"One big thing we didn't understand when we started was we didn't know how big the problem was. We didn't have any data. We used a fault tree analysis approach to try to figure out why alarms get missed," Cvach says.
"We analyzed the problem and started an intervention. We got rid of the duplication. We didn't turn things off. We turned some things to message or visible alarm instead of audible alarm. It's a visual versus an audible representation. We went through every unit and asked the leadership on that unit what do you want this to be and when is this actionable and we worked out default parameters."
The hospital also installed software that triages alarms to nurses' pagers. "We don't send everything to the nurse. They don't want 100 alarms per patient per day, so we came up with these delays," Cvach says.
"We looked at the crisis alarms and the non-crisis alarms. For the crisis alarms, which are very infrequent, we sent those to the nurse through this software. For the non-crisis alarms we set up a delay that allows the alarm to correct itself before it sends a signal to the nurse."
"If it corrects within the timeframe, Cvach explains, "we have established it doesn't send a signal to the nurse. But if it doesn't correct the nurse gets an alarm and acts on it. This really decreases the number of alarms the nurse gets. She is only getting things that are persistent as opposed to those that go away on their own."