Troubled by frequent false alarms from medical devices, a pediatric unit at an Ohio hospital assembled a multidisciplinary task force and set out to fix the problem.
Christopher Dandoy, MD |
A common and not-so-silent killer is lurking in hospitals.
The Joint Commission reports that there were 98 alarm-related sentinel events and 80 alarm-related deaths in the U.S. between January 2009 and June 2012.
But staff at one Ohio hospital discovered a way to quell the noise—and in the process created a better environment for patients and their families.
"When there are hundreds or thousands of alarms, it becomes hard to differentiate between what's real and what's not. Humans have a natural tendency to disregard alarms if they're overused," says Christopher Dandoy, MD, a physician in the Cancer and Blood Diseases Institute at Cincinnati Children's Hospital and lead author of a study on his hospital's experiences on alarm fatigue.
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While these alarms were designed to alert hospital staff that something needs to be attended to immediately. But in practice, the number of alarms can be overwhelming for hospital staff, patients and their families.
Dandoy and his team learned that up to 95% of these alarms are false—usually traceable to non-customized parameters and inadequate staff-training—and that nurses spend up to 30 minutes per shift simply dealing with false alarms.
In addition to desensitizing medical staff to alarms, the incessant beeping and ringing caused problems for patients, too. "Sometimes patients would try to decrease the sounds [from the alarms] on their own," recalls Dandoy.
Both patients and hospital staff reported the alarms made them nervous, said Dandoy. "There's a lot of anxiety surrounding these things." The sound of an alarm can make it hard for a recovering patient to sleep, and can needlessly cause panic and worry for their families.
"The reason this came up was that we looked at the number of alarms we had on our floor, and it was just a monster number," says Dandoy. "It was just a small, small percent of those alarms that were acute decompensations or patients that needed specific attention."
The Search for a Solution
In January 2012, Dandoy established a multidisciplinary task force consisting of various stakeholders, including physicians, nurses, patient care assistants, and the families of pediatric patients. The study focused on a 24-bed pediatric bone marrow transplant unit.
One of the team's strengths was its diversity. "We had a huge team... each person was able to give input," Dandoy remembers, adding that patient family involvement was a top priority. The team reviewed current practices, published recommendations, identified areas that needed improvement, and began to test new practices and ideas using Plan-Do-Study-Act measures.
80% of Cardiac Monitors Set Incorrectly
The team learned that only a small amount—20%—of cardiac monitors were set to the correct parameters for an infant or child, accounting for many of the false alarms heard on the floor daily. An intervention to properly train staff on setting the monitors to the correct parameters for each patient was quickly staged.
"We kind of invented this cardiac monitor care process based upon our findings," Dandoy says. The team additionally worked to ensure correct calibration of other monitoring equipment prone to setting off alarms.
The team also learned that if monitor electrodes are not replaced daily, the number of false alarms increases due to reduced connectivity. Testing found that the number of false alarms increased 25% to 30% each day the electrodes were not changed.
An obstacle to daily replacement, however, is that many patients—especially children—find the removal and replacement of electrodes to be painful.
But the nurses on Dandoy's team had a solution. They knew that immersion in water—as in a bath—makes electrode removal much less painful. The practice has since been adopted throughout the hospital. And a policy of discontinuing the use of electrodes as soon as it is safe to do so has also been adopted.
Results
The number of false alarms has reduced from 95% of all alarms to 50%, and the amount of time nurses spend on resolving them to 10 to 15 minutes per shift. It's also made the hospital environment far more conducive to healing, says Dandoy. "People saw there was a substantial difference... they didn't hear the alarms going off anymore in the halls—[the change] sustained itself just with the sheer positive reaction people had from it."
Lena J. Weiner is an associate editor at HealthLeaders Media.