Background: The Joint Commission published a sentinel event alert in April 2013 related to alarm safety in hospitals. The Joint Commission report included 98 reported events and 80 patient deaths. The majority of these events and deaths occurred in telemetry units, intensive care units and emergency departments. The American Association of Critical Care Nurses (AACN) published a practice alert related to nurse expected practices with cardiac monitored patients. The AACN expected practices for nurses working with cardiac monitored patients include the following: 1) provide proper skin preparation for ECG electrodes; 2) change ECG electrodes daily; 3) customize alarm parameters and levels on ECG monitors; and 4) establish interprofessional teams to address issues related to alarms.
Problem statement: There are multiple undesired effects for the nurses and technicians in the new process. There are many nuisance alarms (leads off; leads off & can see ECG complex; battery needs change). Alarm Profile Notifications and responses are not consistently followed.
Project objective: The project objective is to increase the adherence to the Alarm Profile Notifications and responses as described in the Standard Operating Procedures for telemetry monitoring.
Countermeasures implemented: The clinical nurse specialist coordinated a meeting with the nurses and technicians who work on the telemetry units. The telemetry monitor company representative also met with the nurses and technicians from the telemetry units. Focus groups were conducted to identify the perceived issues of the nurses and technicians. New practices were implemented on the telemetry units including the following: 1) all telemetry pack electrodes changed on the night shift every 24 hours; and 2) all telemetry pack batteries changed on the day shift. Education was provided to the nurses and technicians on the updated Alarm Profile Notifications in the Standard Operating Procedures. Data collection processes and content were revised to improve the ongoing data collection monitoring process.
Results: Improved processes and responses to the alarm profile notifications. Data collection is ongoing to ensure adherence to the Alarm Profile Notifications and responses as described in the Standard Operating Procedures for telemetry monitoring.