Ca rdio pulmo na ry Mo nito rs a nd the Mo nito r Ove rsig ht Co - - PowerPoint PPT Presentation

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Ca rdio pulmo na ry Mo nito rs a nd the Mo nito r Ove rsig ht Co mmitte e : L e a rning fro m the Childre n's Na tio na l Me dic a l Ce nte r E xpe rie nc e

Je ff Ho o pe r MS, Dire c to r o f Bio me dic a l E ng ine e ring He a the r Wa lsh MSN RN PCNS-BC, Simula tio n Outre a c h Co o rdina to r Pre se nta tio n fo r HT SI April 25, 2013

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• 310 Be ds
• 6,000 e mplo ye e s
• L

e ve l 3 NI CU a nd T ra uma Ce nte r

• Physic ia ns a re ho spita l e mplo ye e s
• E

ve ry inpa tie nt b e d ha s a physio lo g ic mo nito r

• Sta nda rdize d o n Philips I

nte llivue mo nito rs

Childre n’ s Na tio na l Me dic a l Ce nte r

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• Ho w se ve ra l mo nito ring e ve nts le d to the

c re a tio n o f a mo nito ring c o mmitte e .

Our Sto ry

Sig nific a nt e ve nts o r injurie s

“Sa fe ty is a Dyna mic No n-E ve nt”

Slide c o nc e pt a da pte d fro m Ja me s Re a so n, Managing the Risks o f Organizatio nal Ac c ide nts, 1997

Ac tive e rro rs b y individua ls re sult in initia ting a c tio n(s) Po o rly de sig ne d pro c e sse s

• r a c tive e rro rs within a

we ll-de sig ne d pro c e ss

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• Mo nito r e ve nt
• Adde d Ce ntra l Sta tio ns in a ll Ac ute Ca re units

Ba c kg ro und

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• Mo nito r e ve nt
• Adde d pa tie nt c a re te c hnic ia n to wa tc h the

mo nito r & “no tify” RNs o f a la rms

Ba c kg ro und

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• Mo nito r e ve nt
• Ano the r e ve nt, RN pho ne s with a la rm

no tific a tio n

• Visua l c ue s (do me lig hts)

Ba c kg ro und

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• Mo nito r F

lo w

Ba c kg ro und

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• Ano the r e ve nt- a ssumptio n tha t a ll a la rms se nt

no tific a tio n to RN pho ne s; PCT did NOT c a ll & RN una wa re tha t pa tie nt ha d multiple ye llo w a la rms

Ba c kg ro und

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• ** All se rio us mo nito r e ve nts we re pa tie nts with

a tra c he o sto my.

Ba c kg ro und

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T he Birth o f the Mo nito r Ove rsig ht Co mmitte e

• Ne e d fo r a ssure pre vio us te c hno lo g y so lutio ns

we re still via b le

• Clinic a l invo lve me nt to c re a te mo nito r

sta nda rds a ro und a la rm ma na g e me nt, de fa ult pa ra me te rs, re se a rc h , e duc a tio n, a nd pro c e ss impro ve me nt

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De ve lo p a c ha rte r a nd “sho p” to va rio us c o mmitte e s to g a in sta ke ho lde rs.

T he Birth o f the Mo nito r Ove rsig ht Co mmitte e

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Me mbe r ship

• Bio me dic a l E

ng ine e ring

• Ca rdio lo g y
• Critic a l Ca re Me dic ine
• Ho spita list Divisio n
• I

nfo rma tic s

• L

e a de rship

• Me dic a l Unit Dire c to rs
• Nursing Sa fe ty Dire c to r
• Nurse s (a c ute & c ritic a l c a re , E

D, & PACU)

• Pe rfo rma nc e I

mpro ve me nt

T he Birth o f the Mo nito r Ove rsig ht Co mmitte e

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• Ane c do ta lly, sta ff e xpe rie nc ing mo nito r fa tig ue
• Disc o ve re d a wo rka ro und tha t wa s ha ppe ning in

re spo nse to mo nito r fa tig ue

T he Birth o f the Mo nito r Ove rsig ht Co mmitte e

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• Se ve ra l studie s a b o ut mo nito ring in o ur

institutio n

• Study re sults no t tra nsla te d into c linic a l

pra c tic e

T he Birth o f the Mo nito r Ove rsig ht Co mmitte e

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• Ane c do ta lly, mo nito r te c h ro le no t e ffe c tive
• Ac c o unta b ility ide ntifie d a s a c o nc e rn

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T he Jo int Co mmissio n a nd the Asso c ia tio n fo r the Adva nc e me nt o f Me dic a l I nstrume nta tio n (AAMI ) F

• unda tio n’ s He a lthc a re T

e c hno lo g y Sa fe ty I nstitute (HT SI ) a nd the E CRI I nstitute suppo rt the ide a tha t he a lthc a re fa c ility le a de rs e sta b lish a la rm syste m sa fe ty a s a prio rity.

T he Birth o f the Mo nito r Ove rsig ht Co mmitte e

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Go a l o f Co mmitte e T he mo nito ring c o mmitte e ’ s g o a l is to impro ve the sa fe ty a nd e ffe c tive ne ss o f physio lo g ic mo nito ring thro ug ho ut Childre n’ s Na tio na l while pro viding struc ture a nd o ve rsig ht to a ll mo nito ring re la te d issue s.

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• Re vie w a nd re c o mme nd b e st pra c tic e s fo r

physio lo g ic mo nito ring

• Re c o mme nd a nd imple me nt stra te g ie s to

de c re a se (sta ff) mo nito r fa tig ue

• Ac hie ve impro ve me nts in mo nito ring

thro ug ho ut the o rg a niza tio n Co mmitte e Ob je c tive s

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Ac tivitie s

• Cre a te d a mo nito r ma p to hig hlig ht the pro c e ss o f

mo nito r o rde ring / initia tio n, ide ntifie d b e st pra c tic e s, a nd c o nc e rns ra ise d b y the pa tie nt c a re te c hnic ia ns.

• Cre a te d five ne w pro file s with a g e a ppro pria te

de fa ult pa ra me te rs

• L
• we re d a la rm vo lume s o n b e dside mo nito rs 3 le ve ls
• L
• we re d a la rm vo lume to the lo we st a udib le a t the

c e ntra l sta tio n

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Ac tivitie s

• Upda te d mo nito r po lic y to b e spe c ific to a la rm

ma na g e me nt, mo nito r te c h dutie s, a nd o ve ra ll ne e d fo r mo nito ring .

• Adde d Ala rm F

a tig ue tra ining to Ce ntra l Nursing Orie nta tio n

• Philips tra ine d e nd use rs o n pro file c ha ng e s in a ll

units

• Pilo ting “mo nito r disc ussio ns” during ro unds to

disc uss pa ra me te rs a nd c o ntinue d use

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Co nduc te d a Surve y

• Co nduc te d a surve y o f RN’ s a nd MD’ s to de te rmine

the spe c ific issue s ne e ding a tte ntio n. T he surve y re c e ive d re spo nse s fro m 288 c linic ia ns (119 RNs, 116 MDs; o the rs inc lude d NPs, PAs, RT s, & PCT s) with the prima ry issue s ide ntifie d a s:

• De fa ult mo nito r a la rm se tting s we re no t a ppro pria te
• T
• o muc h no ise o n the unit a la rm fa tig ue
• Ne e d fo r ne w pro file s re la te d to pa tie nt’ s a g e
• Mo re e duc a tio n a nd a wa re ne ss o f mo nito rs
• I

na ppro pria te use o f mo nito rs

• Sa fe ty c o nc e rns re la te d to e q uipme nt

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1 1 2 4 5 5 7 11 18 20 21 41 5 10 15 20 25 30 35 40 45

MD T

• p Safe ty Conc e r

ns

T

• p 3 MD Co nc e rns: Ala rm F

a tig ue , L imits, & Misuse

Re sults fo r MD vs. RN T

• p Sa fe ty

Co nc e rns

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T

• p 3 RN Co nc e rns: Ac c ura c y, L

imits, & Ala rm F a tig ue

1 2 4 4 5 8 9 9 10 10 14 19 24 28 5 10 15 20 25 30

R N T

• p Safe ty Conc e r

ns

Re sults fo r MD vs. RN T

• p Sa fe ty

Co nc e rns

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Adjuste d Mo nito r Pa ra me te rs

T he fo llo wing c ha ng e s we re ma de to impro ve the e ffe c tive ne ss o f the a la rms in 7E , 6E (GI ),5E , 4E , 4M & E R:

• Ala rm vo lume s a t the c e ntra l sta tio n

we re lo we re d thre e le ve ls

• Ala rm vo lume s o f the mo nito rs in the

ro o ms we re lo we re d thre e le ve ls

• Six pro file s we re c re a te d b a se d o n a g e

with ne w he a rt ra te a nd re spira to ry ra ng e s (mPE WS)

• De sa t Ala rm wa s re duc e d fro m 90 to 88.

No te – the Co mmitte e is a c tive ly mo nito ring CAT s a nd Co de Blue s with ne w mo nito r se tting s to a ssure tha t the ne w re sults ha ve a po sitive impa c t.

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Cur r e nt Pr

• file s

1.

Ne o: (up to 1 mo nth)

HR 180/ 80 RR 60/ 20

• 2. Pe diatr

ic : 1 mo nth- 9 ye a rs

HR 150/ 60 RR 30/ 20 3.

Adult: > 9 ye a rs

HR 100/ 50 RR 30/ 12

• 4. Comfor

t: typic a lly use d fo r e nd o f life ; the

mo nito r is se e n a t the c e ntra l sta tio n, b ut a ppe a rs b la c k in the ro o m

NE W Pr

• file s- for

MP5 E D & Ac ute Car e , e xc luding HKU

1.

Ne wbor n (0-5 mo s.)

HR 100/ 180 RR 20/ 70 2.

Infant (6-11 mo s)

HR 90/ 180 RR 14/ 50 3.

T

• ddle r

(1-2 yrs.)

HR 80/ 170 RR 14/ 40 4.

Sc hool age (3-9 yrs.)

HR 65/ 135 RR 12/ 40

• 5. Adole sc e nt/ Adult (10+)

HR 50/ 120 RR 12/ 30

• 6. Comfor

t- will re ma in sa me

Adjuste d Mo nito r Pa ra me te rs

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E duc a te d Use rs

• Philips pro vide d flo o r b y flo o r

e duc a tio n fo r 1 we e k to tra in use rs

• n ho w to se tup ne w pro file s.
• Nursing Orie nta tio n no w inc lude s

e duc a tio n o n mo nito r a la rms a nd se tting pro file s.

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Co nso lida te d Da ta Re vie w fro m mo nito rs

• Bio me dic a l e ng ine e ring wa s

se nding da ta to nursing le a de rship pre vio usly witho ut a na lysis a nd re vie w.

• T

he c o mmitte e no w re vie ws mo nthly da ta a nd a na lyze s fo r tre nds a nd se nds o ut summa ry a nd a c tio n info rma tio n.

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Pre vio us Style Re po rts–

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Sa mple Re po rt - dra ft–

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Ne w Re po rt – Dra ft –

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Sa mple Re po rt –

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Sa mple Re po rt –

4Main Trend

1000 2000 3000 4000 5000 6000 A p r

• 1

2 M a y

• 1

2 J u n

• 1

2 J u l

• 1

2 A u g

• 1

2 S e p

• 1

2 O c t

• 1

2 N

• v
• 1

2 D e c

• 1

2 J a n

• 1

3 F e b

• 1

3 M a r

• 1

3 A p r

• 1

3 Counts 1 2 3 4 5 6 7

Monitor Red Alarm CAT Calls CODE Calls

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Sa mple Re po rt –

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Sa mple Re po rt –

Patient arrives on unit MD orders monitor for

• patient. Defines type,

rationale, frequency. (MD typically selects normal range) RN or PCT places patient on monitor Initial data/limits entered into system for new admission Every shift monitor techs: * Review accuracy of limits * QA on monitors * If RN contact information correct Goals: * Identify opportunities for communication between RN and MD to discuss need for monitoring * Identify the role of the PCT in the monitoring process

Notes: * Drill down on ways patient is placed on monitor without order * What clinical guidelines auto trigger monitors? * It patient on monitor in ED, are they auto transferred to monitor on unit? Notes: * Can be entered in room, monitor tech then rounds @ start of shift to confirm patient matches monitor settings * Initial data is confirmed via 1) Order 2) MRN 3) ID band * HKU best practice: limits must be updated within 2 hours of arrival on unit, and are then documented in log sheet

Concerns/Issues Raised by Techs: * Accountability: who is responsible for completing and maintaining logs? * Response times: MD, RN too busy to respond to alarms * Alarm fatigue: too long of shifts and no notification ahead of time if a tech is on monitor duty (to prepare mentally) * Location of central monitoring station leads to distractions (parents, covering, etc) but isolating techs isn’t valuable * Education: cross training of techs, appropriate indicators for RNs, and limits/ appropriateness of monitors for MDs * Escalation * Techs not always included in mid-shift changes (i.e. taking the trach out for a bath, transport, patient using bathroom) * Variation across units, variation between MD order and RN PEWS vs. Default Alarm Limits: * Discrepancy * All new orders will have updated parameters * How do we get new parameters in Cerner as default? Log Sheets: * Name, MRN, History * Indicators to watch for (RN creates this list) * Informs notification tree (Day, Night, Charge RN)

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Ne xt Ste ps

• 7 E

a st PI L OT (50 b e d me dic a l/ re spira to ry unit) – Disc ussing mo nito rs during ro unds

• Pilo t to turn o ff YE

L L OW a la rms a t b e dside a nd re ly o n mo nito r te c h

• Re vie w Unit Spe c ific Crite ria fo r

Mo nito rs

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Que stio ns?