Embed Size (px)
Citation preview
Alarm Management Workshop:
A Decade of Action June 7, 2015
Tobey Clark, President
Healthcare Technology Foundation (HTF)
& Director/Faculty
University of Vermont
© 2015 Association for the Advancement of Medical Instrumentation www.aami.org 1
2
Healthcare
Technology Foundation
Mission:• "Improve healthcare delivery outcomes by
promoting the development, application and support of safe and effective healthcare technologies.“
Actions:• The promotion of excellence in clinical engineering leadership through
research, education and certification
• Funding of related research and programs,
• Effective collaborations between medical device producers, regulators, users and clinical engineers,
• The creation of safety-related education material that is useful to members of the pubic
3
Healthcare
Technology Foundation
Major initiatives:
• Public Awareness and Education on Technology Safety
• Managing Risks of Integrated Systems
• Clinical Alarms Management and Integration• “To improve patient safety by identifying issues and
opportunities for enhancements in clinical alarm design, operation, responses, communication, and appropriate actions to resolve alarm-related events.”
– Initiative began 2005
– AAMI annual meeting • Clinical Alarm Hazards: Town Meeting
HTF website: http://www.thehtf.org/
Healthcare Technology Foundation
Clinical Alarm Initiative Key Deliverable
4Numerous citations of HTF White Paper which Includes
2006 US National Clinical Alarms Survey Results
Literature Review
• Alarms significant problem area for many years (ECRI Hazard Report 1974)
• Humans can’t learn more than six alarm sounds and priority difficult to discern (Stanton, 1994)
• The perceived urgency of audible alarms can be inconsistent with the clinical situation (Mondor, 2003)
Design Smart alarms Integration/remote Usability/human
factors Standards
Care managementTrainingMonitoring (rounds)Use best practice guidesInstitutional standards
6
Environmental Better design of facilities
Monitoring (rounds)
Communication Alarm integration to pager, cell
phone, etc.
Clinical engineering Evaluate purchased items for
usability
Test alarms in their environment
Software setup/testing
2011 US National Clinical Alarms
Survey
• Re-survey of the field
• Sponsorship – AAMI, ACCE, PHILIPS & HTF
• Response:
4278 responders – 93% clinical staff
• Reported on the results at the AAMI Medical Device Alarms Summit
8
HTF Clinical Alarms Task Force
• Chair: Izabella Gieras, Huntington Hospital– Jennifer Ott. Thomas Bauld, Marge Funk, Yadin David,
Karen Giuliano, Paul Coss, Marcia Wylie, Tony Easty, and Tobey Clark
• Current/Recent Projects
– Three AJCC papers• Sept 2015: Listening to Nurses' Perspectives on
Clinical Alarms
– WC2015 session
– Alarms and home health
– Patient brochure• Alarms 101
Healthcare Technology Patient
Safety Resource Center
Focus on critical equipment
Healthcare Technology Patient
Safety Resource Center
• What you need to know about Home Infusion
• What’s involved in Home Infusion
• What are the risks
• How can I stay safeUnderstand the technology
Contact information available
Side effects of medication
Infection control
Don’t change pump settings!
Batteries!
11
Alarms Brochure for Patient and Family
• Introduction
• Types of alarms
• Why do these alarms sound? Is something
wrong?
• Impact of Clinical Alarms on Patients and
Families
• Role of the patients and visitors when clinical
alarms sound
• Healthcare Organizations involved with alarms
– Review of publication by patient advocate
12
Alarms Improvement Actions:
University of Vermont Medical Center
• Efforts started in 2004– TJC National Patient Safety Goal
– Alarms inventory and prioritization/all units
– Online education
• Meeting 2014-16 NPSG
– Leadership: Executive, physician, nursing, co-directors
– Alarm prioritization in 84 units• Focus on data analysis
– Policies
– Education
University of Vermont Medical Center (formerly Fletcher Allen Health Care)
University of Vermont Medical Center (formerly Fletcher Allen Health Care)
1,560 incident reports were analyzed. 314 reports directly involved the alarms
Incident Data Review
Incident Review
Incident Review
Alarm Type Review: 30 days data50 bed Tele Unit Grand Total of All Alarms/Alerts: 172,970Philips systemonly
Alarm Type Review:
2 Days, 8am - 4pm (Semi-automatic)
NICU
Alarm Number of alarms Percentage (%)
Low SpO2 136 33.7
Low HR 97 24.0
Desat 51 12.6
High SpO2 31 7.7
High HR 19 4.7
VT High 16 4.0
Infusion complete 15 3.7
Others 16 4.0
Brady 10 2.5
Check syringe 3 0.7
Battery Low 2 0.5
VT not reached 2 0.5
Asystole 1 0.2
Check baby 1 0.2
Check channel 1 0.2
Vent disconnected 1 0.2
MV Low 1 0.2
Pump occluded 1 0.2
Total 404 100
Improvement:
Online Alarms Education
Online education since 2008 Orientation and ongoing education on high priority
device alarms Sections
Importance of alarms
Device background & specific device guide
Alarm audio and video for all device alarms
Meaning and response / Evaluation http://its.uvm.edu/FAHC_Alarms/McClure5/IndexMCC5.html http://its.uvm.edu/FAHC_Alarms/MICU%20Alarms/index.html http://its.uvm.edu/FAHC_Alarms/Shep3South/index.html http://its.uvm.edu/FAHC_Alarms/Web%20Page/IndexNICU2.html
