AST Guideline - Best Practices in Alarm Management in the Operating Room

1 Approved October 7, 2016 Revised January 30, 2017 AST Guidelines for Best Practices in Alarm Management in the Operating Room Introduction The following Guidelines for Best Practices were researched and authored by the AST Education and Professional Standards Committee, and are AST approved. AST developed the following Guidelines to support healthcare delivery organizations (HDO) reinforce best practices in alarm management as related to the role and duties of the Certified Surgical Technologist (CST®), the credential conferred by the National Board of Surgical Technology and Surgical Assisting (NBSTSA). The purpose of the Guidelines is to provide information OR supervisors, risk management, and surgical team members can use in the development and implementation of policies and procedures for alarm management in the surgery department. The Guidelines are presented with the understanding that it is the responsibility of the HDO to develop, approve, and establish policies and procedures for the surgery department regarding alarm management practices according to HDO protocols. Rationale The following are guidelines in alarm management in the surgery department. As a working definition, an alarm is an automatic warning that results from a measurement indicating a deviation from the normal parameters. 18 Medical device alarms perform an essential patient safety function providing a warning alert system to the surgical team that there is a potential problem with the physiology of the patient or the medical device itself, but if not properly managed patient care may be compromised. 1,26 The large number of devices with alarms, such as during surgical procedures, has become identified as a major issue with negative results including healthcare personnel (HCP) becoming overwhelmed responding to several alarms in short spans of time; becoming desensitized, called “ alarm fatigue ”, leading to ignoring and/or missing alarms; delayed responses placing patients at risk; false or nuisance alarms ; or even turning off alarms. 1,26 In the Standards for Basic Anesthetic Monitoring published by the American Society of Anesthesiologists, it states that alarms should only be turned off for short interruptions in “rare and unusual circumstances.” 13 Other issues associated with alarm management include default settings of alarms that are not at an actionable level and alarm limits that are too narrow. 20 In its April 2013 edition of Sentinel Event Alert , The Joint Commission (TJC) reported that a search of the U.S. Food and Drug’s Manufacturer and User Facility Device Experience (MAUDE) database, January 2005 – June 2010 there were 566 patient deaths related to alarm- related device events. 19 In regard to false alarms, Schmid, et al. 17 studied 25 consecutive cardiac surgical procedures reporting the patient monitor and anesthesia workstation generated alarms at 1.2 alarms per minute and 80% of the alarms had no therapeutic consequences leading to what he calls the “crying wolf” phenomenon where alarm fatigue occurs leading to ignoring critical alarms