Alarm Management: From Confusion, to Information, to Wisdom August 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 Partners 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. Platinum Gold Silver
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-BC Director, 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 System Non-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 Prioritize Alarms Review Settings and Limits Evaluate Secondary notifications, delays and escalations Review Electrode Choice, Prep, Placement and Replacement Schedule Clinical Population Evaluate standard alarms by patient population (Evidence Based) Set alarms individually by patient Patients Staff Educate Staff (Nurses and Physicians) Enable/Empower to change limits Educate Families Enable/Empower to speak up
It s called alarm fatigue. We have a problem. 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 Policy Alarm Control Patient Tailored Patient Environment Alarms to Monitor Plan of Care Interdisciplinary Effort Gather Input From Caregiver Data Data Data
As an industry we need to strive for easily obtainable and useful data available to the caregiver
Heat mapping showing the units near real time alarm hot spots with drillable and easy to read data Current Alarm Hot Spots
THE SHIFT REPORT Prior to education and distributed reporting
3 Weeks into the distributed unit shift report 9/25/2013 23
What we see today!
Look what can happen in just ONE month 45 bed cardiac telemetry unit with the shift report distributed to the charge nurse on the unit 3 times daily as of 4/1/2015 100000 Event Count 90000 80000 70000 60000 50000 40000 30000 20000 10000 0 January February March April Month ACCELERATED_VENT ASYSTOLE BRADY 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 telemetry and parameter customization to patient condition on 4/1/2015. Unit was able to decrease alarm count by education of clinical staff. 45000 Event Count 40000 35000 30000 25000 20000 15000 10000 5000 0 January February March April Month ACCELERATED_VENT ASYSTOLE BRADY HEART_RATE_HIGH HEART_RATE_LOW NO_TELEM NURSE_CALL PAUSE PVC_HI TACHY VFIB_VTAC V_TACH VT_HIGH
What s Next? Just Imagine
TCH Alarm Management Journey High Medium Low Priorities Thresholds Limits by Age and Unit Delays Escalations Reduced Quantity of Alarms by 66% Secondary Notifications
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 8year 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 40brpm
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 At Shift Change: Nurse Manager Runs Unit Report Nurse Manager uses report to Set Nurse Assignments Improves Safety reducing likelihood of alarm floods Reduces Alarm Volume Improves Patient Satisfaction Clinical Team makes decision to keep or change alarm limits (orders updated) During Rounds, Clinical team Reviews High Alarming Patients Nurse Manager then highlights patients for Rounds Review
Thank you for attending! Slides & Recording Available Here: http://www.aami.org/thefoundation/content.aspx?itemnumber=1498&n avitemnumber=671
Free Alarm Resources Safety Innovations Series White Papers Patient Safety Seminar Recordings Alarms 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/2933004807416 161025#sthash.69TqUkRf.dpuf
Questions? Please visit the AAMI Foundation s LinkedIn page to post a question: http://www.linkedin.com/groups/health care-technology-safety-institute- HTSI-4284508 Or you can email your question to: slombardi@aami.org.
Thank You to Our Industry Partners 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. Platinum Gold Silver
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