The Joint Commission’s National Patient Safety Goal (NPSG) 06.01.01, Improve the Safety of Clinical Alarm Systems,1 is aimed at minimizing the potential for harm associated with clinical alarms by reducing nuisance alerts for clinicians and improving the management of alarm settings pre-set by vendors. Excess clinical alarms can lead to staff desensitization, and alarms that are ignored or configured improperly have the potential to result in patient harm. Therefore, it is critical that hospitals establish policies and procedures that help identify troublesome critical alarms, outline the appropriate responses to those alarms, and educate staff about the proper operation of alarms under their purview.
Delineating Medication Alerts vs Clinical Alarms
University Hospitals (UH), which comprises 15 hospitals, 28 outpatient health centers, and primary care physician offices in 15 counties in and around Cleveland, Ohio, is committed to combatting alert fatigue. As a first step toward improved alarm management, UH made certain to distinguish between medication alerts and clinical alarms. Smart pumps with programmable drug libraries, including smart IV pumps, patient-controlled analgesia (PCA) pumps, and patient-controlled epidural administration (PCEA) pumps, have both medication alerts and clinical alarms. For medication alerts, most smart pumps employ soft and hard limits to notify users when infused substances are outside programmed parameters for dose range, duration, rate, or concentration. Soft limits allow clinicians to view alert messages, evaluate the medication order and patient condition, and proceed with the infusion if appropriate; hard limits cannot be overridden and instead require review of the medication order and pump reprogramming.
Smart pump clinical alarms are typically preconfigured by the vendor and require clinical review prior to system implementation. The alarms are usually set to trigger once either a low or high limit is exceeded. The most common clinical alarms are air-in-line, patient side occlusion pressure, and free-flow. Air-in-line alarms monitor for air bubbles in the infusion line, while the patient side occlusion pressure alarm monitors for increased pressure in the infusion line as an indicator of a blocked line. A free-flow alarm sounds if the infusion tubing is not loaded properly into the pump, and fluid inadvertently enters the patient.
Investigating the Issue
To address the Joint Commission’s NPSG 06.01.01, Goals and Elements of Performance,2 UH developed a NPSG Alarm Committee, a multidisciplinary group consisting of medical staff, nurses, pharmacy representatives, respiratory therapists, risk management, and clinical engineering that falls under the auspices of the hospital’s quality center. The group began by reviewing several clinical systems with alarms, including cardiac and fetal monitoring, respiratory monitoring, bed/chair/commode monitoring, and smart pumps. Nursing identified smart pumps as being a particularly troublesome source of excessive alarms.
Using an online tool provided by the smart pump vendor, the NPSG Alarm Committee reviewed smart pump alarm data for adult patients from the approximately 2500 smart pumps UH uses system-wide in order to identify trends. At this point, UH’s system-wide smart pump committee, consisting of nurse educators and pharmacists, and which is responsible for reviewing smart pump alerts and alarms, was apprised of the medication alert review initiated by the NPSG Alarm Committee and assumed the process. Meanwhile, the NPSG committee continued its review of the clinical alarms.
The first clinical alarm identified for review by the NPSG committee was the air-in-line alarm. A review revealed that UH had set the limit to detect the smallest air volume (ie, the most sensitive setting), which resulted in an excessive number of alerts. The committee determined that the number of alarms could be safely reduced through improved staff education. The goal was to make improvements to pump set up, rather than adjust pump settings, in order to avoid putting patients at risk. We worked with our smart pump vendor to develop the following recommendations to limit air-in-line alarms:
The NPSG committee, working in conjunction with nursing educators, provided nursing staff with a one-page instruction sheet detailing the above points to remind them how to minimize alarms.
Patient Side Occlusion Pressure
Conversely, UH originally had configured the limit for the patient side occlusion pressure alarm to the highest pressure setting (ie, the least sensitive setting) for adult patients. Upon review, the group discovered that 10% of these alerts were occurring at a volume range of 0.1 mL to 1.0 mL (see FIGURE 1), meaning that the alarms were firing while the nurse was still at the patient bedside but prior to the nurse closing the IV roller clamp.
In response, UH now instructs staff to leave the roller clamp closed during pump setup, but to open the roller clamp just prior to starting the infusion. This way the pump will not attempt to pull fluid too soon, resulting in air in the line. This approach is currently being implemented at UH, and monitoring will continue to measure its effectiveness at limiting excessive nuisance alarms. Moving forward, UH also will review the frequency of free-flow alarms and identify the specific triggers for these alarms.
Creating a Policy and Educating Staff
In addition to gathering data and addressing specific alarms, UH developed a clinical alarms policy to address NPSG 06.01.01 and educate staff. The policy highlights the value of clinical alarms to help ensure patient safety and underscores that alarms be actionable, requiring a clinician to review patient status. Alarm audibility and visual settings may not be disabled, inactivated, suspended, or set at extremes that fall outside of the range required to properly protect the patient. However, alarm volume may be adjusted by clinical staff to meet patient and family needs. Appropriately trained clinical staff can adjust the alarms relative to patient-specific indications, interdepartmental policies, and patient orders.
Clinical staff education addresses alarm rationale, staff competency, and the actions that are expected in response to alarms. To clarify responsibility, the NPSG Alarm Committee developed a table assigning responsibility for each alarm type (see TABLE 1). For smart pump and several other medication delivery device alarms, nursing is responsible for responding to both the medication alerts and clinical alarms.
At each patient handoff, staff is required to validate alarm limits and review the current settings. Regular preventative maintenance and testing of devices, which is typically handled by engineering, ensures ongoing effectiveness. Alarms identified as working improperly are reported to clinical engineering, and an event report is completed. Each UH hospital has a multidisciplinary alarm management committee that reviews site-specific issues and reports back to the NPSG Alarm Committee.
To meet the Joint Commission’s NPSG 06.01.01, hospitals should have interdisciplinary groups evaluate their clinical alarms and response strategies. The goal is to minimize the potential for harm by reducing nuisance alerts and improving the management of alarm settings pre-set by vendors. Distinguishing between medication alerts and clinical alarms is a first step toward proper management, followed by a thorough investigation of why alarms are sounding. Once the offending alarms are identified, appropriate policies and procedures should be developed to guide staff in making effective changes to the technology.
Joseph Moss, PharmD, MBA, the system clinical informatics pharmacist at University Hospitals in Cleveland, Ohio, received a BS in pharmaceutical sciences from the University of Toledo, a PharmD from The University of Arkansas for Medical Sciences, and an MBA in health care at Cleveland State University. In his current role, he is involved with medication management technology and serves as a clinical liaison to medical staff, nursing, and pharmacy to enhance the CPOE environment and smart pump infusion technology. Joseph leads a system pharmacy group to design clinical decision support, enhance medication workflow, and develop order set content. He is the chair of the System Smart Pump Committee, which seeks to further develop infusion technology and enhance end-user adoption by reducing nuisance alerts.