1. 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
Association of University Anesthesiologists
May 5, 2017

2. 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.

3. 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

4. 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)

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

6. 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% 

7. 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?

8. 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

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

10. 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

11. 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

12. What We Need: Smart Alarms
High sensitivity and specificity alarms
Limited alarms per patient per day; NOT
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

13. 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

14. 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

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

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

18. 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

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

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

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