According to The Joint Commission, patient monitoring devices at typical hospitals will transmit tens of thousands of signals each day. Yet in a 2015 study at one medical/surgical hospital, only 10% of these alarms led to required clinical interventions.
When so many safety alert notifications have no clinical value, clinicians often turn off or ignore alarms, lower the volume or adjust the settings – actions that can have serious or fatal consequences.
• A national online survey found that 77% of healthcare professionals believed the high frequency of alarms can reduce trust and cause caregivers to disable alarms.
• The Joint Commission’s sentinel event database cited medical alarm fatigue as a major contributing factor in 80 deaths between January 2009 and June 2012.
• Missed ventilator alarms ranked third on ECRI’s 2017 list of top technology hazards.
How can hospitals reduce the harm associated with clinical alarm systems, one of The Joint Commission’s 2017 Hospital Patient Safety Goals? How can they minimize alarm fatigue while providing clinicians with more clinically relevant information? What strategies, resources and practices do they need to effectively implement and manage alarms and alert notifications?
These and other issues were recently addressed at the annual Voalte User Experience conference (VUE17) in a discussion moderated by Kourtney Govro, the founder and CEO of Sphere3. The panelists were: Nikki Harvey, DNP Student, MSN, RN, a cardiovascular clinical nurse specialist at the University of Kansas Health System; Heike Schleif-Bucken, RNC-NCC, CLC, a clinical coordinator educational resource nurse at Sarasota Memorial Health Care System; and Rikki Jennings, BSN, RN, CPN, a nursing informatics specialist at Connexall.
Following is a recap of the insights and experiences they shared, which hopefully can help other hospitals adopt more effective alarm management and alert notification practices that will minimize alarm fatigue and improve patient care and safety.
1. Make Sure You Understand Caregivers’ Workflow and Information Needs
Solicit input from all operational stakeholders and informatics personnel during the planning stages to ensure that your strategies and new alarm technologies are aligned with daily practices. Technologists make assumptions about how things are supposed to work, but only clinicians can tell you how things actually DO work.
2. Focus on Providing “Clinically Significant” Data
As one panelist said, “Information that’s not clinically relevant shouldn’t be going to caregivers’ smartphones.” The role of the technologist is to develop process management methodologies based on clinicians’ real-world needs to ensure that the right information is sent to right person at the right time.
3. Empower Caregivers to Determine Clinical Relevance
At the University of Kansas Health System, for example, nurses can adjust the parameters of telemetry alarms coming to their mobile devices at a central monitor. Although the nurses have guidelines, they do not require physician orders before they can customize alarms to make them more actionable.
4. Minimize TMI and Unnecessary Disruptions by Continually Refining Alarm Settings
When implementing a new alarm strategy, nurses will want more information to reduce risks, which leads to “over-picking” alarms and higher volumes. After implementing its alarm management system, the NICU at Sarasota Memorial addressed this issue by:
• Increasing high heart alarms
• Decreasing alarms for disconnection
• Adding profiles in the cardiac monitoring system based on babies’ sizes and diseases
• Adjusting saturation parameters
As a result of these refinements, the NICU reduced its alarms per nurse per shift by 33%.
5. Involve Informaticists and Educators to Facilitate Technology Adoption
All the panelists emphasized the importance of pre-assessment before implementing a new system. Rikki Jennings also noted that informaticists and educators need to involve clinicians early in the process to understand how workflows intersect with and affect the use of technology. Educating clinicians on what the technologies can do and how they will be used helps earn their trust that these changes will lead to better patient care and outcomes.
6. Leverage Alarm Data to Identify Workflow Issues
Evaluating this information from a workflow perspective can help hospitals identify problems and inefficiencies relating to lead changes, staffing and bedside care. Sarasota Memorial uses its alarm system data to determine that a bradycardia alarm of at least 10 seconds would count as an incident in its new apnea and Brady protocol.
7. Educate Patients, Too
It’s important to let patients know their nurses aren’t just checking their smartphones for the latest updates on Facebook. Patient communications were prominent in University of Kansas Health System’s rollout of its alarm system and included flyers in the rooms, information in welcoming packets and providing the staff with talking points. At Sarasota Memorial, teams communicate by text on Voalte smartphones when babies are taken out of the NICU, which enables caregivers to keep families informed and helps the hospital achieve high HCAHPS scores.
8. Include Alarms and Alert Notifications as Part of Staff Onboarding
The NICU at Sarasota Memorial considers alarm management as important as charting for all new hires. Heike Schleif-Bucken meets with nurses one-on-one to explain the objectives, how alarms are escalated, the use of silence functions and tips such as changing leads every day – an easy way to cut nuisance alarms by as much as 60%. Annual competency reviews for every nurse include alarm management, and bedside nurses receive extensive training for new upgrades.
9. Measure Impact on Alarm Fatigue and Quality of Care
Some of the metrics used by the panelists included the number of alarms per nurse per shift, the percentage of alarms that were escalated and the percentage that were actionable. They also recommended measuring the impact on adverse events and HCAHPS. For example, Valley Medical Center in suburban Seattle recently reported its metrics to assess the impact of its new smartphone system on its Renal Respiratory Unit, which included hospital-acquired pressure ulcers and skin integrity events; fall and slip events; and medication errors.
10. Numbers Speak Volumes: Putting Information in Front of People Drives Change
University of Kansas Health is in the process of creating alarm dashboards with the knowledge that putting this information in front of people will drive change. Nikki Harvey said that when the staff viewed the data from a previous small test of change in ICUs, the “numbers spoke volumes.”
The panelists agreed that clinicians and nurses want to make changes that will benefit the patient. Implementing these and other best practices in alarm management will provide them with more clinically relevant alert notifications on their smartphones. Such efforts will not only help safeguard patients and improve outcomes but also significantly decrease the alarm burden on clinicians while increasing both nurse and patient satisfaction.
Eric Brill is a pioneer in healthcare alarm and event management systems and the General Manager of Clinical Solutions at Voalte.