A Descriptive Analysis of Adherence to Ventilator Alarm Policy

Abstract

Background:

The Joint Commission National Patient Safety Goal 6.01.01 requires hospitals to, 'Make improvements to ensure that alarms on medical equipment are heard and responded to on time.' Our department policy states, 'Alarms are set to ensure safe delivery of the mechanical ventilation to the patient, alert caregivers to possible changes in patient condition, ensure proper functionality of the ventilator, and to reduce unnecessary alarms to minimize staff alarm fatigue without risk to patient safety. ' Past abstracts have described inappropriately set alarms, while some organizations are attempting to benchmark ventilator alarm settings. As a quality assurance project, we sought to determine staff adherence to department policy.

Methods:

Data collected from fifty ventilators included: high peak inspiratory pressure, high minute ventilation, low minute ventilation, high respiratory rate, high tidal volume, and low tidal volume alarms. Data were compared to our departmental policy by finding the mean and standard deviation for each parameter.

Results:

We found that clinicians were grossly non-compliant with ventilator alarm settings. When setting high tidal volume, 4% of alarm settings were complaint to our policy. For low tidal volume, low minute ventilation, and high respiratory rate the compliance rates were 28%. Two percent of high minute ventilation alarms were set according to policy. High peak inspiratory alarm settings were set to policy on 22% of the ventilators. Mean difference between high tidal volume alarm setting and the policy was 299.75 mL ± 358.78 mL. A mean divergence from policy of 138.72 mL ± 163.35 mL was found in low tidal volume settings. High minute ventilation alarm means were low by 6.15 L/min ± 2.97 L/min. Conversely, low minute ventilation alarms were set too high, with a mean of 1.49 L/min ± 2.67 L/min. Mean respiratory rate settings were too high by 6.4 breaths/min ± 7.22 breaths/min. Finally, high peak inspiratory pressure alarms had a mean setting 8.76 cm H₂O ± 7.15 cm H₂O higher than stated in departmental policy.

Conclusions:

Although benchmarking ventilator alarm data is worthwhile it may be challenging to achieve. One theory for why clinicians did not adhere to our policy is that it may be too conservative. Future research may indicate why clinicians deviate from standards and how best to align ourselves with stated policies. Based on our findings we are devising a plan to meet the Joint Commission standard.