How Can We Safely Reduce 50% of Patient Monitor Alarms in the Surgical Intensive Care Unit? Peter F. Hu, PhD Associate Professor,  Departments of Anesthesiology , Surgery and Epidemiology, and The Program in Trauma University of Maryland School of Medicine Senior Biomedical Engineer of Clinical Engineering,  UM Medical Center Adjunct Associate Professor, Department of Computer Science and Electrical Engineering, University of Maryland Baltimore County phu@anes.umm.edu   Association of University Anesthesiologists May 5, 2017

2014 Joint Commission National Patient Safety Goal Joint Commission approves new National Patient Safety Goal on clinical alarm safety for hospitals Two phases for implementation: Phase I: (January 2014), hospitals will be required to establish alarms as an organizational priority and identify most important alarms to manage Phase II (January 2016), hospitals expected to develop and implement specific policies and procedures for alarms. Education about alarm system management will also be required in January 2016. http://www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf

Alarm Fatigue Average of 350 alarms per patient per day True life-threatening event lost in a cacophony of noise Multitude of devices with competing alarm signals, trying to capture someone’s attention, without clarity around what action is required Inconsistent alarm system functions (alerting, providing information, suggesting action, or taking action) Inconsistent alarm system characteristics (information provided, integration, degree of processing, prioritization) Association for the Advancement of Medical Instrumentation AAMI Clinical Alarm Management Compendium 2015 http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/Foundation/Reports/Alarm_Compendium_2015.pdf

Methods Collected patient vital signs (VS) and alarm data from networked GE Solar monitors in a 24-bed SICU for 4 months (10/12/15 – 2/15/16) using BedMasterEX VS collection server (Excel Medical LLC) Analyzed: alarm VS name in four industry defined alarm classifications, duration, and frequency Most alarms were brief, lasting just a few seconds; specific duration (seconds) was analyzed to achieve 20% and 30% alarm reduction To reduce individual VS alarms, different alarm limit settings were compared with the default settings for hypoxia (SpO2 low ≤ 90%,) and tachycardia (heart rate: HR, HR high ≥ 130 bpm)

Number Of Alarms (Month To Month And Bed To Bed Variability) Beds Total 426,647 alarms in 4 Month  148 alarms /day/bed

Top 5 Reasons For Alarms Category Total N (100%) 1 2 3 4 5 System Warning 66,300 (15.5%) SPO2 PROBE NO ECG CONNECT PROBE NBP MAX TIME SENSOR problem 33.4% 23.6% 16.2% 14.7% 5.8% Patient Advisory 245,779 (57.6%) ART SBP LO PVC CHECK ADAPTER ART SBP HI NiSBP LO 25.7% 15.7% 13.6% 13.3% 6.2% Patient Warning 98,024 (23.0%) SPO2 LO ART Line DISCONECT V TACH VT > 2 NO BREATH Detected 93.4% 2.8% 1.8% 1.1% 0.9% Patient Crisis 16,544 (3.9%) LEADS FAIL HR HI HR LO BRADY  27.1% 25.0% 14.9% 12.4%  11.8% 

Durations (Seconds) Of Alarms In Each Category Categories N (%) 2s 4s 6s System Warning 66,300 (15.5%) 6.26% 10.97% 13.76% Patient Advisory 245,779 (57.6%) 26.55% 34.97% 39.98% Patient Warning 98,024 (23.0%) 24.70% 34.35% 41.65% Patient Crisis 16,544 (3.9%) 18.78% 28.93% 35.87% All Alarms 426,647 (100.0%) 22.67% 30.87% 36.13% Can we wait 2s to reduce 22% or 4s to reduce 30% of alarms?

Most Alarms Are Related to HR and SpO2 Category Total N (100%) 1 2 3 4 5 System Warning 66,300 (15.5%) SPO2 PROBE NO ECG CONNECT PROBE NBP MAX TIME SENSOR problem 33.4% 23.6% 16.2% 14.7% 5.8% Patient Advisory 245,779 (57.6%) ART SBP LO PVC CHECK ADAPTER ART SBP HI NiSBP LO 25.7% 15.7% 13.6% 13.3% 6.2% Patient Warning 98,024 (23.0%) SPO2 LO ART Line DISCONECT V TACH VT > 2 NO BREATH Detected 93.4% 2.8% 1.8% 1.1% 0.9% Patient Crisis 16,544 (3.9%) LEADS FAIL HR HI HR LO BRADY  27.1% 25.0% 14.9% 12.4%  11.8%  PPG: SpO2 related alarms ECG: HR related alarms

SpO2 Alarm Threshold Change Vs. % Alarm Reduction SpO2 Low SpO2% ≤ 90%  88% 41% % alarm changes 41% SpO2 % SpO2 default alarm setting: SpO2≤ 90%

HR Alarm Threshold Change vs. % Alarm Reduction Tachycardia HR ≥ 130  ≥ 135 bpm 40% % alarm changes 40% Heart Rate (HR) HR default alarm setting: HR ≥ 130 bpm

In Practice: 12 Bed Neuro ICU (Not SICU) Alarm Reduction Study 46 Weeks (8 weeks baseline, 38 weeks post intervention) 140 alarms/bed/day (>50%* alarm reduction) 38 weeks post intervention (4/11/16– 1/1/17) 50% 308 alarms/bed/day 8 week Baseline (2/14-3/28/16) Week of alarm resetting * The alarm reduction rate has NOT been adjusted for patient condition or admission patterns

What We Need: Smart Alarms High sensitivity and specificity alarms Limited alarms per patient per day; NOT 150 - 300 Personalized for individual patient (and individual clinician?) Adaptive Alarm Settings (this patient and now) Tell me something that I do not know Status change notification for specific person (RN, MD) —Pattern vs. individual VS change Provide patient physiological stability assessment Prediction of near future trajectory

Conclusion Alarm fatigue from physiologic alarms in SICU is well recognized but a solution to safely reduce alarms has not been established Our study suggests that by delaying all alarms for 4 seconds we could reduce 30% of total alarms Lowering the alarm threshold for low SpO2 by 2% and increasing the tachycardia threshold by 5 bpm could reduce an additional 40% of alarms in SICU Further study is needed to determine what impact such changes would have upon the safety of patients being cared for in the SICU

Alarm Reduction Research Team At The University Of Maryland Neeraj Badjatia, MD Johnnie Chan, CBET Samuel Galvagno, MD, PhD Susana Goff, MS, PMP Sara Hefton, MD Peter Hu, PhD Li Chien Lee, MS Hsiao Chi Li, PhD Yao Li, PhD Catriona Miller, PhD Colin Mackenzie, MD, PhD George Reed, BE, MS Inhel Rekik, BE Peter Rock, MD, MBA Fortunato Swing, ME Samuel Tisherman, MD Shiming Yang, PhD

Thanks phu@umm. edu http://www. medschool. umaryland Thanks phu@umm.edu http://www.medschool.umaryland.edu/Anesthesiology/ For further discussion See you at the poster session A1387 (Poster Board # PS 55) May 5th 1:00-2:30pm

Additional Slides below may be used during discussion Please note: The following analysis is based on Neuro ICU at UMMC, not based on SICU

SPO2 LO Real Alarm Setting Changing Alarm Threshold vs. Alarm Reduction Estimation Algorithm Development # of alarms SPO2 LO Real Alarm Setting GE: real alarm Algo0: no rule applied Algo1: 10 sec window filtering and 4 sec time delay Each alarm duration block

HR HI: % Change (Baseline HR= 120 bpm)

ART_SBP HI: % Change (Baseline SBP= 180 mmHg)

Ni_DBP HI: % Change (Baseline DBP= 100 mmHg)