Best Practices for Alarm Management:

Kaiser Permanente, Children’s National Medical Center,

and The Johns Hopkins HospitalMarch 5, 2014

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Co-Conveners

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Thank You to Our SponsorsThis webinar series is offered at no charge thanks to commercial grants from the companies shown here. HTSI and its co-convening organizations appreciate their generosity. AAMI and HTSI are managing all costs for the series. None of the co-convening organizations participated in seeking, discussing, or otherwise facilitating the commercial grants. The companies had no role in content development, and the webinars do not contain commercial content. Webinar presenters were selected based on topic expertise without regard to industry affiliation by a multi-disciplinary HTSI volunteer planning committee.

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LinkedIn - Questions

Please post questions about alarms on HTSI’s LinkedIn page:

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

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Speaker Introductions

• D. Hunter Burgoon, RN, PHN, Director of Biomedical Technology Integration, Kaiser Permanente

• Jeff Hooper, MS, Director, Biomedical Engineering, Children’s National Medical Center

• Heather Walsh, RN, MSN, PCNS-BC, Simulation Outreach Coordinator, Children’s National Medical Center

• Maria Cvach, DNP, RN, CCRN, Assistant Director of Nursing, Clinical Standards, The Johns Hopkins Hospital

• Marjorie Funk, PhD, RN, FAHA, FAAN, Professor, Yale University School of Nursing (Moderator)

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Kaiser Permanente Alarm Fatigue Project

D. Hunter Burgoon, RN, PHNDirector of Biomedical Technology

IntegrationDaniel.Burgoon@kp.org

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Kaiser Permanente at a GlanceKaiser Foundation Health Plan, Inc.

The Permanente Medical Groups

Kaiser Foundation Hospitals

|

Recognized as one of America’s leading health care providers and not-for-profit health plans

9.1 million members

38 hospitals> 600 medical offices

8 states and the District of Columbia

16,942 physicians174,259 employees

> $50 billion annual operating revenue

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Kaiser Permanente Alarm Fatigue Project Discussion Points

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Awareness and Motivation

Building Consensus

Approval Process

Pilot Project Implementation

Resources and Tools

Results

Next Steps

Alarm Fatigue: A Call for Action

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2010 Boston Globe article in April cited alarm fatigue in patient deaths

2011 AAMI Alarms Summit in October

2011 ECRI moves alarm hazards to #1 risk in November

2012 Kaiser Permanente Alarm Fatigue work group created in June

2012 Kaiser Permanente Alarms Summit held in November

2013 Kaiser Permanente launches first pilot sites on first track in March

2013 TJC SEA 50 released on Alarm Fatigue in April

2013 Kaiser Permanente first pilot site completes implementation in October

2014 TJC NPSG 2014 and 2016 on Alarm Fatigue in effect in January

2014 Kaiser Permanente launches four beta sites

Awareness and Motivation

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Building Consensus

Pilot Project Implementation

New Adult Telemetry Standard• Actionability

Alarm Customization• Clinical Validity• Actionability

Alarm Hygiene• Validity

Pager Repeats• Validity• Actionability

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Pilot Project Implementation

Pager Repeat Reduction

Alarm Hygiene

Alarm Customization

New Telemetry Standard

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Approval Process

Alarm Fatigue Work Group

Alarm Management Work Group

Regional Critical Care Peer Groups

Regional Physician

ChairsCardiology

Critical CarePulmonology

HospitalistED

Chief Nursing Officers

Executive Sponsor

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Approvers

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Results Dispatches Reduced by 50%

ResultsAlerts Reduced by 25%

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Resources and ToolsPilot Site Experience Sharing

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Resources and ToolsHandbook for Implementation

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Resources and ToolsQuick Reference Pocket Guide

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Resources and ToolsCentral Library Page Resource

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Next Steps

December• Alarm Fatigue

Handbook Draft Completed

• 2014 Beta Sites Identified and Preparation Started

• First beta launched other to follow in January

• Alarm Fatigue Library Page Work Started

January• Look for an appropriate

date for a second Alarm Summit

• Launch remaining 3 beta sites

• Refine Alarm Fatigue Handbook based on beta input

• Examine Roseville results – see if more changes could be implemented

• Library Page Launched

February• Assess beta site results

and learnings• Request approval for

New Telemetry Standard

• Socialized Beta results and develop a spread plan

March• Begin the Spread

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Recap

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Awareness and Motivation

Building Consensus

Approval Process

Pilot Project Implementation

Resources and Tools

Results

Next Steps

Children’s National Medical Center: Changing Culture to

Improve Clinical Alarms Management

Jeff Hooper, MSDirector, Biomedical Engineering

Heather Walsh, RN, MSN, PCNS-BCSimulation Outreach Coordinator

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Children’s National Health System

• 303-bed freestanding children’s hospital in Washington, DC

• Physiologic monitors at all inpatient bedsides• Monitor attendants notify RNs of alarms in acute

care units

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Objectives

Following this webinar, participants will be able to:• Identify methods for data collection• Discuss pediatric acute care considerations• Describe strategies to address monitor alarms• Disseminate efforts within institution to change

culture

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Monitor Oversight Committee

• Conducted staff survey about perceptions & concerns

• Lowered volume at central stations 3 levels• Lowered alarm volumes of the monitors in

patient rooms 3 levels • Created 6 profiles based on age with new HR

and RR ranges• Reduced desat alarm from 90 to 88• Added alarm fatigue training to RN orientation

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Clinical Alarms Committee

• Monitor Oversight Committee commissioned in June 2012 Clinical Alarms

• Included respiratory therapists, pharmacist and nurse (smart infusion pumps), nursing director, accreditation manager, & patient safety

• Reviewed & recommended alarm notification for new technology

• Executive Leadership – Executive Medical Director to oversee committee (Cardiologist)

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Low-Hanging Fruit

• Staff assist: standardized through acute care units & significantly decreased false alarms

• Reviewing code blue alarms to physician phones

• Standardized code blue testing

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Automated Notifications

• Current Practice• Nurse call, physiologic monitors

and ventilator alarms alert to Wi-Fi phone

• New Practice• Updating Wi-Fi device to iPhone and including other

EMR-related alerting• Benefit:

• Opportunity to validate which alerts are important for secondary notification

• Used Alarm Committee as the filter for this review process

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What Next?

• Alarm Committee not clear on next issue to tackle?

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Assumptions: Monitor Practices

• “Every patient is on a monitor.”• “Desat alarms create the majority of alarms.”• Patients are not taken off monitor when don’t

need any longer• “Are patients really alarming all the time?”

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Slow Down – Collect Data

0%

10%

20%

30%

40%

50%

60%

70%

80%

4 Main HOCU SCU NSU IRU 7 East

% on Monitor

% Pulse Ox Only

% Lead Issues

% Parameter Issues

Reviewed Alarm history for 50 random patients from 6 acute care units on 4 separate occasions looking at past 12 hours.

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Primary Observations

• Primarily Issues in Acute Care areas• Most alarms are NOT pulse ox• “Tight Alarm Limits” • Electrode placement is an issue• Most patients monitored for all parameters• Less than 50% of acute care patients on

monitors

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Narrow limits (HR & RR) were biggest offender

• Patient in acute care (surgical unit)

• 50 alarms in 2 hours!• Changing RR limit to 10

would have eliminated majority of alarms

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Significant Alarms

• Apnea between low RR alarms

• Clinically significant?• Clear guidelines for

notification/patient assessment

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Limits changed vs. addressing reason for alarm?

• Significant parameter adjustment

• Patient continues to alarm

• Reason for tachycardia? Fever?

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Electrode Issues

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• Very poor electrode connection

• Baseline drift – one electrode is not attached well

• Interference or bad connection?

• Incorrect lead assignment Lead III?

Patient Experience

• “The nurses did not always respond quick enough to the monitors beeping as my child would’ve liked—the noise was very irritating to him, but I learned how to silence them.”

• “Monitors need to not beep inside the room right by my child’s head—he needs to rest. Need to add feature to turn this off, and have nurses alerted outside the room.”

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Patient Experience

• “The monitor was beeping (danger) a lot, especially during the night. I finally asked for help—it was needing to be adjusted for smaller respirations & lower settings (my son had surgery). The tech who came in was fantastic—he reset the settings. It would have been easier for me if this was done without my having to say, ‘Why is this happening?’ I was worried.”

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Next Steps

• Recommendations for trends (3 alarms for same parameter) notify RN

• Change limits as appropriate• Discuss on rounds• Daily electrode changes with skin prep• Staff education (RN, MD, PCT)• Implement new technology

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The Johns Hopkins Hospital: An Alarming Situation:

Managing Clinical Alarms Using a Systems Approach

Maria Cvach, DNP, RN, CCRNAssistant Director of Nursing, Clinical Standards

The Johns Hopkins Hospital

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Problem: Missed Alarm2005-2006 Alarm Related Death by Device

FDA MAUDE DATABASE

Kathy Weil, MS, BSN, RNNurse Consultant

CDRH/FDA

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Monitor Alarm Assessment12-Day Sample of Alarm Data QuantityHigh Priority 1587Medium Priority 6673Low Priority 48277Technical Alarms 2227Grand Total of Alarms 58764Ave Pt Census 14Average Alarms/Bed/Day 350

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Ventilator Alarm Assessment

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7-Day Sample

NICU (14 beds)

PICU (25 beds)

Total ventilator alarms

3390 4156

Alarms/unit/day 242 166

An Alarming Situation

Alarms not set to actionable

limitsToo many alarming devices:

duplicate alarms

Low specificity results in

frequent false alarms

Alarm desensitization

Unclear alarm

responsibility

Large units with inability to hear

alarms

No back-up/ escalation plans

Competing priorities

© adapted from ECRI Institute 2013

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What Should All Hospitals Do?

Improving Alarm Management Requires a Systems Approach

© ECRI Institute 2013

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A Systems Approach• Assemble a multidisciplinary team

• Review recent events and near misses

• Review alarm data

• Ask staff about their concerns

© adapted from ECRI Institute 2013

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Text 2 Tex3

Who should be on the team?Interdisciplinary Alarm Committee

Support from Hospital Administration

Nursing Biomedical and IT

HospitalVendors

Human Factors

RT

Risk Management

Physicians Patient Rep

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A Systems Approach (cont’d)

• Review unit alarm coverage

• Identify patient safety vulnerabilities and potential failures

• Determine underlying causes of potential failures

© adapted from ECRI Institute 2013

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Missed Alarm: Results of Fault Tree Analysis

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Central Monitor Station

• Unit floor plan• Unit workflow• Unit staffing• Redundancy

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JHH Measures to Reduce Quantities of Alarms

• Minimize recurring alarms; standardize alarms across similar units/settings (e.g., pediatrics, telemetry, ICU)

• Enable actionable alarms• Reprioritize auditory and visual alarms

• Auditory: Higher priority• Visual: Low priority

• Adjust parameter limits appropriately for patient population

• Ensure alarm audibility and accountability3/5/2014 53

Maria Cvach DNP, RN, CCRN

Types of Cardiac Monitor Alarms

PatientExamples:

Arrhythmias, HR, BP, pulse ox

TechnicalExamples:

Lead fail, Low battery

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Detailed Alarm Data By Unit

6067

3257

1754

971 917716

521 485 439247 195 93 79 75 56 11 8 7 7

0

1000

2000

3000

4000

5000

6000

7000

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Sample JHH Monitor Alarm Inventory Default Parameter Grid

Parameters

Departments

PULSE OX %

HEART RATE BPM

BP SYSTOLIC

mmHg

BP DIASTOLIC

mmHg

BP MEANmmHg

Low High Low High Low High Low High Low HighMedical ICU 89 105 50 140 90 180 40 110 60 120Surgical ICU 89 105 50 120 90 180 40 110 55 120

Coronary Care 89 105 50 120 90 180 40 110 55 120

Cardiac Surgical ICU 89 105 50 120 80 150 40 110 55 120

Neurologic ICU 90 105 50 120 90 180 40 110 55 120

Weinberg ICU 89 105 50 120 90 180 40 110 55 120

Oncology Department

88 105 50 130 90 180 40 110 55 120

Surgical Progressive Step-down Care unit

89 105 50 140 90 180 40 110 60 120

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Sample JHH Alarm InventoryClinical Equipment Alarm

InventoryRisk to Patient and Response

Level of OversightTypically Available

Secondary AlarmNotification

High priority cardiac monitor alarms

A Varies by unit Varies by unit; includes beside split screens, auto-view on alarm, hallway waveform screens, acknowledgement pagers/phones, unit-based monitor watch

Medium/technical cardiac monitor alarms

B Varies by unit

Low priority cardiac monitor alarms

C Varies by unit

Ventilator A Varies by unit Nurse call auxiliary outlet

ECMO A High Direct supervision

Bed/chair exit alarm A/B Low Nurse call auxiliary outlet

Sequential compression device

C Low None identified

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JHH Alarm Management QI Strategies That Resulted in

Significant Reduction in Alarms Alarm Reduction

Strategy Potential BenefitSustainability

Challenges

Parameter limits and alarm level changes

25%- 74% reduction in frequency of alarms (varied by unit)

Agreement of group on what is an actionable alarm

Daily electrode change46% reduction in frequency of alarms in MPCU and CCU

Behavior may diminish over time; patient discomfort; cost

Alarm escalation notification (each nurse carries acknowledgment pager)

53% reduction in frequency of alarms on a surgical IMC; 23% reduction in time to respond to alarm

Cost of acknowledgement pagers; Using two different devices to communicate alarms

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Maria Cvach DNP, RN, CCRN

Impact of Alarm Management Strategies

UNIT Pre-interventionsAverage Alarms/

Monitored Bed/Day

Post-interventionsAverage Alarms/

Monitored Bed/Day

% Reduction in Cardiac

Monitor AlarmsMICU 215 68 68%

CCU 515 194 62%

WICU 771 203 74%

IMC 240 50 79%

Telemetry 90 57 37%

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What Should Hospitals Do to Improve Alarm Management?

1. Engage support from leadership and a multidisclipinaryAlarm Management Committee

2. Analyze and measure the problem

3. Use data to drive change

4. Prepare an alarm inventory-risk analysis

5. Use a rapid-cycle, QI change approach

6. Identify the best methods to notify staff of alarm signals

7. Develop an alarm policy

8. Provide initial and ongoing education

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Closing Reminders

Thank you for your time and attention!

Mark Your Calendars!Current Challenges With Ventilator Alarms

Tuesday, March 25, 20141:00-2:00 pm Eastern

www.aami.org/htsi/events.html

623/5/2014

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