate Threat
4 2012 Decision Categories PDA Contingent Accreditation Accreditation with Follow-up Survey (AFS)AccreditedEx: Immed Threat to Life or falsification or fail to clear RFIs after two tries when in CONTEx: Failed AFS after 2 tries, or No License, etcEx: Too many RFI’sCoPs non compliant.Ex: Compliant or cleared all RFIs w/ ESCPerspectives 11/2010
5 Alarm Fatigue A Growing Problem FDA article reports 566 patient deaths between 2005 – 2008, related to alarmsThe numbers are self reported and are likely to be higherTwenty-five years ago, few, if any alarms on equipmentToday – increasing equipment and increase in type & # of alarms566 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 offPerinatal monitor did not audibly alarm fetal distress, only visual, went unnoticedA patient stopped breathing but staff just didn’t hear the monitorThe 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 FocusSentinel event alert in 2002 focus on clinical ventilator alarmsIntroduced NSPGMoved clinical alarms to standards ‘05Participating in fall summit by AAMI, ACCE, ECRIProblem continues to growThe 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 systemsBeyond the basics – bed alarms, chair alarms, IV, call button, hand sanitizer.Study of alarms in critical care units900 to 1300 alarms per day, per unit.Alarms every 66 secondsStudy 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 deathsTJC analyzed sentinel events for monitor related causes
11 Common Causes Staff are overwhelmed by the # of alarms Staff don’t respond or hear alarmsStaff turn-off or turn down alarmsAlarm settings not returned to original setting after a patient moveAlarm 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 alarmsNo routine replacement of batteries, leads to excessive “low battery” alarmsPut 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 noiseChildren’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 irritateSounds of alarms do not differentiate a ‘notification’ from a critical event.Sounds are difficult to learn, differentiate which alarmDifficulty learning > 6 alarm signals
14 Causes – Cont.Alarm noise contributes to sound level in unit, disrupts sleep and environment of healingUsers can turn alarms off, change parameters, reduce volume.Alarms are not tailored to the individual patientNurses block out noise to focus on taskMedication 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/dayReduce 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 maintenanceReduce low battery alerts by replacementDeactivate or limit overridesRoutine testing of alarmsSelection of equipmentVendors with meaningful alarm soundsImplement intelligent escalation of alertsInvolve staff in equipment selectionTest alarms, are they audible? Alarm when disconnected? Have appropriate parameters?
18 Improving Safety of Alarms Cont. Alarm Notification AlternativesConsider central surveillance room with monitor watchers than notify care giversConsider alarm integration systems that directs alarms to devices worn by staff
19 Improving Safety of Alarms Cont. Staff TrainingTrain staff on meaning of all alarm soundsTrain staff to check patient before silencing any alarmTrain staff on new equipmentTrain staff on proper alarm placement, skin preparation, ensure competenceIn 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 policiesWho can change alarm settingsWho needs to be monitoredWhat are default settingsWho is responsible for performing clinical alarm monitoring roundsDevelop audit tool to measure compliance with established policiesDevelop and complete check list at shift change for patient alarm settingsIn 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 fruitThese are seen by both the LSC surveyor and the clinical surveyorsPrevent 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 egressEasy to find issues, educate on:Blocked or locked egress doorsCorridor clutter, storage in hallwaysLinen carts and latex carts will be scoredExit 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 latchPenetrations 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 frameDoor positively latchesDoor had a closureNo gaps > 1/8 inch, or undercut >3/4 inchResulted in ITL if multiple problems
25 Fire Protection Equipment (EC.02.03.05 – 42%) Hospital inspects, tests & maintainsfire 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 devicesCheck 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 NFPAThey will review the tagIf bar coded, they will review documentationRequired monthlyCheck 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 & maintainsfire 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 devicesCheck 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 notedGas 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%) Sprinklers18 inch ruleSprinkler pipes can not support other items like cables or wiresSprinkler head clean and free of obstruction, collar flush
30 Medical Gas (EC.02.05.09 – 20%) No parking zone! Get vendor reports, fix problemsGas shut off valves must be labeled with rooms they shut off.Staff know who can shut these offAlarms must be working. Led to ITLTest & 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 chairIn 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 risksComplete risk assessments on areas of potential riskScored in sensitive areas such as Labor and Delivery, PediatricsTrace 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 Checkliststhem out, assign, implement, collect them back, analyze complianceInvolve/educate clinical & frontline staffEveryone knows who to call to get fixedIdentify areas to improve, fix it, then reassessMake LS an every day expectation!
34 Strategies for Success Do Mock Surveys Conduct mock tracers in clinical areasDo EOC System Tracer during your Mock surveyUse 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 projectsValidate that ILSM evaluations exist on paper for each PFI on the eSOCWork with facilities staff and learn the language
36 Strategies for Success Make use of the PPR to document complianceRecord the name and location of each report that documents complianceHelps 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 sessionEnvironment of Care system tracerDocument Review session *Emergency Management system tracerLSC 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.xxCorrect it immediatelyFix in 45 days in corrective maintenance – document it.If it takes >45 days, create a Plan for Improvement (PFI) in your e-SOCConsider equivalency request to TJCwaiting 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 COMMISSIONValidate ID on the extranetInstitute your calling treeEveryone 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