Alarm Fatigue and other EC/LS Hot Spots for Clinical Managers

1. Alarm Fatigue and other EC/LS Hot Spots for Clinical Managers October 2011 Jennifer Cowel, RN MHSA

2. Speaker • Jennifer Cowel, RN MHSA • TJC Experience: Former TJC Hospital Surveyor and former Director of Service Operations in Accreditation in Central Office • Accreditation and regulatory compliance consultant • Vice President and Principal Patton Healthcare Consulting • 630-664-8401 • JenCowel@PattonHC.com

3. Alarm Fatigue & Top ScoredWhat, Me Worry? • Alarm Fatigue – JC Online Aug 2011 • Issue highlighted at TJC Executive Briefings • 4 of the top 5 scored standards were in EC or LS • In 2011 - LSC days increased • Surveyor Focus on industry trends • Alarms have led to Immediate Threat

4. 2012 Decision Categories Ex: Immed Threat to Life or falsification or fail to clear RFIs after two tries when in CONT PDA Contingent Accreditation Ex: Failed AFS after 2 tries, or No License, etc Accreditation with Follow-up Survey (AFS) Ex: Too many RFI’s CoPs non compliant. Accredited Ex: Compliant or cleared all RFIs w/ ESC Perspectives 11/2010

5. Alarm Fatigue A Growing Problem • FDA article reports 566 patient deaths between 2005 – 2008, related to alarms • The numbers are self reported and are likely to be higher • Twenty-five years ago, few, if any alarms on equipment • Today – increasing equipment and increase in type & # of alarms

6. Alarm Fatigue A high-profile Problem • A patient on cardiac monitor died after V-Fib, dysrhythmia processing turned off • Perinatal monitor did not audibly alarm fetal distress, only visual, went unnoticed • A patient stopped breathing but staff just didn’t hear the monitor

7. 10 Years of TJC Focus • Sentinel event alert in 2002 focus on clinical ventilator alarms • Introduced NSPG • Moved clinical alarms to standards ‘05 • Participating in fall summit by AAMI, ACCE, ECRI • Problem continues to grow

8. What is Alarm Fatigue?Or Crying Wolf • Alarm fatigue occurs when clinical personnel fail to respond appropriately to alarms due to inability to understand the critical nature or priority of the alarm. Staff become desensitized after experiencing and handling so many. Alarms are ignored or turned off.

9. Taking a Good Thing Too Far • Go beyond the visual/audible alarm, to cell phone, pager alerts, dashboards, nurse call systems • Beyond the basics – bed alarms, chair alarms, IV, call button, hand sanitizer. • Study of alarms in critical care units • 900 to 1300 alarms per day, per unit. • Alarms every 66 seconds

10. Understanding the Issues • FDA published results of 216 manufacturer reports on monitor related deaths • TJC analyzed sentinel events for monitor related causes

11. Common Causes • Staff are overwhelmed by the # of alarms • Staff don’t respond or hear alarms • Staff turn-off or turn down alarms • Alarm settings not returned to original setting after a patient move • Alarm not properly relayed to wireless or paging system

12. Common Causes • Nuisance Alarms reduce sensitivity • As many as 99% of ICU alarms are false, or non-critical alarms • No routine replacement of batteries, leads to excessive “low battery” alarms • Put a “ring” on it - The solution to many problems or RCAs is to add an alarm on it to prevent recurrence. • Alarms just become back ground noise

13. Causes – Cont. • The Sound of the Alarm • Med Equipment companies create their alarm to fetch attention, the beeping is intended to irritate • Sounds of alarms do not differentiate a ‘notification’ from a critical event. • Sounds are difficult to learn, differentiate which alarm • Difficulty learning > 6 alarm signals

14. Causes – Cont. • Alarm noise contributes to sound level in unit, disrupts sleep and environment of healing • Users can turn alarms off, change parameters, reduce volume. • Alarms are not tailored to the individual patient • Nurses block out noise to focus on task

15. Concrete Steps to Improving Safety/Effectiveness of Alarms • How many alarms are tolerable to staff to avoid fatigue? Anesthesiology Today study suggests 2 – 4 per patient/day • Reduce Thresholds for alarms, use evidence based approach. • Define when a clinician needs to go to bed side

16. Reducing False Positives • A Johns Hopkins Study: lower SpO2 alarm from 90& to 88% reduced alarms by more than 50% • Place delays on alarms, delay alarm by 15 seconds. Journal of Emergency Medicine (JEM) study. Reduced false positives by 80% • Get to only the alarms staff care about

17. Improving Safety of AlarmsCont. • Equipment maintenance • Reduce low battery alerts by replacement • Deactivate or limit overrides • Routine testing of alarms • Selection of equipment • Vendors with meaningful alarm sounds • Implement intelligent escalation of alerts • Involve staff in equipment selection

18. Improving Safety of AlarmsCont. • Alarm Notification Alternatives • Consider central surveillance room with monitor watchers than notify care givers • Consider alarm integration systems that directs alarms to devices worn by staff

19. Improving Safety of AlarmsCont. • Staff Training • Train staff on meaning of all alarm sounds • Train staff to check patient before silencing any alarm • Train staff on new equipment • Train staff on proper alarm placement, skin preparation, ensure competence

20. Improving Safety of AlarmsCont. • Develop and implement policies • Who can change alarm settings • Who needs to be monitored • What are default settings • Who is responsible for performing clinical alarm monitoring rounds • Develop audit tool to measure compliance with established policies • Develop and complete check list at shift change for patient alarm settings

21. Top Scored EC & LS Standards • Surveyors see these everywhere, low hanging fruit • These are seen by both the LSC surveyor and the clinical surveyors • Prevent them from seeing these at your organization and create an impression on day 1

22. Exits and Cluttered Corridors(LS.02.01.20 -57%) Hospital maintains means of egress • Easy to find issues, educate on: • Blocked or locked egress doors • Corridor clutter, storage in hallways • Linen carts and latex carts will be scored • Exit signs – burned out, enough, proper location, • “No Exit” signs posted

23. Fire Protection Features(LS.02.01.10 - 57%) Building & fire protection features minimize the effects of fire, smoke and heat. • Fire and smoke doors labeled, correct type, close, label visible, under cut, door gaps, adhesive tape over latch • Penetrations are sealed with correct material – IT cables biggest offender. Consider a work permit and inspection

24. Fire Doors, cont • Inspect and maintain fire doors • Appropriate fire rating on doors and frame • Door positively latches • Door had a closure • No gaps > 1/8 inch, or undercut >3/4 inch • Resulted in ITL if multiple problems

25. Fire Protection Equipment(EC.02.03.05 – 42%) Hospital inspects, tests & maintains fire safety equipment. • Includes testing of: fire alarms boxes, smoke detectors, sprinklers, portable extinguishers, magnetic release devices, tamper switches & water flow devices. • If outsourced to a vendor keep the report, read the report and act on problems! • Make sure reports are tied to an inventory of devices

26. Fire Extinguisher Dating(EC.02.03.05 cont.) • Month, day, year and initials of inspector required per NFPA 10-1998 • They will review the tag • If bar coded, they will review documentation • Required monthly

27. Fire Protection Equipment(EC.02.03.05 – 42%) Hospital inspects, tests & maintains fire safety equipment. • Includes testing of: fire alarms boxes, smoke detectors, sprinklers, portable extinguishers, magnetic release devices, tamper switches & water flow devices. • If outsourced to a vendor keep the report, read the report and act on problems! • Make sure reports are tied to an inventory of devices

28. Medical Gas(EC.02.05.09 – 20%) • Hospital inspects, tests & maintains medical gas and vacuum systems. • Get vendor reports, fix problems noted • Gas shut off valves must be labeled with rooms they shut off. Staff must know who can shut these off and when. • Alarms must be working. Has led to ITL

29. Provide/Maintain Fire Systems and Equip (LS.02.01.35 33%) Sprinklers • 18 inch rule • Sprinkler pipes can not support other items like cables or wires • Sprinkler head clean and free of obstruction, collar flush

30. Medical Gas(EC.02.05.09 – 20%) • No parking zone! • Get vendor reports, fix problems • Gas shut off valves must be labeled with rooms they shut off. • Staff know who can shut these off • Alarms must be working. Led to ITL • Test & inspect & maintain medical gas and vacuum per policy

31. Safe, Functional Environment(EC.02.06.01 – 20%) • Areas scored here: furnishing and equipment are in good repair, the environment meets needs of patient. • Ripped mattresses, cracked ceiling tile, mold, broken wheel chair • In behavioral health units do environmental risk assessment for suicide risks. Either fix or implement other safety interventions such as increase monitoring. Document and keep your risk assessment. ( or scored at EC.01.01.01)

32. Safety and Security(EC.02.01.01 – 15%) Hospital manages safety and security risks • Complete risk assessments on areas of potential risk • Scored in sensitive areas such as Labor and Delivery, Pediatrics • Trace your own policies, do staff stop you or surveyor when they enter area? • See unsecured O2 scored here JKC

33. Strategies for SuccessPreparing Clinical Areas • Rollout the Clinical Area Checklists • Email them out, assign, implement, collect them back, analyze compliance • Involve/educate clinical & frontline staff • Everyone knows who to call to get fixed • Identify areas to improve, fix it, then reassess • Make LS an every day expectation!

34. Strategies for SuccessDo Mock Surveys • Conduct mock tracers in clinical areas • Do EOC System Tracer during your Mock survey • Use the documentation checklist • “show me where this is documented” • Look for missing dates, think medication refrigerators when doing this!

35. Strategies for Success • Review your eSOC quarterly for updates, completion of projects • Validate that ILSM evaluations exist on paper for each PFI on the eSOC • Work with facilities staff and learn the language

36. Strategies for Success • Make use of the PPR to document compliance • Record the name and location of each report that documents compliance • Helps during on-site survey! • When in doubt, get clarity from SIG

37. Survey Process Preparation • Before your next survey prepare for and/or practice the following: • Day one documents – surveyor planning session • Environment of Care system tracer • Document Review session * • Emergency Management system tracer • LSC building tour *

38. Now That You Know… fix it • Options for managing self identified deficiencies in LS.02.xx.xx – LS.04.xx.xx • Correct it immediately • Fix in 45 days in corrective maintenance – document it. • If it takes >45 days, create a Plan for Improvement (PFI) in your e-SOC • Consider equivalency request to TJC

39. Managing the Onsite Survey …GOOD MORNING, WE ARE HERE FROM THE JOINT COMMISSION • Validate ID on the extranet • Institute your calling tree • Everyone or their back up initiates the pre-planned action. • Rooms are freed up, • Documents are rolled in, opening conference starts. Optional information shows great things only

40. Institute the Action Plan Everyone in Position

41. QUESTIONS? JenCowel@PattonHC.com Please visit and bookmarkwww.pattonhc.com