Hüske Kraus, Dirk - Alarmierende Alarme Präsentation 2016

Alarmierende Alarme:
„Alarm fatigue“ auf der
Intensivstation
Ursachen, Auswirkungen und Gegenmaßnahmen
Dr. Dirk Hüske-Kraus – Clinical Director M2O Services – Philips Medizinsysteme Böblingen
Eine nichtmedizinische Einführung…
“A similar accident took place on 5 October 1999 at Ladbroke Grove. […] It was again caused by a
driver passing a signal at danger[…] As a result 31 people died […] and a further 227 passengers
were taken to hospital. […] It was found that the driver of the local train had cancelled the AWS
alarms at the single yellow and double yellow aspect signals preceding the red signal SN109...”1
“The authors concluded that his action of depressing the acknowledge button had become a
conditioned response, a phenomenon that was not uncommon amongst conductors.”2
There was another Brady alarm (38 < 40) which sounded at 2:12:39 which was
superseded by an Asystole alarm some thirty seconds later which was
silenced by the user five seconds later. The Brady alarm limit was changed
from 40 to 38 but the patient’s ECG had dropped to 17 where a Brady alarm
sounded at 02:13:56 (***BRADY 17 <38) and was silenced some 5 seconds later
by the users. From 2:14:03 to 02:44:00 there were 11 Asystole alarms
silenced by the users. Per the alarm logs the device appears to be
performing normally and the alarms annunciating appropriately. It does not
appear that the device caused or contributed to the patient event.3
1
20.4.2016
Dr. Dirk Hüske-Kraus
Beispiele
Federal investigators concluded that “alarm fatigue’’ experienced by nurses working among constantly beeping monitors
contributed to the death of a heart patient at Massachusetts General Hospital in January.
In a report released yesterday, the investigators said 10 nurses on duty that morning could not recall hearing the beeps
at the central nurses’ station or seeing scrolling tickertape messages on three hallway signs that would have warned
them as the patient’s heart rate fell and finally stopped over a 20-minute span.
Additionally, federal investigators said the volume for a separate audible crisis alarm on the patient’s bedside monitor
was turned off the night before by an unknown person. Mass. General executives had previously told the Globe that this
crisis alarm had been inadvertently turned off.
But investigators for the Centers for Medicare & Medicaid Services said that desensitization to alarms that actually
sounded also was a factor in the patient’s death. […]
link
2
20.4.2016
Dr. Dirk Hüske-Kraus
Beispiel aus GB
An elderly hospital patient suffered severe brain damage and died after staff turned down the volume on an alarm system
monitoring his heart.
David Bough, a 65-year-old driving instructor, was in hospital waiting to have a defibrillator device fitted to his heart when
it stopped beating. But because staff at the University Hospital of North Staffordshire cardiology unit could not hear the
alarm, it was 15 minutes before they realised Mr Bough was in grave danger.
They were alerted by his daughter, Marie McHugh, who was unable to get a response from him when she came to visit
and noticed a warning light flashing on the equipment.
Doctors were able to restart Mr Bough’s heart, but his brain had been starved of oxygen and he died six days later.
An investigation found the volume of the heart-monitor alarm had been turned down to 40 per cent of its maximum on
November 21, 2008.
The speakers had also been turned the wrong way and covered in paperwork.[…]
link
3
20.4.2016
Dr. Dirk Hüske-Kraus
Noch ein Beispiel (D – OP)
Der Anwalt erhob schwere Vorwürfe gegen die Medizinerin und warf ihr eine "glatte Lüge" bei der Aufklärung der Todesumstände vor. "Das Schockierende für mich ist, dass die Horrorzustände in der Klinik kein Einzelfall waren. […]Es lag keine Verkettung unglücklicher Umstände vor, sondern eine Kumulation von Sorgfaltspflichtverletzungen."
Sie sitzt zusammengefallen da während der Aussage des Gutachters, die Züge angespannt, eine gezeichnete Frau. Nach Carolin Wosnitzas Tod ist sie schwer depressiv geworden, wurde mit Alkohol am Steuer erwischt, musste ins Gefängnis. Sie ist hochverschuldet, hat ihren Beruf aufgegeben.
4
20.4.2016
Aber es ist zum Beispiel kaum zu verstehen, dass keinem Arzt oder Pfleger im OP auffiel, dass das akustische Signal nicht funktionierte, das während der Operation mit jedem Herzschlag einen Ton abgibt. Ist kein Herzschlag mehr da, kommt ein Warnton. Müsste ein Warnton kommen. In der Alsterklinik blieben die Apparate stumm. Marion F. bemerkte den Herzstillstand erst, als die "stark gebräunte Patientin auffällig blass" wurde.
Der Richter versucht, das nachzuvollziehen: "Das kennt man doch auch aus dem Fernsehen: Das fällt doch auf, wenn der Ton ausfällt", sagt er. "Na ja, das ist so ein Dauerton", antwortet die Angeklagte. Den höre sie schon seit 20 Jahren, er sei ihr "nicht mehr bewusst".
Dr. Dirk Hüske-Kraus
Alarm fatigue
Definition
Alarm fatigue (Alarmmüdigkeit) ist eine
“Desensibilisierung” klinischen Personals durch zu
viele irrelevante Alarme medizinischer Geräte.
5
20.4.2016
Dr. Dirk Hüske-Kraus
Noch mehr Beispiele (OP und Aufwachraum)
One such dentist recognized an alarm as a sudden decrease in the pulse oximeter reading. He replaced the oximeter
probe on several different fingers and then on several fingers of the opposite hand in an attempt to get a normal reading,
but the readings were all still abnormal. He then requested a pulse oximeter from another operatory and that also
appeared to be faulty until the patient eventually suffered a hypoxia-induced cardiac arrest.1
The parents of Mariah Edwards won a $6 million malpractice settlement after their 17-year-old daughter died last year
following a tonsillectomy at a Pennsylvania surgery center. After the surgery, the high school junior was given a potent
painkiller that slowed her breathing. By the time nurses checked on her 25 minutes later, she had suffered profound and
irreversible brain injury. She died 15 days later. […]
A nurse said in her deposition that the alarm on the respiratory monitor was muted, said Joel Feller, an attorney for the
family. After Edwards’ death, the center announced several changes, including that alarms would no longer be muted.
6
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue: Die Fakten
• Zwischen 150 und 350 Alarme pro Patient
und Tag überfluten ITS-Mitarbeiter1-3. Oft
konkurrieren verschiedene Geräte nahezu
ununterscheidbar um Aufmerksamkeit4-7.
• Lebensbedrohliche Situationen können
durch Fehlalarme überdeckt werden,
Alarmmüdigkeit kann zu Todesfällen
führen8-9
• Zu viele Alarme unterbrechen pflegerische
Tätigkeiten, desensibilisieren das Personal
und erhöhen den Streß für Patienten10
7
20.4.2016
Dr. Dirk Hüske-Kraus
150 ‐ 350 Alarme
pro Patient und Tag
Alarm fatigue: Auswirkungen
Häufige, irrelevante Alarme
Stress, kognitive Belastung
Unnötige Arbeitslast
Häufige Unterbrechungen v. Pflegetätigkeiten
Fehler und Auslassungen
Mitarbeiter‐
zufriedenheit
MA‐Gesundheit MA‐Bindung
8
Effizienz
20.4.2016
Desensibilisierung und Überlastung
Unangemessene Reaktionen a. Alarme
Schlafphasen
circadianer Rhythmus gestört
UE & Komplikationen
Dr. Dirk Hüske-Kraus
“Noise pollution” & “Hyperaktivität im Patientenzimmer”
Patienten‐
zufriedenheit
Reputation
Alarm fatigue: Ursachen
 Anpassung von
Alarmgrenzen auf Patient &
klinische Situation
 Disziplin: Hautvorbereitung,
Maßnahmen am Patienten, Pat. aus Bett
Insuffiziente Sensoren:
Qualität, Lebensdauer
 Verwendung alarmreduzierender Funktionen
 proaktives“
Monitoring
Schwellwertlogik oft
inadäquat
„Overmonitoring“
Alarm „broadcasting“
Häufige, irrelevante Alarme
9
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue: Handlungsoptionen
43%
Alarmreduktion1,
wenn
Mitarbeiter die Alarmgrenzen an den
Patienten(-status)
anpassen
47%
Reduktion der
Alarmfrequenz2,3 durch
Verzögerungsintervalle
bei potentiell selbstkorrigierenden Ereignissen,
z.B. leichte, transiente
SpO2-Entsättigung
Alarmreduktion2,4,5 durch
Vermeidung von Alarmen
bei Maßnahmen am
Patienten
45%
Reduktion3 der SpO2
Alarme durch
Schwellwertsenkung
90% -> 88%
Alarmreduktion6 durch
täglichen
Elektrodenwechsel
10
20-44%
70%
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue: Handlungsoptionen
Anpassung der Grenzen an
Situation/Status
Disziplin:
• Hautvorbereitung
• Maßnahmen am Patienten
„Alarm policy“
Verbrauchsmaterialien & Sensoren
Training/Schulung
Alarmverteilung
Monitoring:
• Proaktiv
• Multiparameter
• Alarmreduzierende Funktionen
11
Monitoring nach Indikation –
Overmonitoring
Konfiguration
• Brauchbare Grenzwerte
• Profile passend zum Patienten (-status)
20.4.2016
Dr. Dirk Hüske-Kraus
Regelmäßiger
Elektrodenwechsel
Alarm fatigue auf der ITS: Caveat
12
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue: Handlungsoptionen
In God we trust. Anybody else bring data!
Kreiskrankenhaus, NL
26.1 rote Alarme pro Tag
und Bett (gesamt 264)
Kreiskrankenhaus, F
92.2 rote Alarme pro Tag
und Bett (gesamt 268)
Universitätsklinik, F
5.6 rote Alarme pro Tag
und Bett (gesamt 93)
13
20.4.2016
Dr. Dirk Hüske-Kraus
Städtisches Krankenhaus, D
7.6 rote Alarme pro Tag und
Bett (gesamt 382)
Ergebnisse
Projekt in Nieuwegein, NL
•
40% nachhaltige Reduktion vermeidbarer Alarme
•
In Kooperation mit den klinischen Mitarbeitern
•
Mitarbeiterzufriedenheit
•
Patientenzufriedenheit
Für „Kostenrechner“
14
Alarm
40%

Betten
Auslastung
12
90%

145 Alarme pro d und Patient
3950 Patiententage p.a.
Alarm absolut

574.000 p.a.
MA‐Bindung / Alarm 5s

800 MA‐Stunden p.a. ,  0,5 FTE
20.4.2016
Dr. Dirk Hüske-Kraus
Projektüberblick
Beteiligte
Status &
Empfehlungen
Umsetzung
(opt.)
Nachkontrolle
15
Arbeitspakete
Zeit
Ergebnisse
Kunde
Pflege: 3 Tg
Ärzte: 2 Tg
Med. Tech. 0,5 Tg
Philips
Consultants
Data analyst
Application Sp.
 Interviews, shadowing
 Quick‐wins identifizieren & umsetzen
 Datenanalyse
 Empfehlungen
3‐6 Wochen
“Baseline Assessment”‐Bericht
• Detailanalyse
• “Quick win”‐Ergebnisse
• Empfehlungen
• Benchmark
Pflege: 5 Tg
Ärzte: 2 Tg
Med. Tech 1 Tg
Consultants
Data analyst
Application Sp.
 Umsetzung der Empfehlungen
 Training
 Konfiguration
 Datenerhebung & ‐analyse
 Übergabe
3‐6 Wochen
Abschluss‐Bericht
• Übersicht über alle Aktivitäten
• Vorher‐Nachher‐Vergleich
• Weitere Empfehlungen
• Benchmark
Pflege: 1Tg
Ärzte: 0,5Tg
Consultant
Data analyst
 Datenanalyse
 Empfehlungen
20.4.2016
Dr. Dirk Hüske-Kraus
2‐4 Tage
Bericht
• Entwicklung
• Empfehlungen
Beispiele (präinterventionell)
16
20.4.2016
Dr. Dirk Hüske-Kraus
Beispiele (während Intervention)
17
20.4.2016
Dr. Dirk Hüske-Kraus
Was lehrt uns das?
Das Problem „Alarm
fatigue“
18
Das Vorgehen
20.4.2016
Das Ergebnis
Dr. Dirk Hüske-Kraus
Vielen Dank
für Ihre
Aufmerksamkeit
Dr. Dirk Hüske-Kraus – dirk.hueske-kraus@philips.com
!
19
20.4.2016
Dr. Dirk Hüske-Kraus
Backup slides
20
20.4.2016
Dr. Dirk Hüske-Kraus
Noch ein nichtmedizinisches Beispiel…
“A cascading series of events caused the computer to notice SEVEN HUNDRED things wrong in the
first few minutes of the accident. The ONE audible alarm started ringing and stayed ringing
continuously until someone turned it off as useless. The ONE visual alarm was activated and
blinked for days, indicating nothing useful at all. The line printer queue quickly contained 700
error reports followed by several thousand error report updates and corrections. The printer queue
was almost instantly hours behind, so the operators knew they had a problem (700 problems actually,
though they couldn’t know that) but had no idea what the problem was.”1
Akute Überlastung
Three Mile Island, 28.3.1979, 4 a.m.
21
20.4.2016
Dr. Dirk Hüske-Kraus
Mehr Beispiele…
The second patient death in four years involving “alarm fatigue’’ at UMass Memorial Medical Center has pushed the hospital to intensify
efforts to prevent nurses from tuning out monitor warning alarms.
Nurses exposed to a cacophony of beeps may no longer hear them or begin to ignore them, and that’s what appears to have happened in
the latest case: A 60-year-old man died in an intensive care unit after alarms signaling a fast heart rate and potential breathing
problems went unanswered for nearly an hour, according to state investigators who reviewed records at the hospital.
The death occurred in August 2010 but was not reported to the state Department of Public Health until this spring. The state cited various
violations by the hospital, including not responding to alarms “in a timely manner.’’[…]
[A previous patient’s] death in 2007 led the hospital to adopt aggressive measures to improve nurses’ responses and tackle alarm fatigue,
which can occur when nurses hear alarms - many of them false - all day long. But the new death shows the problem continues, as it
does at hospitals nationwide. It has led to at least 200 patient deaths since 2005 and likely hundreds more, according to a Globe
investigation published earlier this year.
link
22
20.4.2016
Dr. Dirk Hüske-Kraus
Noch mehr…
DES MOINES, Iowa -- An Iowa man died at a Des Moines hospital in March after a nurse deliberately shut off the alarms used to
monitor patients' conditions, newly disclosed state records show.
Michael Deal, a 65-year-old Army veteran from Spirit Lake, died March 29 at the VA Central Iowa Healthcare System hospital.
Bernard Nesbit, a registered nurse in the hospital's telemetry unit where patients are kept for continuous monitoring, was subsequently fired
for having turned off an array of alarms that were hooked up to all of the patients in that unit. […] "We found the patient unresponsive,
ashen, pale, cyanotic and unresponsive. … Daryle check(ed) for a pulse as we began calling out to the RNs, requesting a Code Blue be
called. …
He said that he later checked the patient monitors and it appeared that all of the alarms in the unit had been shut off for roughly three
hours. During that time, Deal's blood-oxygen level dropped "slowly" from a normal level in the 90s to the 30s — a dangerously low
level — for 45 minutes before he and Jager realized what had happened.
link
23
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue auf der ITS
Epidemiologie: US-endemisch?
D
F
2008
US
2007
Artikel zu “Alarm fatigue”
UK
300
200
100
2014
2013
2012
2011
2010
2009
2006
2005
2004
2003
2002
2001
2000
0
FDA erweitert Review medizinischer Geräte wg. 'alarm fatigue‘, erwähnt 566 “alarm‐
related patient deaths”
Joint Commission: Nationales Patientensicherheitsziel “Clinical Alarm Safety”
ECRI: “Alarm Hazards” Nr. 1 der “Health Technology Hazards 2015” (‘14, ‘13, ‘12…) 24
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue
Definition
ECRI Wikipedia Alarm fatigue occurs when one is exposed to a large volume of alarms and as a result, becomes desensitized to the firing alarms. Desensitization can lead to longer response times or failure to acknowledge important alarms.
Alarm fatigue is sensory overload in clinicians who are exposed to an excessive number of alarms, which can result in desensitization to alarms and unacknowledged alarms. Patient deaths have been attributed to alarm fatigue.
“Alarm fatigue” (Alarmmüdigkeit) ist eine Desensibilisierung klinischen Personals durch zu viele irrelevante Alarme medizinischer Geräte
“Bei der Alarmmüdigkeit (“alarm fatigue”) handelt es sich genau genommen nicht um eine Störung der Aufmerksamkeit, sondern um einen motivational bedingten Schutz der Aufmerksamkeit: was beständig zu Unrecht die eigene Aufmerksamkeit in Anspruch nimmt, verliert an Wertigkeit”1
25
20.4.2016
Dr. Dirk Hüske-Kraus
Handlungsoptionen?
1. Breite Übereinstimmung, dass
Alarmmüdigkeit ein signifikantes
Problem der Patientensicherheit ist.
2. Die wenigsten Teilnehmer sagen, dass
ihre Einrichtung konkrete Maßnahmen
ergriffen hat oder plant
Quelle: STA survey 2014
3. Die Studie legt eine große Unsicherheit
nahe, wie dem Problem zu begegnen ist.
Quelle: Junicon web survey 2012, n=56
26
20.4.2016
Dr. Dirk Hüske-Kraus
Therapeutische Optionen
Fachgesellschaften/Verbände in D? EU?
27
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue im OP: Die Fakten
• Ähnlich hohe Alarmfreguenzen: 1/0,33min ‐ 1/4,5 min1,2,3 (weniger Daten verfügbar1 ), ähnlich hohe Raten irrelevanter Alarme: 64%‐77%1,3
• Niedrige Unterscheidbarkeit der Alarme hinsichtlich Wertigkeit und Herkunft4,5,6,7, hohes Maß an Ablenkung8 und Stress9 • Alarme werden oft stumm geschaltet10,11 oder ignoriert mit dem Risiko der verzögerten Reaktion auf kritische Ereignisse3,10
28
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue auf der ITS
Detail: „Overmonitoring“
Overmonitoring:
“Monitoring for conditions without clinical indication or undue continuation of monitoring/telemetry”
Studien1,2 zeigen, dass in einer Vielzahl von Fällen inadäquates Monitoring (overmonitoring, undermonitoring)
zu finden ist. Beispiel:
Almost all (99%) patients with an indication for arrhythmia monitoring were being monitored, but 85% of
patients with no indication were monitored.
Of patients with an indication for ischemia monitoring, 35% were being monitored, but 26% with no
indication were being monitored for ST-segment changes.
Only 21% of patients with an indication for QT interval monitoring had a QTc documented, but 18% of
patients with no indication had a QTc documented.1
29
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue auf der ITS
Detail: Intervalllogik
Patient safety
(deteriorations detected & cared for adequately)
HR alarms continuous: „meaningless“ –
deteriorations not detected
(„combined sensitivity“↓)
10
30
Almost no HR alarms
(sensitivity↓)
Highest sensitivity and specificity: HR alarmes „meaningful“
50
70
90
110
130
150
1/m
30
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue auf der ITS
Detail: Alarmreduzierende Funktionen
(A): With a desaturation to 86% with a duration of 20 seconds, the audible alarm becomes active only after the alarm condition has persisted for 15 seconds.
(B): With a desaturation to 84% with a duration of 5 seconds, no audio alarm occurs.
Adapted from http://www.masimo.com/pdf/whitepaper/LAB6138B.pdf
31
20.4.2016
Dr. Dirk Hüske-Kraus
(C): With a sudden desaturation to 80%, the audible alarm activates immediately
Alarm fatigue auf der ITS
Detail: „Proaktives Monitoring“
Horizon display has been set
up to meet SIRS criteria.
Also, etCO2 and SpO2 were
added to adress the patient’s
diagnosis of pneumonia and
poor respiratory condition.
Here, the baseline was set to
represent target values.
The deviation bars clearly
show that the patient’s
current values are
significantly deviated from
where we would like them to
be. The trend indicator also
confirms that the patients
condition in the preceding ten
minutes is worsening. The
only stable measurement is
the temperature, but this is
also not within our desired
range.
32
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue auf der ITS
Detail: „Proaktives Monitoring“
33
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue auf der ITS
Detail: Grenzen der Schwellwertlogik
Lynn 2011: Patterns of
unexpected in-hospital deaths:
a root cause analysis
34
20.4.2016
Dr. Dirk Hüske-Kraus
Alarm fatigue auf der ITS
Therapeutische Optionen: Multiparameter-Alarme
Scenario
Detect what
SVT + BP: Supraventricular Tachycardia and Blood Pressure –indicate high heart onset of paroxysmal atrial rate with low blood pressure, as frequently occurs in patients with Atrial fibrillation
fibrillation and a rapid ventricular rate. Tachycardia associated with hypertension, as commonly occurs with light sedation, would not trigger this alarm
VTACH + BP: Indicate ventricular tachycardia with low blood pressure. This Vtach with low blood pressure
definition would be much less likely to be triggered by motion artifact than the EKG alarm is.
LV shock: Detect Left ventricular failure (cardiogenic shock).
TPX & TPND: Detect either tamponade or tension pneumothorax
Hypovl: Indicate low blood pressure from hypovolemia
35
Parameters Limits/Trigger Time HR (Pulse) ART sys Pulse (HR)
HR (Pulse) PVC ARTsys Pulse (HR)
left ventricular shock
ARTsys CVPmean PAPdia Perf
tamponade (obstructive shock) ARTsys CVPmean Perf PAPdia
hypovolemia
ARTmean CVP Perf NIBPm
20.4.2016
Dr. Dirk Hüske-Kraus
+40% within 59 sec ‐15% within 59 sec >110 bpm for 20 sec
+30 bpm within 20 sec ***Vtach ‐30% within 20 sec >110 bpm for 10 sec
<78 mmHg for 300 sec <16 mmHg for 300 sec >16 mmHg for 300 sec <1.2 for 300 sec
<78 mmHg for 180 sec >16 mmHg for 180 sec ‐20% within 3 min >16 mmHg for 180 sec
<50 mmHg for 300 sec <5 mmHg for 300 sec ‐20% within 120 sec/10 min <55 mmHg for 300 sec
“Correlation of information across alarms can suppress artifact, increase the positive predictive value of alarms, and can employ more sophisticated definitions of alarm events than present single‐sensor based systems.”1
Ursachen…
metrology
man
milieu
Stressors
Redundancy
Habits
Noise
Algorithms
Over-monitoring
Attitude
Infrastructure
Qualification
Architecture
Resilience
Configuration
Fault
Sensors, electr.
Acuity
Adv. features
Homogeneity
Distribution
Compliance
Usability
Activity
““material””
36
machine
20.4.2016
Sensor application
Procedures on pat.
Profile selection
Threshold tailoring
method
Dr. Dirk Hüske-Kraus
Monitore sind nicht die einzigen Ursachen
Source: ECRI Alarm Safety Handbook
37
20.4.2016
Dr. Dirk Hüske-Kraus
..und die Folgen
Patientensicherheit
Patientenwohlbefinden
Neurologische
Komplikationen
Störungen
VWD↑
Ängstlichkeit
Inadeaquate Reaktion
auf Ereignisse
Schlafqualitat
Irrelevante
Alarme
Personalbindung u. -gewinnung
Kognitiver Stress
Arbeitslast
Prozesseffizienz
Desensibilisierung
Durchsatz/Umsatz
Reputation
KH-Performance
Mitarbeiter
38
20.4.2016
Dr. Dirk Hüske-Kraus
Therapeutische Optionen
AAMI
“10 Ideas for safe alarm management”1
• Issuing a call to action, championed by executive leadership, which recognizes the challenges, risks, and
opportunities of alarm management, and committing to solving them.
• Bringing together a multidisciplinary team to spearhead action and build consensus.
• Gathering data and intelligence to identify challenges and opportunities.
• Prioritizing the patient safety vulnerabilities and risks to target with alarm management improvements.
• Setting and sharing goals, objectives, and activities to address these vulnerabilities and risks.
• Developing and piloting potential solutions.
• Evaluating the effectiveness of improvements and making adjustments as needed.
• Developing policies and procedures.
• Educating staff to build and maintain competencies.
• Scaling up and sustaining by creating ownership at the unit level and with continuous improvement.
39
20.4.2016
Dr. Dirk Hüske-Kraus
Therapeutische Optionen?
AACN
“Alarm Management Performance Improvement Plan”1
40

Assemble an interdisciplinary Alarm Management Team

Collaborate with Clinical (Biomedical) Engineering to collect alarm data

Define and categorize alarm types.

Determine the clinical significance associated with alarms

Conduct a thorough analysis of all data collected to understand the scope of the alarm problem, focusing on trends

Conduct nonpunitive evaluations/observations of how alarms are managed on a particular patient care unit and shift

Identify the goal or outcome measures that will guide change and improvement efforts

Implement targeted alarm management strategies or interventions incrementally

Monitor progress and sustain improvements

Develop patient care unit policies and protocols

Provide ongoing staff education and support.

Engage managers in coaching staff members regarding alarm management performance expectations.

Remain abreast of changing technology.
20.4.2016
Dr. Dirk Hüske-Kraus
Therapeutische Optionen?
AACN
“Practice Alert”1
 Provide proper skin preparation for ECG electrodes
 Wash the isolated electrode area with soap and water, wipe the electrode area with a rough washcloth or gauze,
and/or use the sandpaper on the electrode to roughen a small area of the skin.
 Do not use alcohol for skin preparation; it can dry out the skin.
 Change ECG electrodes daily
 Change daily or more often if needed.
 Customize alarm parameters and levels on ECG monitors
 Customize the alarms to meet the needs of individual patients.
 Set customized alarms within 1 hour of assuming care of a patient and as the patient’s condition changes
 Customize delay and threshold settings on oxygen saturation via pulse oximetry (SpO2) monitors
 Collaborate with an interprofessional team, including biomedical engineering, to determine the best delay and
threshold settings.
 Use disposable, adhesive pulse oximetry sensors, and replace the sensors when they no longer adhere properly to
the patient’s skin.
41
20.4.2016
Dr. Dirk Hüske-Kraus
Therapeutische Optionen
AACN
“Practice Alert” (cont’d)
 Provide initial and ongoing education about devices with alarms.


Provide education on monitoring systems and alarms, as well as operational effectiveness, to new nurses and all other health care staff on a periodic
basis.
Budget for ongoing education when purchasing monitoring systems.
 Establish interprofessional teams to address issues related to alarms, such as the development of policies and
procedures




Determine the default alarms for the equipment being used.
Evaluate the need to upgrade to next-generation pulse oximetry.
Consider developing a culture of suspending alarms when nurses perform patient care that may produce false alarms.
Standardize monitoring practices across clinical environments.
 Monitor only those patients with clinical indications for monitoring


42
Collaborate with an interprofessional team to determine those patients in a population or care unit who should be monitored and what parameters to use.
Use the American Heart Association’s Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation
20.4.2016
Dr. Dirk Hüske-Kraus
Therapeutische Optionen?
AAMI
“Die fünf größten Wissenslücken im Alarm Management”1
1. Mangel an Dokumentation und Daten, um unerwünschte Ereignisse analysieren und
Ursachen verstehen zu können.
2. Fehlen von evidenzbasierten Richtlinien für die Konfiguration von Alarmeinstellungen
3. Mangelhaftes Verständnis, welche Typen von Alarmsignalen geeignet sind, die richtige
Reaktion zu bewirken
4. Zu wenig Wissen, welche Patienten für wie lange gemonitored werden sollten
5. Zu wenig Verständnis über die beste Art von “sekundärer Alarmierung”
43
20.4.2016
Dr. Dirk Hüske-Kraus