Management of Clinical Alarms.docx

THE MANAGEMENT OF CLINICAL ALARMS

MCP 118PCS.29

VA Salt Lake City HCS Salt Lake City, Utah 84148

Signatory Authority:

VA Salt Lake City HCS, Director Responsible Owner:

Patient Safety Manager Rescinded Document:

None Effective Date:

June 9, 2022 Recertification Date:

June 30, 2027

1. POLICY

All alarm systems incorporated into medical and patient monitoring equipment will be activated when the equipment is being used in patient care. Alarm limits will be set in a range appropriate to the individual patients’ clinical condition such that a significant change in the patient’s condition or an abnormality in the operating condition of the monitoring equipment will trigger an alarm. Alarm parameters will be adjusted to minimize recurring non-actionable audible alarms. Every effort will be made to limit the number of false and nuisance alarms that occur on both a unit and individual patient level. The volume of the alarms will be audible over competing noise and within an appropriate distance to be heard by the responsible clinician. Clinical staff in high-risk areas with multiple alarms will be able to identify, operate and respond to clinical alarms as determined by their service-specific policies, procedures and guidelines. Areas with low alarm utilization are to follow the procedures in this memorandum. Selection criteria for new clinical monitoring equipment will include alarm performance, human factors, and environmental setting.

2. JUSTIFICATION

To establish policy, procedures, and responsibilities to reduce patient harm related to alarm systems.

To establish a process for safe alarm management and response in high-risk areas by addressing technological, environmental, and human factors.

3. RESPONSIBILITIES

a. VA Medical Facility Director. The VA medical facility Director is responsible for ensuring overall VA medical facility compliance with this policy, and appropriate corrective action is taken if non-compliance is identified.

b. Chief of Biomedical Engineering.

(1) responsible for the Equipment Management Program

(2) ensuring selection criteria for physiological monitors emphasizes alarm performance

(3) working with the Patient Safety Manager to correct identified clinical alarm concerns or problems

(4) providing technical support to the high-risk clinical areas in setting equipment parameters and mapping alarms system data when indicated

(5) reviewing and analyzing available data with Patient Safety Manager to monitor the status of successful implementation of alarm management strategies/plans

c. Service Chiefs and Department Managers.

(1) Responsible for ensuring staff are educated and competent in management of the alarm systems for which they are responsible in accordance with Memorandum 11.18, the “VA Salt Lake City Health Care System Competency Assessment Program.”

(2) Working with the Chief of Biomedical Engineering and the Patient Safety Manager to determine the standard default alarm parameters for physiological monitoring in high-risk areas (Normal, Advisory, Warning and Crisis/Critical), (Attachment A)

d. Equipment users. Equipment users are responsible for setting, monitoring, responding to clinical alarms and reporting an “event” or “close call” associated with malfunction or improper use of alarms through the incident reporting system.

e. Patient Safety Manager.

(1) responsible for reporting clinical alarm-related findings from Joint Patient Safety Reports (JPSR) to the facility leadership

(2) identifying physiologic monitors in high-risk clinical areas where monitoring takes place either episodically or continuously,

(3) writing and revising the hospital policy for the Management of Clinical Alarms

(4) ensuring effective communication and deployment of Management of Clinical Alarms policy to high-risk clinical areas.

(5) assisting high-risk clinical areas in the establishment of unit protocols for reducing alarm fatigue and the management of clinical alarms

(6) providing guidance in implementing the effective use of clinical alarms

(7) conducting an annual review and updating the list of alarm-equipped medical devices, (Attachment B)

(8) reviewing and analyzing available data with the Chief of Biomedical Engineering to monitor the status of successful implementation of alarm management strategies/plans.

4. OTHER PARAGRAPHS

Procedures

a. Clinical staff and/or healthcare providers will receive adequate training on new clinical equipment prior to use. Training is the responsibility of area supervisors. Training will include alarm functions and response procedures. Refresher training will be provided as needed. Evidence of training, such as attendance sheets and training reports, will be maintained by the supervisor or education designee.

b. Clinical staff and/or healthcare providers will respond to clinical alarms as indicated by priority level as follows:

(1) CRISIS/CRITCAL: audible alarms indicating a condition that requires immediate attention and could result in temporary or permanent harm.

(2) WARNING: audible alarms indicating a condition that requires prompt attention.

(3) ADVISORY: audible or visual alarm meant to call attention to a medical device or patient condition that needs re-assessment.

c. Staff members will promptly enter the patient’s room when crisis/critical clinical alarms sound and assess the patient and reason for the alarm. Deactivation of an alarm can only occur after the patient has been assessed.

d. Clinical staff will verify alarm limit settings (include visual alerts) and validate alarm parameters every shift.

e. Excessive false or nuisance alarms requiring action that cannot be remedied by clinical staff (i.e., equipment malfunction, false alarm requires deactivation, multiple devices/services are affected, etc.), will be reported to the Nurse Manager or Clinical Nurse Officer, Biomedical Engineering Department and/or Patient Safety for resolution.

f. Best practice and nursing actions for false alarm reduction will be incorporated into Standard Operating Procedures for identified high-risk areas.

g. Alarm volumes will be adjusted so that they are audible, in the presence of ambient noise, to clinical staff within the unit or work area. Efforts will be made to decrease environmental noise when possible.

h. High-risk areas will collaborate with the Biomedical Engineering Department to ensure physiological monitoring devices are configured to reduce non-actionable audible alarms.

i. Alarm parameters will be set utilizing VASLCHCS approved default alarm parameters and in accordance with unit-specific Standard Operating Procedures to meet individual patient needs, minimize duplicate alarms, and minimize noise by using visual advisory alarms when appropriate.

j. Clinical staff and health providers must not disable alarm devices (hard set limits) for any patient monitoring equipment. If an unusual clinical situation arises where a specific alarm parameter needs to be altered or shut-off completely, the following process will be followed:

(1) During normal business hours:

a. Clinical staff will present the issue to the unit nurse manager and provider on service who will then determine if a specific parameter needs to be altered or shut-off completely

b. Unit nurse manager or designee will notify Biomedical Engineering and document request in an email to Chief of bio-med, provider on service, appropriate chief nurse and Patient Safety Manager

c. Biomedical Engineering staff will disable the selected parameter and email the unit NM, provider on service, Patient Safety Manager and chief of bio-med of actions taken

d. The appropriate chief nurse will then inform the Pentad.

e. Unit nurse manager or designee will ensure the monitor is identified by a sign that alarms are disabled. Sign can only be removed by biomedical engineering once the alarms are re-instated.

f. Biomedical Engineering must be contacted immediately by the unit Charge Nurse upon discharge or transfer of the patient so that the disabled parameter is reset BEFORE any other patient is admitted to that monitor.

g. Biomedical Engineering will email the Chief of Biomedical engineering once the parameters have been enabled. The Chief of biomedical Engineering will then email the Unit Manager, Patient Safety Manager, appropriate Chief Nurse and Pentad that the parameters are no longer disabled.

(2) After hours:

a. Clinical staff will ensure they have taken all possible steps to eliminate a continuous false alarm

b. Clinical staff will present the issue to the Chief Nursing Officer (CNO) and provider on service who will then determine if a specific parameter needs to be altered or shut-off completely

c. CNO will notify Biomedical Engineering by calling the boiler plant who will in turn notify the Chief of Biomedical Engineering of the request. The CNO will document request in an email to Chief of bio-med, provider on service, appropriate chief nurse and Patient Safety Manager

d. The Chief of Biomedical Engineering will contact their staff with the afterhours request.

(1) If Biomedical Engineering is available, they will disable the selected parameter and email the unit NM, provider on service, Patient Safety Manager and chief of bio-med of actions taken.

(2) If Biomedical Engineering is not available at the time of the initial request the Chief of Biomedical Engineering will notify the CNO and identify a time when a Biomedical Engineer will be available to complete the request. Once the selected parameter is altered or disabled, they will email the unit NM, provider on service, Patient Safety Manager and chief of bio-med of actions taken.

e. The appropriate chief nurse will then inform the Pentad.

f. Unit nurse manager or designee will ensure the monitor is identified by a sign those alarms are disabled. Sign can only be removed by biomedical engineering once the alarms are re-instated.

g. Upon discharge or transfer of the patient the disabled parameter must be is reset BEFORE any other patient is admitted to that monitor.

(1) The NM or designee will contact Biomedical Engineering on the next working day to re-instate the parameter.

(2) If the unit census does not allow for the ability to wait until the next working day to re-instate the parameter, the unit charge nurse will notify the CNO to contact the boiler plant of our emergent need.

h. Biomedical Engineering will email the Chief of Biomedical engineering once the parameters have been enabled. The Chief of biomedical Engineering will then email the Unit Manager, Patient Safety Manager, appropriate Chief Nurse and Pentad that the parameters are no longer disabled.

i. Temporary silencing of alarms is permitted for routine patient care activities (such as turning, endotracheal suctioning, etc.) provided that clinical staff is at the bedside. Clinical staff must remain in direct observation of the patient until the monitoring alarm system is no longer silenced.

j. Observation of alarms response will be performed bi-annually by the Charge Nurse or designee on each shift as scheduled by the Nurse Manager. These observations will be documented on the observation template (Attachment C). The Nurse Manager will forward completed templates to the Patient Safety Committee via the Patient Safety Manager.

k. Equipment with clinical and other patient safety alarms will be part of medical inventory and scheduled for preventative maintenance. If a piece of equipment is found to be faulty, a work order must be submitted, tagged with yellow maintenance required sticker and Biomed informed.

l. Any staff member who identifies an actual or potential threat to the safety of a patient(s) related to the use of clinical alarms; whether it is related to alarm fatigue, alarm failure, inappropriate deactivation of alarms, or otherwise, will complete a JPSR incident report through the VHASLCHCS Intranet.

5. DEFINITONS

a. Clinical Alarms. Alarm systems that are either built in or attached to medical equipment and monitoring systems, and that are triggered by physiologic changes in the patient or by variations in measured parameters of medical equipment directly applied to the patient. Clinical alarms include but are not limited to cardiac monitors, pulse oximetry, ventilators, bipap-cpap, infusion pumps, patient call lights, and bed exit alarms.

b. Alarm Fatigue. Phenomenon that occurs when one is exposed to a large number of frequent alarms and consequently becomes desensitized to them. Desensitization can lead to longer response times or to missing important alarms.

c. False Alarms. Presence of an alarm when no actionable event has occurred in the patient, equipment, or alarm system.

d. Nuisance Alarms. Those alarms deemed false or of little meaning to the patient’s clinical condition.

e. High-risk areas. Clinical areas where continuous physiological monitoring occurs without constant 1:1 observation. High-risk areas include the Intensive Care Units, Telemetry Unit, Acute Medical Unit, Acute Surgical Unit, the Emergency Department, and the Post Anesthesia Care Unit.

6. REFERENCES

a. Association for the Advancement of Medical Instrumentation (2014-18). Anthology, Alarm Management Solutions. Available at: https://www.aami.org/docs/default-source/foundation/alarms/aamifoundationalarmanthology.pdf?sfvrsn=26d265b3_10

b. Association for the Advancement of Medical Instrumentation (2014-18). Alarm System Vocabulary. Available at: https://www.aami.org/docs/default-source/foundation/alarms/alarm-system-vocabulary.pdf?sfvrsn=49695f46_2

c. Cosper,P., Zellinger, M., Enebo, A., Jacques, S., Razzano, L., Flack, M.N. (2017). Improving clinical alarm management: Guidance and strategies. Biomedical Instrumentation & Technology.

d. Cvach, M., Kitchens, M., Smith, K., Harris, P., Flack, M. N. (2017) Customizing alarm limits based on specific needs of the patients. Biomedical Instrumentation & Technology.

e. The Joint Commission. National Patient Safety Goals (2022). Available at: https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf

7. RECISSION

None.

8. REVIEW

This policy will be reviewed, at minimum at recertification and including when there are changes to the governing document.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of June 2027 This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

/s/ Amy Christian, for Angela Williams, Pharm. D, MS, VHA-CM VHASLCHCS Director Date Approved: 6/9/2022

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MCPs are available at: http://vaww.visn19.portal.va.gov/sites/slc/policies-memorandums/SitePages/Home.aspx

Attachments Attachment A Unit Default Alarm Parameters

Attachment B Hospital Risk Assessment VHASLCHCS Clinical Alarm Risk Assessment Clinical alarms are intended to alert hospital staff of potential problems, but if not managed properly they can compromise patient safety. For the purpose of this inventory, clinical alarms are defined as follows:

a) Alarms on medical equipment that are triggered by physiologic monitoring of the patient.

b) Alarms of medical equipment directly applied to the patient and are triggered by variations in measured parameters

c) Alarms that are self-activated by the patient Examples of equipment with Clinical Alarms include but are not limited to cardiac monitors, pulse oximetry, ventilators, bi-pap-c-pap, infusion pumps, patient call lights, and bed exit alarms.

Please complete an alarm risk assessment of your unit by completing your individual unit worksheet below. The equipment listed is from your prior assessment in 2018, please add or delete equipment if needed. Please return by COB 2/16/22.

Risk and Probability Scoring:

Probability (P)- likelihood of alarm sounding within 8-hour period

· Frequent/Expect it=4

· Likely=3

· Maybe/Occasional=2

· Rare/Uncommon=1

· Never=0 Current System (CS) for how we address/respond to the alarm; is there an SOP, process or an engineered mechanism in the device that turns device off or slows:

· None= 4

· Poor= 3

· Fair= 2

· Good= 1

· Excellent = 0 Potential Risk/Severity (R) to patient if Alarm goes unanswered, has been silenced without corrective action or parameters changed inappropriately Acuity of the patient must be considered

· Catastrophic - Loss of life/limb, permanent loss of function = 4

· Major Event- Permanent lessening of bodily functioning (sensory, motor, physiologic or intellectual), disfigurement, surgical intervention required, increased length of stay or level of care = 3

· Moderate Event - Temporary loss of function, treatment required but condition reversible, no long- term effect to patient, may increase length of stay =2

· Minor Event – No injury. No increased length of stay, increased level of care, additional treatment and/or financial impact to patient = 1

Hospital Inventory: 3W (3), 2E, (2), ICU (I), Tele (T), PACU (P), AMU (A), ED (E)

0-4 Current System (CS) for responding

0-4 Potential Risk (R)

1-4 Total Risk Score (P+CS+R) <6 low risk, 6-12 high risk

Attachment C Cardiac Monitoring Alarm Management Department Observation Tool Salt Lake City VAMC Unit/Shift_______________________________ Date________________________________

Please audit a minimum of eight observations/requirements. Submit completed report to Patient Safety Manager Bi-annually.

# of non-compliant observations

Alarm parameters are set according to facility policy or unit-specific guidelines.

Response to alarms occurs according to unit-specific guidelines

Nuisance or false alarms are not occurring

Clinical Alarms are audible throughout the unit image1.png