MANAGING MONITOR ALARMS: LESSONS LEARNED

MARIA CVACH, RN, MSN, CCRNASSISTANT DIRECTOR OF NURSING , CLINICAL STANDARDS

THE JOHNS HOPKINS HOSPITAL

October  5th , 2011

Maria Cvach, RN, MSN, CCRN Assistant Director of Nursing, Clinical StandardsThe Johns Hopkins Hospital

Monitor Alarm Task Force Standardizing practices throughout JHH Cardiac and Physiological Monitor Policy

Physician‐Led Alarm Management Committee Revise defaults to actionable levels, house‐wide Develop criteria for placement on and discontinuation of 

physiologic monitors

New Clinical Building‐related Pilots for Alarm Management Contracted with ECRI for NCB Alarm Management

ALARM MANAGEMENT INITIATIVES

April 27,

2011

ASSESSMENT OF ALARMS: SAMPLE OF 12 DAY ALARM ANALYSIS

Priority Quantity Day 1 Day 2  Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12

Crisis‐ 0 1587 93 107 134 70 86 123 151 141 124 293 137 128

Warning‐ 1 6673 540 504 339 625 831 612 987 689 899 414 121 112

Advisory‐ 2 48277 4208 5067 1810 1484 6252 5244 7401 3007 1501 2124 6046 4133

System Failure‐ 3 2227 166 276 293 162 223 359 239 215 80 122 43 49

Grand Total of Alarms 58764 5007 5954 2576 2341 7392 6338 8778 4052 2604 2953 6347 4422

Ave Pt Census 14

Ave Alarms/Pt/Day 350 358 425 184 167 528 453 627 289 186 211 453 316

How to quantify the number and types of alarms from physiologic monitor?• Variety of programs exist

• JHH uses Globestar middleware but previously used ADU/Pager LAN software• Provide this feedback to Alarm Mgmt Committee and unit manager and develop

plan for improvement

TABLE 2CHANGES ARE INDICATED IN RED FOR WICU/SICU

ASYSTOLE CRISISVFIB/VTAC CRISIS

V TACH CRISISVT > 2 CRISIS Message

V BRADY CRISIS COUPLET WARNING Message

BIGEMINY WARNING MessageACC VENT MESSAGE

PAUSE WARNING MessageTRIGEMINY ADVISORY Message

R ON T MESSAGEPVC MESSAGE

TACHY WARNING MessageBRADY WARNING Message

IRREGULAR MESSAGEHR WARNING (limits 50 and 115 120)

CO2 NO BREATH ADVISORYRM NO RESP WARNING

PVC ADVISORY Message

STADVISORY Message (limits changed from -1 and 1 to -2 and 2)

ARTADVISORY (limits Sys H-180 L-90; Mean H - 120 Lo-55; Dia H-110 Lo 40)

PA ADVISORY MessageCVP ADVISORY MessageCO2 ADVISORY Message

NBPADVISORY (limits Sys H-180 L-90; Mean H - 120 Lo-55; Dia H-110 Lo 40)

SPO2 ADVISORY (Limit - 89)

Modest Default Parameter Changes:• Actionable alarms• Visual alarm vs

Audible Alarm• Parameter limits

adjusted

Priority

ICU AQuantity

7 day Pre

DefaultJune 2010

ICU A Quantity

7 dayPost

DefaultDecember

2010

ICU BQuantity7 day PreDefaultJune 2010

ICU BQuantity

7 day PostDefault

Dec 2010

IMCQuantity12 day

PreDefault

April 2010

IMCQuantity

12 day PostDefaultJan/Feb

2011

ICUC Quantity

12 day PreDefault

April 2010

ICUCQuantity

12 day PostDefault

Feb /March 2011

ICUDQuantity

12 day PreDefault

April 2010

ICUDQuantity

12 day PostDefault

April 2011

ICUEQuantity

12 day PreDefault

Dec 2010

ICUEQuantity

12 day PostDefault

April 2011

Crisis‐ 0 162 72 91 31 867 1072 878 585 251 271 979 402Warning‐ 1 3110 1149 18932 2801 11904 6465 13577 4731 3180 2430 6488 1471Advisory‐ 2 23058 13125 65595 31989 79344 14272 42681 46131 34026 18575 65806 25669System 

Warning 3 3514 3704 1699 3561 2485 2443 2130 2575 1205 1820 13117 5705Grand Total of 

Alarms 29844 18050 86317 38382 94600 24252 59266 54022 38662 23096 86390 33247Ave Pt Census 13 13 16 13 14 14 18 22 13 13 14 13

Ave Alarms/Pt/Day 317 203 771 431 563 144 274 208 251 145 527 213% reduction 36% 44% 74% 24% 42% 60%

Ave Alarms/Pt/Day 

Crises 2 0.8 1 0.3 5 6 4 2 2 2 6 3Ave 

Alarms/Pt/Day Warning 33 13 169 31 213 38 63 18 21 15 40 9Ave 

Alarms/Pt/Day Advisory 245 147 586 359 472 85 198 177 221 117 401 165

Ave Alarms/Pt/Day 

System Warnings 37 42 15 40 15 15 10 10 8 11 80 37

Monitor Alarm Reduction Initiative Default Parameter Changes

SYSTEM WARNING-3

ICUA PRE

ICUA POST

ICUBPRE

ICUBPOST

IMCAPRE

IMCA POST

ICUC PRE

ICUCPOST

ICUDPRE

ICUDPOST

ICUEPRE

ICUEPOST

TOTAL 3514 3704 1699 3561 2485      2445  2130 2575 1205 1820 13117 5705

PERCENT CHANGE

5% 109% -1.6% 21% 51% -57%

ARRHY SUSPEND 432 12.29%

135 3.64

152 8.95%

110 3.09%

732 29.46%

689 28.18%

560 26.29%

1112 4.18%

271 22.49%

388 21.32%

172 1.31%

89 1.56%

LEADS FAIL 270 7.68%

582 15.71

172 10.12%

289 8.12%

518 20.85%

568 23.23%

744 34.93%

820 31.84%

444 36.85%

525 28.55%

458 3.49%

513 8.99%

RR LEADS FAIL 261 7.43%

534 14.42%

226 13.3%

417 11.71%

1065 42.86%

939 38.40%

612 28.73%

414 16.08%

293 24.32%

591 32.47%

699 5.33%

465 8.15%

NBP FAIL 55 1.57%

19 .51%

7 .41%

57 2.29%

101 4.13%

18 .85%

27 1.05%

74 4.07%

17 .13%

22 .39%

NBP MAX TIME 6 .17%

7 .19%

3 .08%

27 1.09%

44 2.07%

4 .16%

71 5.89%

8 .44%

6 .05%

27 .47%

NBP OVER PRES 1 .03%

5 .13%

3 .18%

6 .17%

9 .42%

22 .85%

9 .75%

88 4.84%

2 .02%

18 .32%

SENSOR 90 2.56%

24 .655

29 1.71%

20 .56%

6 .24%

48 1.96%

16 .75%

81 3.15%

107 8.88%

99 4.44%

240 1.83%

290 5.08%

SPO2 PROBE 2386 67.9%

2392 64.58%

1109 65.27%

2668 74.92%

1 .05%

11331 86.38%

4260 74.67%

SPO2 SENSOR 13 .37%

6 .16%

1 .06%

16 .45%

17 .68%

26 1.06%

45 2.11%

48 1.86%

10 .83%

44 2.42%

192 1.46%

19 .33%

CHNGE BATTERY 1 .04%

3 .16%

LF: NO TELEM

NBP MODULE 2 .04%

NO TELEM 63 2.58%

80 3.76%

40 1.55%

NURSE CALL 1 .04%

OFF NETWORK 1 .04%

SPO2 ARTIFACT 1 .05%

4 .16%

6

System Warning Alarms

Variation in configuration of system warning

alarms on monitored units

7

24 hour electrode change

pilot:July 2011

MPC4 and CCU

ALARM NOTIFICATION

HOW DO YOU GET TRUE ANDRELIABLE ALARM INFORMATION

TO THE CARE GIVER?

Weekly Alarm Management Committee8

NOTIFICATION OF ALARMS

What is the best method for notifying staff of alarm conditions?Approach may vary from unit to unit Monitor watch

Appears to be beneficial No well defined studies or metrics

Split screen – useful for fully monitored units and for patient: nurse ratio of 2:1

Waveform screen in hallway Increased noise in hallway Doesn’t address lower priority alarms

Mobile wireless device Need waveform to compare alarm to context

View on alarm/Auto‐view on alarm Increased noise at bedside Split screen can appear confusing Doesn’t address the lower priority alarms

VIDCO

• For crisis alarms only • Shows waveforms/data• Maximum=16 per Vidco• Sound can be muted• Not able to manipulate

bedside monitors

April 27,

2011

NOTIFICATION OF ALARMS

Middleware (Example: Globestar/Emergin) Pagers or phones

Without waveform, these devices have limitations  (i.e., no context to connect the text message with a view of the alarm)

Waveforms would improve alarm fidelity Alarm escalation and alarm delays possible

12

Crises alarms will be sent immediately to the nurses;Warning and system warning alarms will be sent after a

60 second delay to allow for auto correction or staff in room to silence.

1

ALARM ESCALATION

SUMMARY

Means to control alarm numbers: Analyze each units monitor 

alarms to determine baseline

Set monitor defaults to actionable levels 

Individualize alarms based on patient’s baseline

Consider instituting delays to allow for auto correction 

Change electrodes daily Foster culture of alarm 

safety 

Means to assure notification: Monitor watch

Hallway waveform displays Continuous split screen VOA/AVOA Wireless notification 

devices Single portal for assignments Institute escalation to other staff 

Zoning for large units

14

Redundancy is importantUnits need multiple ways to assure

alarm audibility

Need: Waveform sent to notification device with alarm text message

Multi‐parameter alarm algorithms to reduce  frequent false positive alarms

Alarm logic algorithm that increases the urgency of the alarm based on the number of times the alarm has occurred

Ability to access message alarms in patient alarm history Timely physiologic monitor upgrades to  match technology improvements in free standing devices

Better understanding of all the default settings and the impact of each 15

Perspective of Bedside User: What is still needed for better alarm management?