Hospitals have long struggled with “alarm fatigue,” when busy nurses become desensitized to the constant noise emanating from cardiac telemetry monitoring systems. Although less than 10 percent of alerts are immediately clinically relevant, important warning signs can be missed in the din of nuisance pings. According to the American Heart Association (AHA), fewer than 1 in 4 adults survived an in-hospital cardiac arrest in 2013, and in prior studies, up to 44 percent of inpatient cardiac arrests were not detected appropriately.
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Alarm fatigue has become a national phenomenon that has led to patient deaths. In response, in 2014, The Joint Commission began requiring hospital systems to develop and utilize effective alarm management policies by 2016. Meanwhile professional organizations identified rampant overuse of telemetry in low-risk patients as a chief contributor to alarm fatigue.
At Cleveland Clinic, a dedicated off-site central monitoring unit (CMU) provides 24/7 secondary cardiac telemetry monitoring for non-critically ill patients at the health system’s main campus and two of its regional hospitals. To avoid unnecessary monitoring of patients at low risk, the CMU team developed and rolled out standardized criteria for putting patients on telemetry in 2014.
“Having written criteria decreased our telemetry census by 15 percent without an increase in cardiac-related adverse events,” says Molly Loy, MSN, RN, CNL, project manager and the nurse leader on the CMU. Loy worked with CMU physician leader Daniel Cantillon, MD, and CMU manager Bryan Dodrill and others to get the nursing units and ordering providers up to speed with identifying the appropriate indication for telemetry.
In August, results from the CMU’s first 13 months of using the standardized criteria were published by JAMA showing that there’s real hope of reducing rates of nonimportant alarms without an increase in cardiopulmonary arrest events. During that time, the CMU monitored 99,048 patient orders and detected serious problems and accurately notified on-site staff for 79 percent of 3,243 events, which included a rhythm and/or rate change within one hour or less of the event. As of September, accurate notification to hospital on-site staff was over 84 percent.
Further, advance warning was provided directly to an emergency response team, and for those that went on to develop cardiopulmonary arrest, 93 percent were successfully resuscitated. This compares with a national benchmark of about 24 percent survival of in-hospital cardiac arrest as reported in the AHA’s “Heart Disease and Stroke Statistics – 2013 Update.”
A mission-control center…
Designed as a sort of off-site mission-control center, Cleveland Clinic’s CMU is staffed by trained technicians. Beyond providing continuous cardiac rhythm monitoring, CMU staff monitor blood pressure, heart and respiratory rates, pulse oximetry and even measures like intracranial pressure for patients in neurologic step-down units.
Removed from the distractions of normal hospital activities, CMU technicians provide urgent notification to bedside nurses or hospital emergency rapid response teams to aid patients in immediate danger of cardiac arrest. Such response teams aren’t new, but the linkage to central monitoring is.
…Paired with standardized telemetry criteria
Key to the program is a requirement that Cleveland Clinic ordering providers specify the reason for putting a patient on telemetry, using standardized criteria based on 2004 AHA/American College of Cardiology guidelines. In addition to common indications like atrial or ventricular tachycardia, bradycardia or post-cardiac surgery status, the team added a few indications not in the 2004 guidelines, including deep vein thrombosis/pulmonary embolism, stroke/transient ischemic attack and hospital transfer within 72 hours.
“By eliminating low-risk patients from being monitored, we were able to concentrate our efforts on patients who really require our attention,” Dr. Cantillon explains. “That’s getting at the crux of alarm fatigue — reducing the signal-to-noise ratio.”
Taking efficiencies to scale
This fall, the team embarked on final testing of a new telemetry platform that is allowing for greater efficiencies. A new system is being installed and implemented over the winter, and the team is completing feasibility studies with the technology. The CMU will be expanding its scope to include all its affiliated hospitals, including Cleveland Clinic Florida. Nurse training across the hospitals began in October and the rollout will be completed in 2017.
“With the new platform, patients are risk-stratified and cared for by a team of monitor techs. When a patient’s risk crosses a certain threshold, an alert is automatically generated. From this, the system allows context syncing of a patient’s electronic medical record (EMR) and their telemetry information, facilitating quick review and notification to the nursing staff by the monitor tech,” Loy explains. “Prior to this, technicians would watch up to 48 patient waveforms. In the new environment, technicians can focus on a single risk-stratified patient at a time.”
For hospital-based nurses, the new technology platform supports effective alarm management through standardization, training and advanced technology, and it is furthering patient safety. Nursing education involves the following alarm management communication points:
- Indication for telemetry
- Importance of correct patient identifiers in system,
- Contact information for the nurse who is caring for the patient,
- Nonactionable alarm prevention through skin preparation and electrode placement,
- Pausing the monitor when appropriate,
- Monitoring protocols and patient-specific alarm parameters
With the new system, when there is an issue, the patient’s tile turns red, moves to the top of the screen and oscillates, calling immediate attention to it. The technician can then look at the waveform, open the patient’s EMR and immediately notify the patient’s nurse. Technicians now work in teams and are able to watch more patients at one time because the technology in the background is using an algorithm to call attention to patients at risk, when necessary.
“We are leveraging what technology can do for us,” says Loy, explaining that this year they have been working with the system so that when an alarm is triggered, the CMU tech can immediately call the patient’s nurse via their badge connection. “We are so excited that this new technology allows us to care for more patients,” says Loy. “This will help patients across our hospitals.”
The improvements provide new standards in high quality, cost effective patient monitoring that are unprecedented in the world of telemetry.