Purpose of Clinical Alarms Physiologic monitor alarms are intended to alert clinicians to potentially hazardous changes in a patients condition or if a device is not functioning properly Cvach ID: 723128
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Slide1
Alarm Safety in the NICUSlide2
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) Slide3
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 secondsSlide4
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 hospitalizationSlide5
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 alarmsDisruption in workflow causing errors due
to distraction
Missed alarms
(AACN, 2013)Slide6
Unintended Results
In 2007
“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)Slide7
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 sensorSlide8
Alarm Management
White dots in Pulse ox packaging
Don’t throw them away!
Use: Place on probe over actual sensor to improve signalPeel off top layerAnd place stickylayer over sensorto improve signal
and adhesivenessSlide9
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 Slide10
Alarm Management
Causes and examples of poor pulse ox signalsSlide11
Alarm Management
Charting pulse ox alarm limits
Alarm limits charted every shift must match
what is set on the patient’s monitorClick on blue reference text to identifyalarm parameter protocols Slide12
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 needSlide13
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 sensorSlide14
Alarm Management
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
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
Proper Skin Prep and
Placement for ECG leadsSlide15
Alarm Management
Understanding what the alarms mean:
Patient alarms
are red and yellow alarmsRed 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 blueIndicate when the monitor cannot detect or measure reliably
The monitor will sound for the highest priority alarmSlide16Slide17
Examples of Poor ECG Signals
Description- Trace switching from high to low steps
Possible causeloose or defective electrodesCorrective 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 respirationSlide18
Examples of Poor ECG Signals
Description-
Rough or jagged baseline
Possible causes
Poor electrical contact, respiratory interference, faulty or dry electrodesCorrective actionsReapply 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.Slide19
Alarm Management
Changing and care of ECG electrodes
Evaluate lead integrity with care
Check adhesive gel integrityFaded image on electrodeChange with bathing and if soiled
Images will fade over time indicating
possible need to be changedSlide20
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 therapySlide21
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 fatigueImproving management of alarms occurs throughAppropriate electrode management and skin preparationKnowledge of poor signal indications and solutionsDiscussion/RCA at the bedside for patient who are excessively alarming
Education and priority given towards oxygen therapy throughout department