Last month’s inaugural meeting of the National Coalition for Alarm Management Safety prompted me to consider how much we have learned about the effective management of clinical alarms—and how much we have yet to learn.
I had the opportunity to provide some data on infusion pump alarms and alerts collected over a three- month period from 730 hospitals and including an analysis of 39,000,000 alarms. Although a report on the two-day meeting will be published later this year, I thought it might be of interest to share some of the key observations and findings from this huge amount of data.
Wireless connectivity to infusion pumps was initially implemented to track and collect dose error reduction software (DERS) alerts and subsequent caregiver actions (reprogram, override, etc.), and to broadcast drug library updates. More recently, the wireless system has been expanded to transmit and collect all infusion data, including alarms such as “occlusions” and alerts such as “infusion completed.” While most infusion pumps are not assigned to individual patients, we are able to collect data based on care area, drug or fluid infused, frequency, and type of alarm and alert.
Drilling down into this trove of data has been very helpful in starting to understand the types and frequency of pump alarms, but it also has raised questions for which we do not have answers. We see the highest types of alarms are occlusions, representing 50% of all pump alarms. Eighty percent of these alarms are due to occlusions below the pump, and the highest frequency location is in medical/surgical units. Nurses attribute many of these occlusion alarms to catheter placement. Catheters placed in the wrist or the elbow frequently kink during normal hand and arm movement, causing the pump to signal a blocked IV line. Clearly, this is a nuisance to patients, their families, and the nurses who must visit the bedside and restart the pumps (assuming the patients do not restart their own pumps). The catheter may have been placed by a number of clinicians— the EMTs during transport, physicians and nurses in the emergency department, or anesthesia personnel in the OR—so dealing with this issue poses many challenges.
Air-in-line alarms are another frequent source of pump alarms. The pooled data reveals that air-in-line alarm frequency is second only to occlusions, but when looking at individual hospitals, there is considerable variation in the drugs associated with these alarms. For example, in one 900 bed hospital, 28% of all air-in-line alarms were associated with the drug amiodarone, while in a comparable hospital, the same drug accounted for only 2% of the air-in-line alarms. Assuming approximately the same use of the drug in the ICU patients, why would the experience vary by a factor of 14? In another hospital, six drugs were involved in 68% of the air-in-line alarms, while in a comparable hospital, only one of these six drugs were in its top six. With so much variation throughout much of medical practice and hospital care, perhaps we should not be surprised that efforts to paint pump alarms with the same brush will not be successful.
In much the same way that our early look at the DERS data raised numerous questions, highlighted practices that previously were hidden, and identified significant opportunities for improvement, the early look at the pump alarms and alerts seem to hold the same promise. Infusion pumps differ from monitors in several ways: they do not typically have false alarms, the frequency of alarms is a small fraction of what is experienced with monitors, and they do not automatically reset if the alarm condition clears. They are similar in that many of the alarms and alerts are configurable, and they can be customized for specific patient types and/or care areas.
With the availability of the data, we can now begin to investigate variation in patterns, identify problematic practices, and share best practices to address the pump alarms and alerts. We will also better understand how best to approach the future of distributed alarms, a process that holds promise of reducing or eliminating many of the alarms that contribute to the noise, interfere with patient recovery, and impact caregiver productivity.
Tim Vanderveen, PharmD, MS, is vice president of CareFusion’s Center for Safety and Clinical Excellence. He is also a member of the AAMI Board of Directors.