Training, education and individualization are some of the keys to better alarm management discussed by leading health experts during a recent webinar. The March 4, 2014 webinar was hosted Premier Safety Institute as part of their Advisor Live series.
Discussing the importance of training in reducing alarm fatigue, Joan Speigel, MD, Assistant Professor, Anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center, said:
With end tidal CO2, of course, the training is the most important thing, is what to ignore and what not to ignore. Certainly it requires a lot of training. I don’t know how much I take it for granted that I understand the device very well—in capnography, that is. For the untrained person, what is going to trigger an alarm is very different than for myself.
Dr. Spiegel was joined in the webinar by
- Bhavani S. Kodali, MD, Associate Professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School;
- Harold Oglesby, RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJC);
- Gina Pugliese RN MS FSHEA, Vice President, Premier Safety Institute (moderator); and
- Michael Wong, JD, Executive Director, Physician-Patient Alliance for Health and Safety.
Below is a transcript of the discussion on alarm management to which we have added topic headers for ease of referral.
#1 Need for Training
BK: One point that is very, very clear is, to establish monitoring in the postoperative period, it requires a lot of training. Sometimes it is very, very difficult to achieve good monitoring in big hospitals because of the simple nature of personnel involved. As Harold [Oglesby] pointed out, it requires first of all an initiative by the respiratory therapists who can understand capnography. Anesthesiologists know very well capnography but they are not actually the persons to implement it.
The second thing is, there is a lot of training that is necessary for nurses about capnography. And then, there has to be some teaching to the patients themselves, as was pointed out, because to keep that nasal cannula in position requires some support on the part of the patient. The patient’s families should ensure that it doesn’t fall off by fixing it. The fixation of the catheter again is a training thing because the catheters can be fixed and stay for a pretty long time.
The last one is about alarms. There has to be a lot of education and also filtering certain false alarms and making alarms that are more predictable of some ongoing process rather than false alarm. Sometimes the combination is better—pulse oximetry with capnography to see if the false alarms can be minimized—but so far there is no standard criteria that has come up that can be used on a much wider scale in every postop position to say that this thing should be the most reliable methodology. In absence of that, it probably has to be worked out at each location. Train people, train the patients, and use the systems. Make sure that they get more predictable results.
#2 Strategies to address alarm fatigue
JS: What I’d like to point out is that, I think what these alarms do is two things. One, it’s the essence of the alarm itself, but also just having the device there, so an end tidal CO2 alarm, actually is a surrogate for patient attention. I find that to be fascinating whether or not it’s really the device that’s helping the patient or whether or not it’s the nursing staff and the family who is paying attention to the device and hence the patient. Regardless, if the outcomes are better, I think that’s a very interesting thing to think about.
In terms of alarm fatigue, yes, as anesthesiologists we’re saturated with devices and machinery in the operating room, as an example, and our minds are trained to hear certain alarms and not others. The louder the alarm, in a sense, the worse it is. I think that something that, because it requires attention, is also not necessarily a bad thing, so you have the problem of overreaction to alarms and under-reaction. I think there could be a sweet spot there where certain alarms can be beneficial regardless.
With end tidal CO2, of course, the training is the most important thing, is what to ignore and what not to ignore. Certainly it requires a lot of training. I don’t know how much I take it for granted that I understand the device very well—in capnography, that is. For the untrained person, what is going to trigger an alarm is very different than for myself.
It would be interesting for me to actually see these things in place before I make a decision about it. I don’t see them in the PACU [postoperative anesthesia care unit] very much—I’d like to see that—and do almost a QA [quality assurance] pilot trial to see in my experience what that looks like and what the alarm does. I can look at the data and everybody tells me that the alarms are very loud so I’d like to see a little bit more data on this and patients postop and get more empiric data on this before I can say what can be done to revise it.
HO: I can tell you from personal experience that our devices, and the way our facilities our designed, is we are based in our campuses with pods. We don’t only monitor capnography on the PCAs but it has expanded because of the success of monitoring patients on PCA. We also monitor patients that are on high dose opioids; say, for instance, dilaudid. If they’re on a dose that’s higher than two milligrams within every three hours or so, they have to have end tidal CO2 monitoring on them.
We also monitor end tidal CO2 on patients that are receiving propofol for moderate sedation. There are a lot of patients that are being monitored and if you’re in a pod and the alarm goes off, the alarm is loud and it is annoying. The alarm itself is part of the reason we have stimulations of our patients. If it stimulates the patient, it also stimulates the staff.
It is one of those alarms that is hard to ignore and it is definitely loud.
JS: The alarms that make up, at least for me—we used to have Drager machines, the Omegas—and they have very soft alarms. But I will tell you that when those go off, you really listen. Alarm fatigue is very interesting and requires some thought.
HO: It does.
#3 Customizing Alarms
HO: We set low respiratory rate, high EtCO2. The numbers are patient-dependent but the values default to 50 for end tidal CO2 for high; respiratory rate less than 10 it will alarm. The therapist, when they do their assessments, they may make adjustments depending on the patient.
If they have a COPD [chronic obstructive pulmonary disease] patient that normally runs a higher EtCO2, then they will make an adjustment based on the patient’s trend, so that patient may end up with an alarm that is higher. Like I said, it is generally set by what is going on with the patient; if not, it is usually on the default settings.
BK: That is a critical point which you made now, is no standard alarm is good for two patients. That is the problem with alarm fatigue. If you just continue to use the same parameters for every patient, then it results in alarm fatigue. That point comes with experience. Once you know, OK, this patient’s end tidal is always around 50, so you come up with a different parameter for him.
#4 Educating Patients
HO: The key for us in order to have the success that we had was, one, education; particularly patient and family education where we educated the patients, specifically on why they were wearing the device and educated the family on why they were wearing the device.
We had much higher compliance with the device. Sometimes the patients and family members had to educate some of the staff and remind them why the patient was on the end tidal CO2 monitor and not to get too hyped about alarms. We developed a basic and understandable education for the families and the patients. When they understood what it was there for, our compliance shot out the roof and we had no issues with compliance in wearing the device.
MW: Communication with patients and their families is just so critical in achieving safe and effective PCA use and better alarm management. At PPAHS, we’ve recommended four essentials for patient safety. First, to ensure patients and their families are provided with information on proper use of the PCA pump.
HO: The other thing I just want to put out there is the fact that a lot of the staff wanted to put an end tidal CO2 monitor just on the patients that look the sickest—just on the patients with the biggest necks, the patient that looked like they would be probable. When you go back and look at Michael [Wong]’s pictures from those patients who just had poor outcomes and deaths, only a couple of them looked like they were sick. The other ones looked like they should walk out of the hospital.
MW: You’ll see, except for Robert Goode and Louise Batz, the other four are teenagers. You expected them to leave the operating room, in which case, they did. All of them had successful procedures. It was just postoperatively when the adverse events occurred. Ensuring that the patients know what the pump is doing—and I think that ISMP [Institute for Safe Medication Practices] and others have said no PCA by proxy—make sure the families understand that they’re being monitored for safety reasons.
Make sure the oximetry is clipped on their finger and the capnography is on the nose. Those kinds of things. Save yourself some trouble and educate the patient on what read-outs there are on these machines.
Lastly, educate the patients on why the alarms are sounding and what to do when they sound. Gesturing with the hand upon which the oximetry is clipped could sound an alarm. Taking off the capnography cannula will sound the alarm. Those kinds of things. So save yourself some trouble and that’s going to decrease the number of nuisance alarms that you hear.