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JCAHO’s clinical alarm safety goal requires teamwork, collaboration
Work closely with biomed professionals to ensure alarms meet standard
As quality improvement professionals tackle the Joint Commission on Accreditation of Healthcare Organizations’ patient safety goals, one of the goals is proving to be more challenging and confounding than the others. As one Joint Commission official puts it, the goal regarding clinical alarms is "the one that they assign to you if you didn’t go to the patient safety meeting. They have a patient safety meeting and say, OK. Whoever didn’t show up for the meeting, you do the alarm thing.’"
In the 2003 Patient Safety Goals released by the Joint Commission, goal No. 6 is "improve the effectiveness of clinical alarm systems." The goal states that accredited facilities should "implement regular preventive maintenance and testing of alarm systems" and "assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit." Because that goal involves some technical issues that are not found in the other patient safety goals or accreditation concerns, peer review and quality improvement professionals often are unsure how to proceed, says Britton Berek, CCE, MBA, associate director of the standards interpretation group for the Joint Commission.
"This one is not as straightforward as the other ones," he says. "People have a hard time wrestling with who should do what. I think one of the problems has been that they see this is about alarms, so they think this must be for the biometric guys. But there’s more to it than that. You can’t just hand it off to the biometric guys and be done with it."
So what’s the best strategy for addressing this patient safety goal? Berek says you break down the goal into different components and assign tasks to various departments throughout your organization. Ensuring that clinical alarms work well requires a multidisciplinary, collaborative approach, he says.
"When any one person looks at it, they’re overwhelmed. That’s probably the most frequent response to this goal. People say, I don’t even know where to begin.’ There are very different aspects to it; so if you dump it on nursing, they won’t be able to handle the biomed aspects, and if you dump it on biomed, they won’t be able to handle the user concerns. So it really needs to be a multidisciplinary approach," Berek adds.
Because it poses a particular challenge, goal 6 may be the last patient safety goal addressed by many institutions. The 2003 National Patient Safety Goals — the first to be issued by the Joint Commission — were released in 2002 and are in effect through the end of the year. The Joint Commission established these goals to help accredited organizations address specific areas of concern in regards to patient safety. Each goal includes no more than two succinct, evidence- or expert-based recommendations.
Each year, the goals and associated recommendations are re-evaluated; some may continue while others will be replaced because of emerging new priorities. New goals and recommendations are announced in July and become effective on Jan. 1 of the following year. The goals for 2004 will be released this month.
The Joint Commission surveys accredited health care organizations for implementation of the goals, and failure by an organization to implement any of the applicable recommendations (or an acceptable alternative) will result in a special Type I recommendation.
Berek says your first step
should be checking out the "Frequently Asked Questions" about the patient safety
goals on the Joint Commission’s web site (www.jcaho.org/accredited+organizations/patient+safety/npsg/
"Use that information to help define the scope, and divide this thing into buckets," he advises. "There are environment-related issues, user-related issues, and equipment issues. Then go on and assign people in those different buckets to different tasks. Then, finally, document for us that all this occurred."
The scope of the patient safety goal is broad, Berek says. "Clinical alarm" brings to mind ventilators and cardiac monitors, but he says the goal really involves nearly any device that emits an audible warning or alert.
The official definition offered by the Joint Commission includes any device "triggered by physical or physiologic monitoring of the individual, by variations in measured parameters of medical equipment directly applied to the individual, or self-actuated by the individual."
Examples of clinical alarms include cardiac monitor alarms, apnea alarms, elopement or abduction alarms, infusion pump alarms, alarms associated with gas pressure or concentration, and emergency assistance alarms such as the panic buttons found in patient bathrooms.
Work with experts in other departments
There are many ways to address the patient safety goal, but Berek says the best approach will involve a collaboration across many departments — quality improvement, facilities, biomed, and nursing, for starters.
The biomed department may take on the bulk of the work that is technical in nature, but there is a great deal of work that is not, Berek says.
That was what Tim Cox, RRT, director of respiratory care at the duPont Hospital for Children in Wilmington, DE, found when he sought to improve clinical alarms at his facility.
The hospital’s effort to upgrade its pulse oximetry systems coincided with the effort to comply with patient safety goal No. 6, and Cox says it would not have been possible without the cooperation of several departments. Biomed and quality improvement representatives both sit on the hospital’s patient safety committee, and Cox joined the effort to devise a better way to monitor pulse oximetry on pediatric patients. (They decided to acquire more sophisticated equipment, though that is not the only way to address alarm problems.) A key component of the project was making sure that all the different departments kept the end user in mind.
"You want to be able to look at it through the eyes of the health care provider," he says. "Whatever you do should enhance their care of the patient, as opposed to being obstructive. You could be obstructive by applying a lot of technology that is fundamentally OK and provides good data, but the bottom line is whether it is of value in managing the patient."
One of the first steps is to make sure that all equipment with an alarm is inventoried and included in a preventive maintenance program. A good starting point is to create a master list of all devices with alarms and make sure that you include all the different kinds of ventilators, for instance. Then make sure that each of those items is on someone’s list for preventive maintenance. That task usually falls to facilities or biomed, and sometimes they share the task.
Just make sure that no device falls between the cracks. Frequently, those department will schedule annual or semiannual maintenance of each device that includes removing the cover, cleaning, and testing, a practice that Berek says is good but not enough.
"If that’s the only time things are looked at — once a year to see if the alarm is working — that’s probably not enough," he says. "There also should be some kind of quickie check that the user does without taking the cover off, rather than waiting for this major event to see if the thing makes noise."
Berek cautions that some alarms may not come to mind immediately when you are preparing your inventory and charting preventive maintenance. Elopement and abduction alarms may be overlooked because they don’t spring to mind immediately as "clinical" alarm systems, but he says they’re included in the patient safety goal.
Involving the user for ongoing alarm checks doesn’t have to be a burden for staff, Berek says. Some facilities implement programs in which some alarms are checked routinely by typical users, such as the nurses on an obstetrics unit.
You can devise a system in which individual infant abduction alarms are charted on the unit and the nurses test a few of them each day or week. It can be as simple as taking a few of the tags and walking to a protected exit to see if they activate. The results can be noted on a chart, and then a few different alarms are tested the next time. In the same way, the nurses can challenge a different exit each day to make sure that component of the system is functional. Over time, all the individual alarms and sensors are checked but without much burden falling on the user all at once.
Similar testing can be included in the start-up policies and procedures for equipment such as ventilators and cardiac monitors. If the nurses already have a checklist they go through to ensure the equipment is set up and running properly, Berek suggests you add a check of the alarms.
That type of user testing can be done quickly and easily, he says, and the documentation is created when the nurse simply checks off on a chart that the device was tested and functional on that date. But Berek cautions that there will be some circumstances in which users cannot perform all the necessary testing themselves. With elopement and abduction alarms, for instance, there probably will be exits that are not easily accessible to the nurses.
"The engineering or facilities department may need to take care of some tasks instead of the users," he says. "There might be an elopement sensor on the back door at the dock, for example, and that’s not accessible to the nurse user. Maybe engineering needs to put that sensor on a schedule and check it every month or two."
Human factors must be considered
Regular alarm checks are important, but according to Berek, there is more to the patient safety goal. Accredited facilities also have to ensure that clinical alarms are audible in the actual settings in which they are used, and that staff are adequately trained to discern their meaning and respond appropriately.
There has been some debate among health care providers about whether the patient safety goal requires comprehensive measurement of sound levels throughout the facility or minimal decibel levels for alarms, but Berek tells Hospital Peer Review that the answer is no. Decibel-level testing might be helpful but it is not required, he adds.
The Joint Commission is looking for a practical analysis in "real-world conditions," Berek says, but there usually is no need for a scientific measurement of sound levels.
Likewise, the Joint Commission does not have standards for the decibel level of clinical alarms. The bottom line, Berek says, is that staff should be able to hear the alarms in whatever situations they are used.
"You don’t need a decibel meter to determine that. You can test it with just what you’ve got, by listening for the alarm in a realistic scenario," he explains.
That will require assessments of each unit or patient care area, giving consideration to the many different devices in use at once, the level of activity at different times of day or with different patient populations, and the physical layout of the area. Noise levels are an important consideration, Berek says, so you cannot assume an alarm is sufficiently audible when you test it at 9 a.m. before the unit gets busy and loud.
You may determine that some alarms are not audible from certain areas of the unit, and that’s not necessarily a problem if you work around it, he says.
"You may determine that you just won’t put a ventilator in the rooms at the end of the unit, or that ventilators have to be placed in rooms across from the nursing station," he says. "Your solution can be incorporated into your policies and procedures, rather than trying to find a technical solution that makes every device audible from every room. We’re certainly not suggesting you monkey around with a [Food and Drug Administration-] approved device to make it louder."
Staff education and surveys also can play an important role in meeting this safety goal. The Joint Commission expects staff to be able to prioritize alarms quickly and effectively, so that must be factored into the environmental assessment. It may not be enough that the alarm can be heard at the nursing station if the nurse can’t discern the difference between an alarm that needs an emergency response and one that doesn’t.
"Equipment density is currently 10 to 12 pieces of equipment per [intensive care unit] bed, for instance, so that’s probably that many alarms, plus different levels of alarms on some of the equipment," Berek says.
"You need to make sure that staff are taught about the different alarms, and that they can make them out. If five alarms go off at once and the nurse can’t tell which one to respond to first, that’s a problem," he adds.
Cox also suggests that your record of sentinel events could help you focus your quality improvement efforts with clinical alarm systems. Have there been any sentinel events in which an alarm played a role? Any near misses?
Remember that you can’t say it’s the clinicians’ fault for not hearing or responding to the alarm quickly enough. It is almost certainly a systemic problem that you can address, rather than just a health care worker who should work harder, he says.
Oximetry upgrade to improve patient safety
Buying new equipment often is an option when alarm systems are insufficient, but that is not always necessary. Sometimes a facility can address problems by adding auxiliary systems such as alarm relays, beepers for nurses who are out of hearing range, and other electronic systems that overcome physical barriers to hearing alarms.
Cox’s hospital decided to upgrade its pulse oximetry systems, making it one of the first hospitals in the country capable of continuously monitoring the blood oxygen saturation levels of all of its inpatients anywhere in the hospital. The facility chose to use the Nellcor Intouch Remote Oximetry Notification System, a remote alarm paging system that transmits data from the bedside to a pager worn by the clinician. The page displays the bed number, alarm message, and the patient’s oxygen saturation and pulse.
Cox says the system can help the hospital meet the clinical alarm system recommendations by providing a secondary alarm system, since the hospital found that primary alarms are not always sufficiently audible for clinicians to rapidly identify which room in the unit the alarm is coming from.
The hospital is installing 158 pulse oximeters next to every bed in its general care units and inpatient treatment rooms throughout the hospital and combining them with the notification system that immediately alerts physicians or nurses when a patient’s SpO2 value (the measure of the saturation of oxygen in blood) goes below a specific threshold.
Upgrading the oximeters and alarm systems should directly improve patient safety, Cox says. Recent research in his hospital system found that ICU monitor alarms were a major burden on both nurses and patients, with more than 90% of the alarms sounding being false alarms. (See: Crit Care Med 1994; 22:981-985.) Between 44% and 63% of alarms in this study were caused by pulse oximeters, and 94% of these alarms were nonsignificant.
"This was a case in which we determined that we could do better and we could improve patient safety," Cox says. "Clinical alarms sound like a very technical issue, but it really gets down to whether you can get help to your patient as fast as possible. There are a lot of ways to make sure you’re protecting your patients."
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