Value Grand Rounds - May 2017
Alarm management and the work of the Clinical Monitoring Committee was the topic of the May Value Grand Rounds. Sue McGrath, PhD, who chaired the committee and acted as project sponsor, presented the alarm project work along with Otelah Perry, MS, MT (ASCP), CMQOE, a Value Institute senior performance improvement consultant.
Situation: The growing number of devices that alarm, combined with suboptimal patient monitoring and alarm management strategies, has increased alarm fatigue- the desensitization of clinicians to alarms. Alarm fatigue is an issue in many industries, but it’s especially problematic in health care because it can cause severe patient harm, including death. In June 2013, The Joint Commission set National Patient Safety Goals for all hospitals in order to address alarm system issues in health care.
Background: Dartmouth-Hitchcock’s Clinical Monitoring Committee was enlisted as a steering committee and Perry was selected as the Blackbelt, due to her experience with system level projects. The team was also able to draw on previous D-H internal experience in designing alarm systems for the general care setting.
An inventory of all D-H devices from the Clinical Engineering database revealed that there were over 10,000 devices with the potential for device alarms. In order to understand the problem, the team completed assessment of patient safety events and 150-plus hours of direct observation in all inpatient units, procedure areas and outpatient infusion areas. The team discovered:
- Non-standard configurations between units providing same level of care
- Missing or inadequate policies, procedures, and education to address required elements of performance
- Variation in clinical staff work associated with monitor use
- Monitor settings different than reviewed best practices
- No system for providing support related to clinical alarms
Assessment: Perry and her team assessed a number of factors as they figured out how to move toward meeting the deadlines for the National Patient Safety Goals. They recognized that this is a complex problem and that addressing device alarms will continue to be an issue as additional technologies are introduced into the clinical setting, affecting stakeholders and clinical areas across the D-H system. After considering different process improvement approaches, they selected the DMAIC method (Define, Measure, Analyze, Improve, Control.) “As we were selecting a project execution method, we acknowledged that this project was not a traditional incremental improvement effort since specific best practices to address the problem had already been identified. However, in reflecting on the Value Institute’s DMAIC method, we recognized that it simply represents a version of the scientific method where we systematically make observations and measurements and perform experiments to implement changes in systems and processes,” said McGrath. “This helped us decide that this project execution method was the best fit for this work, allowing us to explore the problem in depth, while also incorporating best practices as appropriate.”
- Implement revised Adult Critical and Progressive Care Configurations: Standardized by care area type and aligned to best practice reviews.
- Implement revised Age Group Profiles: Apply age specific settings for Newborn-Adult for Critical Care and across units that may care for multiple age groups (PICU, ED, IR, MRI, CT, Endo, PACU, Pain Free, OR, Same Day, Cath Lab).
- Revise Procedures and Policies using a standard definitions and format: Using content developed by the clinical subject matter experts over the course of the project workshops, include risk, response, roles and responsibilities.
- Process for Clinical Monitor Configuration Changes: Creating an expected process for proposing, gaining approval, maintaining care area standard, testing and implementing changes.
Ongoing efforts include:
- Policy and procedure completion: 35 existing documents were revised and 12 new documents were created. To date, 85% of these documents are in final stages or approved
- Education plan for clinical teams
- Long-term measurement plan
- Execution of standard work for control by the alarm system engineer role
- Clinical Monitoring Committee oversight
- Real-time alarm situational awareness