Putting together an alarm management plan
Continuing Education Objectives
After reading this article, you will be able to:
- Explain the steps necessary to devise and implement a plan for alarm management
- Identify key alarm management issues for healthcare organizations
Editor's note: Column author Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, is a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor.
The topic of alarm hazards has crowned ECRI's top 10 list of health technology hazards for the last four years. It's no wonder: Spend any amount of time in a hospital, either as an employee or a visitor, and you are bound to be greeted by a barrage of beeps, various alarms, and other sounds.
Studies have shown that healthcare workers are subjected to hundreds of such alarms every shift, and that after a while, the sounds turn into white noise that can be ignored, causing alarm fatigue.
Alarm sounds can come from any number of sources, including:
- Infusion smart pumps
- Bed exit alarms
- Pulse oximetry
In 2013, The Joint Commission issued Sentinel Event Alert #50 after a study showed that 80 patients had died as a result of alarm-related events. And in 2014, The Joint Commission issued a National Patient Safety Goal (NPSG) on clinical alarms, NPSG.06.01.01, to help hospitals combat this problem.
Healthcare systems have had almost two years to determine the most important alarm signals and figure out how to manage those signals within their facilities. Surveyors can ask questions about the 2016 standards now, but the standards will not take effect until January 1, 2016.
In phase one of NPSG.06.01.01, hospitals were tasked with identifying alarm safety as a top priority and to begin the process of identifying the most important alarm signals to manage. If they haven't begun to do these things, they should start now.
The following serves as a guideline for identifying the most important alarms. Hospitals should determine what works best for them and modify their approach as appropriate for certain clinical units and patients:
- Assemble a multidisciplinary team.
- Analyze recent events?have there been any near misses?
- Talk to medical staff.
- Determine patient risk if an alarm is ignored or doesn't work.
- Identify which alarms are needed and which ones add to alarm noise and fatigue.
- Identify possible causes of potential alarm failures.
- Create best practices and policies.
The second phase of the NPSG rolls out January 1, 2016. In this phase, hospitals will need to have devised a plan and implemented policies for managing alarm hazards. The following information should be included in the hospital's plan:
- Identify appropriate settings for alarms (clinical)
- Identify when alarms can be disabled
- Identify who in the healthcare organization can change alarm parameters and/or disable the alarms
- Identify who has authority to set/change alarm parameters
- Identify who has authority to set alarm parameters to "off"
- Establish systems check for observing and responding to alarm signals
- Establish settings check to ensure individual alarms have appropriate settings, detectability, and operation
Finally, licensed independent practitioners and staff will need to be educated about the policies and procedures as applicable to their areas of responsibility. Education and training should be ongoing.
Responsible alarm management will allow healthcare workers to respond to critical alarms in a timely manner as well as providing a more quiet and restful environment for patients.
American Association of Critical Care Nurses. Developing a Comprehensive Alarm Management Plan.
Blouin, A., & The Joint Commission. Alarm Safety: Preparing for NPSG Compliance in 2016.
CHPSO, a division of the Hospital Quality Institute. Clinical Alarm Management. www.chpso.org/clinical-alarm-management
Clinical Alarms. www.aami.org/htsi/alarms/index.html
The Joint Commission Announces 2014 National Patient Safety Goal. www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf
Sentinel Event Alert #50.www.jointcommission.org/sea_issue_50/2
A Work Plan for The Joint Commission Alarm National Patient Safety Goal. http://thehtf.org/documents/A%20Work%20Plan..Alarm..NPSG.pdf
Key issues for healthcare organizations
Are clinical alarm settings appropriate?
Who can disable alarms?
When can parameters be changed?
Who has the authority to set/change parameters?
Who has the authority to disable/"turn off" parameters?
Who responds to and monitors alarm signals?
Are alarm signals detectable, operational, and accurately set?
ECRI's top 10 health technology hazards
1.Alarm hazards: inadequate alarm configuration policies and practices
2.Data integrity: incorrect or missing data in electronic health records and other health IT systems
3.Mix-up of IV lines, leading to misadministration of drugs and solutions
4.Inadequate reprocessing of endoscopes and surgical instruments
5.Ventilator disconnections not caught because of mis-set or missed alarms
6.Patient-handling device use errors and failures
7."Dose creep": unnoticed variations in diagnostic radiation exposures
8.Robotic surgery: complications due to insufficient training
9.Cybersecurity: insufficient protection for medical devices and systems
10.Overwhelmed recall and safety alert management programs
Editor's note: The following is an excerpt from Preventing Healthcare-Associated Infections by Peggy Prinz Luebbert, MS, CSL(ASCP), CIC, CHSP. Visit http://hcmarketplace.com/preventing-healthcare-associated-infections-a-guide-to-establishing-an-effective-infection-prevention-program for more information.
Outbreaks should be suspected when the facility detects healthcare-associated infections, recovery of unusual or epidemiologically significant pathogens, or when an unusual microbe is recognized. Healthcare-associated outbreaks often have multiple causes. The goal of any outbreak investigation is to identify probable contributing factors and to stop or reduce the risk for future occurrences.
If an outbreak or cluster is suspected in the hospitals or clinics, an infection preventionist (IP) will typically assume primary responsibility for the investigation. In some cases, the outbreak investigation may take priority over routine surveillance and other routine activities. Not all outbreaks require a full investigation. The decision to investigate an outbreak will be based on factors such as the severity of illness, potential for additional cases to occur, institutional priorities or requirements, and availability of resources.
Epidemics or outbreaks are defined as an increase over the expected occurrence of an event. It is important to remember that a single case of an unusual disease (e.g., Legionella, Ebola) may constitute an outbreak. Some small outbreaks are often referred to as "clusters." Some outbreaks investigated by IPs in the healthcare setting include: lice, bedbugs, Clostridium difficile, hepatitis C, surgical site infections, Aspergillis pneumonia, and norovirus.
During a facility's annual risk assessment, potential outbreak etiologies should be evaluated. For example, have there been outbreaks of bedbugs or norovirus in the community? Is lice a common concern with your population? If deemed to be a potential risk, specific management plans should be developed ahead of time to give the facility guidance when an outbreak does happen. I have included sample examples of both a bedbug management plan as well as lice management plan in this book.
Epidemiological investigation of outbreaks should be conducted in a standardized way. However, since no two outbreaks are the same, it is important to realize that an investigation may not need all of the following steps or may combine some steps or even repeat the steps many times. In this chapter, we will provide a basic primer of an epidemiological investigation in the healthcare setting. Many resources?including public health classes?are available to assist in further information on this complex topic.
Typically, the CDC identifies 10 steps in an investigation and separates them into two sections: the initial investigation and then the follow-up investigations.
Confirm the presence of an outbreak. When an outbreak or cluster is suspected, the first step in the investigation is to confirm that what is reported to the IP is truly real. To establish that an outbreak is real (i.e., there are more cases than expected), an investigator can examine health department surveillance records, hospital records, and other disease registries. If this information is unavailable, other options include interviews with doctors, clinical staff, or even some people within the community. For example, I once received a phone call from a clinical manager noting that she had two patients on her unit that were just diagnosed with tuberculosis. When I went to investigate, it turned out the two patients had PPD skin tests performed. The results of the PPD tests were positive, but the patients had no symptoms and their chest x-rays were negative. Therefore, we did not have an outbreak; just two patients who had been exposed to TB in the past. In another situation, I received a phone call from a chemist in the clinical laboratory who told me that she had just run a batch of liver chemistry tests and a higher number than usual were elevated. Once I investigated the patient's clinical records and interviewed their (and other) physicians, I was able to confirm that we potentially had a hepatitis A outbreak in the community.
Alert key partners about the investigation. It is crucial to alert key individuals of a potential outbreak. Facility administrators and risk management, along with appropriate public affairs staff, should be made aware as soon as possible. In many hospitals, the Hospital Incident Command (HIC) system may be initiated to assist the investigator in managing the outbreak as well. Depending upon the situation, the emergency room staff as well as the laboratory may need to be alerted so that they can report any new cases or related activities. Again, depending upon the organism/illness, the local public health system should be made aware of the potential risk to the community to assist in the investigation as needed. For example, in a recent norovirus outbreak I assisted in, we contacted the health department to help find a rehab facility willing to take a patient from the involved facility.
Perform a literature review. A literature review can assist in identifying possible sources that might merit further investigation and might help in finding ways to limit further transmission through proper isolation and treatments.
Establish a preliminary case definition. It is important initially to set up a definition of what you are going to consider to be a "case" in your outbreak. Depending upon the organism, population, or even time frame, specific information may be important to add to the case definition. Some examples of definitions might include:
Any positive Legionella lab result
Staph aureus infections following orthopedic surgeries
Confirmed laboratory influenza cases
Clostridium difficile HAIs in a clinical unit
Develop a methodology for case finding. Identifying additional cases in the outbreak will take some further investigation. A review of laboratory results, for example, will assist if the organism is one that can be confirmed in the laboratory. The investigation will need to take into consideration whether the lab test confirms a true infection or just colonization. In some cases, it may be important to know new colonizations, as they may indicate a reservoir for further cases. Clinical assessment of all potential patients affected may also be an effective way to identify cases. In some situations, you may need to go further than just the patients in clinical assessments. In an ongoing difficult lice outbreak in a large long-term care facility, we found our reservoir was an asymptomatic husband of one of the residents. In some cases, you may want to do some surveillance cultures to assist in finding cases. During an MRSA outbreak in a large NICU, we needed to do nasal swabs of the children to identify further colonizations.
Prepare an initial line list and epidemic curve. The key step to help focus on the potential sources or risk factors involved in the outbreak is to develop a line listing of cases. It is important initially to identify potential common factors on this list; however, each factor you add to investigate is going to add time to the investigation. Thus, the investigator needs to weigh the risk with the time involved in evaluating a large group of factors. Once the preliminary line list is evaluated, one can always add more factors for those patients who truly meet the definition. Some details on these line lists might include:
Date/time of symptoms
Date admitted to facility
Staff caring for patient during specific time periods, including respiratory therapists, physical therapists, and phlebotomists
Predisposing health factors
In many outbreaks, epidemic curves can be very helpful in evaluating modes of transmission. Below (in the full book) is an example of a curve that would help determine the probable period of exposure in a common source outbreak. It is beyond the scope of this book to interpret potential epidemic curves you may develop. I suggest that when a facility is in need of developing and interpreting these epidemic curves, it should collaborate with a statistician in the facility, or if necessary, with public health outbreak investigators for assistance.
Observe and review potentially implicating patient care activities. At this time, the line listing may give the investigator some general clues to who/what/where the outbreak may be occurring. For example, during a Clostridium difficile outbreak, the investigator may have noted that all the infections were on one side of a nursing unit. Going on the unit and observing, listening, and asking staff questions?in a nonpunitive way?may assist in identifying if a work practice is not up to par. In this circumstance, the investigator may look into cleaning processes, hand hygiene, and movement of reusable equipment. Don't be afraid to spend time watching to identify people who may do things differently, or see how/when medications are given, etc.
Consider whether environmental sampling should be performed. After reviewing the line list and doing some observations and interviews, it may seem that the potential source of an outbreak is environmental, and cultures may be necessary. As satisfying as it may seem to get a positive culture from a source, most outbreaks that an IP investigates will not come from a specific source. Environmental cultures should never be the first step in an outbreak. These cultures can also be expensive, difficult to interpret, and misleading. If the investigation is leading to the environment, focus on the surfaces that seem most likely to be involved. Meet with your microbiology staff to be sure the right methods are used to obtain the specimen and that the lab is actually able to process the specimen for the organisms you may be interested in. These microbiologists will also be able to give guidance on what types of items the organism in question would most likely be contaminated with. For example, if Legionella is suspected from a water supply, consider that most clinical laboratories will be unable to perform this complex testing procedure and would need to send the specimen to a reference lab.
Implement initial control measures. Once the investigator and key staff involved recognize control measures that may assist in limiting the spread of the outbreak, it is important to implement them as soon as possible. These control measures could be related to checking a specific protocol or use of a specific item, such as a bronchoscope, or may be related to a process associated with delivering a medication. The implementation of changes should be documented as they occur, including timelines and expenses. In addition, the importance of education of staff involved is key to ensure compliance with the changing control measures.