2.50
Hdl Handle:
http://hdl.handle.net/10755/306555
Category:
Abstract
Type:
Poster
Title:
Silence is not a Solution: Strategies for Alarm Fatigue
Author(s):
Calder, Shelley; Nadworny, Daniel
Lead Author STTI Affiliation:
Non-member
Author Details:
Shelley Calder, MSN, RN, CEN, scalder@bidmc.harvard.edu; Daniel Nadworny, BSN, RN, CEN
Abstract:

Evidence-based Abstract

Purpose: The soundtrack of the modern day emergency room is dominated by an excessive amount of alarms, unfortunately leading to desensitization or alarm fatigue with frontline staff.

Significance: Alarm fatigue has been identified as a contributing factor in several patient deaths. Review of the Manufacturer and User Facility Device Experience Database for 2011 for the class of arrhythmia-detecting monitors indicated 550 reported alarm hazards, resulting in 35 deaths. Experts believe this data is significantly under-reported and the actual incidents of patient harm due to alarm fatigue are potentially much higher.

Design: The team used a retrospective 31 day review of the red/high level alarms in the emergency department. Data was collated in alarm groups based on acuity as well as functionality. Post intervention, one year later, the data was again reviewed retrospectively for 31 days.

Setting: A Level I, teaching hospital with 620 licensed beds, which includes; 54 monitored emergency beds and 56,000 annual visits.

Participants /Subjects: A multidisciplinary team of front line staff including; emergency department nurses, technicians, and physicians along with monitor vendors and clinical engineering as needed. The event was facilitated by emergency department lean leaders.

Methods: Using Lean methodologies, as a framework for process improvement, front line staff were selected to participate in this rapid improvement event. In addition to the data compiled from the monitors the team went to “Gemba”, (the real place where the work is being done). During this time we observed multiple staff silencing alarms, improper lead placement and minimal use of alarm profiles. Based on the data collected and observations, the group identified education and equipment related interventions. A short five minute education video was created describing the issues related to alarm fatigue and emphasized interventions to reduce non-value added alarms. A bedside poster was created as a daily visual reminder to staff of individual roles when responding to alarms. The poster also included a reference guide and a visual for proper lead placement; this was placed in each room. Monitor and alarm configurations were also adjusted based on current practice and workflow.

Results/Outcomes: Prior to our rapid improvement event in March 2011 there were 8,572 red alarms totals or an average of 276 alarms/day. The following year, in 2012 we sampled our monitor data once again; there were 4795/month total and an average of 155/day. This was a 45% decrease from the previous year. The team continues to work with monitor vendors and staff to identify opportunity for further reduction is essential.

Implications: Alarm fatigue is a problem faced in many institutions, as leaders it is important to understand your departmental risk. Assessment of alarm fatigue and its causes can only be truly understood by going to Gemba. Emergency nurse leaders must work with front line staff to identify and understand alarm issues. Involvement of frontline staff is critical in the identification and implementation of solutions.

Keywords:
Alarm Fatigue
Repository Posting Date:
9-Dec-2013
Date of Publication:
9-Dec-2013
Conference Date:
2013
Conference Name:
2013 ENA Leadership Conference
Conference Host:
Emergency Nurses Association
Conference Location:
Ft. Lauderdale, Florida, USA
Description:
2013 ENA Leadership Conference Theme: Shape the Future. Held at the Greater Fort Lauderdale Broward County Convention Center
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission.

Full metadata record

DC FieldValue Language
dc.language.isoen_USen_GB
dc.type.categoryAbstracten_GB
dc.typePosteren_GB
dc.titleSilence is not a Solution: Strategies for Alarm Fatigueen_GB
dc.contributor.authorCalder, Shelleyen_GB
dc.contributor.authorNadworny, Danielen_GB
dc.contributor.departmentNon-memberen_GB
dc.author.detailsShelley Calder, MSN, RN, CEN, scalder@bidmc.harvard.edu; Daniel Nadworny, BSN, RN, CENen_GB
dc.identifier.urihttp://hdl.handle.net/10755/306555-
dc.description.abstract<p>Evidence-based Abstract</p><p>Purpose: The soundtrack of the modern day emergency room is dominated by an excessive amount of alarms, unfortunately leading to desensitization or alarm fatigue with frontline staff.</p><p>Significance: Alarm fatigue has been identified as a contributing factor in several patient deaths. Review of the Manufacturer and User Facility Device Experience Database for 2011 for the class of arrhythmia-detecting monitors indicated 550 reported alarm hazards, resulting in 35 deaths. Experts believe this data is significantly under-reported and the actual incidents of patient harm due to alarm fatigue are potentially much higher.</p><p>Design: The team used a retrospective 31 day review of the red/high level alarms in the emergency department. Data was collated in alarm groups based on acuity as well as functionality. Post intervention, one year later, the data was again reviewed retrospectively for 31 days.</p><p>Setting: A Level I, teaching hospital with 620 licensed beds, which includes; 54 monitored emergency beds and 56,000 annual visits.</p><p>Participants /Subjects: A multidisciplinary team of front line staff including; emergency department nurses, technicians, and physicians along with monitor vendors and clinical engineering as needed. The event was facilitated by emergency department lean leaders.</p><p>Methods: Using Lean methodologies, as a framework for process improvement, front line staff were selected to participate in this rapid improvement event. In addition to the data compiled from the monitors the team went to “Gemba”, (the real place where the work is being done). During this time we observed multiple staff silencing alarms, improper lead placement and minimal use of alarm profiles. Based on the data collected and observations, the group identified education and equipment related interventions. A short five minute education video was created describing the issues related to alarm fatigue and emphasized interventions to reduce non-value added alarms. A bedside poster was created as a daily visual reminder to staff of individual roles when responding to alarms. The poster also included a reference guide and a visual for proper lead placement; this was placed in each room. Monitor and alarm configurations were also adjusted based on current practice and workflow.</p><p>Results/Outcomes: Prior to our rapid improvement event in March 2011 there were 8,572 red alarms totals or an average of 276 alarms/day. The following year, in 2012 we sampled our monitor data once again; there were 4795/month total and an average of 155/day. This was a 45% decrease from the previous year. The team continues to work with monitor vendors and staff to identify opportunity for further reduction is essential.</p><p>Implications: Alarm fatigue is a problem faced in many institutions, as leaders it is important to understand your departmental risk. Assessment of alarm fatigue and its causes can only be truly understood by going to Gemba. Emergency nurse leaders must work with front line staff to identify and understand alarm issues. Involvement of frontline staff is critical in the identification and implementation of solutions.</p>en_GB
dc.subjectAlarm Fatigueen_GB
dc.date.available2013-12-09T16:59:42Z-
dc.date.issued2013-12-09-
dc.date.accessioned2013-12-09T16:59:42Z-
dc.conference.date2013en_GB
dc.conference.name2013 ENA Leadership Conferenceen_GB
dc.conference.hostEmergency Nurses Associationen_GB
dc.conference.locationFt. Lauderdale, Florida, USAen_GB
dc.description2013 ENA Leadership Conference Theme: Shape the Future. Held at the Greater Fort Lauderdale Broward County Convention Centeren_GB
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission.en_GB
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