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Patient Safety Tip of the Week
September 17,
2024
Reducing Alarms
on a Pediatric Unit
Alarm fatigue has been one of our most frequent topics (see
full list of prior columns below). Alarm frequency has been reported to be as
high as 350 alarms per bed per day in some ICUs and in some NICUs as high as
one alarm every 60 seconds.
Texas Childrens Hospital was able
to achieve a sustained reduction in alarms on a pediatric progressive care unit
(Mullen 2024). That unit
was experiencing 180-250 alarms per day or 1 alarm every 3 to 4 minutes per
clinician. Over the course of 10 years and multiple PDSA cycles, the average
number of alarms/day/bed decreased from 177.69 to 96.94, a 45.45% reduction. The
percentage of time in alarm decreased from 7.52% to 2.83%, a 62.37% reduction. So,
how did they do it?
That PCU was part of the critical care department and
included patients who were tracheostomy and ventilator-dependent, and other
critically ill patients requiring continuous monitoring. Many nurses on that
unit were experiencing alarm flooding. Thats where there are more alarms in a period
of time than a person is physically able to respond to or more than 10 alarms
in 10 minutes. That unit, in fact, experienced on average 87 floods per day!
Like the situation in most hospitals, many of those alarms were false alarms or
nuisance alarms or alarms that required no physical response.
They began by forming an alarm management steering committee,
consisting of bedside nurses, nursing management, physicians, advanced practice
providers, and representatives from biomedical engineering, information
services, and a vendor from the software company that provided their alarm
data.
Analysis of their alarm data found that 15 types of alarms
were responsible for 98% of alarms in the unit. Moreover, one patient accounted
for over 600 alarms in a 24-hour period. The alarm data clearly identified the
first target for their intervention: oxygen saturation (SpO2) alarms accounted
for greater than 50% of total alarms in the unit, and many of these required no
intervention. So, the key element of their first PDSA cycle was a policy change
that changed the SpO2 alarm limit from 93% to 90%.
An important component of PDSA cycle #2 was empowering nurse
alarm champions. Alarm champions would round with the medical team and
discuss the benefit of adjusting alarm limits for specific patients. The alarm
champions would also review the alarm load for the nurses working on the unit,
helping redistribution of patient assignments. And, importantly, they were key
to changing the culture.
In addition to the alarm champions, the PCU clinical
specialist played a key role in development of the alarm champions program and served
as a resource and change agent for this initiative. Clinical specialists in that
organization are masters-prepared pediatric nurses responsible for staff
development, education, evidence-based practice, and quality outcomes.
The third PDSA cycle focused on technology. SpO2 alarms
remained the most frequent alarms but many of these were false alarms, caused
by patient movement, blood pressure monitoring, or other short-term
interference. The technological solution was use of a smart delay. Typically,
an alarm would be triggered immediately when the SpO2 fell below the threshold.
Basically, smart delay means that an alarm can be set to alarm only if the
SpO2 remained below threshold after a designated number of seconds. They piloted
extending the duration of the smart delay on several patients and expanded
this to all patients once they found no adverse effects. They also noted that
the second most frequent alarms were related to failures of ECG or respiratory
leads. They changed from 3-lead to 5-lead systems to reduce false alarms due to
lead failure.
All 3 PDSA cycles resulted in improvements. The change in
SpO2 setting resulted in a 10% reduction in SpO2 alarms per day and alarm champions
found no significant adverse effects. The lengthening of the smart delay and
the switch to 5-lead systems resulted in a reduction of 28.51% of alarms/bed/day
and time in alarm by 29.4%.
As in many successful quality improvement projects, use of a
multidisciplinary steering committee and use of clinical champions were crucial
drivers for the success of this program.
Though this was a pediatric unit, we see no reason the
quality improvement project could not be replicated on almost any inpatient
unit. Kudos to all the people at Texas Childrens Hospital who worked on this
project.
Prior Patient Safety
Tips of the Week pertaining to alarm-related issues:
·
March 5, 2007 Disabled Alarms
·
March 26, 2007 Alarms Should Point to the
Problem
·
April 2, 2007 More Alarm Issues
·
June 19, 2007 Unintended Consequences of
Technological Solutons
·
April 1, 2008 Pennsylvania PSAs FMEA on
Telemetry Alarm Interventions
·
February 23, 2010 Alarm Issues in the News
Again
·
March 2, 2010 Alarm Sensitivity: Early
Detection vs. Alarm Fatigue
·
March
16, 2010 A
Patient Safety Scavenger Hunt
·
November 2010 Alarms in the Operating Room
·
February
22, 2011 Rethinking
Alarms
·
February
2013 Joint
Commission Proposes New 2014 National Patient Safety Goal
·
May 2013
Joint
Commission Sentinel Event Alert: Alarm Safety
·
July 2,
2013 Issues
in Alarm Management
·
August
2013 Joint
Commission Formalizes 2014 NPSG on Alarm Management
·
February
4, 2014 But
What If the Battery Runs Low?
·
October
2014 Alarm
Fatigue: Reducing Unnecessary Telemetry Monitoring
·
December
15, 2015 Vital
Sign Monitoring at Night
·
February
9, 2016 It was just a matter of
time
·
August
16, 2016 How
Is Your Alarm Management Initiative Going?
·
February
21, 2017 Alarm Fatigue in the ED
·
April
18, 2017 Alarm Response and Nurse
Shift Duration
·
April
25, 2017 Dialysis and Alarm Fatigue
·
October
17, 2017 Progress on Alarm Management
·
November
21, 2017 OSA, Oxygen, and Alarm
Fatigue
·
May 1
2018 Refrigerator Alarms
·
April
16, 2019 AACN Practice Alert on Alarm
Management
·
September
2019 Alarm Fatigue in the
Emergency Room
·
October
8, 2019 Another Freezer Accident
·
June 23,
2020 Telemetry Incidents
·
August
2020 Pulse Oximetry in Children
·
September
15, 2020 An Eerily Familiar Incident
·
January
26, 2021 This Freezer Accident May
Cost Lives
·
February
7, 2023 Reducing Unnecessary
Telemetry
·
January 2024 Alarm
Fatigue Better or Worse?
References:
Mullen J, Sattari S, Rauch M, et al. Utilizing Data and
Alarm Champions to Enhance Alarm Management: A Pediatric Quality Improvement
Initiative. Journal of Nursing Care Quality 2024; 39(4): 369-375
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