Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care Unit Mary E. Hefferan Ferris State University

Identifying a Need Alarm fatigue Leads to desensitization, loss of trust, and disruption in patient care Each monitored bed can produce up to 700 physiologic alarms per day Up to 80-99% of alarms are not clinically significant and require no clinical intervention 2005-2008: reported 566 patient deaths 2009-2012: 98 alarm related sentinel events www.wisegeek.com (AACN, 2013; Cvach, 2012; Cvach, Biggs, Rothwell, & Charles-Hudson, 2013; Stokowski, 2014)

Identifying a Need The Joint Commission (JC) New National Patient Safety Goal (NPSG) announced: Phase I: “Establish alarms as an organizational priority” (JC, 2013, p. 1) Phase II: Focus on policy development and staff education Emergency Care Research Institute (ECRI) Alarm hazards listed as #1 in 2015 top 10 Health Technology Hazards Excessive alarming leads to “cry wolf” environment logonoid.com (ECRI, 2007; ECRI, 2014; JC, 2013)

Environment Helen Devos Children’s Hospital Neonatal Intensive Care Unit (NICU) 8 ward style rooms (6-12 patients per room) New addition: 40 private rooms Total = 103 available beds Either open cribs, warmer tables, or isolettes www.mdnews.com

Researching a Solution American Association of Critical-Care Nurses found proper skin preparation Enhances skin conductivity Reduces skin impedance Proper placement of EKG leads Reduces can reduce false alarms due to rapid heart rate and arrhythmias Customization of alarms Decreased alarms by 43% per bed per day solutions.3m.com (AACN, 2013; ECRI, 2007) preemies.about.com

Project Plan Provide staff education Establish protocol Increase awareness of alarm safety Encourage discussion of alarm parameters into nurse hand off Establish protocol Identifies proper skin preparation and placement for EKG/pulse ox leads to reduce false alarming yourethecure.org

Key Stakeholders Christina Schmoekel MSN, RNC-NIC, CPHIMS Amy Atwater, RN, BSN Kari Luymes Beth Huizinga, CNS improvecarenow.org

QSEN Competencies Safety Teamwork and Collaboration Knowledge Skill Attitude www.uab.edu

ANA Scope and Standards of Practice Standard 1: Assessment Standard 2: Problem and Issues Identification Standard 5: Implementation www.nsna.org

Root Cause Analysis

Change and Leadership theory Kurt Lewin’s Theory of Planned Change 1. Unfreezing 2. Movement/change 3. Refreezing Transformational Leadership (Manchester et al., 2014; MindTools, 2014)

Outcome Measurement Biomedical Engineering Bedside tally sheet Collect monitor alarm data Bedside tally sheet Alarms that cannot be measured electronically

Predicted Results Support the JC’s new NPSG of alarm safety Increase awareness and discussion of alarm parameters and safety Reduce non-clinically significant and false alarms by 25% per day Less alarm fatigue No significant events missed due to alarm fatigue www.partykrakow.com

Goals Goal 1: Create an educational program that increases awareness of alarm safety and encourages nurse-hand off discussion of alarm parameters Goal 2: Create an EKG/pulse ox skin preparation protocol with supporting education based on evidence based research

Timeline 1/2015 Survey nurses regarding factors that contribute alarm fatigue Gather baseline monitor alarm data 1/2015-3/2015 Create presentations that will be available through Spectrum Health (SHILO) 3/2015-4/2015 Answer questions and receive feed back through weekly or bi-weekly on site visits 4/2015-5/2015 Assess follow up monitor alarm data Future recommendations

References American Association of Critical-Care Nurses. (2013). Alarm management. Critical Care Nurse, 33(2013), 83-86. Retrieved from www.cconline.org American Association of Critical-Care Nurses. (2013). Strategies for managing alarm fatigue [PowerPoint slides]. Retrieved from http://www.aacn.org/wd/practice/docs/actionpak/teaching-presentation-managing-alarm- fatigue-final.ppt Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation and Technology,46(4), 268-277. doi:10.2345/0899-8205-46.4.268 Cvach, M. , Biggs, M., Rothwell, J. K., & Charles-Hudson, C. (2013). Daily electrode change and effect on cardiac monitor alarms: An evidence based approach. Journal of Nursing Care Quality, 28(3), 265-271. doi:10.1097/NCQ.0b013e31827993bc Emergency Care Research Institute. (2007). The hazards of alarm overload. Health Devices, 73-83. Retrieved from www.ecri.org Emergency Care Research Institute. (2014). ECRI institute announces top 10 health technology hazards for 2015. Retrieved from https://www.ecri.org/Press/Pages/ECRI-Institute-Announces-Top-10-Health-Technology- Hazards-for-2015.aspx Giltinane, L. C. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39. Retrieved from http://rcnpublishing.com/journal/ns Graham C. K., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-34. doi:10.4037/ajcc2010651 The Joint Commission. (2013). The Joint Commission announces 2014 national patient safety goal. Retrieved from http://www.jointcommission.org/assets/1/18/jcp0713_announce_new_nspg.pdf Manchester, J., Gray-Miceli, L. D., Metcalf, A. J., Paolini, A. C., Napier, H. A., Coogle, L. C., & Owens, G. M. (2014). Facilitating Lewin’s change model with collaborative evaluation in promoting evidence based practices of health professionals. Evaluation and Program Planning, 47(2014), 82-90. Retrieved from http://dx.doi.org/10.1016/j.evalprogplan.2014.08.007 Marshall, E.S. (2010). Transformational leadership in nursing: From expert clinician to influential leader. (1st ed.). New York: Springer Publishing Company, LLC Phillips, J., & Barnsteiner, H. J. (2005). Clinical alarms: Improving efficiency and effectiveness. Critical Care Nursing Quarterly, 28(4), 317-323. Retrieved from http://journals.lww.com/ccnq/Abstract/2005/10000/Clinical_Alarms__Improving_Efficiency_and.3.aspx QSEN Institute. (2012). Graduate KSAs. Retrieved from http://qsen.org/competencies/graduate-ksas/#safety Stokowski, A. L. (2014). Time to battle alarm fatigue. Retrieved from http://www.medscape.com/viewarticle/820738_4