Alarm Management: From Confusion, to Information,

to WisdomAugust 3, 2015

AAMI Foundation• Vision: To drive the safe adoption and use of

healthcare technology• Visit our website to learn more about our alarm

initiative – National Coalition for Alarm Management Safety:• Get involved and consider making a donation to this

important national effort!• http://www.aami.org/thefoundation/content.aspx?Item

Number=1494&navItemNumber=672• Contact Sarah Lombardi at slombardi@aami.org

Thank You to Our Industry PartnersThis Patient Safety Seminar is offered at no charge thanks to funding from our National Coalition for

Alarm Management Safety industry partners. The AAMI Foundation and its co-convening organizations appreciate their generosity. The AAMI Foundation is managing all costs for the series.

The seminar does not contain commercial content.

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LinkedIn Questions

Please post questions about alarms on the AAMI Foundation’s LinkedIn page:

http://www.linkedin.com/groups/Healthcare-Technology-Safety-Institute-HTSI-4284508

Speaker Introductions

• Kevin Smith, BSN, RN, CNML, CVRN-BCDirector, NCH Healthcare System

• Samantha Jacques ,PhD, FACHE, Director, Biomedical Engineering, Texas Children’s Hospital

Disclosures

• Texas Children’s Hospital has invested in Medical Informatics Corp.

Objectives

• Prepare to meet the regulatory requirements for alarm management and patient safety

• Understand Factors that influence Alarm Fatigue• Learn how to drive pertinent data to minimize

alarm fatigue and improve clinician awareness of patient specific alarm limits

NCH Healthcare SystemNon-for-profit, multi-facility healthcare system in Naples, Florida • 2 hospitals (716 beds)

• An alliance of 650 physicians and medical facilities throughout Collier County and Southwest Florida

• Extensive inpatient and outpatient services

• In 2014, the system had 36,386 admissions, 93,634 ED visits, 3,418 births, 453 open heart surgeries, 11,688 surgical procedures and over 3,900 on staff

About Our Health Systems – Texas Children’s Hospital

• Hospital System• Tertiary Care Hospital• Community Hospital• 4 Health Centers• 5 MFM/OBGyn clinics• 50+ primary care pediatric

practices

• 650 Licensed Beds• 173 NICU beds• 118 ICU (including CVICU)• 289 Acute Care/IMU/Rehab• 70 L&D/MBU

• FY 2014 Stats• 117,275 EC Visits• 32,446 Admissions• 189,057 Patient Days• 27,945 Surgeries

Hurdles in the Long Distance Race

4

Data is not easy to come by

Little Literature or Evidence Based Guidelines on Alarms

One Size Solutions does NOT fit all situations/ units/ institutions

Culture isn’t easy to change

Multi - Factorate Alarm Issues

Alarm Settings, Limits and

Delays

Artifacts

Clinical Population

Staff

Patients

• Prioritize Alarms• Review Settings and Limits• Evaluate Secondary notifications,

delays and escalations

• Review Electrode Choice, Prep, Placement and Replacement Schedule

• Evaluate standard alarms by patient population (Evidence Based)

• Set alarms individually by patient

• Educate Staff (Nurses and Physicians)• Enable/Empower to change limits

• Educate Families• Enable/Empower to speak up

We have a problem….It’s called alarm fatigue.

Alarm fatigue occurs when staff become desensitized to alarms, leading to missed true events and/or delayed response.

Alarm Fatigue

• Defined as 350 alarms/patient/day• But what is an alarm?

We Create a Chaotic Environment

Why Does It Have To Be Confusing? Confusion Leads To Chaos…Chaos Leads To Ignored Alarms… Ignored Alarms Have Resulted in Death..

A Little Clearer?

We need a way to decrease false alarms so that real alarms are not missed

Educate Early and Often

Alarm PolicyAlarm ControlPatient TailoredPatient EnvironmentAlarms to Monitor Plan of CareInterdisciplinary EffortGather Input From CaregiverData Data Data

As an industry we need to strive for easily obtainable and useful dataavailable to the caregiver

Current Alarm Hot Spots

Heat mapping showing the units near real time alarm hot spotswith drillable and easy to read data

THE SHIFT REPORTPrior to education and distributed reporting

9/25/2013 23

3 Weeks into the distributed unitshift report

What we see today!

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January February March April

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ount

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ASYSTOLE

BRADY

HEART_RATE_HIGH

HEART_RATE_LOW

NO_TELEM

NURSE_CALL

PAUSE

PVC_HI

TACHY

VFIB_VTAC

V_TACH

VT_HIGH

Look what can happen in just ONE month45 bed cardiac telemetry unit with the shift report distributed to the charge nurseon the unit 3 times daily as of 4/1/2015

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January February March April

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nt C

ount

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ACCELERATED_VENT

ASYSTOLE

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HEART_RATE_HIGH

HEART_RATE_LOW

NO_TELEM

NURSE_CALL

PAUSE

PVC_HI

TACHY

VFIB_VTAC

V_TACH

VT_HIGH

The impact proper alarm education can have in ONE month

32 bed medical telemetry unit that received unit education on telemetryand parameter customization to patient condition on 4/1/2015.

Unit was able to decrease alarm count by education of clinical staff.

What’s Next?

Just Imagine

TCH Alarm Management Journey

• High• Medium • Low

Priorities

• Limits by Age and Unit

Thresholds• Delays• Escalations

Secondary Notifications

Reduced Quantity of Alarms by 66%

Meet Nurse Nancy• Nancy is a Progressive Care (Step down unit) nurse with

15 years experience‐ She is assigned three patients for her 12 hour shift by the unit

charge nurse

• 8yo Cystic Fibrosis patient post lung transplant

• 2 year old on renal patient post pheresis

• 11 month old post heart surgery

‐ Monitors are set with following alarm parameters:

SPO2 HR RR

8 year old 93 – 100% 55 – 85 bpm 12 – 18 brpm

2 year old 93 – 100% 70 – 110 bpm 20 – 30 brpm

11 month old 93 – 100% 80 – 120 bpm 25 – 40 brpm

• In ONE shift Her patients have a total of 336 alarms –• On average she spends 14% of her shift in ALARM FLOOD – (more

than 10 alarms in 10 min)• This day she experienced 7 Floods – 2:25 hours of her shift

• Nancy cannot prioritize how to deliver care during a flood – high risk environment

• Secondary notification – Greater than 50% of her messages are “warning” or “crisis”

• She only has 70 min of alarm “silence”

Lessons Learned

•Alarms Happen for unusual reasons – need to understand environmental factors

•Limits set by Age and Unit should be data driven – physiological “normal” based on literature may not be appropriate for the UNIT population – e.g. Respiratory Floor/ Cardiovascular Floor

•Limits by Age and Unit allow better baseline for UNIT, but don’t necessarily match INDIVIDUAL PATIENT NEED

A New Way•Partnered with Medical Informatics Corp

•Real Time Analytics Dashboard Approach•Unit

•Nurse

•Patient

•Uses•Historical Information

•Track changes from PDSA cycles

•Nurse Assignments

•Leverage real time data to make clinical decisions on alarm settings on an INDIVUIDUAL PATIENT

Unit Dashboard

Unit Dashboard – Deep Dive

Unit Dashboard – Bed View

Unit Dashboard - Nurse Assignment

Patient Specific Dashboard

Patient Specific Dashboard – Deep Dive

Patient Specific Dashboard – Deep Dive

Workflow

Nurse Manager uses report to

Set Nurse Assignments

Nurse Manager then highlights

patients for Rounds Review

During Rounds, Clinical team Reviews High

Alarming Patients

Clinical Team makes decision

to keep or change alarm limits (orders

updated)

At Shift Change: Nurse Manager Runs

Unit Report

Improves Safety –reducing likelihood of alarm floods

Reduces Alarm VolumeImproves Patient Satisfaction

Thank you for attending!

Slides & Recording Available Here: http://www.aami.org/thefoundation/content.aspx?ItemNumber=1498&n

avItemNumber=671

Free Alarm ResourcesSafety Innovations Series

• White Papers• Patient Safety Seminar

RecordingsAlarms Management Patient Safety Seminars

• Webinar Recordings• Webinar Slides• Key Points Checklists

Mark Your Calendars!

Next Alarm Management Seminar: • Effects of Patient Load and other Monitoring System

Design Choices on Inpatient Monitoring Quality • August 10, 2015, 12:00 PM - 1:00 PM EDT• Presenters:

• Melanie Wright, SAMC• Noa Segall, Duke University

• To Register: https://attendee.gotowebinar.com/register/2933004807416161025#sthash.69TqUkRf.dpuf

Questions?Please visit the AAMI Foundation’s LinkedIn page to post a question: http://www.linkedin.com/groups/Healthcare-Technology-Safety-Institute-HTSI-4284508

Or you can email your question to: slombardi@aami.org.

Thank You to Our Industry Partners

Gold Platinum Silver

This Patient Safety Seminar is offered at no charge thanks to funding from our National Coalition for Alarm Management Safety industry partners. The AAMI Foundation and its co-convening

organizations appreciate their generosity. The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content.

Consider Making a Donation to the AAMI Foundation Today!

Click here to donate online: http://my.aami.org/store/donation.aspx

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