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The APSF Board of Directors' Workshop
Friday, October 22, 2004
13:00 17:00
Moderated by Drs. Michael A. Olympio and Robert K. Stoelting
Riviera Hotel, Royal Pavilion 3
"On the Use of Audible Beep Tone from the Pulse Oximeter and Audible Physiological Alarms"
To stimulate anesthesia leadership, practitioners, and industry representatives to consider and debate an APSF initiative regarding the use of audible pulse oximeter tones and physiological alarms in the perioperative arena.
Specific Objectives
- Reported to the ASA Board of Directors, the APSF Executive Committee Motion of February 06, 2004, and published in ASA Newsletter 68(6):25-6:
"APSF will publish, in a future edition of the APSF Newsletter, a discussion of the use of audible alarms on physiological monitors and the use of audible beep tone from the pulse oximeter during all anesthetics. In addition, the APSF will sponsor an APSF Board of Directors' workshop on this topic on October 22, 2004, in Las Vegas, NV."
- Published the APSF perspective, "Pulse-OX Tone Conveys Vital Information" by Goldman and Robertson in the APSF Newsletter, Summer 2004;19(2):20,23.
- Announced the workshop in the APSF Newsletter, Summer 2004; 19(2): 20,3 "APSF Stresses Use of Audible Monitor Alarms"
- Selected speakers and round table chairs representing APSF Executive Committee, ASA Closed Claims Investigation Group, JCAHO, APSF Corporate Council, Society for Critical Care Medicine and the Coalition for Critical Care Excellence, American College of Surgeons, ASA Committee on Equipment and Facilities, and the ASA Section on Professional Standards
- To acknowledge the current standards for intraoperative audible tones and alarms
- To consider and then conclude whether the APSF should make recommendations that the ASA Standards for Basic Anesthetic Monitoring include the audible pulse oximeter tone and at least one audible physiological alarm
- To consider the impediments and limitations of monitoring audible tones and alarms
- To explore technological opportunities that might address these limitations, including the state of "smart-alarm" technologies
- To obtain the perspectives of representative organizations and comments from the ASA Section on Professional Standards
Background
Though 20 years have passed since the airing of CBS 20/20 Documentary "Deep Sleep", the potential for perioperative tragedy secondary to the suspension, misuse, or absence of audible tones and alarms is frighteningly real, even today. Recent closed-claims events (to be reported by Caplan) poignantly detail the consequences of such omission. In a related issue, JCAHO published a Sentinel Event Alert, Issue 25, February 26, 2002 on preventing ventilator-related deaths and injuries. They determined that in 65% of 23 cases, there was a malfunction, misuse, or inadequate audible alarm. One recommendation was to "Ensure that alarms are sufficiently audible with respect to distances and competing noise" but another recommended, "Direct observation of ventilator-dependent patients preferred in order to avoid over dependence on alarms." Indeed, some clinicians argue that vigilance obviates the need for audible tones and alarms.
Following the Sentinel Event report, JCAHO made clinical alarm safety one of its six National Patient Safety Goals in 2003. Goal number six stated, "Improve the effectiveness of clinical alarm systems" (ECRI: HRC Risk Analysis Volume 4, Critical Care 5, May 2003, pp1-11). Goal 6b was to Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit. They recognized that most alarm-related problems occur because they are defeated too easily or they are not detected; alarm limits may be inappropriately set and frequent nuisance alarms are a major contributor to the omissions or actions taken by clinicians. The Sentinel Event Alert Advisory Group "considers this goal and its recommendations relevant to the entire array of alarm systems " and JCAHO went on to state:
Operating room exhaled carbon dioxide monitors, because they are used with personnel immediately present, are unlikely to have alarm-audibility issues. However, there are other aspects of alarm and monitor use during anesthesia that need to be addressed. These include alarm settings (such as setting appropriate high and low alarm limits), alarm integration, and pre-use checks. This activity should be delegated to a separate group that includes anesthesiologists.
Quite surprisingly, and well into these proceedings, JCAHO rescinded its Number 6 recommendation on audible alarms, and an explanation of that decision can be found at: http://www.aami.org/publications/AAMINews/2004September/0904.jcaho.html. We anticipate further clarification from our JCAHO speaker, Dr. Thomas Lavell.
Of further note are the ASA Standards for Basic Anesthetic Monitoring (last amended October 21, 1998) which mandate only one audible alarm, "that is capable of detecting disconnection of components of the breathing system." and applicable only when ventilation is controlled by a mechanical ventilator. Even the low oxygen concentration limit alarm and the electrocardiogram are not required to be audible. It is further stated that, "Adequate illumination and exposure of the patient are necessary to assess color" but a "quantitative method of assessing oxygenation such as a pulse oximeter shall be employed" without reference to audible tones.
Whereas the Anesthesia Patient Safety Foundation "strives to utilize its expertise and resources to identify areas that are most likely to benefit patient safety in the present and future" we are most pleased to bring you this workshop.
Program
| 1:00 - 1:05 |
Welcome from the Committee on Technology |
Michael A. Olympio, MD |
| 1:05 - 1:30 |
Introduction to the APSF Initiative |
Robert K. Stoelting, MD |
| 1:30 - 1:45 |
Closed Claims Evidence for Safety and Liability |
Robert A. Caplan, MD |
| 1:45 - 2:10 |
JCAHO Perspectives on Intraoperative Tones |
Thomas Lavell, MD |
| 2:10 - 2:35 |
A Rational Consideration of the Issues |
Julian Goldman, MD |
| 2:35 - 2:45 |
Break |
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| 2:45 - 3:15 |
Break-out Groups
Group leaders are charged with the responsibility of directing their group's discussion to answer the following questions:
- What is your recommendation on the APSF initiative?
- What are the major impediments to audible monitoring?
- What solutions do you recommend?
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APSF Corporate Advisory Council
- Abe Abramovich
- Roy Hays
- Michael Mitton
Society for Critical Care Medicine with the Coalition for Critical Care Excellence
- Margaret M. Parker, MD
- Patricia McGaffigan
American College of Surgeons
- R. Scott Jones, MD
American Society of Anesthesiologists
- Frank E. Block, Jr. MD |
| 3:15 - 4:05 |
Group Leader Presentations (8 minutes for each of 6 groups) |
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| 4:05 - 4:20 |
Improving the Effectiveness of Clinical Alarm Systems through "Smart-Alarm" Technologies |
Walter Huehn |
| 4:20 - 4:40 |
ASA Section on Professional Standards: Perspectives |
Jerry A. Cohen, MD
Jack L. Moore, MD |
| 4:40 - 5:00 |
Summary and Discussion: Where do we go from here? |
Robert K. Stoelting, MD |
| (Submitted 09.15.2004) | |
Distinguished Panel of Speakers
Michael A. Olympio, MD
Workshop Organizer and Moderator
Chair, Committee on Technology
Executive Committee, APSF
Robert K. Stoelting, MD
President of APSF
Workshop Leader
Robert A. Caplan, MD
Executive Committee
APSF
Thomas Lavell, MD
JCAHO
Julian M. Goldman, MD
Committee on Technology
APSF
Abe Abramovich
APSF Corporate Advisory Council
APSF Committee on Technology
Datascope
Roy Hays
APSF Corporate Council
Spacelabs
Michael Mitton
APSF Corporate Council
APSF Committee on Technology
Datex-Ohmeda, a Division of GE
Margaret M. Parker, MD
President, Society for Critical Care Medicine
Coalition for Critical Care Excellence, Safety Committee
Patricia A. McGaffigan, MS, RN
Coalition for Critical Care Excellence,
Industry Partner
Aspect Medical Systems
R. Scott Jones, MD, FACS
American College of Surgeons
Frank E. Block, Jr. MD
Committee on Equipment and Facilities
American Society of Anesthesiologists
Walter Heuhn
APSF Corporate Advisory Council
Philips
Jerry A. Cohen, MD
Chair, Section on Professional Standards
American Society of Anesthesiologists
Jack L. Moore, MD
Chair, Committee on Standards of Care
American Society of Anesthesiologists
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