Nursing Informatics

Janice Freeman, Erin Rentch,

Renee Higa-Tanner, & Jennifer Short

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QSEN Goal:

“…address the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the healthcare systems.”⁷

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QSEN: Informatics

Definition: The use of information and technology to communicate, manage knowledge, mitigate error, and support decision making. ⁷

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Nurse Informaticists: RNs who assess opportunities for innovative technology to improve clinical practice by analyzing current and future clinical workflows. Based upon these observations, they facilitate the design, development, testing, training and implementation of automated clinical systems.¹

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Timeline:

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Technology introduced to healthcare

Technology implemented in CCUs

Computer-based information systems (CIS)

POC systems to standardize care

Internet emergence → increased data exchange.

Informatics field emergence

PC emergence

Embedded clinical decision support for nursing & interdisciplinary practice

1950s

1960s

1970s

1990s

1980s

2000s

2010s

EHR “Meaningful Use” funding

(Troseth, 2012)

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QSEN Informatics: KSAs

(QSEN Institute, 2014)

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Problem, Planning, &

Solution Development

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Alarm Fatigue

What is Alarm Fatigue?

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• Alarm fatigue occurs when hospital staff becomes desensitized to alarm alerts causing missed alarms or delayed responses.

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Different Alarm Types

• Telemetry alarms (Arrhythmias)
• Heart rate
• Bed and chair alarms
• O2 saturation sensors
• IV pumps
• Patient call lights
• Ventilator machine
• Respiratory rate

Video: https://www.youtube.com/watch?v=r8s21EZ9lVk

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Causes of Alarm Fatigue

• Joint Commission estimates that 85-99% of alarms are false or insignificant
• Staff not adequately trained on monitor programming
• Frequent alarming of non-critical alarms
• ICU Study: 563 alarms sounded/per patient/per day!

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Why is it a problem?

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• Safety & patient care is compromised by the distracting sound of the very alarms that are designated to help keep the patients safe
• 566 alarm-related patient deaths (Jan. 2005-Jun. 2010)
• Patient’s families get concerned when alarms go off & nurses do not respond immediately to check on them
• #1 Technology hazard of 2013
• If nurses answer all alarms, they fall behind in their work
• If nurses don’t respond to the 1% of truly critical alarms, patients are exposed to significant danger

(Sincox & Nault, 2014)

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Joint Commission Action Items for Alarm Fatigue

A1. As of July 1, 2014, leaders establish alarm system safety as a hospital priority

A2. During 2014, identify the most important alarm signals to manage based on the following:

• Input from the medical staff and clinical departments
• Risk to patients of the alarm signal is not attended to or if it malfunctions
• Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
• Potential for patient harm based on internal incident history
• Published best practices and guidelines

A3. As of January 1, 2016, establish policies and procedures for managing the alarms identified in EP 2. Above that, at a minimum, address the following:

• Clinically appropriate settings for alarm signals
• When alarm signals can be disabled
• When alarm parameters can be changed
• Who in the organization has the authority to set alarm parameters
• Who in the organization has the authority to set alarm parameters to “off”
• Monitoring and responding to alarm signals
• Checking individual alarm signals for accurate settings, proper operation, and detectability

C4. As of January 1, 2016, educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.

(Joint Commision Perspectives, 2013)

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2014 National Patient Safety Goals

Joint Commission

• Goal 6: Reduce the harm associated with clinical alarm systems
• NSPG.06.01.01: Use alarms safely
• Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
• Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety...many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them.

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Issues Development and Exploration

• Protects patients from avoidable injuries and other complications
• Reduction in nuisance or false-positive alarms
• Increase in reaction time and probability of response during critical or “real” alarms
• Decrease in excessive monitor alarms

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Obstacles

• Lack of buy-in from management and staff
• Lack of training on how to modify alarms
• Non-compliance with individualizing alarm parameters for each patient, when necessary
• Residual alarm fatigue behavior
• Engineers might not have ability to tailor monitors

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Development of Solution

• Form Alarm Management Task Force
• 1 month collection of baseline data of false & critical alarms
• Verified the definitions of each setting and ramification of any changes
• Develop educational materials to train staff, prior to implementation
• Literature review of current solutions and change implementation
• Consult with monitor representative for assistance (Edwards)
• Create nurse alarm survey & post-implementation survey
• Create & send out survey to past unit patients to measure alarm noise & nurse responsiveness
• Create follow-up survey to send out post-implementation

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Resources

Duration of the Project:

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• 1 Month Baseline Data Collection
• January 1st - February 1st, 2015
• 8 Months of Study
• February 1st - September 1st

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Resources cont.

One Unit--Step Down Medically Induced ICU (30 beds)

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• Director of Nursing (DON)
• Charge Nurses
• 2 Super-Users currently stationed on the unit
• 30 Nurses
• 8 CNA’s
• 4 Telemetry Technicians
• 4 Unit Secretaries
• Company Representative (Philips) to provide an
• In-Service and train super-users (day/night)

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Resources

Costs:

Super-User (Additional Staff) $6,000

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Outsourcing: Data Collection & Analysis $5,000

• Survey of Nurses for alarm fatigue (Beginning & End)
• Survey of Patients for the month of January & obtain baseline alarm frequency
• Patient survey for noise levels related to alarms & responsiveness to alarms

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Marketing Strategies:

• Staff will be trained on their shift time by the Super-User $0
• Thank you lunch/shift upon completion: $300
• Internal Memos regarding the project $0

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Literature Review

• Monitor Alarm Fatigue-Integrative Review

• Provided an organized approach to appraise, synthesize, and translate

evidence.

• Reviewed 172 abstracts & read 85 articles entirely

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• Organized into 5 major themes:

1-Excessive alarms and effects on staff

2-Nurse’s response to alarms

3-Alarm sounds & audibility

4-Technology to reduce false alarms

5-Alarm notification systems

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Literature Review

• An Evidence-Based Approach to Reduce Nuisance Alarms and Alarm Fatigue

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• Reports on the results of a retrospective analysis conducted by the company to determine the incidence of alarms at various alarm threshold and delay setting.

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• ”less than 1% of alarms were clinically actionable, requiring bedside interventions”! (pg. 46)

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• Results showed that by lowering the alarm limits to 88% with a 15-second delay reduces alarms by 88%.

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Literature Review

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• Monitor Alarm Fatigue: Standardizing Use of Physiological Monitors and Decreasing Nuisance Alarms

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• Purpose was to describe a unit-based quality improvement initiative that enabled the task force to quantify the frequency of alarms & to implement small change projects.

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• Task force goal was to make all alarms to be actionable events.

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• This initiative resulted in a 43% reduction in critical physiologic monitor alarms.

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Literature Review

• Fighting Bed Alarm Fatigue in Orthopedic Units

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• Article explains the dangers of alarm fatigue and steps that can be taken to manage it.

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• Of the 1% of the actionable events, the Joint Commission reported 98 alarm-related sentinel events, 80 of which were fatal.

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• Steps to preventions:
• Conducting staff development
• Spend more time in the room
• Educate patient & family about the alarms
• Reevaluate the need for bed alarm each shift
• Alarms that can automatically turn off if patient stops moving

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Change Models, Theories, & Strategies

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Lewin: Change Theory

• Unfreezing → Change agent convinces members to change (awareness phase)
• Staff is likely already aware because they are receiving all of the alarms
• BUT quantifying, using data collection, will make the issue apparent
• Movement → Change agent identifies, plans, and implements appropriate strategies, ensuring that driving forces exceed restraining forces.
• This is when resistance needs to be recognized, addressed, and overcome
• Change should be well-planned and gradual in nature
• Re-freezing → Change agent assists in stabilizing the system change so that it becomes integrated into the status quo
• Should occur at least 3-6 months after implementation
• This does NOT eliminate the possibility of further improvements
• Evaluation of change

(Marquis & Huston, 2015)

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Burrowes and Needs: Change Model

• Precontemplation → No intention to change
• Contemplation → Considers making a change (but not committed) [Unfreezing]
• Preparation → Intent to change in near future
• Action → Modification of behavior occurs [Movement]
• Maintenance → Changes maintained and relapse avoided [Refreezing]

Benefits of this model include ability assessing readiness for change at different levels

(Marquis & Huston, 2015)

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Driving & Restraining Forces

Driving forces = Facilitators

• To eliminate a problem that is undermining productivity
• Proposition of reduced alarm fatigue
• Exploit systems already available
• Proposition of increased patient safety

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Restraining forces = Barriers

• Fear of the unknown
• Unwillingness to take risks
• Additional cost of training
• Change fatigue

(Marquis & Huston, 2015)

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Resistance & Change Strategies

Resistance is dependent on the type of change proposed.

• Must consider:
• Values, education, cultural and social backgrounds
• Individual experiences with change (positive or negative)
• Implementation: Technological changes < Social changes [this is good for us!]

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Change Strategies: What is needed to prompt change in others.

• Rational-empirical → Provide current research as evidence to support change.
• Concept: Knowledge is power
• Normative-reeducative → Group norms and peer pressure are used to socialize and influence people to change.
• Concept: Humans are social
• Power-coercive → Use of authority by the agent to enact change
• Concept: People are stubborn, forced change is necessary

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TIP: By selecting from each set of strategies, the change agent increases the chance of successful change.

(Marquis & Huston, 2015)

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Change Development

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What makes a project unsuccessful:

• The ability of the change agent to deal appropriately with conflicted human emotions and to connect and balance all aspects of the organization that will be affected by that change
• Solution: We included all staff on the unit, as well as axillary respiratory therapists, who interact with patients and monitors
• Outsiders as change agents are usually rejected, because they are thought to lack knowledge and expertise
• Solution: We are having implementation come from in-house source
• Too many changes, too fast - - implementation is all about timing!
• Solution: Essentially, only 2 changes made (alarm limits & tones)

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(Marquis & Huston, 2015)

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Change Development

What makes a project successful:

• An effective change agent (manager)
• Leader for developmental, political, and relational expertise to ensure that needed change is not sabotaged.
• Solution: May be one in the same, but leader-manager will act as change agent
• Balance stability and change
• Solution: Stability in keeping current equipment, change in modifying its use
• Proper timing
• Solution: Alarm fatigue at it’s peak AND #1 technology hazard in health care
• Planning
• Solution: Phases of intervention defined, education and resources made available
• Driving forces increased, restraining forces decreased
• Solution: Education to eliminate fear of change, aim of reducing alarm fatigue and increasing patient safety.

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Change Implementation & Evaluation

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Implementation

TRAINING:

• Superusers on shift will provide education on upcoming changes
• Modules will be provided for monitor refresher course

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CHANGE:

• O2 sensors decreased to 88% and a delay at 15 seconds
• Modified cardiac alarms
• Changed alarm levels and tones
• Change Heart Rate parameters (increase Low & High)
• Increase amount of PVC’s per minute
• Assigning coding to alarm levels for prioritization

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Evaluation

• How effectiveness evaluated
• Nurse Alarm Survey readministered
• Clinical engineers monitored alarms during 8 months of study
• Patient survey on noise level of alarms and nurse responsiveness to alarms

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HCAHP Survey

• During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?
• Never
• Sometimes
• Usually
• Always
• I never pressed the call button

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• During this hospital stay, how often was the area around your room quiet at night?
• Never
• Sometimes
• Usually
• Always

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Evaluation

• Results
• Nurse Alarm Survey
• Overall noise level decrease
• Alarm noise decrease
• 67% decrease in cardiac alarms and 85% decrease in low SpO₂ alarms
• Patient survey show decrease in alarm noise and an increase in nurse responsiveness to alarms

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Evaluation

• Effectiveness of plan
• 70 % Overall reduction in non-actionable alarms
• What facilitated change
• Buy-in
• Having a culture receptive to change
• Support from management and nurse leaders
• What inhibited change
• Noncompliance
• Change fatigue
• Lack of support from management and nurse leaders

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Evaluation

• Suggested alternative approaches
• Phased implementation
• Possible consequences
• Change fatigue
• Probabilities for future use
• Use on intensive care units and PACU
• Thresholds and time delays modified to be appropriate for unit
• Wireless secondary alarm system - connect to phone

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References

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• Children’s Hospital of Orange County. (n.d.) Nursing Informaticians. Unpublished intranet document.
• Cvach, M. (2012). Monitor alarm fatigue an integrative review. Biomedical Instrumentation & Technology, 4, 268-277.
• Daniels, K. (2014). Fighting bed alarm fatigue in orthopedic units. Nursing 2014, 9, 66-67. Retrieved from www.nursing2014.com
• Graham, K. C., & Cvach, M. (2010). Monitor Alarm Fatigue: Standardizing Use of Physiological Monitors and Decreasing Nuisance Alarms. American Journal of Critical Care, 19(1), 28-34. doi:10.4037/ajcc2010651
• Marquis, B.L., & Huston, C.J. (2015). Leadership Roles and Management Functions in Nursing: Theory and Application
• QSEN Institute. (2014). Pre-Licensure KSAs. Retrieved October 10, 2014, from http://qsen.org/competencies/pre-licensure-ksas/
• Troseth, M. (2012). QSEN nursing informatics deep dive: Integrating quality, safety and education strategies into nursing competences. Retreived from http://www.aacn.nche.edu/qsen-informatics/2012-workshop/presentations/troseth/Roles,_Competencies,_Skills.pdf
• Welch, J. (2011). An evidence-based approach to reduce nuisance alarms and alarm fatigue. Horizons, 2, 46-52.

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