A Journey to Reduce Alarm Fatigue: Tips on What...
Transcript of A Journey to Reduce Alarm Fatigue: Tips on What...
September 18, 201712pm 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, PMPProject Manager
Quality Project ManagementUT Southwestern Medical Center
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Speaker Introduction
Peggy Bartholomew, MHSM, RN, PMP
Project ManagerQuality Project Management
UT Southwestern Medical Center
A JOURNEY TO REDUCE ALARM FATIGUE: Tips on What Not to Do
Conflict of Interest Disclosure
• I have no actual or potential conflict of interest in relation to this presentation.
Who is UT Southwestern?
Zale Lipshy University Hospital William P. Clements University Hospital
Charting a CourseOperational Barriers to Impacting Alarm Reduction
Know the Destination
• Navigating uncharted territory
How many people does it take to create a project team?
Logistical Challenge
• Two hospitals• In 1989, Zale Lipshy opened
as the first University Hospital
• In 2000, St. Paul Hospital joined with Zale Lipshy Hospital
Creation of a new policy
Move to a New Facility
Redirecting the CourseDetermining When to Ask for Help
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
Redirecting the CourseBarriers to Impacting Alarm Reduction
• 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
Nurses
Providers
Ancillary Staff
Hope on the HorizonOne Approach to Reduce Non-Actionable Alarms
Top 10 Alarms
ECG Leads Off Alarm
High Arrhythmia Medium Arrhythmia High Parameter Medium Parameter Low/Technical
CVICU• Piloted
arrhythmia default setting changes
MICU• Piloted alarm
parameter default setting changes
NSICU• Piloted
manual customization of all alarm settings
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
Arrival to DestinationAchieving the Goal
Pre/Post Full ImplementationTotal Alarms
(Pre/Post Full Implementation)
% Change in Total Alarms
(Pre/Post Implementation)
Total Alarms Per Bed/Per Day
(Pre/PostImplementation)
% Change in Total Alarms
Per Bed/Per Day(Pre/Post
Implementation)
MICU 118,576/56,422
- 48% 173/79 - 46%
CVICU 152,043/77,933
- 51% 216/116 - 46%
NSICU 68,526/43,462
- 37% 120/74 - 38%
SICU 54,433/45,843
- 16% 81/68 - 16%
ED 79,710/49,331
- 38% 71/44 - 38%
Four weeks pre-intervention – Jan 2017Four weeks post-intervention – dates variable
Monitoring Plan – CVICU
A X X
0.00
50.00
100.00
150.00
200.00
250.00
300.00
4-Se
p-16
18-S
ep-1
6
2-Oc
t-16
16-O
ct-16
30-O
ct-16
13-N
ov-1
6
27-N
ov-1
6
11-D
ec-1
6
25-D
ec-1
6
8-Ja
n-17
22-Ja
n-17
5-Fe
b-17
19-F
eb-1
7
5-Ma
r-17
19-M
ar-17
2-Ap
r-17
16-A
pr-1
7
30-A
pr-1
7
14-M
ay-1
7
28-M
ay-1
7
11-Ju
n-17
25-Ju
n-17
Indi
vidua
l V
alue
Period
High/Medium/Low Alarms per Bed per DayCVICUI Chart
Arrhythmiadefault changes
Full implementation
Monitoring Plan – MICU
0.00
50.00
100.00
150.00
200.00
250.00
300.00
4-Se
p-16
11-S
ep-1
618
-Sep
-16
25-S
ep-1
62-
Oct-1
69-
Oct-1
616
-Oct-
1623
-Oct-
1630
-Oct-
166-
Nov-1
613
-Nov
-16
20-N
ov-1
627
-Nov
-16
4-De
c-16
11-D
ec-1
618
-Dec
-16
25-D
ec-1
61-
Jan-
178-
Jan-
1715
-Jan-
1722
-Jan-
1729
-Jan-
175-
Feb-
1712
-Feb
-17
19-F
eb-1
726
-Feb
-17
5-Ma
r-17
12-M
ar-17
19-M
ar-17
26-M
ar-17
2-Ap
r-17
9-Ap
r-17
16-A
pr-1
723
-Apr
-17
30-A
pr-1
77-
May-1
714
-May
-17
21-M
ay-1
728
-May
-17
4-Ju
n-17
11-Ju
n-17
18-Ju
n-17
Indi
vidua
l V
alue
Period
High/Medium/Low Alarms per Bed per DayMSICUI Chart
Alarm parameterdefault changes
Full implementation
Monitoring Plan – NSICU
0.00
50.00
100.00
150.00
200.00
4-Se
p-16
11-S
ep-1
618
-Sep
-16
25-S
ep-1
62-
Oct-1
69-
Oct-1
616
-Oct-
1623
-Oct-
1630
-Oct-
166-
Nov-1
613
-Nov
-16
20-N
ov-1
627
-Nov
-16
4-De
c-16
11-D
ec-1
618
-Dec
-16
25-D
ec-1
61-
Jan-
178-
Jan-
1715
-Jan-
1722
-Jan-
1729
-Jan-
175-
Feb-
1712
-Feb
-17
19-F
eb-1
726
-Feb
-17
5-Ma
r-17
12-M
ar-17
19-M
ar-17
26-M
ar-17
2-Ap
r-17
9-Ap
r-17
16-A
pr-1
723
-Apr
-17
30-A
pr-1
77-
May-1
714
-May
-17
21-M
ay-1
728
-May
-17
4-Ju
n-17
11-Ju
n-17
18-Ju
n-17
Indi
vidua
l V
alue
Period
High/Medium/Low Alarms per Bed per DayNSICUI Chart
Full implementation
Manual customization of default changes
Monitoring Plan – SICU
-50
0
50
100
150
200
250
18-D
ec-1
6
25-D
ec-1
6
1-Ja
n-17
8-Ja
n-17
15-Ja
n-17
22-Ja
n-17
29-Ja
n-17
5-Fe
b-17
12-F
eb-1
7
19-F
eb-1
7
26-F
eb-1
7
5-Ma
r-17
12-M
ar-17
19-M
ar-17
26-M
ar-17
2-Ap
r-17
9-Ap
r-17
16-A
pr-1
7
23-A
pr-1
7
30-A
pr-1
7
7-Ma
y-17
14-M
ay-1
7
21-M
ay-1
7
28-M
ay-1
7
4-Ju
n-17
11-Ju
n-17
18-Ju
n-17
Indi
vidua
l V
alue
Period
High/Medium/Low Alarms per Bed per DaySICUI Chart
Full implementation
Monitoring Plan – ED
20
30
40
50
60
70
80
90
100
29-Ja
n-17
5-Fe
b-17
12-F
eb-1
7
19-F
eb-1
7
26-F
eb-1
7
5-Ma
r-17
12-M
ar-17
19-M
ar-17
26-M
ar-17
2-Ap
r-17
9-Ap
r-17
16-A
pr-1
7
23-A
pr-1
7
30-A
pr-1
7
7-Ma
y-17
14-M
ay-1
7
21-M
ay-1
7
28-M
ay-1
7
4-Ju
n-17
11-Ju
n-17
18-Ju
n-17
Indi
vidua
l V
alue
Period
High/Medium/Low Alarms per Bed per DayED
I ChartFull
implementation
Just Do It – Central Monitoring Unit
30
40
50
60
70
80
29-Ja
n-17
5-Fe
b-17
12-F
eb-1
7
19-F
eb-1
7
26-F
eb-1
7
5-Ma
r-17
12-M
ar-17
19-M
ar-17
26-M
ar-17
2-Ap
r-17
9-Ap
r-17
16-A
pr-1
7
23-A
pr-1
7
30-A
pr-1
7
7-Ma
y-17
14-M
ay-1
7
21-M
ay-1
7
28-M
ay-1
7
4-Ju
n-17
11-Ju
n-17
18-Ju
n-17
Indi
vidua
l V
alue
Period
High/Medium/Low Alarms per Bed per DayCUH-Tele
I Chart
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
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
References
• Alarm & Noise Management – Phase I: Current State Assessment; Healthcare Transformation Services, Lisa Pahl and Jillann Walker, February 25th, 2016.
• Alarm Management - Phase II: Post Changes - Healthcare Transformation Services, Lisa Pahl and Jillann Walker, December 21, 2016.
• American Association of Critical-Care Nurses. AACN Practice Alert. Alarm management. Crit Care Nurse. 2013;33(5): 83-86. Available at: http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf. Accessed July 20, 2015.
• 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. 2014.
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