Clinical alarms are supposed to alert clinical staff that intervention with a patient is required, or to remind them that care needs to be delivered.
Unfortunately, the overwhelming majority of alarms nurses, respiratory therapists and other caregivers respond to have nothing to do with a patient's medical condition.
Respiratory therapists (RT) and registered nurses (RN) are forced to respond to hundreds of daily alarms-the majority of which end up as non-actionable, requiring no intervention-leading to alarm fatigue and disrupting them from their primary job: engaging with patients.
The problem of alarm proliferation-and the lack of hospital-wide policies and procedures to manage it-achieved prominence with the release of the Joint Commission's National Patient Safety Goal (NPSG) on clinical alarm safety.
The NPSG mandates that hospitals must identify and prioritize alarms based on internal considerations by Jan. 1, 2016. In Phase II, which also begins in January, "hospitals will be expected to develop and implement specific components of policies and procedures. Education of those in the organization about alarm system management will also be required."
The critical nature of ventilators as life-support devices and the volume of alarms they produced were major drivers in the decision for the Connecticut-based Hospital for Special Care (HSC), to implement a solution that would dramatically reduce non-actionable alarms.
In addition to alarm reduction, HSC's goals also included collecting and distributing real-time data from more than 100 ventilators (each with its own set of alarms), as well as pulse oximeters, for enhanced, continuous patient surveillance, and analyzing objective, comprehensive clinical data after any patient incident to assess response processes and preventative measures.
Defining the Challenge
With locations in New Britain and Hartford, Conn., HSC is the only long-term acute-care (LTAC) hospital of its kind in New England serving adults and children, and one of only a handful in the country. HSC is nationally recognized for advanced care and rehabilitation in pulmonary care, acquired brain and spinal cord injury, medically-complex adults & pediatrics, neuromuscular disorders, cardiac disease.
The respiratory therapy department at HSC manages more than 100 ventilators-each with its own set of alarms-at patients' bedsides across the hospital, including:
The Pediatric Unit, a 30-bed, four-team unit that offers rehabilitation therapies, as well as learning programs that focus on building patients' physical, cognitive and social abilities.
The Respiratory Care and Respiratory Step-Down Units, 36- and 38-bed units, respectively, for patients requiring intensive nursing and respiratory care, including intravenous medication and non-invasive respiratory monitoring.
The Close Observation Unit, a 12-bed, interdisciplinary team-based unit that focuses on weaning adult patients from mechanical ventilation.
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For many years, the number of ventilators and the complicated layout of the units forced HSC's respiratory therapists to spend much of their shift racing from room to room responding to hundreds of non-actionable alarms.
As a long-term care and rehabilitation facility, many patients at HSC are active, which is typically good for their recovery process; however, the number of false alarms blaring daily was distracting to clinical staff and disruptive to patients. In most cases, alarms were going off because a patient coughed or was talking-events that didn't require staff intervention.
The respiratory therapists have a lot of patient care responsibilities in addition to responding to ventilator alarms, and there was concern that alarm fatigue could become a serious problem due to the number of nuisance alarms.
Addressing clinical alarm hazards in all their forms requires a holistic approach, free of the well-known departmental and data silos that hinder patient care and optimal clinical workflows. Alarm management is constantly changing, and needs to evolve with the needs of the hospital's patients, as well as its clinical staff. Technology played a critical role in alarm reduction and prioritization at HSC.
HSC's platform achieved real-time surveillance of 100+ patients on ventilation support and reduced the number of ventilator alarms by an estimated 80%, helping achieve compliance with both Phase I and II of the Joint Commission's National Patient Safety Goal on clinical alarm management, as well as the four associated Elements of Performance (EPs).
Here are some of the results of HSC's clinical alarm management initiative:
Vent Check Automation. HSC's platform removed the manual processes associated with vent checks. The platform captures all the measured parameters (peak airway pressures, volumes, etc.) and settings, eliminating the risk of transcription errors. The automated process also means that respiratory therapists spend less time performing menial documentation tasks and spending more time assessing, treating and engaging with patients.
Continuous Surveillance and alarm monitoring. HSC's team of RTs can provide continuous monitoring of vital patient information and intervene before a situation becomes critical, enhancing patient safety. The system was first implemented in the Pediatric Unit. Of the care units with ventilated patients at HSC, the Pediatric Unit has the most complex layout, making it difficult for clinical staff to move quickly from patient to patient. The unit utilizes three different types of ventilators from different manufacturers, so a vendor-neutral approach was critical.
Networked laptop and desktop computers as well as scrolling message bars were deployed at key locations throughout the Pediatric Unit, providing respiratory therapists with access to data and alarms from all ventilated patients. In addition, ventilator alarms were routed through pagers to the specific respiratory therapists assigned to each patient.
Quality and Reporting Data. Prior to implementing the platform, HSC was dependent on individual recollections from the clinical responders after an alarm incident. Today, HSC has a clearer picture of every event. The data collected from devices is used by Respiratory Care Services in reporting to the Performance Management Audit Committee, which monitors ventilator management performance, and also helps identify potential areas of need. The system also automates processes that were previously done manually, such as manual ventilator checks, which frees up the RT to focus more on the patient rather than the ventilator.
Improved Patient Care. With real-time access to patient data and alarms, the respiratory therapy team at HSC was able to see the condition of any patient in the unit and respond appropriately. Data from its alarm management platform enabled them to start identifying non-actionable alarms that could be adjusted or eliminated entirely. HSC estimates that they have successfully reduced ventilator alarms by 80 percent.
Alarm management has made a big difference in the efficiency and effectiveness of HSC's staff, and reduced stress for patients and their families.
Technology will play a critical role in getting alarms under control-but it is not enough. Technology alone without input from the workforce can actually lead to lack of adaption. Clinical and IT leadership, including nurses, respiratory therapists, biomedical engineers and information technology staff, must come together to develop the policies and standards necessary to prioritize and reduce the number of alarms and setting protocols for altering current or default alarm parameters.
Jeanne Venella, DNP, is Chief Nursing Officer for Bernoulli, in Milford, CT.
Connie Dills, MBA, RRT, RPFT, is Respiratory Practice Manager for the Hospital for Special Care in New Britain and Hartford, Conn.