Improving Home Ventilator Alarm Use Among Children Requiring Chronic Mechanical Ventilation

Abstract

Background and objectives: Children requiring long-term mechanical ventilation are at high risk of mortality. Setting ventilator alarms may improve safety, but best practices for setting ventilator alarms have not been established. Our objective was to increase the mean proportion of critical ventilator alarms set for those children requiring chronic mechanical ventilation followed in our pulmonary clinic from 63% to >90%.

Methods: Using the Institute for Healthcare Improvement Model for Improvement, we developed, tested, and implemented a series of interventions using Plan-Do-Study-Act cycles. We followed our progress using statistical process control methods. Our primary interventions were: (1) standardization of the clinic workflow, (2) development of an algorithm to guide physicians in selecting and setting ventilator alarms, (3) updating that algorithm based on review of failures and inpatient testing, and (4) enhancing staff engagement to change the culture surrounding ventilator alarms.

Results: We collected baseline data from May 1 to July 13, 2017 on 130 consecutive patients seen in the pulmonary medicine clinic. We found that 63% of critical ventilator alarms were set. Observation of the process, standardization of workflow, and adaptation of an alarm algorithm led to an increase to 85.7% of critical alarms set. Through revising our algorithm to include an apnea alarm, and maximizing provider engagement, more than 95% of critical ventilator alarms were set, exceeding our goal. We sustained this improvement through January 2021.

Conclusions: Our stepwise approach, including process standardization, staff engagement, and integration of an alarm algorithm, improved the use of ventilator alarms in chronically ventilated pediatric patients.

FIGURE 1

Key driver diagram showing global and SMART Aim, key drivers, and interventions. LOR, level of reliability; Vte, tidal volume.

FIGURE 2

Alarm algorithm showing general guidelines for alarm parameters organized by type of ventilator. Text describes general principles to approach. RR, respiratory rate.

FIGURE 3

Annotated p-chart showing rate of critical alarms set as patients depart from pulmonary clinic visit. Dates span from May 1, 2017 to January 25, 2021. (A) Baseline data through July 13, 2017 with mean of 63.8%. (B) Shift in mean to 80.8% after beginning observation, revising of clinic workflow and implementing alarm algorithm. (C) Shift in mean to 85.7% after incorporating apnea alarm. (D) Shift to 95.1% (surpassing 90% goal) that was sustained following multiple interventions to improve team engagement and promote culture change. Special cause below lower control limit in March 2020 is likely due to practice changes secondary to coronavirus disease 2019.