Standardized Approach Markedly Reduces Cardiac Monitor Alarms

Christopher E. Dandoy, MD, MSc Divisions of Bone Marrow Transplantation and Immunodeficiency, and James M. Anderson Center for Health Systems Excellence Cincinnati Children's Hospital Medical Interview with:
Christopher E. Dandoy
, MD, MSc
Divisions of Bone Marrow Transplantation and Immunodeficiency, and
James M. Anderson Center for Health Systems Excellence
Cincinnati Children’s Hospital Medical Center Editor’s Note: Dr. Dandoy discusses a novel program to reduce the frequency of cardiac alarms in the setting of a large inpatient intensive care unit.

Medical Research: What is the background for this study? Why did you decide to do this study?

Dr. Dandoy: During our three month investigation period we had roughly a million alarms go off in our intensive care unit. Our unit nurses reported spending 30-40 minutes per day responding to the various alarms.

We first looked to see if there were established guidelines in the literature for cardiac monitors and found there were none. The alarms were a source of frustration and anxiety not just for the unit staff but also for patients and family members.

Medical Research: What are the elements of your alarm reduction program?

Dr. Dandoy: The first element was simply to have a plan or a process for initial ordering of monitor parameters based on age-appropriate standards. In our case, we established a standard order set in Epic, our electronic records program.

Epic Cardiac Monitor Order Set Epic Cardiac Monitor Order Set

The second element was to change the patient monitor leads daily. We know that lead conductivity and sensitization fades our after 24 hours, leading to inaccurate monitoring. The challenge was to find a way of changing the leads daily with a minimum of patient discomfort. We discovered that by soaking the leads first, pain could be eliminated. To reduce staff time, the nurses perform the monitor lead changes when they bath the patient.

The third element consisted of evaluating the cardiac monitor parameter settings. For example:

We increased the SpO2 alarm delay from 5 to 10 seconds because the majority of the SpO2 alarms self-correct within the delay period set.
We also found that a high respiratory rate alarm, without other vital sign abnormalities, is nearly always a false alarm.
The fourth element consisted of determining a reliable method for appropriate discontinuation of the monitoring devices. We now routinely assess whether the monitors are necessary or can be discontinued.

Medical Research: What are the barriers to implementing this program in a wider fashion? How expensive is it to implement and maintain?

Dr. Dandoy: The main barrier to implementation was the daily lead change, which we overcame by incorporating into the daily bathing time, decreasing both patient discomfort and staff time. The cost of the daily lead change was minimal at just about $1 dollar per lead.

There was general acceptance of the program by the unit’s staff. The median time that individual nurses spent addressing monitor alarms decreased from 20 to 25 minutes per shift to 10 minutes per shift, including the time it took each nurse to complete the monitor log.

As a measure of success, the program has been self-sustaining in the unit since the study ended and has spread to other units in the hospital.

Medical Research: What further research do you plan in this area?

Dr. Dandoy: We plan to address the effects of monitor alarms on sleep and whether a reduction in alarms can have a positive impact on patient sleep and satisfaction.


A Team-Based Approach to Reducing Cardiac Monitor Alarms

Christopher E. Dandoy, Stella M. Davies, Laura Flesch, Melissa Hayward, Connie Koons, Kristen Coleman, Jodi Jacobs, Lori Ann McKenna, Alero Olomajeye, Chad Olson, Jessica Powers, Kimberly Shoemaker, Sonata Jodele, Evaline Alessandrini, and Brian Weiss

Pediatrics peds.2014-1162; published ahead of print November 10, 2014, doi:10.1542/peds.2014-1162


BACKGROUND AND OBJECTIVES: Excessive cardiac monitor alarms lead to desensitization and alarm fatigue. We created and implemented a standardized cardiac monitor care process (CMCP) on a 24-bed pediatric bone marrow transplant unit. The aim of this project was to decrease monitor alarms through the use of team-based standardized care and processes.

METHODS: Using small tests of change, we developed and implemented a standardized CMCP that included: (1) a process for initial ordering of monitor parameters based on age-appropriate standards; (2) pain-free daily replacement of electrodes; (3) daily individualized assessment of cardiac monitor parameters; and (4) a reliable method for appropriate discontinuation of monitor. The Model for Improvement was used to design, test, and implement changes. The changes that were implemented after testing and adaptation were: family/patient engagement in the CMCP; creation of a monitor care log to address parameters, lead changes, and discontinuation; development of a pain-free process for electrode removal; and customized monitor delay and customized threshold parameters.

RESULTS: From January to November 2013, percent compliance with each of the 4 components of the CMCP increased. Overall compliance with the CMCP increased from a median of 38% to 95%. During this time, the median number of alarms per patient-day decreased from 180 to 40.

CONCLUSIONS: Implementation of the standardized CMCP resulted in a significant decrease in cardiac monitor alarms per patient day. We recommend a team-based approach to monitor care, including individualized assessment of monitor parameters, daily lead change, and proper discontinuation of the monitors.