From the National Coalition for Alarm Management Safety. A JOURNEY TO REDUCE ALARM FATIGUE: Tips on What Not to Do

Transcription

1 September 18, pm to 1pm From the National Coalition for Alarm Management Safety A JOURNEY TO REDUCE ALARM FATIGUE: Tips on What Not to Do Peggy Bartholomew, MHSM, RN, PMP Project Manager Quality Project Management UT Southwestern Medical Center

2 AAMI Foundation NEW: Annual Meeting Hot Topics in Healthcare! San Diego, CA November 18 and 19, day conference Nursing CEs and Respiratory Therapist CEs...great presentations and great food! $50 dollars/day or $70 dollars for both days To Register:

3 A Special Thanks

4 Thank You to Our Industry Partners! DIAMOND 4

5 Thank You to Our Industry Partners! Platinum Gold 9/25/2013 5

6 LinkedIn Questions Please post questions on the AAMI Foundation s LinkedIn page. OR Type a question into the question box on the webinar dashboard.

7 Speaker Introduction Peggy Bartholomew, MHSM, RN, PMP Project Manager Quality Project Management UT Southwestern Medical Center

8 A JOURNEY TO REDUCE ALARM FATIGUE: Tips on What Not to Do

9 Conflict of Interest Disclosure I have no actual or potential conflict of interest in relation to this presentation.

10 Who is UT Southwestern? Zale Lipshy University Hospital William P. Clements University Hospital

11 Charting a Course Operational Barriers to Impacting Alarm Reduction

12 Navigating uncharted territory Know the Destination

13 How many people does it take to create a project team?

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15 Logistical Challenge Two hospitals In 1989, Zale Lipshy opened as the first University Hospital In 2000, St. Paul Hospital joined with Zale Lipshy Hospital

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18 Creation of a new policy

19 Move to a New Facility

20 Redirecting the Course Determining When to Ask for Help

21 Post Move Observations Diminished sense of urgency to reduce alarm fatigue Generalized policy and limited expectations on managing alarms Lack of empowerment to manage alarms Delay in embracing new technology Increased alarm load Alarm Fatigue

22 Redirecting the Course Barriers to Impacting Alarm Reduction

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24 High occurrence of non-actionable alarms Lack of awareness of default settings Gaps in our customization processes and practices Gap in understanding and use of our technology Identified policy gaps Providers Ancillary Staff Nurses

25 Hope on the Horizon One Approach to Reduce Non-Actionable Alarms

26 Top 10 Alarms

27 ECG Leads Off Alarm

28 High Arrhythmia Medium Arrhythmia High Parameter Medium Parameter Low/Technical

29 CVICU Piloted arrhythmia default setting changes MICU Piloted alarm parameter default setting changes NSICU Piloted manual customization of all alarm settings

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31 SBAR Communication Shared with providers and nursing Modified event reporting system to include clinical alarms Encouraged staff to submit event reports or notify Nursing manager to ensure patient safety

32 Arrival to Destination Achieving the Goal

33 Pre/Post Full Implementation Total Alarms (Pre/Post Full Implementation) MICU 118,576/ 56,422 CVICU 152,043/ 77,933 NSICU 68,526/ 43,462 SICU 54,433/ 45,843 ED 79,710/ 49,331 % Change in Total Alarms (Pre/Post Implementation) Total Alarms Per Bed/Per Day (Pre/Post Implementation) % Change in Total Alarms Per Bed/Per Day (Pre/Post Implementation) - 48% 173/79-46% - 51% 216/116-46% - 37% 120/74-38% - 16% 81/68-16% - 38% 71/44-38% Four weeks pre-intervention Jan 2017 Four weeks post-intervention dates variable

34 Monitoring Plan CVICU Arrhythmia default changes A X X High/Medium/Low Alarms per Bed per Day CVICU I Chart Full implementation Individual Value 4-Sep Sep-16 2-Oct Oct Oct Nov Nov Dec Dec-16 8-Jan Jan-17 5-Feb Feb-17 5-Mar Mar-17 2-Apr Apr Apr May May Jun Jun-17 Period

35 Monitoring Plan MICU Alarm parameter default changes High/Medium/Low Alarms per Bed per Day MSICU I Chart Full implementation Sep Sep Sep Sep-16 2-Oct-16 9-Oct Oct Oct Oct-16 6-Nov Nov Nov Nov-16 4-Dec Dec Dec Dec-16 1-Jan-17 8-Jan Jan Jan Jan-17 5-Feb Feb Feb Feb-17 5-Mar Mar Mar Mar-17 2-Apr-17 9-Apr Apr Apr Apr-17 7-May May May May-17 4-Jun Jun Jun-17 Individual Value Period

36 Manual customization of default changes Monitoring Plan NSICU High/Medium/Low Alarms per Bed per Day NSICU I Chart Full implementation Sep Sep Sep Sep-16 2-Oct-16 9-Oct Oct Oct Oct-16 6-Nov Nov Nov Nov-16 4-Dec Dec Dec Dec-16 1-Jan-17 8-Jan Jan Jan Jan-17 5-Feb Feb Feb Feb-17 5-Mar Mar Mar Mar-17 2-Apr-17 9-Apr Apr Apr Apr-17 7-May May May May-17 4-Jun Jun Jun-17 Individual Value Period

37 Monitoring Plan SICU Individual Value 18-Dec Dec-16 1-Jan-17 8-Jan Jan Jan Jan-17 5-Feb Feb Feb Feb-17 5-Mar Mar Mar Mar-17 2-Apr-17 9-Apr Apr Apr Apr-17 7-May May May May-17 4-Jun Jun Jun-17 High/Medium/Low Alarms per Bed per Day SICU Full I Chart implementation Period

38 Monitoring Plan ED Individual Value 29-Jan-17 5-Feb Feb Feb Feb-17 5-Mar Mar Mar Mar-17 2-Apr-17 9-Apr Apr Apr Apr-17 7-May May May May-17 4-Jun Jun Jun-17 High/Medium/Low Alarms per Bed per Day ED I Chart Full implementation Period

39 Just Do It Central Monitoring Unit 80 High/Medium/Low Alarms per Bed per Day CUH-Tele I Chart Individual Value 29-Jan-17 5-Feb Feb Feb Feb-17 5-Mar Mar Mar Mar-17 2-Apr-17 9-Apr Apr Apr Apr-17 7-May May May May-17 4-Jun Jun Jun-17 Period

40 Sustaining the Progress & Future Plans Transitioning to a future Alarm Safety Committee and Process Owner Determining the frequency of monitoring Developing Standard Operating Procedures Sharing the data Continuing the progress

41 Lessons Learned Determine a governance structure Organize, structure, and plan efforts early Find a process owner sooner rather than later Narrow the focus Understand the workflow and equipment Educate early and often Ask for help if needed; know your limitations

42 References Alarm & Noise Management Phase I: Current State Assessment; Healthcare Transformation Services, Lisa Pahl and Jillann Walker, February 25 th, Alarm Management - Phase II: Post Changes - Healthcare Transformation Services, Lisa Pahl and Jillann Walker, December 21, American Association of Critical-Care Nurses. AACN Practice Alert. Alarm management. Crit Care Nurse. 2013;33(5): Available at: Accessed July 20, ECRI Health Devices (2003). ECG Leads Off Shouldn t Be a Low Priority. ECRI Institute. The Alarm Safety Handbook. Strategies, Tools, and Guidance. ECRI Institute

43 Thank you!

44 Future/Ongoing Initiatives 9/25/

45 September 25, noon to 1pm EST Sonia Pinkney PEng, MHSc Manager, Electromedical Group, Medical Engineering, University Health Network Human Factors Engineer, HumanEra Adjunct Lecturer, IHPME, University of Toronto and Andrea Cassano-Piché, M.A.Sc., P.Eng Human Factors Engineering Consultant Human Factors North Inc., Canada Where s My Line? Learn how to reduce the safety risks associated with problems in IV line identification and with IV pump boluses with validated evidence-based recommendations 9/25/

46 Thank You to Our Industry Partners! DIAMOND 46

47 Thank You to Our Industry Partners! Platinum Gold 9/25/

48 Questions? Post a question on AAMI Foundation s LinkedIn Type your question in the Question box on your webinar dashboard Or you can your question to: mflack@aami.org.

49 Consider Making a Donation to the AAMI Foundation Today! Making Healthcare Technology Safer, Together Thank you for your support!