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Assessing Implementation Adherence to Alarm Management Bundle to Reduce Nonactionable Alarm Frequency
Abstract
Problem: Following a near-miss arrhythmia event and a weekly average of 3,247 high heart rate and low pulse oximeter alarms, a large, urban medical center seeks to reduce alarms through alarm management strategies especially as it relates to repeated alarms. There is a high volume of nonactionable alarms or alarms that do not require clinical intervention, which contributes to alarm fatigue and near-miss events. Excessive alarms lead to disruption in the milieu, errors, and staff burnout. Purpose: Nonactionable alarms can be reduced with a standardized care intervention. This quality improvement project aims to support the reduction of non-actional alarms through use of a standardized, nurse-driven set of principles targeting alarm management, otherwise known as the CEASE bundle. Methods: The quality improvement project lead (QI-PL) evaluated the current approach to alarm management through review of policy and practice and proposed a standardized alarm management bundle based upon a review of the evidence. Project champions were provided with education, and a set of measurement tools were created. The alarm management bundle was implemented over 15 weeks. Adherence to the different elements of the bundle, and frequency of non-actionable alarms was evaluated weekly as patients were available. Results: Weekly trends demonstrated low adherence to some elements of the bundle, specifically, electrode replacement as an alarm management strategy. A reduction in nonactionable alarms was observed, specifically, a 6% decrease in high heart rate alarms. Pulse oximetry alarms did not decrease. Conclusions: Implementing a nurse-driven alarm management bundle has been shown to decrease nonactionable heart rate alarms in pediatric inpatient settings. The CEASE bundle allows for nurse autonomy in implementing an evidence-based alarm reduction technique in a simplified form. Sustainability depends on continued nursing engagement and future implementations may consider ways to increase staff adherence.Identifier to cite or link to this item
http://hdl.handle.net/10713/22800Collections
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