(98) Sounding the Alarm on Fatigue, A Wake-up Call: How We Decreased Alarm Fatigue and Enhanced Communication to Improve Patient Safety

Title: Sounding the Alarm on Fatigue, A Wake-up Call: How We Decreased Alarm Fatigue and Enhanced Communication to Improve Patient Safety

Abstract : Introduction
Based on a serious safety event involving patient device monitoring and management of abnormal vital signs, a root cause analysis was completed with a multidisciplinary team.
Purpose
A key driver diagram was developed, which identified two opportunities for improvement, recognition and reporting of abnormal vital signs and clinical alarm management.
Methods
Reviewed, updated, and disseminated changes for Monitoring, Alarm, and Vital Sign Policies clarifying language for setting and responding to alarms and communicating alarm alerts. The vital sign policy added concise steps to take for abnormal vital signs and subsequent communication with providers.
Modified shift to shift and daily rounding reports to include review of patient vital sign ranges for previous twenty-four hours.
Standardized messaging texts from RN to Provider with expectation of response timing.
Offered nursing documentation campaign that included instructions of what, when, and where to document.
Collaborated with Information Services, Biomedical Engineering, and the monitor company to adjust default alarm parameters, change age profiles to correspond with vital sign ranges, and add an additional profile for patients not receiving continuous cardiopulmonary monitoring.
Built cardiopulmonary monitoring, continuous pulse oximeter monitoring orders with discrete parameters for notification of alarms with age specific alarm parameters.
Built vital sign monitoring orders to include parameters of provider notifications outside of “normal” vital signs with a sidebar report display of age specific vital signs.
Outcomes
Changes in the default alarm limit settings showed a significant decrease in alarm alerts. There was a 35% reduction in one week review of pre- and post-alarm alerts post changes (52,290 to 34, 211). Audits were completed for patients requiring clinical monitoring to sustain results. Audits demonstrated 83% of patients had monitor alerts set at new default parameters and of those monitor alerts not set within the new default parameters, 62% had specific orders to change parameters.