1. Alarm Safety in the NICU

2. 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)

3. 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

4. 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

5. 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)

6. 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)

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

17. 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

18. 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.

19. 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

20. 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

21. 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