Alarm Safety in the NICU

Purpose of Clinical Alarms Physiologic monitor alarms are intended to alert clinicians to potentially hazardous changes in a patient’s condition or if a device is not functioning properly. (Cvach, 2012) The Joint Commission defines clinical alarm as “any alarm that is intended to protect the individual receiving care or alert the staff that the individual is at increased risk and needs immediate assistance” (Phillips & Barnsteiner, 2005, p. 317)

Alarm Safety Awareness Although critical to providing safe patient care, excessive alarming creates an environment that can pose a risk to patient safety (Cvach, 2012). In intensive care environments, staff and family can be exposed to up to several hundred alarms per patient per day (iNICQ, 2015) For example, The American Association of Critical Care Nurses (2014) found that a 15-bed critical care unit averaged 942 alarms per day or one critical alarm every 90 seconds

Alarm Safety Awareness Excessive clinical alarming leads to disruptions in daily workflow that can result in errors due to distraction or inattention (Cvach, 2012) The Emergency Care Research Institute identified alarm hazards as the #1 Health Technology Hazard four years in a row (ECRI, 2015) The Joint Commission reported 98 alarm-related sentinel events from 2009 to 2012 80 resulted in death 13 resulted in permanent loss of function 5 caused unanticipated additional care and extended hospitalization

Alarm Fatigue Excessive clinical alarming can lead to a hazardous condition called “alarm fatigue” (Cvach, 2012) Alarm fatigue occurs when clinicians are exposed to an excessive number of alarms leading to desensitization and sensory overload causing: Lack of or delayed response to alarms Disruption in workflow causing errors due to distraction Missed alarms (AACN, 2013)

Unintended Results In 2007 In 2010 “low battery” alarms went unanswered resulting in a patient death due to cardiac arrest In 2010 Bedside alarms were turned off Alarms at central monitor station were not heard or seen by staff Clinicians cited alarm fatigue as a contributing factor to the patient’s death (AACN, 2013)

Proper application and site assessment for Pulse Ox Sensor Alarm Management Proper application and site assessment for Pulse Ox Sensor Application- Ensure the sensor photo-detector is applied to the fleshy part of the monitoring site (fleshy part of large toe, sole of foot, palm of hand) in order to shield the photo-detector from light. Interference can occur with excessive patient movement and high levels of ambient light. Site assessment- Pulse ox site changes should occur at least every 8 hours, or if care is given every 6 hours, to ensure adequate adhesion, circulation, skin integrity, and correct optical alignment. Do not use tape to secure sensor which may cause restriction in blood flow, inaccurate readings, damage to skin and/or sensor

White dots in Pulse ox packaging Alarm Management White dots in Pulse ox packaging Don’t throw them away! Use: Place on probe over actual sensor to improve signal Peel off top layer And place sticky layer over sensor to improve signal and adhesiveness

Good pulse ox signal vs. poor Alarm Management Good pulse ox signal vs. poor The size of the waveform relates to the quality of the SpO2 signal. The waveform should reach the inner gridlines to ensure a reliable signal. The heart rate measured on the pulse ox should match

Causes and examples of poor pulse ox signals Alarm Management Causes and examples of poor pulse ox signals

Charting pulse ox alarm limits Alarm Management Charting pulse ox alarm limits Alarm limits charted every shift must match what is set on the patient’s monitor Click on blue reference text to identify alarm parameter protocols

Alarm Management Remember to update limits for patient’s corrected gestational age Special considerations for when normal SpO2 parameters cannot be reached -patients with CHD needing customized parameter limits ordered -speak to physician about obtaining order for setting limit to 100% if on 21% FiO2 or possibly assessing respiratory support need

Changing and care of pulse ox probes Alarm Management Changing and care of pulse ox probes Site change with hands on care (q6 or at least q8h) Keep sensor clean by wiping with 70% isopropyl alcohol pad or mild detergent Replace entire sensor if any visible defects are present (exposed wires/circuitry) White sticky dots can be used to improve adhesiveness if needed If damaged, soiled, or not adhesive replace with NEW sensor

Proper Skin Prep and Placement for ECG leads Alarm Management Proper Skin Prep and Placement for ECG leads Skin Preparation- Cleanse areas of skin necessary for preparation of ECG lead and temperature probe placement with warm sterile water and cotton. Pat, to not rub dry. ECG leads should not be dry; do not use water under electrodes Placement- Neonates expand their chests laterally. It is best to place the two respiratory electrodes in the right mid-axillary and left lateral chest areas at the patient’s maximum point of breathing movement to optimize the respiratory wave

Alarm Management Understanding what the alarms mean: Patient alarms are red and yellow alarms Red alarms indicate a high priority patient alarm alerting clinicians to a potentially life threatening situation Yellow alarms indicate a lower priority patient alarm limit violation Technical alarms are blue Indicate when the monitor cannot detect or measure reliably The monitor will sound for the highest priority alarm

Examples of Poor ECG Signals Description- Trace switching from high to low steps Possible cause loose or defective electrodes Corrective action change all electrodes using good skin preparation Description- Rhythmic up and down movement of the ECG baseline Possible causes Patient movement, improperly applied electrodes, respiratory interference, or two different brands/types of electrodes applied Corrective actions Make sure patient is comfortable and still, reapply electrodes if improperly applied, make sure patient is not pulling on electrodes. Ensure electrodes are of the same brand/type, move electrodes away from areas with greatest movement during respiration

Examples of Poor ECG Signals Description- Rough or jagged baseline Possible causes Poor electrical contact, respiratory interference, faulty or dry electrodes Corrective actions Reapply electrodes if necessary, check for loose connections on leads/cables, move electrodes away from areas with greatest movement during respiration, apply new electrodes if needed Description- Fuzzy, irregular baseline Possible causes Tense, uncomfortable patient, tremors, diaphoresis, poor electrode placement Corrective actions Ensure patient is comfortable, check that Electrodes are applied to flat, non-muscular areas of the torso, reapply electrodes if necessary.

Changing and care of ECG electrodes Alarm Management Changing and care of ECG electrodes Evaluate lead integrity with care Check adhesive gel integrity Faded image on electrode Change with bathing and if soiled Images will fade over time indicating possible need to be changed

Achieving Target Alarm Limits Root cause analysis done at the bedside to determine causes of continued alarming has shown to improve compliance with SpO2 alarm limit settings (Armbruster, Schmidt, Poets, & Bassler, 2010) High priority given to oxygen therapy throughout department Individualization of care Continued education regarding oxygen therapy

Conclusion Alarms are critical to providing safe patient care, but excessive alarming creates an environment that can pose a risk to patient safety by promoting alarm fatigue Improving management of alarms occurs through Appropriate electrode management and skin preparation Knowledge of poor signal indications and solutions Discussion/RCA at the bedside for patient who are excessively alarming Education and priority given towards oxygen therapy throughout department