Clinical alarm systems testing—a program assessment model

AORN Journal, August, 2004 by Wesley Richardson

In July 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) approved six national patient safety goals to be implemented in 2003. (1) Goal six is to "improve the effectiveness of clinical alarm systems." This goal was developed as a result of ventilator-related sentinel events. (1) The Joint Commission reviewed 23 reports of deaths or injuries (ie, 19 deaths, four comas) related to long-term ventilation. Sixty-five percent of these cases were related to malfunction or misuse of an alarm or an inadequate alarm. (2)

A clinical alarm is defined as

   any alarm that's intended to protect
   the individual receiving care or alert
   the staff that the individual is at
   increased risk and needs immediate
   assistance. (3)

The joint Commission's goal is

   relevant to the full spectrum of alarm
   systems that are triggered by physical
   or physiologic monitoring of the
   individual, by variation in measured
   parameter of medical equipment
   directly applied to the individual, or
   self-activated by the individual. (3)

The Joint Commission's expectation is that organizations will implement and document regular preventive maintenance and testing of clinical alarm systems, ensure alarms are activated with appropriate settings, and ensure clinical alarms are audible with respect to distances and competing noise within each unit. (1) One way to do this is to develop and implement a clinical alarm system testing program that involves all staff members.

ELEMENTS OF A CLINICAL ALARM SYSTEM

The perioperative area has numerous and varied clinical alarms, and it is extremely important to identify and test all of them. All perioperative areas, including preoperative holding, the OR, and postoperative areas, must be assessed. One problem is that the many alarms in these areas may be viewed as nuisances and ignored or dismissed as unimportant. For example, some alarms, such as pneumatic pump stocking alarms, anti-thrombolytic compression boot alarms, and electronic cooling pad device alarms, may be considered minor and may not prompt an appropriate reaction. Although these alarms are not considered as important as holding area, OR, or postanesthesia care unit patient monitors, if they are not attended to, it may negatively affect patient care.

To date, there are few published recommended strategies for meeting JCAHO's goal regarding clinical alarm systems. Although JCAHO offers suggestions for meeting the goal, it does not dictate any specific strategies or guidelines for developing and designing a clinical alarm systems testing program.

One way to develop a clinical alarm systems testing program involves using a fishbone diagram to investigate the causes of an ineffective clinical alarm system (Figure 1). (4) The elements that make up a clinical alarm system include equipment, staff members, the environment, and other dynamics specific to a unit or type of equipment. (4) The interaction between these fundamental elements is used to determine the efficacy of a clinical alarm system.

[FIGURE 1 OMITTED]

EQUIPMENT EVALUATION. When evaluating equipment, managers first must determine whether a particular piece of equipment is included in a preventive maintenance program and is scheduled regularly for service. This usually is a function of an institution's biomedical services department, so to remain abreast of equipment status, unit managers may have to request preventive maintenance service records from that department. Nurse managers can delegate the responsibility for observing the clinical alarm test along with the responsibility for alerting the biomedical services department about new items; old, common items; or items with a known history of malfunctions or alarm volume controls that go to "off" inappropriately.

STAFF MEMBERS. Everyone associated with a particular piece of equipment must be familiar with it and competent to use it correctly. Competency should include the ability to adjust and tailor alarm settings to individual patients. To get ma appropriate response, each staff member must be able to identify and understand the meaning of all clinical alarms. Assessing how a given alarm is perceived by all personnel is extremely important for developing an effective clinical alarm system. For example, if an equipment alarm triggers frequently, staff members may view that alarm as a nuisance and either ignore it or not respond immediately. All staff members must be aware of personal or individual clinical alarm response behaviors and be encouraged to adjust their practices accordingly when needed.

PERIOPERATIVE ENVIRONMENT. Perioperative nurses may become so accustomed to a high ambient noise level (eg, surgical equipment, radios, loud talking) that alarms may not be noticed immediately. If there are physical barriers, such as sound-blocking walls or doors or equipment with similar-sounding alarms, the clinical alarm system may be compromised. The proximity of a clinical alarm to staff members also is a consideration. Some alarms might be ignored by the circulating nurse because they usually are monitored directly by the anesthesia care provider; it is assumed this person will respond to the alarm. In addition, an alarm that is triggered rarely has a high potential of being compromised because staff members may not be familiar with it, which may result in their inability to respond to the alarm. Assessing staff member knowledge is paramount to ensure everyone knows how to respond appropriately to all alarms. A flaw in any of these variables contributes to an ineffective clinical alarm system.