In June 2013, The Joint Commission approved National Patient Safety Goal NPSG.06.01.01, which seeks to address clinical alarm safety and the overarching goal of reducing the harm associated with clinical alarm systems in hospitals. The NPSG is designed for implementation in two phases. In phase I, which began in January 2014, hospitals are required to establish alarms as an organizational priority and identify the most important alarms to manage based on their own internal situation. In phase II, beginning in January 2016, hospitals will be expected to develop and implement specific components of policies and procedures (P&Ps) and to provide education about alarm system management to staff members. See TEXT BOX for the four NPSG.06.01.01 elements of performance (EPs).1
Cook Children’s Health Care System is a pediatric, not-for-profit, integrated health care system in Fort Worth, Texas, that comprises eight companies, including the medical center, which offers 60 specialties and subspecialties, houses 428 inpatient beds, a level II trauma center, an emergency department that handles more than 100,000 patient visits each year, and 106 private or semi-private rooms in the level IV neonatal intensive care unit.
Effective clinical alarm management is a priority at Cook as it aligns with our promise to improve the health of every child in the region through the prevention and treatment of illness, disease, and injury.
A Robust Approach
Cook Children’s has taken a multifaceted approach to address phase I of the NPSG. To begin, education was provided on the importance of alarm management to leaders, clinical committees, and front-line staff. Then the quality department conducted an internal survey of nursing staff to obtain feedback on which alarm signals were felt to be the most critical for proactive management. The survey consisted of three questions: 1) Which are the most important alarms to manage in your area? 2) Which alarms entail the greatest risk if not attended to promptly? 3) Which alarms contribute to alarm noise and fatigue?
According to the results of the survey, the alarms that carried the greatest risk if not attended to promptly included those associated with ventilators, physiological monitoring, infusion pumps, non-invasive blood pressure monitors, and pulse oximeters. Alarms identified as contributing to noise and alarm fatigue included those associated with pulse oximeters, infant warmers, thermometers, and infusion pumps. Each device was then evaluated via a proactive risk assessment, which yielded consistent results when compared to the staff survey. In addition, voluntary event reports and equipment-specific alarm reports were reviewed when available.
Our multidisciplinary clinical committees—comprising representatives from quality, risk management, nursing, information technology, pharmacy, respiratory therapy, and patient safety, as well as a physicians, family representatives, and educators—were integral to maximizing this improvement opportunity and incorporated alarm analysis as a core element of the group’s responsibilities. In addition, the medication safety team had been monitoring intravenous infusion alarms on a monthly basis since 2012 using the smart pumps’ proprietary software program.
We created a quick glance dashboard to reflect the most frequent medications involved with smart pump alarms, compliance rates with using the alarming software,and alert rates per 1,000 infusion starts (see TABLE 1). Recent updates to the smart pumps’ Web-based reporting tool have allowed the medication safety team to look beyond drug-specific alerts and review infusion alarms that occur during the delivery of medication. Examples of such alarms include line occlusions, air sensed in the line, door alarms, syringe pressure, and free-flow alarms (see ONLINE-ONLY FIGURE 1). This new data has produced a better understanding of the actual nature and frequency of alerts experienced by staff and is being utilized in ongoing efforts to manage alert fatigue by reducing nuisance alerts as much as possible.
The second phase of NPSG.06.01.01 requires establishing P&Ps by January 2016 to address the alarms identified as important to manage. In order to develop meaningful standard procedures, several questions must be answered:
- What is the clinically appropriate setting?
- When can alarms be disabled?
- When can alarm parameters be changed?
- Who has the authority to change or turn off alarm parameters?
- What response to alarm signals is expected?
In phase II, we plan to discuss these questions with bedside providers at monthly Nursing Council meetings. Gathering feedback and ideas from end users via thoughtful discussion about best practice is required to draft a useful policy on alarm management.
Moving forward there are several challenges that must be addressed, including:
- Prioritizing alarms. Alarms can be difficult to prioritize as they do no not indicate the severity of the problem.
- Data integration. Collecting and integrating alarm data from multiple types of equipment can be a complex pursuit.
- Customization. Customizing alarms and blocking the ability to turn off an alarm continue to be challenging.
- Identifying problem alarms. In some cases, the only way to identify how often an alarm is triggered or how staff handles an alarm is to physically observe the activity, which is impractical on a large scale.
- Preventing false alarms. We continue to experience a significant number of false alarms, which, over time, can lead to alarm fatigue.
- Alarm resolution. In some situations it is unclear how to resolve complex alarm issues.
With increased focus and active collaboration with equipment vendors, we anticipate overcoming these obstacles.
Clinical alarms are intended to alert health care professionals to potential patient problems, but to be effective these alarms must be properly managed. Striking the right balance between excessive and insufficient alarming ensures important alerts are addressed by staff rather than overlooked. Proactive alarm management is required for hospitals to implement the changes necessary to meet NPSG.06.01.01.
- National Patient Safety Goal on Alarm Management. Joint Commission Perspectives. July 2013, Vol. 33, Issue 7. http://www.jointcommission.org/assets/1/18/jcp0713_announce_new_nspg.pdf. Accessed February 4, 2015.
Lorraineá Williams, PharmD, is the patient and medication safety officer at Cook Children’s Health Care System and works as a pediatric consultant with the Institute for Safe Medication Practices. She has presented at the state and national level on medication safety, utilization of smart pump data, and bar coding technology. Lorraineá served as an adjunct professor of pharmacology at the Texas Wesleyan University Graduate Program for Nurse Anesthesia from 2004 to 2010. She obtained her Doctorate of Pharmacy at the University of Texas at Austin.
Cindy Guess, BSN, RN, CPHQ, AVP, is responsible for health system-wide accreditation and regulatory compliance. She has worked for Cook Children’s Health Care System for 14 years and is a member of the quality division, which includes safety, risk, accreditation, and customer service. Cindy has served on several advisory boards with the intent of building resources to assist health care providers in meeting regulatory requirements. Key departments in her purview include health information management, infection control, risk management, and medical staffing services.
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