Alarm Safety in the NICU - PowerPoint Presentation

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 alarmSlide16
Slide17

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