Alarm Management IMPLEMENTING EVIDENCE BASED PRACTICE TO REDUCE THE FREQUENCY OF PHYSIOLOGICAL ALARMS Julie Zimmerman, RN, MS, CCRN, CNS Albert Lobato, Telemetry Technician Mark Miller, RN, USD CNS Graduate Student

The Joint Commission 2014 National Patient Safety Goal 6 REDUCE THE HARM ASSOCIATED WITH CLINICAL ALARM SYSTEMS Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety. CONCERNS: Numerous Alarms & Alarm devices Increased exposure to alarms Staff desensitization Delayed responses & missed alarm signals Improper modification/disabling of alarms Non-Actionable alarm settings/limits

Alarms – The Problem Palomar Health Medical Device Alarm Safety Committee, 2013.

American Association of Critical Care Nurses Alarm Management Recommendations Expected Practice Provide proper skin preparation for ECG electrodes. (Level B) Change ECG electrodes daily. (Level E) Customize alarm parameters and levels on ECG monitors. (Level E) Customize delay and threshold settings on oxygen saturation via pulse oximetry (SpO2) monitors. (Level E) Provide initial and ongoing education about devices with alarms. (Level E) Establish interprofessional teams to address issues related to alarms, such as the development of policies and procedures. (Level E) Monitor only those patients with clinical indications for monitoring. (Level C) AACN Best Practice Alert, May 2013.

HOW ARE WE DOING? ALARM FREQUENCY Data collection on 10 patients admitted for at least 24 hours on: 2 East, 10 East CCU, and TICU

HOW ARE WE DOING? CURRENT ECG PRACTICE Staff Survey Results from 2 East, 10 East CCU, and TICU

2 EAST PILOT PRACTICE CHANGES & NURSING ACTIONS Provide proper skin preparation for ECG electrodes. Properly apply and replace ECG electrodes daily. Individualize alarm parameters Ensure patient/patient family alarm education Promote Alarm Safety- Audibility, Practices, & Communication Palomar Health Medical Device Alarm Safety Committee, 2013.

Proper Skin Preparation Clip excess hair at ECG electrode sites Wash the isolated electrode area with soap and water. Use a rough washcloth or gauze to roughen a small area of the skin. Ensure electrode sites have properly dried. Do not use alcohol for skin preparation. Palomar Health Medical Device Alarm Safety Committee, 2013.

IMPROVED CONDUCTIVITY 1. Remove part of the stratum corneum to allow for electrical signals to travel to the electrode. 2. Scratch the stratum granulosum to reduce motion artifact.

R= right, L= left, ICS = intercostal space, MCL – midclavicular line, Correct 5 – Lead ECG Electrode Placement FIVE-LEAD SYSTEM RA – white electrode – Place where the Right arm joins the torso. (below R clavicle, 2nd ICS, R MCL) RL – green electrode – At the level of the lowest rib. (R lower ribcage, 8th ICS, R MCL) LA – black electrode – Place where the Left arm joins the torso. (below L clavicle, 2nd ICS, L MCL) LL – red electrode –At the level of the lowest rib. (L lower ribcage, 8th ICS, L MCL) V or Chest – brown electrode – placed in V1 (4th ICS, R SB) or V3 position (midway btwn 4th &5th ICS) R= right, L= left, ICS = intercostal space, MCL – midclavicular line, SB= sternal border V1 V3

Correct ECG Electrode Placement 5 Lead ECG Site Selection: Avoid bony prominences Avoid fatty areas Avoid major muscles Palomar Health Medical Device Alarm Safety Committee, 2013.

BEFORE AND AFTER: Proper ECG prep & placement Palomar Health Medical Device Alarm Safety Committee, 2013.

Individualize Alarm Parameters Personalize alarms to meet the needs of individual patients. Consider patient’s medical condition, status changes, and activity levels. Adjust alarms within 1 hour of assuming care. Individualization of physiological alarm parameters, conducted on a PCU/IMU resulted in a 43% reduction in critical monitor alarms. Additionally, clinical evidence demonstrates personalizing patient alarms reduces the number of false alarms. MCP 572.1 Management of Clinical Alarms in Patient Care Settings UCSD Medical Center Practice Guidelines for Assessment and Reassessment, Clinical Alarms

Promote Alarm Safety: AUDIBILITY PRACTICES Confirm ALL clinical alarms are audible from outside patient rooms. ***EVEN when patient doors are closed*** PRACTICES Disconnecting patients from physiological monitors: Constitutes a change in a patient’s level of ordered care Can only occur with a required physician/provider order OR, Only when essential for direct patient care or safety. Is performed solely by qualified healthcare personnel. Must NOT be performed by patients/patient family members.

Promote Alarm Safety: COMMUNICATION Conduct proper communication with the telemetry technicians. Guidance on when to call/notify telemetry technicians: 1) When disconnecting patients from the physiological monitors. 2) Before administration of intravenous cardiac medications/drips. 3) Prior to patient transportation/transfer off of a unit. 4) Upon returning to the unit. 5) Preceding pacemaker interrogation. 6) Prior to admission or discharge.

Tedx Alarm Video Click on the link above to the Tedx Alarm Video. This may illicit an emotional response. The text above is hyperlinked; however, the link is posted below and may be cut and pasted for email/sharing. Some individuals may wish to view this video at home or in a private setting.