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Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care UnitMary Hefferan Ferris State UniversityReducing Monitor Alarm Fatigue in the Neonatal Intensive Care UnitA. Description of Quality Improvement ProjectThis quality improvement project will address the patient safety issue of monitor alarm fatigue in the neonatal intensive care unit through staff education that addresses factors that reduce unnecessary alarming. Oxygen saturation alarm limits for premature infants (less than 36 weeks) were 86%-96%; according to the Vermont Oxford Network (VON, 2014). For those born at 36 weeks or later they are 92%-100%. Standard alarm parameters are necessary but act only as a starting point for care. Currently, there is a lack of discussion regarding alarm parameters during nurse to nurse report at the chosen site for this project. Individualized parameters should be discussed during nurse handoff to further reduce unnecessary alarming. Many factors weigh in for each infant when establishing alarm parameters such as supplemental oxygen use, cardiac abnormalities, and acuity. To individualize this process, I plan to increase awareness of customizing individual alarms to meet the specific needs of the patient through staff education and on-site support and how it improves alarm safety. Also, proper placement and changing of pulse ox/EKG leads and skin preparation has been shown to reduce the number of false alarms. I also plan to establish a protocol and supportive education regarding proper pulse ox/EKG placement and skin preparation based on the gestational age of the patient and skin integrity. Staff education will be achieved through online courses, handout materials, and on-site support. B. Evidence Based SupportIn 2013, The Joint Commission (JC) announced a national patient safety goal (NPSG) that addressed alarm management and safety (JC, 2013). Phase I urged hospitals to “establish alarms as an organizational priority” (JC, 2013, p. 1) and focus on management of the most important alarms. Phase II focused on policy development and education of staff regarding alarm safety. The JC recognized alarm fatigue as a patient safety issue and stress the importance of standardizing alarm management to reduce variations in care. Alarm fatigue and desensitization to alarms can lead to a reduction in trust of the alarm, disruption in patient care, and lead to disabling of the alarm posing a severe risk to patient safety (Grahm & Cvach, 2014). Cvach (2012) states “from 2005 through 2008…[there were] 566 reports of patient deaths related to monitoring device alarms” (p. 269). The Emergency Care Research Institute (ECRI, 2007) states excessive monitor alarms can distract clinicians and lead to a “cry wolf” environment that can reduce response to real emergencies. Adding to the problem, the American Association of Critical-Care Nurses (AACN, 2013) found “80% to 99% of EKG monitor alarms are false or clinically insignificant” (p. 83) The AACN (2013) found proper skin preparation enhances conductivity and reduces skin impedance thereby reducing false monitor alarming. By properly preparing skin and appropriately placing EKG leads, it can reduce false alarms due to rapid heart rate and arrhythmia (ECRI, 2007). Also, Cvach, Biggs, Rothwell, and Charles-Hudson (2013) found that after implementing a daily electrode change, monitor alarms decreased by 46% per bed per day. Customizing alarm parameters to meet the specific needs of the patient showed a 43% reduction in false alarms after staff was educated regarding the change (AACN, 2013). C. Description of UnitThis project will take place in the Helen Devos Children’s Hospital (HDVCH) in the neonatal intensive care unit (NICU). The unit consists of 8 ward-style rooms that hold anywhere from 6 to 12 babies per room and in the new addition there are 40 private rooms for a total of 103 beds. Each room can contain a combination of open cribs, warmer tables, or isolettes. The alarm noises can vary from monitor alarms, ventilator alarms, and IV pump alarms. Parents are welcome and may sit by the bedside of their infant as well. D. Stakeholder InvolvementChristina Schmoekel has agreed to be my preceptor for this project and is the clinical informatics educator for HDVCH. I connected with her through another fellow MSN student and was interested because she has a NICU background and is currently in an informatics role. Christina has her MSN, RNC-NIC, and CPHIMS certification. She has connected me with the NICU manager and Amy Atwater who will be involved for this project and will be my main resources for this project. Amy is a registered nurse who coordinates special projects. She linked me with Beth Huizinga, a clinical nurse specialist, who provided me with her input regarding my project goals. Kari Luymes is a nurse technician who attended the recent meeting who will assist me in collecting data and as a reference for current policies. I have also been given the contact names of a biomedical engineer representative and the lead respiratory therapist to be contacted for assistance in data collection. E. QSEN CompetenciesSafety: Knowledge: “Describe best practices that promote patient and provider safety” (QSEN Institute, 2012, “Safety”). The goal of this project is to educate staff regarding best practice regarding alarm management. This will promote patient safety by reducing unnecessary alarms that can result in alarm fatigue that compromises patient safety. Skill: “Participate as a team member to design, promote, and model effective use of technology and standardized practices that support safety and quality” (QSEN Institute, 2012, “Safety”). To develop the educational component that supports best practice, my goal is to collaborate with the NICU team to establish how to utilize monitor alarm technology to promote patient safety. Through educating staff I hope to model the effective use these standardized practices. Teamwork and CollaborationAttitude: “Appreciate the importance of inter-professional collaboration. Value collaboration with nurses and other members of the nursing team” (QSEN Institute, 2012, “Teamwork and Collaboration”). Maintaining an attitude that promotes collaboration is essential to implementing this quality and safety program. I plan to elicit feedback from all members of the nursing team and management. F. ANA Scope & Standards of Practice for Nursing InformaticsStandard 1-Assessment: collecting information and data regarding current practice and workflow to identify the potential effect of a solution to the current need (ANA, 2008). During the planning phase, information will be collected regarding current standards for alarm parameters, establishment of parameters, and current practice regarding skin preparation and changing of EKG leads. Assessment will include prioritizing the data and analyzing the most crucial needs for the unit (ANA, 2008).Standard 2-Problem and Issues Identification: identify the needs of the unit to determine the desired outcomes and develop a plan for implementation (ANA, 2008). Based on the needs of the unit determined from stakeholder involvement and evidence based research, outcomes and specifics of the plan will be identified. The problem/need has been identified through the initiation of the NPSG and the data regarding risks to patient safety. Standard 5-Implementation: implement a plan in a “safe and timely manner” implementation (ANA, 2008, p. 71) and collaborate with other stakeholders before, during, and after. Implementation will include a documented plan and “evidence based-actions” (ANA, 2008, p. 71) regarding the steps to achieve goals and desired outcomes. RCAA meeting with the stakeholders, Christina, Amy, and Kari was held to identify current barriers to safe alarm management. Some of the major barriers identified were that often it is difficult to hear certain alarms when they alarm within the new private rooms. Also discussed as a potential barrier, is that a physician order must be obtained to change alarm parameters or discontinue them; reducing the likelihood that parameters will be specified to the needs of each patient. I also discussed barriers with my former NICU co-workers and they identified issues with the two minute pause option being utilized too often versus the more brief silence option. See Appendix A for a full listing of root causes that lead to alarm fatigue. Change and Leadership TheoryKurt Lewin’s Theory of Planned ChangeUnfreezing: Recently the NICU staff and I participated in a webinar regarding alarm fatigue and management. This served as a tool for “unfreezing” current practice and raised awareness of the risk to patient safety. I will reinforce the unfreezing by providing further evidence based research regarding alarm fatigue within the educational presentation. Data that will be collected from the monitor alarms should represent a need for change and assist in the unfreezing of old beliefs as well. Lewin’s unfreezing stage acts as a stimulus to drive change and prepares the “organization to accept that change is necessary” (MindTools, 2014, para. 8) by showing that the existing standard cannot continue.Movement/Change: As a result of the unfreezing and raised awareness, my project for improvement will guide the unit towards change and education regarding safe alarm management will be established. (Manchester et al., 2014; MindTools, 2014). I hope to facilitate this movement towards change by eliciting feedback and adapting the change to meet the specific needs of the unit. Educating staff and providing evidence based research should promote the acceptance of the change. Refreezing: The new practice standards will be reinforced and a “refreezing” is expected to occur within the unit. Manchester et al. (2014), state that identifying “clinical champions” (p. 85) will drive the organization to maintain this change. As I implement this project I will serve as a clinical champion and connect with those interested to further carry on the proposed change. Transformational Leadership: This style of leadership is identified to empower others and be a “visible role model” (Giltinane, 2013, p. 37) for others. Transformational leadership is “positively associated with followers’ commitment to improvement and change” (Marshall, 2010, p. 28). I hope to inspire others and express a clear vision for the project. Enabling open communication and establishing a presence will assist in fostering a culture of team work and collaboration (Marshall, 2010). By connecting with others and collaborating with the team, I hope to develop trust and motivate others. Transformational leaders set specific goals and show commitment (Marshall, 2010). I plan to develop an overall aim statement for this project based on the specific goals of the project to support this characteristic of a transformational leader. Also, I intend to show commitment by being on site when possible rather than utilizing technology to communicate. Outcome MeasurementTo measure the outcomes of this project, with the help of biomedical engineering, I will collect monitor alarm data that will evaluate the number of alarms per patient per day after the proposed education is completed. This alarm data will be categorized into clinically significant or non-significant (requires no clinical intervention). The goal will be to see a reduction in the non-significant alarm data, which is a cause of alarm fatigue. I will also collect data at the bedside with tally sheets for alarms that cannot be tracked electronically (ventilators, CPAP). Cvach (2012) found after altering alarm limits “to actionable levels” and individualizing patient parameter limits, there was a 43% reduction in duplicate alarms. The overall alarm management improvement project resulted in a “46% reduction in total alarms/pt/day” (Cvach, 2012, p. 272). Without the scheduled lead change component, I hope to show at least a 25% reduction in non-clinically significant alarms. Predicted ResultsBy utilizing evidence based research to develop standards for alarm parameters, my project should support the JC NPSG of alarm management. After this project, the nurse to nurse report will include discussion of alarm parameters for each patient which will increase specificity of alarms and reduce non-clinically significant alarms. I expect a reduction of at least 25% of alarms per day. Also, by educating staff regarding proper EKG skin preparation and placement, I expect this to reduce the number of false monitor alarms. Reducing the number of false monitor alarms should reduce alarm fatigue and the associated risks to patient safety. I hope by incorporating these improvements awareness of alarm safety will increase and clinically significant events will not be missed due to alarm fatigue. Reducing Monitor Alarm Fatigue in the Neonatal Intensive Care UnitGoals with QSEN/ANA SupportSub-Objectives to meet Goal Activities to meet Each Sub-objectiveTimeline for each Goal 1: State GoalCreate an educational program that increases awareness of alarm safety and encourages nurse-hand off discussion of alarm parametersMeets QSEN Competencies/KSA(s):Safety: Knowledge- “Describe best practices that promote patient and provider safety” (QSEN Institute, 2012, “Safety”). Safety: Skill: “Participate as a team member to design, promote, and model effective use of technology and standardized practices that support safety and quality” (QSEN Institute, 2012, “Safety”). Teamwork and Collaboration: Attitude-“Appreciate the importance of inter-professional collaboration. Value collaboration with nurses and other members of the nursing team” (QSEN Institute, 2012, “Teamwork and Collaboration”).Meets ANA Scope & Standards for specialty role:Standard 1-Assessment: collecting information and data regarding current practice and workflow to identify the potential effect of a solution to the current need (ANA, 2008). Standard 2-Problem and Issues Identification: identify the needs of the unit to determine the desired outcomes and develop a plan for implementation (ANA, 2008). Standard 5-Implementation: implement a plan in a “safe and timely manner” and collaborate with other stakeholders before, during, and after implementation (ANA, 2008, p. 71). 1.1 Determine current causes of nuisance alarming and alarm fatigue through RCA1.2 Develop standardized EKG lead/pulse ox changes and proper skin preparation based on gestational age of patient and skin integrity1.3 Educate staff regarding alarm safety and benefits of alarm parameter customization1.4 Evaluate effectiveness of educational program1.1Meet with stakeholders then with staff to determine specific needs and requests of the unit staff1.2 Survey nurses regarding current causes of alarm fatigue1.3 Gather monitor alarm data for baseline comparison1.4 Create online presentation regarding alarm safety and benefits of customized parameters1.5 Answer questions regarding alarm safety and evaluate effectiveness after education. 1.6 Gather monitor alarm data following education1.1 10/20141.2 1/20151.3 1/2014-2/20151.4 1/2015-2/20151.5 3/2015-4/20151.6 4/2015-5/2015Goal 2: State GoalCreate an EKG/pulse ox skin preparation protocol and supportive educational component based on evidence based research Meets QSEN Competencies/KSA(s):Safety: Knowledge- “Describe best practices that promote patient and provider safety” (QSEN Institute, 2012, “Safety”). Safety: Skill: “Participate as a team member to design, promote, and model effective use of technology and standardized practices that support safety and quality” (QSEN Institute, 2012, “Safety”). Teamwork and Collaboration: Attitude-“Appreciate the importance of inter-professional collaboration. Value collaboration with nurses and other members of the nursing team” Meets ANA Scope & Standards for specialty role:Standard 1-Assessment: collecting information and data regarding current practice and workflow to identify the potential effect of a solution to the current need (ANA, 2008). Standard 5-Implementation: implement a plan in a “safe and timely manner” and collaborate with other stakeholders before, during, and after implementation (ANA, 2008, p. 71). 2.1 Determine current causes of nuisance alarming and alarm fatigue through RCA2.2 Develop standard skin preparation protocol based on evidence 2.3 Conduct education regarding new protocol to NICU staff2.4 Evaluate effectiveness of new protocol2.1 Meet with stakeholders then with staff to determine specific needs and requests of the unit staff2.2 Meet with leadership to discuss protocol and specific needs of unit2.3 Develop online educational presentation regarding protocol2.4. Answer questions and elicit feedback regarding new process2.5. Gather alarm data following education and new policy 2.1 10/20142.2 1/20152.3 2/2015-3/20152.4 3/2015-4/20152.5 4/2015-5/2015-742950-18923000Appendix AReferencesAmerican Association of Critical-Care Nurses. (2013). Alarm management. Critical Care Nurse, 33(2013), 83-86. Retrieved from American Association of Critical-Care Nurses. (2013). Strategies for managing alarm fatigue [PowerPoint slides]. Retrieved from , M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation and Technology,46(4), 268-277. doi:10.2345/0899-8205-46.4.268 Cvach, M. , Biggs, M., Rothwell, J. K., & Charles-Hudson, C. (2013). Daily electrode change and effect on cardiac monitor alarms: An evidence based approach. Journal of Nursing Care Quality, 28(3), 265-271. doi:10.1097/NCQ.0b013e31827993bcEmergency Care Research Institute. (2007). The hazards of alarm overload. Health Devices, 73-83. Retrieved from Giltinane, L. C. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39. Retrieved from C. K., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-34. doi:10.4037/ajcc2010651The Joint Commission. (2013). The Joint Commission announces 2014 national patient safety goal. Retrieved from , J., Gray-Miceli, L. D., Metcalf, A. J., Paolini, A. C., Napier, H. A., Coogle, L. C., & Owens, G. M. (2014). Facilitating Lewin’s change model with collaborative evaluation in promoting evidence based practices of health professionals. Evaluation and Program Planning, 47(2014), 82-90. Retrieved from , E.S. (2010). Transformational leadership in nursing: From expert clinician to influential leader. (1st ed.). New York: Springer Publishing Company, LLCPhillips, J., & Barnsteiner, H. J. (2005). Clinical alarms: Improving efficiency and effectiveness. Critical Care Nursing Quarterly, 28(4), 317-323. Retrieved from and Safety Education for Nurses Institute. (2012). Graduate KSAs. Retrieved from ................
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