Alarm Management Practice Alert

One of the sessions at a recent NTI conference discussed the AACN alarm management practice alert and the recent practice alert update.

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Alarm Management Practice Alert

How to manage the many alarms that the bedside nurse must assess? "The Joint Commission has identified alarm management as a national patient safety goal and requires hospitals to take action to reduce unnecessary alarms as a condition of accreditation." allnurses.com's Community Manager, Mary Watts, BSN, RN had the opportunity to interview Halley Ruppell, PhD, RN and Stacy Jensen, CNS at NTI. Some issues they discussed included:

  • Tailoring the alarm setting to the individual patient and the disease process. For instance some children with congenital heart issues experience a "normal" SpO2 saturation below the standard so setting the parameters lower results in fewer nonactionable alarms
  • Actual alarm management teams including engineers have come together to enact age-appropriate alarm settings that would somewhat standardize parameters.
  • Placement of electrodes, skin prep prior to placement, and the amount of pressure applied to skin are all part of the monitoring process
  • SpO2 sensors being applied correctly and the use of the correct sensor on the correct body part are key to proper management of alarms also

Quality improvement activities are very important to the care of the critically ill patient; for both pediatric and adult patients. Nonactionable alarm overload can result in nurses actually not hearing alarms as well as disregarding alarms. With many "false alarms,” this results in less response to the alarm increasing the chance of missing an actionable alarm.

The process alarm alert was updated in 2018. Here is the link to the practice alert. During the interview, it was discussed that there is not a lot of research involving the differences between pediatric and adult critical care monitoring. This has resulted in a standardized monitoring system for both adults and pediatrics which isn't always individualized. It is imperative that clinicians order appropriate monitoring for patients and that monitors are not overused. This can also lead to alarm fatigue.

Another issue that was discussed was buy-in from the bedside nurses. The feedback received after the initiative was published involved hard data. This provided the bedside nurse with evidence-based information proving the efficacy of the practice alert. Listening to fewer alarms really engaged the nurses and brought awareness of alarm fatigue to the bedside nurse. This is important also for the families bedside and promoted the engagement of both staff and visitors. Change in practice can sometimes become burdensome for the bedside nurses but with evidence-based information, you can obtain more engagement. It was eye-opening for nurses to realize that they didn't hear all the alarms. It's a sensory overload type of situation.

Leadership must also recognize the need for change. Per AACN; "The strategies for nursing leaders include the following:

  • Establish an interprofessional team to gather data and address issues related to alarms
  • Develop unit-specific default parameters and alarm management policies
  • Provide initial and ongoing education on monitoring systems and alarm management for unit staff
  • Develop policies and procedures for monitoring only those patients with clinical indications for monitoring"

Yet another piece of this project was a collaboration between the researchers and the industry that makes the monitors. It is very important to involve business leaders and engineers.

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traumaRUs

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Specializes in Clinical Leadership, Staff Development, Education.

I work on a rehabilitation floor and the few alarms we have can be overwhelming. We use bed and chair alarms frequently on patients who are not impulsive as well as bed alarms sounding for truly high fall risks. It makes it difficult to triage which alarm to check first when multiple are sounding off at same time.

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I have such conflicted feelings about this. The topic is so important, but I think the implementation can actually cause more alarm fatigue (if done incorrectly). I work on in a pediatric cardiac ICU, and our alarm parameters vary widely; a teenager with heart block and cardiomyopathy may have alarm settings of HR 50-100, RR 10-30, and O2 90-100, while a preemie with hypoplastic left heart may have HR 130-210, RR 30-70, and O2 65-85.

A while back my unit had a sentinel event during which we had two patients simultaneously code onto to ECMO. Patient A coded first; the nurse for the Patient B (the room next door) was helping with Patient A's code, and Patient B's alarm parameters weren't ordered or set correctly. Patient B acutely decompensated, and nobody noticed since everyone (nurses and providers) was so focused on Patient A's code. Before anyone even realized what happened, Patient B was in full-blown cardiac arrest.

As a result, our providers have attempted to make our alarm parameters much more patient-specific, and nursing is required to use the ordered parameters as part of our safety check. Unfortunately, the parameters are almost always written for an ideal patient condition: when the patient is at rest, not moving or being handled.

Unfortunately, these super-tight parameters don't account for the fact that we don't work under ideal conditions. Most of our kids are very fussy (mainly because they're all post-op). My newborn patient might have a resting HR of 120-160, but if he's screaming his brains out, he's hitting 180-190. This can persist for 90% of the shift, which means that the alarms are constantly ringing. It's alarm fatigue on steroids.

Here's the problem. In the case above, I would usually ask to change the alarm parameters from 120-160 up to 120-190 (to account for the fact that my cranky, post-op newborn lives in the 180s). However, the providers give a lot of push-back because it would be inappropriate if he were sound asleep with a HR in the 180s. Tachycardia when he's agitated is totally expected, but tachycardia at rest is a warning sign.

Unfortunately, the end result is that the alarms constantly ring, and now important alarms are being missed. For instance, our ST segment change alarms sound exactly the same as our 'mild tachycardia' alarms (Phillips 'yellow alarm'). ST segment elevation/depression is a very ominous sign in our cardiac peds patients, and often precipitates cardiac arrest. However, if a fussy patient is constantly alarming as tachycardic (totally fine), nobody will see the ST segment elevation alarm (not at all fine).

In our unit's attempt to make our alarm parameters safer, we've actually made the situation so much more dangerous (IMO). Patient-specific alarms are great, but when you tighten the reigns too much, the end result is overwhelming alarm fatigue.

Appropriate alarm parameters are great, but it is so much more important that nurses are educated to know norms (based on condition) and recognize changes. I'd rather have looser parameters and assume the responsibility for noticing subtle changes than have super-tight parameters and start ignoring the alarms completely.

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Specializes in Nephrology, Cardiology, ER, ICU.
17 hours ago, J.Adderton said:

I work on a rehabilitation floor and the few alarms we have can be overwhelming. We use bed and chair alarms frequently on patients who are not impulsive as well as bed alarms sounding for truly high fall risks. It makes it difficult to triage which alarm to check first when multiple are sounding off at same time.

This!

Its very important that the orders for monitors are appropriate. An AAOx3 pt usually does not need a bed alarm.

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Specializes in Nephrology, Cardiology, ER, ICU.
16 hours ago, adventure_rn said:

I have such conflicted feelings about this. The topic is so important, but I think the implementation can actually cause more alarm fatigue (if done incorrectly). I work on in a pediatric cardiac ICU, and our alarm parameters vary widely; a teenager with heart block and cardiomyopathy may have alarm settings of HR 50-100, RR 10-30, and O2 90-100, while a preemie with hypoplastic left heart may have HR 130-210, RR 30-70, and O2 65-85.

A while back my unit had a sentinel event during which we had two patients simultaneously code onto to ECMO. Patient A coded first; the nurse for the Patient B (the room next door) was helping with Patient A's code, and Patient B's alarm parameters weren't ordered or set correctly. Patient B acutely decompensated, and nobody noticed since everyone (nurses and providers) was so focused on Patient A's code. Before anyone even realized what happened, Patient B was in full-blown cardiac arrest.

As a result, our providers have attempted to make our alarm parameters much more patient-specific, and nursing is required to use the ordered parameters as part of our safety check. Unfortunately, the parameters are almost always written for an ideal patient condition: when the patient is at rest, not moving or being handled.

Unfortunately, these super-tight parameters don't account for the fact that we don't work under ideal conditions. Most of our kids are very fussy (mainly because they're all post-op). My newborn patient might have a resting HR of 120-160, but if he's screaming his brains out, he's hitting 180-190. This can persist for 90% of the shift, which means that the alarms are constantly ringing. It's alarm fatigue on steroids.

Here's the problem. In the case above, I would usually ask to change the alarm parameters from 120-160 up to 120-190 (to account for the fact that my cranky, post-op newborn lives in the 180s). However, the providers give a lot of push-back because it would be inappropriate if he were sound asleep with a HR in the 180s. Tachycardia when he's agitated is totally expected, but tachycardia at rest is a warning sign.

Unfortunately, the end result is that the alarms constantly ring, and now important alarms are being missed. For instance, our ST segment change alarms sound exactly the same as our 'mild tachycardia' alarms (Phillips 'yellow alarm'). ST segment elevation/depression is a very ominous sign in our cardiac peds patients, and often precipitates cardiac arrest. However, if a fussy patient is constantly alarming as tachycardic (totally fine), nobody will see the ST segment elevation alarm (not at all fine).

In our unit's attempt to make our alarm parameters safer, we've actually made the situation so much more dangerous (IMO). Patient-specific alarms are great, but when you tighten the reigns too much, the end result is overwhelming alarm fatigue.

Appropriate alarm parameters are great, but it is so much more important that nurses are educated to know norms (based on condition) and recognize changes. I'd rather have looser parameters and assume the responsibility for noticing subtle changes than have super-tight parameters and start ignoring the alarms completely.

Yes and this is what the update is all about - individualizing alarms to the specific pt.

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10 hours ago, traumaRUs said:

Yes and this is what the update is all about - individualizing alarms to the specific pt.

I know. I guess my point is that nursing may have a very different understanding of 'individualizing alarms' than providers. Our providers thought that they were 'individualizing alarms' and in doing so tightened the parameters and made alarm fatigue worse.

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Specializes in Critical Care.

I individualize my alarms as a point of habit. Like, I hate when I walk into a COPD patient's room and see the O2 alarm set to go off at 89%... WHY? Or, if my patient lives at a heart rate of 50-70 BPM, no reason to have the alarm go off if she drops below 60. I just use my nursing judgment to individualize things. I think people should be encouraged to do this, but I disagree with providers "prescribing" where the alarms should be set for the reasons another poster has already gone into.

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Specializes in ER.

One reason for too many bed alarms is one sized fits all fall risk assessment tools.

Having said that, when I was hospitalized I tried to get up to pee, not wanting to bother staff. I'm totally narcotic naive, and I have a slight fall after vomiting and also my IV came out.

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