Boston Medical Center (Boston, MA) was selected as a finalist for ECRI Institute's 10th Health Devices Achievement Award for its low-cost, high-impact processes for improving the management of telemetry monitoring alarms.
The Health Devices Achievement Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. ECRI Institute announced the winner and four other finalists for the 10th award in February 2016. For details about the other submissions that achieved recognition, see The Health Devices Achievement Award: Recognizing Exceptional Health Technology Management.
ECRI Institute congratulates the applicant, James Piepenbrink, and the rest of the Boston Medical Center team.
The Challenge
To evaluate, test, and implement alarm management improvements in a consistent manner, building on the successes of Boston Medical Center's (BMC) previous alarm management initiatives
The Landscape
1. An ongoing study of alarm metrics and clinician workflow conducted over the past five years by BMC's multidisciplinary Clinical Alarm Task Force has led to significant improvements in how the hospital manages cardiac telemetry patients and how it uses technologies in medical-surgical telemetry care areas.
a) The task force directed its focus toward telemetry monitoring because these systems were found to contribute significantly to the overall alarm load.
b) Excessive numbers of nuisance alarms—particularly audible alarms—can:
(1) Disturb patients and disrupt staff
(2) Add to the clinicians' workload
(3) Increase the risk that clinicians will experience alarm fatigue
2. As part of this effort, the task force analyzed default alarm settings and reviewed how changes to those settings are managed in an effort to:
a) Reduce the number of alarms that sound for clinically insignificant conditions
b) And thereby improve:
(1) The reliability and timeliness of clinician responses, and thus the quality of patient care
(2) Patient satisfaction with the hospital experience
(3) Staff satisfaction with the working environment
3. A previously described pilot program targeting arrhythmia and heart rate alarms on a general cardiology floor resulted in an 89% reduction in those alarms.
a) Key aspects of that program—which addressed standardization, training, use, and workflow—are outlined in the Key Takeaways section, below.
b) In addition, ECRI Institute has described components of BMC's program in previous Health Devices articles. See:
(1) How Boston Medical Center Got a Handle on Telemetry Alarms. Health Devices 2014 Jan 15.
(2) Using a Cart-Based System to Provide Patient Monitoring Training at the Point of Care. Health Devices 2012 Jan 1.
(3) Standardization of Alarm Defaults for Telemetry Helps Boston Medical Center Reduce Nuisance Alarms. Health Devices 2010 Dec 1.
4. Subsequent roll-out of the program to BMC's nine other medical-surgical telemetry care areas—converting all 310 telemetry beds to the new default changes—was likewise successful, yielding a 60% reduction in telemetry alarms hospital-wide.
5. During the roll-out, however, the task force identified opportunities for additional improvements. One of these was the opportunity to eliminate duplicate crisis-level alarms that would activate for high heart rate and tachycardia. ("Crisis" alarms are those that BMC has determined require an immediate staff response.)
6. BMC's approach for implementing this improvement was highlighted in its submission for the Health Devices Achievement Award.
a) Over the years of its existence, the Clinical Alarm Task Force has evolved to incorporate a structure for assessing and implementing proposed adjustments to alarm settings.
b) The procedure now involves rigorous process management, data analysis, clinical trials, education, and governance, as outlined below.
The Process
The task force:
1. Identified the opportunity to reduce unnecessary audible alarms—in this case, to eliminate duplicate crisis-level alarms that would activate for high heart rate and tachycardia.
2. Identified any risks associated with the change.
3. Collected and analyzed alarm data from all 10 of its medical-surgical telemetry units to identify the current state of tachycardia and high heart rate alarms.
4. Gained an understanding of the algorithm the manufacturer used to define tachycardia.
5. Proposed a change to the alarm default for tachycardia, decreasing it to the lowest level of alert while maintaining a record of these alerts in the alarm history.
a) The proposed change would reduce crisis alarms while ensuring that the tachycardia alarms appear in alarm histories and can be reviewed by the clinical teams.
b) The task force recommended that the high heart rate alarm remain set at crisis level. Staff were already adept at making changes to the upper limit for this parameter, when warranted, following consultation with another registered nurse (according to the hospital's alarm management protocol, as described in our January 15, 2014, article).
6. Defined the recommended solution and outlined the results that could be expected if the change were to be implemented.
7. Presented the proposed changes to several clinical committees to allow for discussion prior to enabling the changes.
The Results
1. BMC believes that its management of telemetry patients is greatly improved as a result of:
a) Fewer alarms
(1) The initial pilot program and the subsequent facility-wide roll-out led to large reductions in the number of alarms.
(2) The subsequent change to the tachycardia alarm setting eliminated the activation of a redundant crisis-level alarm, which reduced the overall alarm count for crisis alarms by 41% while maintaining a high level of safety.
b) Better information contained within the system (e.g., alarm histories)
c) Improved communication between the nurses and the medical staff, as they work together to manage the patient in a more comprehensive manner
2. As a result of all BMC's alarm management initiatives:
a) The care areas are much quieter. This change is appreciated by patients and has greatly improved the morale of the staff.
b) Nurses have more time to spend with the patients.
c) The organization has seen a marked improvement in its Press Ganey inpatient metrics (measuring patient satisfaction). BMC believes the two benefits noted above have led to its increased scores in the following categories:
(1) Nurse Domain
(2) Noise Level in and Around Room
(3) Promptness to Response Call
(4) Personal Issues Domain
(5) Overall Assessment Domain
d) Staff are more engaged in the improvement process and now ask for additional changes. Because staff have been engaged in this process since the beginning, they understand its value and want to participate.
3. Throughout the process, patient safety has been maintained. BMC reports that, since the original pilot, it has not had a single incident report or a code blue in any of its medical-surgical telemetry units.
Key Takeaways
1. BMC notes that the implementation of a successful alarm management strategy begins with:
a) An assessment of risk in the environment
b) A review of procedures, order sets, alarm data, and workflow
2. While the process can be overwhelming, BMC recommends using a phased approach and managing expectations, understanding that the process can take months or even years to implement.
3. Key aspects of the BMC approach are that it:
a) Is process-driven
b) Does not involve significant expense
c) Is transferrable to other organizations
4. Following are several factors that BMC considers to be essential components for managing telemetry alarm default changes:
a) Process and baseline knowledge:
(1) Establish a multidisciplinary team to review and discuss changes and to serve as the governance structure for implementing all projects.
(2) Understand the alarm defaults and alarm settings for the telemetry systems used at your facility.
(3) Extract and analyze alarm data for all parameter, technical, and arrhythmia alarms.
(4) Observe staff responses to alarms, identifying barriers to timely response. Assess the noise in the care area as well.
(5) Using the information collected, work with the clinical stakeholders to identify:
(a) Alarms that require action by the staff
(b) Alarms that are clinically insignificant
b) System configuration and clinical practice:
(1) Standardize alarm defaults across patient care units, wherever possible.
(2) Implement daily electrode changes to improve signal acquisition.
(3) Make all audible alarms actionable. That is:
(a) Verify that an alarm will sound for alarm conditions that require a response.
(b) Remove audible notification for clinically insignificant alarms.
(4) Empower nursing staff to eliminate false alarms.
(a) BMC allows nurses to make appropriate adjustments to alarm settings in real time—before getting a physician's order—provided that the proposed change is first validated with a second registered nurse.
(b) Previously, staff would have to wait for a physician's order to make a change to the alarm default setting.
(c) BMC has found that this change in process allows nuisance alarms to be eliminated much more quickly.
c) Education, training, and communication:
(1) Create an educational process for all staff nurses to ensure that there is a baseline understanding of cardiac arrhythmias. All nurses at BMC must complete an examination at 90% or better.
(2) Develop a telemetry training cart to assist with training staff on the use of the telemetry system and assessing competency.
(3) Have "super users" available to support staff during pilot periods. Staff can benefit from being able to discuss issues with a peer who has a good understanding of the system and the goals of the pilot study.
(4) Communicate changes throughout the organization, so that all staff understand the project and results.